In many low- and lower-middle income countries, clinical services for chronic, severe noncommunicable diseases (NCDs), such as type 1 diabetes and advanced rheumatic heart disease, are only available through urban referral centers. At first-level (district) hospitals, at most the management of common NCDs, such as hypertension, type 2 diabetes, and asthma, may be available. For those with severe NCDs, the distance to the nearest referral center forces patients to make the impossible choice of paying for unaffordable transport and loss of work and family time versus not receiving care. Far too often, the result is late presentation of the disease or lost to follow-up, which leads to early death and disability.
Since 2006, Partners In Health has systematically designed and implemented strategies for progressive decentralization and integration of NCD services in rural areas. One area of focus has been the development of specialized, nurse-led outpatient PEN-Plus clinics to care for patients with severe, chronic NCDs. This has been an expansion of WHO Package of Essential Noncommunicable Interventions for Primary Care (PEN). In 2011, PIH published a set of protocols, monitoring indicators, forms, and preliminary costing for these clinics through the PIH Guide to Chronic Care Integration for Endemic Non-Communicable Diseases. Over the past decade, PIH has gained experience with supporting the introduction of these specialized NCD clinics in Rwanda, Malawi, Haiti, and Liberia.
In order to better serve other countries that would like to introduce similar services, PIH has now assembled a toolkit with materials that we have found helpful for training and program operation. The PEN-Plus Toolkit serves as a district-level focused supplement to existing materials focused on primary health centers, including: (WHO PEN), Integrated Management of Adolescent and Adult Illness (IMAI), and others.
The PEN-Plus Toolkit contains seven sections, each of which has implementation tools in an editable format that can be adapted to local contexts:
- Implementation and Work Planning
- Baseline Assessment
- Clinical Guideline Development
- Training and Mentorship
- Progressive Decentralization
- Medical Informatics
- Monitoring and Evaluation
The contents of the toolkit for specialized outpatient clinics for severe NCDs at district hospitals are largely focused on the needs of countries where chronic care for severe NCDs is only available at national or regional referral centers. A short-term goal for these health systems is to decentralize integrated chronic care services, particularly for severe NCDs, to district hospitals in preparation for further decentralization and integration of services for more common and less severe NCDs at health centers.
Although the priority conditions addressed will vary depending on local epidemiology, in most cases severe NCDs include:
- Type 1 diabetes
- Heart failure due to rheumatic heart disease
- Malignant hypertension
- Sickle cell disease
- Patients requiring anticoagulation
- Severe asthma
- Advanced malignancies requiring pain management
- End-stage kidney and liver disease requiring palliative therapies
While this toolkit can be useful for public sector implementers and policymakers, many of the tools are framed from the perspective of non-governmental organizations who are seeking to provide direct support to the Ministries of Health as implementing or technical partners.
In general, chronic care services even for severe NCDs can be delivered by mid-level providers such as nurse practitioners, clinical officers, and physician assistants working under the supervision of generalist and specialist physicians. Task-shifting to mid-level providers is oftentimes the most practical solution given the limited quantity of physicians at district hospitals. Because there may be a relatively small number of patients presenting with severe NCDs to district hospitals with catchment areas of less than 500,000, clustering conditions with related workflows under the scope of one set of providers ensures sufficient volumes to ensure quality service provision and benefit from shared infrastructure. For the same reason, we recommend grouping adult and pediatric patients together. Furthermore, integration allows for limited resources, such as staff and medical equipment, to be more efficiently utilized within a single care delivery model across multiple diseases.
What is the approach to clinical capacity building?
Initiating the first PEN-Plus clinics will require training of mid-level providers by either local or visiting specialists. This initial investment establishes local training sites that can then train other mid-level providers over a period of as little as three months and lead to rapid scale-up of district-level NCD clinics to all district hospitals in the country at relatively low cost.
What is the role of NCD clinicians at first-level hospitals to support health centers?
Successful decentralization of NCD services to PEN-Plus clinics at district hospitals also provides the foundation for training, mentorship, and supervision of health-center providers delivering a more integrated set of chronic care services that also includes mental health and chronic infectious diseases such as HIV and TB. Additionally, PEN-Plus clinics can strengthen the referral system between health centers and district hospitals.