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.”