At the PEN-Plus clinic in Lisungwi, Malawi, Kerefasi Wiliyamu, a 14-year-old living with type 1 diabetes, is examined by clinical officer Kenwood Kumwenda, while his mother, Sofiya Simoni, speaks with clinical officer Medson Boti. Photo: Karin Schermbrucker/Slingshot Media for PIH.
The article—coauthored by leaders from WHO/AFRO, UNICEF, and the NCDI Poverty Network—describes how the PEN-Plus strategy has grown exponentially since it was first developed at three rural district hospitals in Rwanda in the late 2000s. In the 2010s, PEN-Plus was scaled up nationally in Rwanda and implemented successfully in three other lower-income countries. It has since been initiated in 10 more lower-income countries in Africa and South Asia and adopted as a regional strategy by unanimous vote of the 47 member states of WHO’s African Region in 2022, with ambitious targets to achieve high levels of coverage by 2030.
PEN-Plus programs give nurses and other mid-level providers at district hospitals the specialized training, medicines, and equipment they need to diagnose and treat severe NCDs like type 1 diabetes, sickle cell disease, and rheumatic and congenital heart disease. Those four conditions alone are responsible for around 150,000 preventable deaths every year among the world’s poorest people, including almost 100,000 among children, adolescents, and young adults.
The PEN-Plus Partnership includes leading organizations focused on childhood heart disease, type 1 diabetes, and sickle cell disease working together with the World Health Organization and UNICEF to mobilize the technical and financial resources required to rapidly scale up implementation of PEN-Plus and dramatically increase the number of the poorest children and young adults on high-quality treatment for these three conditions and other severe chronic NCDs by the end of the decade.
“A lack of resources remains the major challenge for an equitable response to the intersection of extreme poverty and severe chronic NCDs,” the authors of the commentary conclude. “As demonstrated by the Lancet NCDI Poverty Commission, the poorest countries—many of which are victims of historic injustice—cannot afford essential health services on their own.
“By aligning the passion of people affected directly by conditions such type 1 diabetes, congenital and rheumatic heart disease, and sickle cell disease, the PEN-Plus Partnership hopes to mobilize the external resources needed to end one of the great and enduring tragedies in the world today.”
Staff from the Center for Integration Science in global health equity gathered in November 2022 to celebrate the center’s launch during an inaugural symposium. Gene Bukhman is center front. Photo by Stu Rosner.
“The Center for Integration Science is a group of clinicians, researchers, and administrators focused on moving health resources to the world’s poorest people. We’re doing this by finding new service delivery models that can expand health care and by mobilizing social movements to enact lasting change.”
Those were CIS Executive Director Gene Bukhman’s opening words in an interview featured in the March edition of Brigham Clinical & Research News, a monthly newsletter of Brigham and Women’s Hospital.
In the interview, Bukhman:
highlighted the Center’s mission and goals — “to accelerate global health equity by identifying integrated units of operational effectiveness and health care delivery, and then scaling implementation through collective action”;
identified gaps in global solidarity and financing as the principal obstacle to achieving them; and
described the new approach the Center is taking to break the impasse — “by forging new kinds of coalitions across multiple disease spaces and among people who treat, advocate for, or live with these diseases.”
“The best example of this,” Bukhman said, “is the PEN-Plus strategy, which stands for Package of Essential Noncommunicable Disease Interventions Plus. It’s an approach developed in the late 2000s at the Brigham with partners in Rwanda to simplify care for different types of severe, chronic noncommunicable diseases. We identified the most essential elements of treating these conditions, trained nurses and other mid-level providers to deliver this care, and forged connections among advocates working on disparate diseases. PEN-Plus has since expanded to 14 countries.”
When asked to sum up what distinguishes the Center from other initiatives and collaborations, Bukhman answered succinctly.
“One major difference is that we’re developing models of service delivery at the same time we’re studying the sociology of advocacy movements. Braiding these crucial strands of work together is unusual in medicine and global public health.”
To build on that momentum, WHO/AFRO experts from the non-communicable diseases (NCDs) program were in Boston in late January to meet with leaders and staff from both the Boston and Maputo co-secretariats of the NCDI Poverty Network. The PEN-Plus Regional strategy is designed to increase the capacity of first-level health facilities in rural and peri-urban areas to diagnose and treat severe, chronic NCDs such as type 1 diabetes, sickle cell disease, and rheumatic heart disease using standardized and evidence based, protocols supported by mentorships of the service providers.
During the three days of meetings, the AFRO and Network teams reviewed the PEN-Plus implementation framework that the WHO/AFRO team developed and discussed how the Network can best support achieving the ambitious goal of the regional strategy – to have 70% of member states rolling out PEN-Plus services by 2030. They also covered approaches to country prioritization, operational research needs, and monitoring and reporting methods at national, regional, and global levels.
On the third day, representatives from the Helmsley Charitable Trust, UNICEF, and the American Heart Association joined the WHO/AFRO and NCDI Poverty Network teams. These organizations are key members of a high-level Advisory Group for the PEN-Plus Partnership that focuses on resource mobilization strategies to support PEN-Plus initiation and scale-up.
The meetings were hosted by the Center for Integration Science in Global Health Equity, which serves as the Network’s Boston co-secretariat, working in conjunction with the Maputo co-secretariat based at Universidade Eduardo Mondlane in Mozambique. The Center is a joint initiative of Brigham and Women’s Hospital, Harvard Medical School, and Partners In Health.
Following the adoption of the PEN-Plus strategy to address severe NCDs at first-level referral health facilities by the World Health Organization Regional Office for Africa (WHO/AFRO), the West African Health Organization (WAHO) hosted a three-day regional review meeting on the WHO Package of Essential NCD Interventions for Primary Health Care (WHO PEN) that included a presentation on PEN-Plus and the NCDI Poverty Network. Participants met in Cape Verde between 14-16 September 2022.
The event included a presentation from Dr. Prebo Barango of the World Health Organization Regional Office for Africa (WHO/AFRO) on PEN-Plusas an integrated care delivery strategy to provide chronic care for severe NCDs such as type 1 diabetes, sickle cell disease, and rheumatic heart disease in rural areas. Center for Integration Science Managing Director and NCDI Poverty Network West Africa Regional Lead Emmanuel Mensah followed Dr. Barango’s presentation by sharing the progress the Network has made in introducing, implementing, and scaling-up PEN-Plus in West Africa.
The meeting focused on achievements in implementing the WHO PEN to address the regional burden of NCDs as well as the challenges. The Africa Center for Disease Control (CDC) and WAHO presented a strategic plan for NCDIs and mental health for the region.
NCDI Poverty Network Co-Chair Dr. Ana Mocumbi and the Mozambique Co-Secretariat and Southern Africa Regional Hub team recently hosted CIS Executive Director and NCDI Poverty Network Co-Chair Dr. Gene Bukhman and CIS Director of Programs Dr. Emily Wroe for a three-day visit to the provinces of Maputo and Sofala as Mozambique prepares to implement PEN-Plus.
Mozambique is one of ten NCDI Poverty Network countries that are initiating PEN-Plus services by opening their first PEN-Plus clinics at rural district hospitals in 2022. Over the next three years they will establish training sites to support expansion to other districts and develop operational plans for national scale-up. In Mozambique, Nhamatanda Rural Hospital will host the PEN-Plus clinic, providing affordable, accessible care for rheumatic heart disease, type 1 diabetes, sickle cell disease, and other severe, chronic NCDs to the vulnerable community.
During the three-day visit, Dr. Mocumbi, Dr. Bukhman, and Dr. Wroe met with key stakeholders, including PEN-Plus implementing partners Doctors with Africa CUAMM, officials from the Mozambique government and Ministry of Health, and representatives from the WHO and UNICEF country offices.
The Network made a one-day excursion to Nhamatanda Rural Hospital where they met with future PEN-Plus clinicians, hospital leadership, and CUAMM. While in Beira, the capital of Sofala Province, the Network team met with the Clinical Director of Beira Central Hospital and discussed how the referral hospital will support efforts to train mid-level providers to diagnose and treat the package of severe, chronic NCDs that are covered by PEN-Plus.
The Mozambique Co-Secretariat took the occasion of the visit to host a scientific seminar that provided an overview of PEN-Plus and the NCDI Poverty Network’s work to the larger Universidade Eduardo Mondlane (UEM) community, as well as representatives from the Ministry of Health and World Health Organization.
This was the first time Dr. Wroe and Dr. Bukhman of the Boston Co-Secretariat have been able to visit the Mozambique Co-Secretariat and Regional Hub based at UEM since they were established in October 2021.
Leaders from the World Health Organization Regional Office for Africa (WHO AFRO), WHO Headquarters, and other stakeholders invested in the implementation of PEN-Plus met in Geneva on 24 May to discuss PEN-Plus as a key strategy for decentralizing care for severe NCDs and providing the world’s most vulnerable with accessible and affordable health care for chronic conditions including type 1 diabetes (T1D), sickle cell disease (SCD), and rheumatic and congenital heart disease (RHD/CHD).
World Health Organization Regional Director for Africa Dr. Matshidiso Moeti gave remarks at the event and expressed her excitement at the opportunity PEN-Plus offers to find ways to integrate care for NCDs.
WHO Regional Director for Africa Matshidiso Moeti addresses PEN-Plus stakeholders at World Health Assembly.
WHO AFRO has developed a regional strategy for PEN-Plus, which is on the agenda to be reviewed and adopted at the August 2022 regional committee meeting.
Speaking as the Co-Chair of the NCDI Poverty Network, Dr. Gene Bukhman highlighted the importance of integration to provide life-saving NCD care in rural and peri-urban communities in low- and lower-middle income countries (LLMICs). Network Co-Chair Dr. Ana Mocumbi explained that PEN-Plus is one such integrated care delivery strategy that leverages linkages between conditions to train mid-level providers in the skills needed to provide chronic care services for T1D, SCD, and RHD/CHD. Speaking on behalf of the Malawi Ministry of Health, Dr. Jones Masiye explained to the group that PEN-Plus was successfully implemented in 2018 in the Neno district of Malawi. Malawi is moving forward with plans to scale-up PEN-Plus nationally by establishing two new clinics in strategically located Salima and Karonga.
Additional speakers at the event were NCDI Poverty Network Voices Advocacy Fellow Anu Gomanju and Helmsley Charitable Trust Program Officer James Reid. Speaking on why support for integrated care delivery models like PEN-Plus are so important, James Reid stressed “No matter where a child is born, however remote, they deserve to live a long fulfilling life. They deserve the right to essential medicine and supplies, and they deserve quality, affordable, and consistent care to treat their NCD.”
Other participants represented the United Nations Development Programme (UNDP), NCD Alliance, Life for a Child, the Pan-African Society of Cardiology (PASCAR), Global Alliance for Rheumatic and Congenital Hearts (Global ARCH), and many other leading financing, policymaking, technical, and advocacy institutions.
PEN-Plus stakeholders will meet again in September 2022 to celebrate the official launch of the PEN-Plus Partnership, which has brought together 42 organizations and 40 individuals to convene regularly and provide technical, policy, advocacy, and financing support to countries implementing and scaling-up PEN-Plus.
If you are interested in supporting PEN-Plus expansion, you may consider joining the NCDI Poverty Network and participating in one of the PEN-Plus working groups. Learn more about Network membership here.
The Center for Integration Science in Global Health Equity (CIS) hosted its inaugural symposium on Thursday, 10 November 2022 at the Joseph B. Martin Conference Center at Harvard Medical School (HMS).
The Center is a joint initiative of the Division of Global Health Equity at Brigham and Women’s Hospital, the Program in Global NCDs and Social Change at Harvard Medical School, and the NCD Synergies project at Partners In Health. The event introduced the Center as a platform for clinicians, researchers, and academics to collaborate in applying integration science to design, implement, evaluate, and bring to scale models for decentralizing services progressively and integrating those services to optimize both health system resources and patient outcomes and well-being.
“The mission of the Center for Integration Science is to accelerate the just redistribution of resources in the interest of global health equity by identifying integrated units of operational effectiveness in health care delivery and scaling their implementation through collective action.”
– CIS Executive Director Dr. Gene Bukhman
Together with the Universidade Eduardo Mondale in Mozambique, the Center also serves as the co-secretariat for the NCDI Poverty Network, a group of 22 low- and lower-middle-income countries (and growing) that was formed in December 2020 to implement the recommendations of the Lancet Commission on Reframing Noncommunicable Diseases and Injuries for the Poorest Billion.
Towards a Science of Integration for Global Health Equity
The symposium began with opening remarks from CIS Executive Director Dr. Gene Bukhman and brief introductions from the CIS leadership team.
BWH President Dr. Robert Higgins, BWH Department of Medicine Interim Chair Dr. Bruce Levy, and Partners in Health Co-Founder Todd McCormack also delivered opening addresses at the event.
CIS Executive Director Dr. Gene Bukhman
Dr. Bukhman, who is also Co-Chair of the NCDI Poverty Network, then presented the background of decades of innovation in clinical care, research, and analysis that led to the establishment of CIS. Starting in the 2000s, Bukhman and colleagues at Partners In Health worked with the Ministry of Health in Rwanda to develop a strategy for progressive decentralization and integration of chronic care services at first-level hospitals for multiple non-communicable conditions that were endemic causes of preventable death and suffering among children and young adults.
The Lancet Commission on Reframing NCDs and Injuries for the Poorest Billion, which Bukhman co-chaired with Dr. Ana Mocumbi from Universidade Eduardo Mondlane, identified lack of access to care for severe NCDs as the biggest gap in universal health coverage in low-income countries and proposed a strategy to address it by building integrated care teams of mid-level providers, auxiliaries, and physicians at lower levels of the health system to deliver packages of interventions that require related skills and benefit from shared space and information systems.
Following publication of the Lancet Commission report in 2020, 15 lower-income countries that had conducted parallel analyses through national NCDI Poverty Commissions came together to forge the NCDI Poverty Network as a platform for implementing the Commission’s recommendations. The Network has since grown to include 22 countries, 14 of which are implementing or scaling-up PEN-Plus, a proven integrated delivery model that decentralizes integrated chronic care services for severe chronic NCDs like type 1 diabetes, rheumatic heart disease, and sickle cell disease. In August 2022, the 47 member states of WHO’s African region adopted PEN-Plus as a regional strategy to address severe NCDs.
Dr. Emilio Tostão, Scientific Director, Universidade Eduardo Mondlane
The Center for Integration Science will build on these successes to support further expansion and national scale-up of PEN-Plus and to develop, test, evaluate, and implement other integrated service delivery models
Following Dr. Bukhman’s presentation, Universidade Eduardo Mondlane Scientific Director Dr. Emilio Tostāo provided an overview of the partnership between CIS and Universidade Eduardo Mondlane as the co-secretariat of the NCDI Poverty Network, which works to mobilize resources to support health sector interventions that reduce suffering and prevent death from non-communicable diseases among the world’s poorest children and young adults.
Panelists highlight the power of integration science in advancing global health equity
The Inaugural Symposium featured three panel discussions with leading global health policy makers, patient advocates, researchers, implementers, and academics who discussed how integration science can be (and has been) used to inform the design, implementation, evaluation, and scale-up of integrated service delivery models for interventions prioritized based on equity.
From left to right: Alma Adler, Emilio Tostão, Ryan McBain, and Chantelle Boudreaux
The first panel featured a discussion on integration science as the study of delivery model design, including optimal clustering of tasks among providers and interfaces within and outside of the health system. Panelists included Dr. Tostāo, NCDI Poverty Network East Africa Regional Lead Dr. Wubaye Walelgne Dagnaw, CIS Lead Investigator Dr. Ryan McBain, and CIS Associate Director for Integration Research Dr. Chantelle Boudreaux. CIS Research and Monitoring and Evaluation Director Alma Adler moderated the discussion, which focused on developing techniques for studying the distribution of tasks within health systems, as well as techniques for modelling optimal clustering of these tasks.
From left to right: Maia Olsen, Moses Echodu, Apoorva Gomber, and Jon Shaffer. Gregg Gonsalves and Ana Gomanju pictured on screen.
The second group of panelists consisting of global health advocates and community organizers discussed how to build a multi-disease social movement in support of integrated care delivery strategies like PEN-Plus. The panelists included Associate Professor of Epidemiology at Yale School of Public Health Dr. Gregg Gonsalves, CIS Type 1 Diabetes and Global Health Equity Research Fellow Dr. Apoorva Gomber, Postdoctoral Fellow of Sociology at Johns Hopkins University Dr. Jon Shaffer, and Voices of NCDI Poverty Fellows Anu Gomanju from Nepal and Moses Echodu from Uganda. The panel was moderated by CIS Advocacy Director Maia Olsen.
From left to right: Vikram Patel, Gedeon Ngoga, Emily Wroe, and Robert Riviello
In the final panel, Pershing Square Professor of Global Health at Harvard Medical School Dr. Vikram Patel led a discussion about experiences with implementation of integrated delivery models in the areas of chronic care for severe NCDs, acute/critical care, and breast and gynecological care. CIS Training Director Gedeon Ngoga, CIS Director of Programs Dr. Emily Wroe, Associate Professor of Surgery and of Global Health and Social Medicine at Harvard Medical School (HMS) Dr. Robert Riviello, and World Health Organization Regional Office for Africa Cervical Cancer Technical Officer Sharon Kapambwe shared their perspectives and insights during the discussion.
You can read more about CIS and its work here and watch a recording of the event below.
Participants in PEN-Plus heart failure management course evaluate and discuss cardiac ultrasound images.
A training model that combines in-person classroom instruction with a digital, e-learning platform has been successfully piloted in Rwanda to train PEN-Plus nurses and physicians in the knowledge, skills, and competencies to diagnose and treat heart failure. The training model and corresponding learning materials are being developed and tested as part of a PEN-Plus curriculum that can be adapted by NCDI Poverty Network countries as they initiate and scale-up implementation of PEN-Plus services.
Initial survey data and focus group feedback suggests that the new training model is an effective way to convey knowledge about the causes, symptoms, and treatment protocols for heart failure, and to acquire and practice skills required for diagnosis and treatment. Rwanda will continue to utilize the new training model as a means of scaling-up PEN-Plus nationally, and plans are being made to test the same cardiology training model in Liberia and Malawi.
After completing two weeks of online training modules, 20 trainees from five rural, district hospitals spread across the country met with six facilitators at the Partners in Health training site in Rwinkwavu between 1-5 November for the first in-person component of the training model. After spending that week practicing new skills and discussing case studies as a group, pairs of newly trained nurses and physicians returned to their hospitals with master trainers for an additional week of supervised in-person training and mentoring.
The online portion of the training, developed by the e-learning and training team of the NCDI Poverty Network Secretariat, covered topics such as cardiac anatomy and physiology, causes of heart failure, and ways to diagnose and treat cardiomyopathy, congenital heart disease, and right heart failure. The online course also included knowledge checks as well as a pre- and post-course exam. Additional advanced modules covering prosthetic heart valves and anticoagulation medication are currently under development.
Congenital heart failure is one of the topics covered in the eight online heart failure training modules.
The in-person portion of the training focused on skills-based learning. By first introducing topics online as part of a flipped classroom model, in-person instructors can focus their attention on leading hands-on training exercises in which trainees apply their knowledge in practice. During the in-person portion of the training model, participants learned and practiced new skills, like how to perform and interpret an echocardiogram, and discussed challenging cases with mentors.
Participant feedback and e-learning data are currently under review. The results will be used to improve both the online and in-person portions of the training model and will assist the NCDI Poverty team as they develop training modules for other conditions covered by PEN-Plus, such as type 1 diabetes and sickle cell disease.
“The highlight of this training is identifying a successful training model that could potentially be used to scale-up PEN-Plus in other Network countries,” said Dr. Sheila Klassen, a cardiologist who works with the NCDI Poverty Secretariat on curriculum development and training. “Having this training go so well and know we could possibly replicate with similar success is very exciting.”
