Protocol for an evaluation of the initiation of an integrated longitudinal outpatient care model for severe chronic non-communicable diseases (PEN-Plus) at secondary care facilities (district hospitals) in 10 lower-income countries

Alma J Adler, Emily B Wroe, Andrea Atzori, Neusa Bay, Wondu Bekele, Victoria M Bhambhani, Remy Bitwayiki Nkwiro, Chantelle Boudreaux, Dawson Calixte, Jonathan Chiwanda Banda, Matthew M Coates, Wubaye Walelgne Dagnaw, Katia Domingues, Laura Drown, Symaque Dusabeyezu, Darius Fenelon, Neil Gupta, Isaac Ssinabulya, Yogesh Jain, Yogeshwar Kalkonde, Innocent Kamali, Catherine Karekezi, Biraj Man Karmacharya, Bhagawan Koirala, Julie Makani, Fabio Manenti, Alexio Mangwiro, Beatriz Manuel, Jones K Masiye, Fastone Mathew Goma, Mary Theodory Mayige, Amy McLaughlin, Emmanuel Mensah, Nicole Mocumbi Salipa, Reuben Mutagaywa, Alvern Mutengerere, Gedeon Ngoga, Marta Patiño, Giovanni Putoto, Todd Ruderman, Devashri Salvi, Santigie Sesay, Fameti Taero, Emílio Tostão, Sterman Toussaint, Gene Bukhman, Ana Olga Mocumbi, for the PEN-Plus Partnership study group.

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The Package of Essential Noncommunicable Disease Interventions—Plus (PEN-Plus) is a strategy decentralising care for severe non-communicable diseases (NCDs) including type 1 diabetes, rheumatic heart disease and sickle cell disease, to increase access to care. Inthe PEN-Plus model, mid-level clinicians in intermediary facilities in low and lower middle income countries are trained to provide integrated care for conditions where services traditionally were only available at tertiary referral facilities. For the upcoming phase of activities, 18 first-level hospitals in 9 countries and 1 state in India were selected for PEN-Plus expansion and will treat a variety of severe NCDs. Over 3 years, the countries and state are expected to: (1) establish PEN-Plus clinics in one or two district hospitals, (2) support these clinics to mature into training sites in preparation for national or state-level scale-up, and (3) work with the national or state-level stakeholders to describe, measure and advocate for PEN-Plus to support development of a national operational plan for scale-up.