From 29 July to 1 August 2019, WHO AFRO, WHO Rwanda, and Ministry of Health Rwanda hosted a four day Regional Consultation in Kigali, Rwanda entitled “WHO PEN and Integrated Outpatient Care for Severe, Chronic NCDs at First Referral Hospitals in the African Region (PEN-Plus)”.
The regional consultation brought together Ministries of Health and WHO Country Representatives from seventeen member states, including Benin, Botswana, Burkina Faso, Côte d’Ivoire, Eritrea, eSwatini, Ethiopia, Guinea, Kenya, Lesotho, Liberia, Malawi, Nigeria, Rwanda, Sierra Leone, Tanzania, and Uganda.
Partners In Health and Harvard Medical School supported the consultation, with PIH NCD and clinical leadership attending from Rwanda, Malawi, Liberia, Sierra Leone, Lesotho, Haiti and Boston. Colleagues also attended from the Clinton Health Access Initiative (CHAI), Pan-African Society of Cardiology (PASCAR), REACH, Rwanda Diabetes Association, the African Palliative Care Association (APCA), and the Global Sickle Cell Disease Network.
According to the press release published by WHO AFRO on 29 July 2019:
“Building on critical work that WHO/AFRO and member states have already begun, to define and promote essential packages of care for non-communicable diseases at primary care levels (PEN), the consultation will evaluate current progress in implementation of PEN and discuss a regional strategy for expanding access to high-quality care for severe, chronic NCDs (PEN-Plus).
“PEN-Plus” strategies provide an integrated platform at first-referral level hospitals to address priority conditions such as type 1 diabetes (T1D), rheumatic heart disease (RHD), and sickle cell disease, as well as palliative care for advanced malignancies and other conditions. “PEN-Plus” approaches are also designed to complement PEN and offer an opportunity to develop the leadership needed to train, supervise, and mentor implementation and expansion of chronic care services for more common and less severe NCDs at health centres.”
In the first two days of the consultation, country representatives presented their progress in implementation of WHO PEN packages of essential NCD interventions at primary care level and discussed how best to address common challenges across the African region, including availability of funding, retention of trained health workers, data collection, and availability of essential medicines and equipment.
In the remaining half of the consultation, WHO AFRO, the NCD Synergies team at Partners In Health, and Harvard Medical School presented preliminary survey findings and a draft regional strategy for PEN-Plus, which emphasized the importance of an integrated model of care to address a set of severe conditions that are catastrophic especially in young populations and disproportionately impact the very poorest. Many severe and chronic NCDs such as type 1 diabetes, heart failure, and sickle cell disease require advanced management that can be delivered effectively by mid-level providers at first-level/district hospitals. PEN Plus can also accelerate progress on WHO PEN interventions at primary health center level – through improving care at district hospital level, countries can support scale up of primary care and put themselves on a strong pathway towards achieving universal health coverage.
Presentations from the Rwanda Ministry of Health, Rwanda Biomedical Centre, Partners In Health/Inshuti Mu Buzima, Liberia Ministry of Health and Social Welfare, and Malawi Ministry of Health provided national examples of how to manage scale up of PEN-Plus services. Participants also had an informative dialogue on how mentorship and referral pathways between WHO PEN and PEN-Plus can work together at country level to strengthen a comprehensive delivery platform and address the full spectrum of NCD care to those that need it most.
In addition to targeted feedback to preliminary PEN-Plus strategy documents and supplemental material through a consultation framework, participants also had a chance to learn from site visits to three district hospitals near Kigali – Masaka, Nyamata, and Rutongo. Hearing directly from hospital directors and nurse leaders who have developed strong and well-functioning NCD clinics based on PEN-Plus principles to support patients with severe, complex NCDs in all regions across Rwanda was an inspiring way to move forward critical discussion throughout the week.
Since October 2017, WHO AFRO has been collaborating with the Program in Global NCDs and Social Change at Harvard Medical School (HMS) and the NCD Synergies project at Partners In Health (PIH) to support PEN Plus development. Much of this initial work has been based on the leadership of PIH clinical programs in Rwanda, Malawi, and elsewhere, as well as findings from National NCDI Poverty Commissions in various countries throughout the region. Experience from this work is available online through the Chronic Care Toolkit.