New Lancet Commentary Highlights Feasibility of Decentralizing Care for Severe, Chronic NCDs

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.


A commentary published in The Lancet Diabetes and Endocrinology in early May showcases the power of PEN-Plus and the PEN-Plus Partnership to bring lifesaving care for severe, chronic NCDs to first-level hospitals in poor, rural areas of lower-income countries.

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.”

WHO/AFRO Member States Adopt Regional Strategy to Implement PEN-Plus

On 23 August 2022, the 47 Member States of the WHO/AFRO region voted unanimously to adopt the regional PEN-Plus strategy to address severe NCDs at first-level referral health facilities in the region. Thirty-three of the region’s 47 Member States (70%) submitted statements in advance of the vote on the resolution – all in support.

Implementation of this strategy will increase the capacity of first-level health facilities in rural and peri-urban areas to diagnose and treat severe, chronic non-communicable diseases (NCDs) such as sickle cell disease, type 1 diabetes, and rheumatic heart disease. It will also – as the strategy points out – accelerate and strengthen implementation of WHO’s Package of Essential NCD Interventions (PEN) for prevention and management of less severe conditions at primary care level, which is currently being implemented in only 45% of the region’s Member States.

“WHO has been providing support to member states to implement PEN for primary health care in low-resource settings since 2008,” Dr. Benido Impouma, Director of the WHO/AFRO Regional Office’s Communicable and Noncommunicable Diseases Cluster, stated in presenting the resolution. “The region now needs to focus on specific severe NCDs such as type 1 diabetes, sickle cell disease, and rheumatic fever, ensuring that vulnerable populations with these diseases have access to diagnosis and treatment within their communities…. ”

“Implementing PEN-Plus is critical to reducing premature disability and deaths in those living with these diseases [severe NCDs such as type 1 diabetes, sickle cell disease, and rheumatic fever].”

— Benido Impouma, Director Communicable and Noncommunicable Diseases Cluster, WHO/AFRO

Adoption of the Regional Strategy marks the successful culmination of a process that began more than three years ago, when WHO/AFRO and the Rwanda Ministry of Health hosted a regional consultation on WHO PEN and PEN-Plus in Kigali, at which Prebo Barango of WHO/AFRO and collaborators from the secretariat of the Lancet NCDI Poverty Commission and NCDI Poverty Network presented a preliminary draft of the regional PEN-Plus strategy.

Since that consultation, WHO/AFRO has worked with the NCDI Poverty Network, UNICEF, the Helmsley Charitable Trust, and other partners to support national scale-up of PEN-Plus in Malawi; initiation of PEN-Plus clinics and training sites in eight other countries in the region – Ethiopia, Kenya, Uganda, Tanzania, Mozambique, Zambia, Zimbabwe, and Sierra Leone; and finalization of the draft Regional Strategy that has now been adopted.

Now, with adoption of the regional PEN-Plus strategy, WHO/AFRO has established ambitious goals to have 50% of Member States rolling out PEN-Plus services to district hospitals by the year 2025, 65% by 2028, and 70% by 2030.

“The adoption of the WHO PEN-Plus resolution and strategy by countries in the African region shows their commitment to helping those afflicted by severe chronic NCDs. These conditions include diseases such as type 1 diabetes, rheumatic heart disease, sickle cell disease, and others that have previously fallen through the cracks of global policy and action,” NCDI Poverty Network Co-Chairs Gene Bukhman and Ana Mocumbi said, following the vote. “Now, the NCDI Poverty Network’s PEN-Plus Partnership is organizing a movement to support these countries financially so that the poorest are not left behind,”

Click on these links to learn more about PEN-Plus and the PEN-Plus Partnership.