PEN-Plus Partnership Strategic Plan - 2025-2028

PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

Celebrating and accelerating our collective progress in bringing healthcare and hope to people living in extreme poverty with severe, chronic noncommunicable diseases such as type 1 diabetes, sickle cell disease, and rheumatic and congenital heart disease

Contents 3 Introduction

4 Executive Summary

12 Priorities and Targets

Above: Salimatu Sesay, shown with sons Abubakarr (left) and Alusine, relocated her family five hours to Koidu, Sierra Leone, to be close to the PEN-Plus clinic that diagnosed her rheumatic heart disease. Right: Namazzi Mercy, a medical intern, takes the blood pressure of 11-year-old Lubwama Jackson, who receives treatment for his sickle cell disease at the PEN-Plus clinic in Nakaseke, Uganda.

6 Setting the Stage

22

24

Join Us

About the NCDI Poverty Network

PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

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A PROVEN STRATEGY PEN-Plus is a package of clinical services that enables frontline providers in low-income health systems to provide care for people living with severe, chronic noncommunicable diseases that require complex and precise ongoing management, such as type 1 diabetes, sickle cell disease, and rheumatic and congenital heart disease.

PEN-Plus clinics change the lives of people with these conditions in rural settings. The clinics are decentralized and fully integrated into public health systems, so they bring affordable care closer to home. With well-managed care, patients and their families have more resources, time, energy, and hope to pursue their futures. For families living in deep poverty, the impact is transformative.

THIS IS THE PROMISE OF PEN-PLUS.

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PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

Introduction Dear Friends, Four years ago, a coalition of leaders representing

Harry B. Helmsley Charitable Trust and Breakthrough

nongovernmental organizations, governments, hos-

T1D—expanded their support, the Network itself grew

pitals, philanthropies, universities, and communities

in reach and influence. Institutions such as UNICEF,

joined forces to launch the NCDI Poverty Network. We

the World Diabetes Foundation, St. Jude Children’s Re-

pledged to work together with lower-income countries

search Hospital, the Foundation for Cardiovascular Care

to address the unmet burden of severe, childhood-on-

in Africa, and the American Heart Association have since

set noncommunicable diseases (NCDs).

added their support and expertise to this movement.

As documented by the Lancet Commission on Re-

The strength, success, and sustainability of PEN-Plus

framing NCDs and Injuries for the Poorest Billion, our

interventions lie with country government leadership.

agenda had historically fallen into a huge gap between

At the same time, we recognize that systemic global

the global NCD and child health movements. As a re-

inertia, human resource constraints, and financing chal-

sult, the burden of these devastating diseases was still

lenges remain threats to meaningful progress toward

being carried disproportionately by the youngest and

care for children living with severe NCDs everywhere.

poorest of the world.

These threats are most acute for the poorest countries.

Our commitment is what we now call the PEN-Plus

This plan encapsulates the work that we, as nongov-

Partnership, both a rallying cry and a coordinated,

ernment actors within the NCDI Poverty Network,

multi-sector effort to support countries’ progress in en-

will do together over the next crucial three years to

suring high-quality, fully integrated, person-centered

address these threats and to meet the promise that

care for people living with severe, chronic NCDs.

is PEN-Plus. We invite you to join us in this transformative work.

Our shared efforts across the Network to bring PEN-Plus interventions to everyone who needs them have already

With gratitude and optimism,

made rapid progress. Since 2020, the number of countries implementing PEN-Plus has grown from 4 to 15. Already more than 11,000 people are enrolled in PEN-Plus clinics. For nearly all those patients, the clinics represent the first time in their young lives they have had access to sustained, expert care for their condition.

In 2022, all 47 member states of the World Health Organization’s African Region endorsed PEN-Plus as their official strategy for reaching people living with severe NCDs. As early funders—including The Leona M. and

DR. GENE BUKHMAN AND DR. ANA MOCUMBI

Co-Chairs, NCDI Poverty Network September 2024

PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

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Executive Summary

S

EVERE, CHRONIC NONCOMMUNICABLE DISEASES—particularly childhood-onset

conditions such as type 1 diabetes, sickle cell disease, and rheumatic and congenital heart disease—are largely absent from major global health funding priorities and policies. Yet collectively they represent a devastating burden of disease, particularly for the poorest regions of the world, where diagnosis and ongoing care are difficult to access. When untreated, these conditions are debilitating and deadly, burdening affected families with significant emotional and economic hardship.

The NCDI Poverty Network is leading the charge to change this reality. Over the next three years, we will work with an established coalition of partner organizations and national governments to integrate care for people living with severe NCDs into public health systems. We will accomplish this goal by scaling a package of clinical services called PEN-Plus (the Package of Essential Noncommunicable Disease Interventions – Plus).

Our focus on Equity, Quality, and Financing for PEN-Plus interventions will promote growing efficiencies in care made possible by scale. This focus will also catalyze new, sustainable sources of support for ongoing service delivery.

We are starting this next stage of our journey having already achieved significant progress. Fifteen countries are implementing PEN-Plus, with services now available to a combined catchment area of more than 25 million people in lower-income countries. We are poised to double that impact by 2028, drawing on the momentum made possible by our commitment to patient care, our hardwon experience, and the advocacy we see accelerating across sub-Saharan Africa and South Asia.

Rooted in clinical expertise, research, and community engagement, PEN-Plus is bringing hope to those doubly burdened by severe NCDs and extreme poverty.

We invite you to take action by joining us.

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PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

PEN-PLUS PRIORITIES AND TARGETS, 2025–2028

Equity Health equity for people living with severe noncommunicable diseases is the core premise underpinning PEN-Plus.

Quality Innovations aimed at solving resource challenges are a critical part of enabling the scaling up of PEN-Plus.

Financing

Key investments by NCDI Poverty Network partners can catalyze enduring support for PEN-Plus programs.

Ensure that PEN-Plus services are accessible to a combined catchment area of 51 million people living in low-income countries

Ensure that 100 percent of established PEN-Plus clinics exceed the minimum performance indicator thresholds for key patient care and operational processes

Unlock an estimated $40 million annually in support of PEN-Plus interventions across public sector, official development assistance, and philanthropic financing streams

PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025-2028

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Setting the Stage

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N RURAL SUB-SAHARAN AFRICA AND SOUTH ASIA, regions home to 90 percent of

the world’s poorest populations, most people living with severe, chronic NCDs (such as type 1 diabetes, sickle cell disease, and rheumatic and congenital heart disease) must travel long distances for many essential healthcare services. Ultimately, hundreds of thousands of people living with these life-threatening conditions—many of them children and adolescents—are left without options for affordable treatment.

As a result, one in two children with type 1 diabetes in

movements. Accordingly, global NCD and child health

rural sub-Saharan Africa dies before diagnosis,1 and

policies promoted interventions that many people will

in South Asia, people living with type 1 lose an aver-

need across their life course, such as vaccines, hyper-

age of 45.2 healthy years from their lifespan. Half of

tension drugs, education campaigns, and public poli-

the nearly one thousand babies born with sickle cell

cies that foster behavior modifications.

2

disease in Africa each day will not live to see their fifth

As an unintended consequence, conditions such as

birthday. And children with rheumatic heart disease

type 1 diabetes, sickle cell disease, and childhood heart

in low- and lower-middle-income countries have a

disease have become largely invisible on the global

greater than 70 percent chance of dying before the

stage, underfunded through public financing or pub-

age of 25.4

lic health systems. Vertical programs—many run by

3

PEN-Plus clinics around the world are a practical, sustainable solution to turning around these tragic and ultimately avoidable statistics.

How have these disparities persisted, often fly-

disease-specific organizations and accessible nearly

ing well below the radar of the global NCD and child

exclusively to urban populations—sought to fill this

health agendas?

gap. Yet the Lancet Commission on Reframing NCDs

As these global health movements gained mo-

and Injuries for the Poorest Billion (the NCDI Poverty

mentum in the 2010s, multilateral and bilateral suc-

Commission) found that, in the absence of integrated

cess metrics (often tied to funding) were intentionally

care delivery strategies, hundreds of thousands of

designed to reach the most people possible, with a fo-

the world’s children, adolescents, and young adults

cus on overall population health. This approach failed

living in lower-income rural areas would go with-

to acknowledge the priority of severe, but individually

out lifesaving care for severe conditions that almost

less common conditions when designing public health

always lead to premature death if left untreated.5

Did You Know?

6

Severe noncommunicable diseases were largely unaddressed in global health agendas until just a few years ago. The NCDI Poverty Network is shifting that reality, working alongside governments to leverage a decade of research and clinical innovation as a springboard for action.

PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

The Promise of PEN-Plus

UGANDA

PEN-Plus was born out of this context. In 2006, a group of clinicians began developing a new, integrated care-delivery model for people living with severe, childhood-onset NCDs at two public district hospitals in rural Rwanda, as part of a longterm collaboration between the Ministry of Health and Inshuti Mu Buzima (Partners In Health–Rwanda).

Their guiding thesis was that the most effective and sustainable way to reach all people living with severe NCDs would be to move beyond vertical, centralized, and nongovernmental-organization-led interventions.

Instead, healthcare leaders should identify a viable pathway for governments to provide these services through integration and decentralization of care within public health systems. The clinicians built the model as a complement to an earlier strategy: the WHO Package of Essential Noncommunicable (PEN) Disease Interventions. WHO PEN focuses on more common NCDs— such as hypertension, type 2 diabetes, and asthma—at

EIGHTEEN-YEAR-OLD FARIDA AGUTI (left), and her 22-year-old sister, Rukia Aumo, smile broadly outside the PEN-Plus clinic in Atutur, Uganda, where they receive care for sickle cell disease.

the health center and community levels.

The innovation of PEN-Plus was in the design. The clinicians trained mid-level healthcare providers to diagnose and treat a cluster of severe NCDs that shared

tations and confirmed initial diagnoses, and specialists

certain clinical cadences. This training proved especially

visited the clinics every month or two to provide ongo-

crucial in treating type 1 diabetes and childhood heart

ing mentorship, consult on more complex cases, and link

disease, for which too much or too little medication can

patients to referral hospitals for more acute specialty in-

mean the difference between life and death.

terventions, such as cardiac surgery.

The PEN-Plus approach also took advantage of shared space, workflow patterns, and training needs.

Poised for Scale

Providers—principally nurses and clinical officers—

The first PEN-Plus clinics offered a model for how

could be effectively trained in just three months. Soon

lower-income country health systems could feasibly,

only two or three of these advanced care professionals

safely, and effectively integrate care for patients with

were needed to staff each clinic, where they saw 15 to

severe NCDs into their existing operations. By 2017,

30 patients a day. Physicians supervised initial consul-

the Government of Rwanda had successfully scaled PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

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Setting the Stage

INDIA

district of Rwanda found that the ongoing annual operating costs of PEN-Plus were only $0.23 per capita, suggesting the model’s affordability even for resource-constrained governments.9 Taken together, these results led to pilot programs in Haiti, Malawi, and Liberia that validated the adaptability of the PEN-Plus model to different contexts.10 Based on these experiences, PEN-Plus served as a centerpiece of the Lancet NCDI Poverty Commission Report published in 2020, which presented detailed evidence of the urgent need for these types of services across all lower-income countries.11 Not content with leaving these findings to academia, the report authors joined with representatives of 15 lower-income countries to form the NCDI Poverty Network. This coalition of lower-income country governments and technical, policy, funding, and advocacy

INDIA’S FORAY INTO PEN-PLUS IMPLEMENTATION has begun with Chhattisgarh State in the central part of the country.

Sangwari, a not-for-profit organization focused on equity and better healthcare, provides care for people living with severe NCDs in the Surguja district of northern Chhattisgarh.

partners united in a single cause. The mandate of the Network is to support local leadership, financing infrastructure, and pathways to scale to ensure the PENPlus model reaches everyone, everywhere it is needed.

Achieving this goal is beyond the capacities of any single funder, government, or nongovernmental orga-

PEN-Plus clinics to each of its 42 district hospitals, with

nization. Rather, it demands a coordinated effort across

the original clinics serving as national training sites.

the value chain—and at local, national, and global lev-

Following the national scale-up in Rwanda, research studies confirmed high levels of feasibility and pene-

our collective expectations of what is possible.

tration of PEN-Plus implementation. Three years after

Over time the Network grew to include hundreds

the national-level training of nurses, all PEN-Plus clinics

of organizations, a coalition of unprecedented breadth

were staffed by at least one nurse with advanced train-

and depth working toward a shared goal: to ensure

ing. Overall, the clinics had a high availability of national

that the poorest people living with severe NCDs in

essential medicines for PEN-Plus conditions and a good

lower-income countries have access to quality care

adherence to PEN-Plus clinical protocols.

close to home. This commitment has coalesced into a

6

Research also provided robust evidence of the effec-

Network initiative we now call the PEN-Plus Partner-

tiveness of the PEN-Plus model in addressing patient

ship, both a rallying cry and a coordinated, multi-sec-

needs, increasing health workforce capacity, and re-

tor effort to support countries’ progress in ensuring

maining cost-effective even in low-resource settings.

high-quality, fully integrated, person-centered care

In addition, a microcosting study from the Burera

for people living with severe NCDs.

7,8

8

els—to shift entrenched systemic barriers and raise

PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

AT THE PEN-PLUS CLINIC In Lisungwi, Malawi, nurse Victor Kaphaso provides seven-year-old Kevini Jamu with medication and specialized care for sickle cell disease.

PEN-PLUS IN ACTION: MALAWI THE MALAWI MINISTRY of Public Health, in collaboration with Abwenzi Pa Za Umoyo (APZU), a Partners In Health sister nonprofit organization, launched the country’s first PEN-Plus clinic in the southern district of Neno. The clinic was designed to prioritize care for people living with severe, chronic NCDs based on the Malawi NCDI Poverty Commission’s 2018 findings.

Following that early success, the Ministry of Public Health and its implementing partners developed the country’s PENPlus operational plan in 2021, outlining a phased national

expansion to all district hospitals by 2026. The Salima and Karonga district hospitals were chosen for the initial rollout, with APZU facilitating a six-week training in Neno to equip the newer teams with practical expertise in managing severe NCDs. Each hospital assigned one clinical officer and one nurse for the advanced training and then launched a PENPlus clinic upon their completion of the program.

Malawi, which continues to be on track to fulfill its earlier promise, has since joined Rwanda in playing a major leadership role in the ongoing refinement of PEN-Plus.

PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

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Setting the Stage

Thanks to the Network’s efforts, in the past three

first International Conference on PEN-Plus in Africa,

years PEN-Plus has transformed from an effort run by

which convened representatives from 52 nations.

a single nongovernmental organization to a model en-

In 2022–23 alone, more than 400 additional

dorsed by all 47 member states of the WHO African

healthcare workers—including nurses and clinical

12

Region, with care being delivered in 15 countries.

officers—received PEN-Plus training and ongo-

UNICEF’s leadership has played a key role in seeding

ing mentorship. Even more dramatically, more than

initiation in Bangladesh and expansion within Malawi,

11,000 people with severe, chronic NCDs now re-

Mozambique, Nepal, and Zimbabwe.

ceive treatment in PEN-Plus clinics.

The WHO African Region has also assumed a

In partnership, national and global experts in the

major leadership role in rolling out technical sup-

type 1 diabetes, sickle cell disease, and childhood

port for member states to move toward PEN-Plus

heart disease communities are contributing their

That work received global interest in

combined efforts to PEN-Plus patient populations.

2024, when the WHO African Region hosted the

The Scottish Government has incorporated PEN-Plus

initiation.

13

into its global health strategy. And U.S. legislators are beginning to engage on this issue by including lan-

SIERRA LEONE

guage about the needs of people living with childhood-onset NCDs in their guidance to USAID. This swift progress has been driven forward and supported by shifting macro trends in global health capacity and investment. National government leadership and an increasing global focus on health-system-strengthening investments have raised the overall capacity of health systems in lower-income countries to address severe conditions. Many health systems can now provide appropriate referrals for acute episodes, have functioning laboratories and specialized equipment, and employ providers trained in the dosing and management of potentially toxic medications.

Severe NCDs are also broadly recognized as a growing and urgent global priority, opening space to highlight the gap in treatment access and to foster momentum to address that gap through a proven model

FATMATA FOFANAH, a six-year-old with congenital heart disease, lives in Kono, Sierra Leone. With support from the nearby PEN-Plus clinic, her symptoms have eased enough for her to be able to play with her friends again.

of care. It is a testament to the progress of decades of investment in broader NCD and childhood public health efforts that PEN-Plus is positioned to scale exponentially. The groundwork has now been laid for a monumental leap forward in access to care for children, adolescents, and adults living with severe NCDs.

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PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

PEN-PLUS CONNECTS THE DOTS THE PEN-PLUS PACKAGE OF CARE fills a major gap in the health system for people living with severe, chronic noncommunicable diseases in low-resource settings. In the absence of PEN-Plus, many people with these diseases remain undiagnosed, and when their condition reaches a dangerously acute stage, they struggle to find a higher level of care. Even if they manage to access care during an emergency, they lack the continuous followup care they will need throughout their lives.

With PEN-Plus connecting the dots across levels of care, entire healthcare systems in lower-income countries can

Referrals, training, mentorship

Health Center (WHO PEN)

provide lifesaving support to people with severe NCDs. Rural, community-based WHO PEN health centers can refer patients with conditions needing more complex care to PEN-Plus clinics at first-level hospitals, also known as district hospitals. There, with their advanced training, PENPlus providers can quickly recognize the need to send patients with acute cases to referral hospitals for higher levels of care, such as cardiac surgery. Patients who have received heart valve replacements, for example, can then access their followup anticoagulation treatment in the PEN-Plus clinic close to home.

Referrals, training, mentorship

First-Level Hospital (PEN-Plus) Referrals

Referral Hospital

Referrals

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Priorities and Targets 2025–2028

T

As more and more countries and institutions adopt the PENPlus model, the NCDI Poverty Network is committed to ensuring these services continue to address the needs of even the poorest populations.

HE RAPID EXPANSION OF PEN-PLUS and its adoption by all the countries in the World

Health Organization’s African Region are a testament to the growing demand for— and flexibility of—this model of care.14 Further expansion will require an increasing decentralization of program leadership, a higher level of external financing, and well-managed public financing mechanisms.

This shift also demands that we as member organiza-

possible. We work with our government partners to

tions of the NCDI Poverty Network focus our efforts to

ensure equity of services within populations, using a

ensure that PEN-Plus adoption maintains momentum,

person-centered approach to enable favorable out-

delivers quality care across healthcare systems, ele-

comes for the most vulnerable patients.

vates the power and leadership of people living with

Over the next three years, the Network will pro-

these conditions in PEN-Plus countries, and reaches

vide targeted support to healthcare workers and

even the least-resourced communities.

policymakers in the 15 countries with operational

Over the next three years, we will build on our

PEN-Plus clinics. This support will facilitate the path

collective achievements to date as a springboard for

for the countries to scale services to benefit even

action to reach new heights, focusing on three pri-

more patients. We will also provide technical sup-

orities to ensure the PEN-Plus promise is realized:

port to at least 11 new countries in the process of

Equity, Quality, and Financing.

planning for and initiating PEN-Plus services.

PRIORITY 1 STRATEGIES

Priority 1: Equity 2028 Global Target: Ensure that PEN-Plus services are accessible to a combined catch-

1a

Provide technical assistance and financial support to lower-income countries

ment area of 51 million people living in low-

In countries already implementing PEN-Plus—

er-income countries (2024 baseline: 25 million)

Bangladesh, Ethiopia, Haiti, India (Chhattisgarh State), Kenya, Liberia, Malawi, Mozambique, Nepal,

12

Equity is the driving force behind all we do, just as equity

Rwanda, Sierra Leone, Tanzania, Uganda, Zambia,

in health outcomes for people living with severe, chronic

and Zimbabwe—the NCDI Poverty Network will

NCDs across higher-income and lower-income coun-

accompany health sector leaders to address barri-

tries is the core premise underpinning PEN-Plus.

ers to scale and provide additional capacity-building

The NCDI Poverty Network channels and mobi-

and financing to facilitate progressive expansion of

lizes more resources toward countries and districts

PEN-Plus services. One area of focus across many

with the least funding, tailoring country partnerships

countries will be to identify new ways to leverage the

to accelerate sustainable care provision as quickly as

PEN-Plus platform to improve the entire continuum

PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

of care, from primary-level early case findings of se-

ZIMBABWE

vere NCDs, to rapid referrals to higher levels of care for needs such as cardiac surgery.

The Network will continue working with the NCDI Poverty Commissions of Afghanistan, Benin, Burkina Faso, Cambodia, Cameroon, the Democratic Republic of the Congo, Ghana, and Nigeria to build on their completed reports, to offer technical support, and to provide catalytic funding to initiate new PEN-Plus services. These commissions are cross-sector committees that identify health system gaps in care for people living with severe NCDs, lead the PEN-Plus planning process, and foster the political will needed to progressively integrate care for severe NCDs. In collaboration with WHO’s Regional Office for Africa, the Network will also help in-country leaders in Lesotho, Niger, and the Republic of the Congo to convene their own NCDI Poverty Commissions.

And, in coordination with UNICEF, the Network will support new NCDI Poverty Commissions in lower-income countries and states in South Asia.

1b

Build peer support networks within PEN-Plus communities

TAWONASHE MUGURA, an 11-year-old with both sickle cell disease and type 1 diabetes, receives his care at the PEN-Plus clinic at Masvingo General Hospital in southeastern Zimbabwe.

We will be driven by the expertise of disease-specific advocates living and working in

Working closely with local clinical teams, the NCDI Pov-

PEN-Plus countries to move toward developing

erty Network will cultivate hyperlocal patient leadership

a supportive community and collective power for

to increase psychosocial support, reduce stigma, and

PEN-Plus patients. This work has already started

build solidarity across the type 1 diabetes, sickle cell,

through the Voices for PEN-Plus, a group of ad-

and childhood heart disease communities. This grass-

vocates from PEN-Plus countries who are using

roots-level organizing is crucial for shifting narratives

their lived experience with severe NCDs and ad-

of power and resources from the ground up. To be ef-

vocacy expertise to foster connection and solidar-

fective, this work must be decentralized and responsive

ity among people with NCDs. In Zimbabwe, for

to a range of contexts while providing tangible value to

example, one of those advocates is collaborating

people living with severe NCDs and their families.15

with SolidarMed, a Swiss nongovernmental orgaPEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

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Priorities and Targets

nization, to grow the peer-support infrastructures

social support frameworks as they accompany gov-

within communities served by PEN-Plus clinics.

ernment partners through planning and implemen-

1c

Ensure access to care through robust social support

tation. We will also supplement these frameworks to alleviate additional financial burdens borne by people living with severe NCDs and their families.

Social determinants of health are well-doc-

Enabling Environment: In addition to aligning with

umented critical components of good health, espe-

each country’s priority frameworks, the Network’s Eq-

cially for people living with chronic disease. For many

uity Priority aligns with Sustainable Development Goal

PEN-Plus patients, especially those living in extreme

Target 3.4. This goal calls for a reduction by one-third of

poverty, the monthly provision of funds for food and

premature mortality from NCDs by 2030 through the

transportation can make the difference between sick-

prevention and treatment of NCDs and the promotion

ness and health. In the pursuit of health equity, these

of mental health and well-being, as measured against a

are not nice-to-haves but must-haves.

2025 baseline. The equity focus also corresponds with

NCDI Poverty Network members will work to ensure PEN-Plus clinics are integrated into existing

UGANDA

the meaningful engagement framework established by the WHO Global Coordination Mechanism.16 The Network follows a Four-Phase Theory of Change, a well-defined sequence of support to accompany country governments in implementing PEN-Plus.

This process builds buy-in across critical stakeholders, allows for country-specific customization of PEN-Plus, and facilitates the flow of technical advice, training, and supplemental resources to provide patient care.

The Network’s collective relationships and spheres of influence have fueled the geographic expansion of PEN-Plus, and conversations with key decision-makers in expansion countries are already underway.

Priority 2: Quality 2028 Global Target: Ensure that 100 percent of established PEN-Plus clinics exceed the minimum performance indicator thresholds for key ATEGEI SAFIA poses for a portrait in front of her home with 14-year-old Emong Abdul Shakur and 11-year-old Anyait Stella, both of whom receive treatment for sickle cell disease at the PEN-Plus clinic in Atutur, Uganda.

patient care and operational processes (2024 baseline: currently being aggregated) Multiple countries and stakeholders are now expanding components of PEN-Plus programming na-

14

PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

PROVEN PATHWAY FOR PEN-PLUS ADAPTATION AND SCALE

1 Phase 1: Situation Analysis and Priority Setting

Phase 2: Delivery Model Design

2

3 Phase 3: Initial Implementation

FOLLOWING ITS FOUR-PHASE THEORY OF CHANGE, the NCDI Poverty Network approaches PEN-Plus implementation by investing significant time in building the relationships, policy infrastructures, and local expertise needed to ensure PEN-Plus interventions are wholly owned by and integrated within each partner country’s public health system.

These strategies have proved to be adaptive across the 23 countries already engaged in PEN-Plus planning and imple-

4 Phase 4: National Scale-Up

mentation. Multiple research studies have validated the framework, and the global type 1 diabetes, sickle cell disease, and childhood heart disease communities support these services, which are in demand by ministries of health.

In addition, philanthropy has proved to be a powerful tool in jumpstarting work on the ground. Once this work has begun, governments become active partners in integrating services for long-term sustainability.

tionally. At the same time, challenges are becoming

made possible by the expansion of PEN-Plus inter-

apparent in supply chains, data systems, and human

ventions to date.

resources. There is now an increasing need for innovations that can solve these problems at scale.

PRIORITY #2 STRATEGIES

The Network will play a critical role in both addressing persistent operational roadblocks and creating global standards for incentives, training, and quality of care for people living with severe NCDs.

2a

Coordinate nationally and regionally to achieve key performance indicators

These cross-cutting projects will pave the way for

Accurate and timely data are essential for both clin-

countries to take advantage of economies of scale

ical management and operational decision-making.

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15

Priorities and Targets

They are also the basis of research insights and pub-

also work with partners to establish routine data sys-

lic health surveillance, which can influence resource

tems for PEN-Plus, including national health infor-

investments and policy.

mation systems and regional data systems through

The NCDI Poverty Network has developed a standard list of key performance indicators for tracking

the WHO African Region and the Africa CDC.

rics.17 The 15 countries implementing PEN-Plus use

Analyze and tackle supply 2b chain challenges and systemic market failures affecting essential medicines and supplies

standardized data collection tools and reporting forms

Regulatory challenges and dysfunctional international

to track these indicators.

markets—which raise prices and cause stockouts—

clinical and operational progress in PEN-Plus clinics, including enrollment and cohort sizes, age and gender breakdowns, and clinical process and outcomes met-

Over the next three years, the Network will con-

remain systemic barriers to care for many people liv-

tinue to make key performance indicators and tools

ing with severe NCDs. Essential medicines and sup-

accessible to key decision-makers. The Network will

plies for treating these conditions, such as insulin and hydroxyurea, have been left out of the major global

NEPAL

procurement and dissemination mechanisms.

Nongovernment actors are well-positioned to address these structural challenges. In the short term, the NCDI Poverty Network will facilitate meeting immediate needs for medications and supplies, working with partners and suppliers to address both stockouts and sourcing challenges.

In the medium term, Network members will work directly with governments to support national-level solutions. These solutions include the inclusion of medications and supplies for severe NCDs within essential medicines and diagnostics lists, mechanisms to project needed quantities, management strategies that support uninterrupted distribution to health facilities, and policies that eliminate the need for out-of-pocket payments.

Finally, to improve the long-term, underlying global structures that cause downstream issues for countries

A PEN-PLUS WORKSHOP IN KATHMANDU in June 2024 brought representatives from all eight countries of UNICEF’s Regional Office for South Asia together with ministry officials, technical partners, and advocates to map out strategies for integrating care for severe NCDs into national health strategies.

and clinics, the Network will cultivate partnerships with organizations that bring technical expertise in the supply chain and market access space.

Throughout this work, we will seek to use the growing patient volumes across PEN-Plus countries as a leverage point to expand and accelerate the dis-

16

PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

REPUBLIC OF THE CONGO

DEMOCRATIC REPUBLIC OF THE CONGO

National Scale Subnational Scale Advanced Planning Initiation

PEN-PLUS EXPANSION This map illustrates countries’ current level of engagement with PEN-Plus strategies through the NCDI Poverty Network. Between 2025 and 2028, the Network will collaborate with these countries and dozens of partner organizations to expand PEN-Plus services and reach our collective global targets.

REPUBLIC OF THE CONGO

DEMOCRATIC REPUBLIC OF THE CONGO

semination of the most effective medicines and tech-

NCDI Poverty Network’s regional advisors provide

nologies—such as analogue insulin—to the least-

ongoing support and accountability for PEN-Plus

resourced settings.

clinical teams as operations unfold.

2c

Provide ongoing clinical training, mentorship, and continuing medical education

The Network also runs working groups organized around expertise on specific diseases, including type 1 diabetes, sickle cell disease, and cardiac conditions. These groups bring together

While countries establish their own training capabili-

clinicians—from in-country specialists and trainers

ties as part of the initiation of PEN-Plus services, the

to frontline providers and implementers—to draft, PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

17

Priorities and Targets

RWANDA

and clinics, and to provide incentives and recognize excellence in PEN-Plus care.

2d

Reveal new insights through research Research is essential to understanding

and validating the PEN-Plus model, including its quality, efficiency, and acceptability across various settings. The NCDI Poverty Network supports research across four primary domains: • Scoping reviews to understand the current state of service delivery for severe NCDs in low-resource settings; • Qualitative interviews with people living with severe NCDs in low-resource settings to betMASTER TRAINER Naasson Nduwamungu teaches Laetitia Twizerimana to use point-of-care echocardiography in Rwinkwavu, Rwanda.

ter understand their needs and barriers to care; • Feasibility studies on the introduction of new care modalities, such as the first randomized controlled trial of continuous glucose monitoring in a rural area of a low-income country;18 and • Longitudinal studies of PEN-Plus services to

refine, and validate training and protocols. These

document their efficacy and acceptability to

expert groups also identify gaps in PEN-Plus pro-

patients and providers over time.

grammatic standards, discuss potential solutions to implementation challenges and advocacy priorities,

Enabling Environment: The NCDI Poverty

foster cross-country learning, and share best prac-

Network coordinates with PEN-Plus countries to

tices within each clinical discipline.

ensure their data management systems can moni-

These touchpoints provide channels for the shar-

tor care expansion and fidelity to quality standards.

ing of decades of accumulated knowledge of these

The Network encourages the integration of PEN-

conditions. The touchpoints also nurture a shared

Plus indicators into national health information sys-

culture of person-centered care that is responsive

tems, supports WHO initiatives for standardized

to the lived experience of people with severe NCDs.

NCD data reporting, and aligns with the efforts of

Over the next three years, the Network will build

the Africa CDC to establish stronger regional sur-

on this relationship-driven set of supports to aid

18

veillance mechanisms for NCDs.

countries in developing more formal mechanisms for

Rwanda and Malawi, both of which operate PEN-

credentialing and certification for individual clinicians

Plus on a national scale, are key partners in identi-

PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

fying and guiding next-level inputs in monitoring, evaluation, procurement, training, and credentialing to strengthen national PEN-Plus programs.

3b

Cultivate new opportunities for private philanthropy The expansion of PEN-Plus is an intersec-

In addition, the type 1 diabetes, sickle cell dis-

tional effort that touches on philanthropic priorities

ease, and childhood heart disease communities

across a variety of spectrums, offering room for lead-

have recognized supply chain challenges and de-

ership in projects that save lives and streamline sys-

veloped robust policy platforms around access to

tems. The PEN-Plus model can also be an effective

medicines and supplies.

tool for moving health systems progressively toward Universal Health Coverage. Catalytic philanthropic

Priority 3: Financing

investments can unlock new systemic efficiencies,

2028 Global Target: Unlock an estimated

deliver immediate relief to people living with severe

$40 million annually in support of PEN-Plus

provide proof of concept in specific locations, and NCDs in PEN-Plus countries. Over the next three

interventions across public sector, official development assistance, and philanthropic financing streams (2024 baseline: approximately $20 million annually)

MOZAMBIQUE

By building political will where it is needed most, the NCDI Poverty Network’s nongovernment actors can catalyze direct investments in treatment for people living with severe NCDs and facilitate pathways toward full financing of care delivery through country health budgets and official development assistance.

PRIORITY #3 STRATEGIES

3a

Open new streams of official development aid through coordinated advocacy efforts

The NCDI Poverty Network members will continue to encourage the direct funding of PEN-Plus initiatives and inputs from the U.S. Government through legislative advocacy. We will also engage with bilateral development agencies to seek an increase in the overall volume of official development assis-

ELISA EDSON, an eight-year-old living with type 1 diabetes, awaits her appointment at the PEN-Plus clinic in Nhamatanda, Mozambique.

tance allocated to caring for people living with severe NCDs in lower-income countries.

PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

19

Priorities and Targets

years, the Network will collaborate with the philan-

markets where opportunities exist to influence offi-

thropic community to identify areas of mutual inter-

cial development assistance, budget allocations, and

est and high impact that will advance us toward the

development bank initiatives. Through this organiz-

targets outlined in this plan.

ing work, advocates will be positioned to increase

Provide support to PEN-Plus 3c countries in facilitating favorable national-level policies and resource allocations Drawing on the strength of local disease-specific

the visibility of the needs of people living with severe NCDs and their families as local and national issues.

3d

Focus a global spotlight on the needs of the world’s most vulnerable people

advocacy organizations operating in PEN-Plus coun-

NCDI Poverty Network members will leverage their

tries, the NCDI Poverty Network will establish an

own global platforms and expertise to keep the needs

organizing infrastructure and policy agenda in key

of people living with severe NCDs front and center in global dialogues. This issue is relevant to policymakers focused on NCDs, child health, climate and

SIERRA LEONE

vulnerable populations, gender equality, and health system resilience. We will collectively and individually make these connections explicit through bilateral conversations to expand the Network—as well as public dialogue through media and convenings— to grow the global movement, political will, and resources needed to support countries’ integration of care for people living with severe NCDs. Enabling Environment: While post-COVID, inflationary macroeconomic trends pose threats to major public sector funding streams, the international development field has demonstrated a willingness to embrace and finance increasingly complex development challenges, especially in the healthcare sector.

Alongside this trend comes a demand for solutions that tackle complex gaps in care through comprehensive, integrated approaches that have credible

EMMANUEL JOSEPH FOFANAH, a clinical officer at the PEN-Plus clinic in Koidu, Sierra Leone, has undertaken comprehensive training in diagnosing and treating severe noncommunicable diseases.

pathways to scale and realize systemic efficiencies across health conditions.

This recognition of the power of integration has been mirrored in philanthropic trends, which have shown an increasing appetite for big bets, long investment horizons, and a desire to tackle the most

20

PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

Qualitative Targets

SETTING THE STANDARD

[Sidebar to come]

THE NCDI POVERTY NETWORK maintains documented clinical tools and programmatic standards that define the PEN-Plus model. These documents are foundational in PEN-Plus program planning and ongoing quality assessment.

They outline the diagnostic, treatment, and patient-support services critical to achieving positive outcomes for people living with severe, chronic NCDs. These standards also inform areas for individual clinics and healthcare operations leaders to identify and address gaps in care, such as essential medications and equipment, facility capacity, and care provider competencies. The Network continuously updates these standards and tools based on partner experiences and emerging best practices. The Network also offers the updated versions on its website.

rds Checklist

1.2 Programmatic Standa

Tools For Cardiac Disease

a given PEN-Plus to determine whether used as a quick guide This checklist can be for early action. and to help identify areas programmatic standards

Cross Cutting / Health

clinic is meeting the

Systems

integrated chronavailable on-site to provide t providers are consistently c Nonspecialis clinical officers, or medical ic care for severe NCDs rovider refers to nurses, (A nonspecialist—or mid-level—p the context.) officers, depending on and the clinic’s volume needs adequate to meet both of providers trained is c Numberschedules staffing and are consistently are dedicated to the clinic through the health care providers to all hospital staff rotating c The same to week (as opposed staffing the clinic week clinic) and training in the diagnosis across have received thorough to care for those patients c Clinic staff members severe, chronic NCDs management of the prioritized the lifespan

Case finding procedures

from the inpatient setting

for people with severe,

linkage discharge c There istoabeclear PEN-Plus clinic prior to enrolled directly in the

Signs or symptoms of heart failure?

Check medical records for previous echo

c A dedicated and days

Notes

days when the PEN-Plus

Blood pressure ≥180/110 mmHg or history of hypertension

support lab testing and treatment

YES

YES

Loud murmur

Rheumatic mitral stenosis

Hypertensive heart disease

Other valvular or congenital

NO

Notes

Dilated right ventricle

held on all PEN-Plus clinic

YES

Isolated right heart failure

YES

Pericardial disease

NO

Heart failure unlikely (normal echo)

Notes

cost either for free or at minimal who cannot pay

Consider other diagnoses

No clear explanation

Is the client missing

1) Furosemide and/or HCTZ if hypervolemic 2) BP control: goal sBP <140 mmHg

Goal dose 25 mg BID 25-50 mg BID 50-100 mg BID 10 mg od

Heart rate <55, low doses in pregnancy (should not use atenolol in pregnancy)

50 mg TID 20-40 mg od 20 mg BID 10 mg od

Cr >2.3, sBP <100, pregnancy

Angiotensin receptor blockers: candesartan Angiotensin receptor blockers: valsartan

7

8 mg OD 20-40 mg BID

32 mg OD 160 mg BID

lipohypertrophy

or infection?

Any changes

Are these changes

Patterns If AM glucose > 10 mmol/L (180 mg/dL) Pre-Lunch glucose > 10 mmol/L (180 mg/dL) Pre-Dinner glucose > 10 mmol/L (180 mg/dL) Bedtime glucose > 10 mmol/L (180 mg/dL) Overnight glucose > 10 mmol/L (180 mg/dL)

dose is changed,

NO

NO

in diet or activity?

NO/NOT MODIFIABLE

When ever insulin

YES

modifiable?

explain to the

patient why the

YES

YES

Ask why? Work with client on plan to increase frequency Assess for and address any food insecurity Give new insulin Educate about storage

of insulin

Educate on rotating injection sites

Educate on proper administration of insulin

Educate on improving diet and physical activity Address illness, consider temporary increase in insulin

Increase PM

NPH (Lente) insulin 10-20% Increase AM Regular (Actrapid) insulin 10-20% Add regular insulin at lunch (start with same dose increase AM as PM) or NPH (Lente) insulin 10-20% Increase PM Regular (Actrapid) 10-20% If no symptoms of overnight hypoglycem ia, increase PM (Lente) 10-20% NPH

dose was changed,

so that they understand

what the glucose

numbers mean

Cr >2.3, sBP <100, pregnancy

Spironolactone

12.5 mg daily

25 mg daily

Cr >2.3 or K >5.5, pregnancy

25 mg TID

75 mg TID

sBP <100 mmHg

40 mg TID

sBP <100 mmHg or headache

10 mg TID

YES

YES

NO

sites. Is there

Has the client been sick recently? changes? (ie Any recent hormonal menstruation)

Contraindication

Hydralazine Isosorbide dinitrate (ISDN)

Counsel on hypoglycem ia prevention Assess for and address any food insecurity

YES

pattern

Ask client to demonstrat e how they draw Is it correct? Can up and administer they differentiate insulin.

If they mix insulin, between both of their insulins? are they mixing means insulin not mixed correctly) correctly? (both vials cloudy

1) Refer for pericardiocentesis if tamponade (low BP, tachycardic, IVC dilated) 2) Treat the cause (TB, HIV, cancer)

12.5 mg TID 5 mg od 2.5 mg BID 2.5 mg od

concerns

Skip to step 3

Decrease PM NPH (Lente) insulin 10-20% Decrease AM Regular (Actrapid) insulin 10-20% Decrease lunchtime Regular (Actrapid) or AM NPH (Lente) Decrease PM Regular (Actrapid) 10-20% 10-20% Decrease PM NPH (Lente) 10-20%

or skipping injections?

NO

*Note that combined diagnoses are possible and can be made in consultation with an expert *Family planning should be considered in all cases of heart failure affecting women of childbearing age

12.5 mg od 6.25 mg BID 12.5 mg BID 2.5 mg od

occuring in a

NO

Assess injections

1) Furosemide 2) Treat lung disease (asthma/COPD, TB) if present

Starting dose

and hypoglycemia

How is the client storing insulin? went bad? (highs Is there a chance mostly at the to heat) end of the month, the insulin or exposure

1) Cardiologist consultation 2) Furosemide if hypervolemic 3) BP control 4) Consider penicillin for secondary prophylaxis if mitral valve thickening and calcification is present

ACE inhibitor: captopril ACE inhibitor: lisinopril ACE inhibitor: enalapril ACE inhibitor: ramipril

Address their

ia

present

3a. Evaluate most recent history for patterns 2-4 weeks of logbook or glucometer of hyperglycem ia 3b. Ask client about symptoms of hyperglycem weeks and typical ia in the past times of day they 2-4 (i.e. nocturia) occur, including overnight

1) Furosemide if hypervolemic 2) Beta blocker (goal HR 60-80 bpm) 3) Penicillin (secondary prophylaxis) 4) Cardiologist consultation

Beta-blocker: atenolol Beta-blocker: carvedilol Beta-blocker: metoprolol CR Beta-blocker: bisoprolol

YES

No Hypoglycem

2c. If hypoglycem ia is infrequent, can happened? (ie skipped a meal, client explain why it had extra activity) Pattern AM glucose < 4.4 mmol/L (80 mg/dL) Pre-Lunch glucose < 4.4 mmol/L (80 mg/dL) Pre-Dinner glucose < 4.4 mmol/L (80 mg/dL) Bedtime glucose <?4.4 mmol/L (80 mg/dL) Overnight glucose < 5.6 mmol/L (100 mg/dL)

1) Furosemide if hypervolemic 2) ACEi (titrate to goal dose) 3) Beta-blocker (titrate to goal dose) 4) if max ACEi and BP not low: add spironolactone 5) Investigate & treat causes of cardiomyopathy 6) If peripartum: add ASA 81 mg od

Cardiomyopathy medications

Hypoglycemia

Readings

GLUCOMETER READINGS

NO

NO

Pericardial effusion

conditions have sufficient time for

are receiving all those insurance coverage); c All patientswho can pay (with or without for those fees without out-of-pocket are receiving services

YES

NO

clinician from primary care high-volume severe or complex NCDs tension.) s and provide apto track upcoming appointment Optimal: There is a mechanism least once weekly pointment reminders at

Social work & social

ASA 100mg daily Penicillin V 250mg twice daily or Penicillin IM inj Furosemide (contraindication: Cr >2.3) Hydrochlorothiazide (HCTZ) (contraindication: Cr >2.3) Amlodipine: 2.5-10 mg po od (goal BP <140/90 mmHg) Nifedipine: 20-80 mg po od (goal BP <140/90 mmHg)

e Glucometer

BASED ON HOME

1. Does the client have any concerns glucose values or patterns with they would like their blood to talk about?

NO

are scheduled to separate clinical c Clinic days (This indicates a need time for appointments. conditions, such as hyper-

c

Cardiomyopathy

Mitral valve abnormality (2/3) - Thick / calcified mitral leaflets - Elbow shaped anterior leaflet - Fixed posterior leaflet

and reclinic is held, and all staff of the week.)

such that severe or complex

YES

s Based On Hom

2a. Evaluate most recent history for patterns 2-4 weeks of logbook or glucometer of hypoglycem ia.

2b. Ask client about symptoms of hypoglycem weeks and typical ia in the past time of day they 2-4 convulsions, occur, including eating at night, overnight (i.e night sweats)

Address any hypoglycemia, even if infrequent, prior to addressing hyperglycemia

NO NO

chronic

designated be every day c There areare days. (Note: This may available during those sources

Treat as cardiomyopathy & refer for echo

NO

YES

all ages, with conditions is open to patients of often into the PEN-Plus program that the PEN-Plus conditions c Enrollment guiding eligibility, noting diagnosis and care in the PEN-Plus package and young adults, necessitating occur in children, adolescents, across the lifespan a working and pediatric OPD) have to the clinics (such as adult NCDs and can refer patients c Staff in outpatient and symptoms of severe signs the of care to knowledge workup and enrollment PEN-Plus clinic for diagnostic where appropriate, for severe NCDs and, programs and outreach includes education such as through school c Communityand linkage to PEN-Plus care, screening community health workers the clinic to be consistent space enables

Follow protocol according to diagnosis

NO

Ultrasound available?

Reduced left ventricular systolic function

NCDs

Appointment structure

Non-cardiomyopathy medications: !"# $ %&'()"*+",&-.+/*0()%&-)"#12/

YES

s

st Insulin Dose

CHART OF INSULI N ADJUSTMENT

PROTOCOL FOR HEART FAILURE DIAGNOSIS AND MANAGEMENT

Notes

Staffing

Tools For Diabete

3.3 How To Adju

2.1 Protocol For Heart Failure

20

15

persistent global issues through smart solutions and

munity of practice. The Network’s decentralized,

engaged partnerships.

comprehensive approach to addressing the needs

With its reach currently spanning 23 countries,

of people living with severe NCDs offers multiple

the NCDI Poverty Network represents multiple av-

entry points for international partners to engage

enues to seed, grow, and support PEN-Plus inter-

new resources to meet compelling needs while re-

ventions while accruing significant efficiencies in

specting each participating country’s ownership

sharing lessons learned and building a global com-

and accountability.

PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

21

Join Us

N

OTHING CHANGES IF NOTHING CHANGES. In joining their respective strengths, the global partners of the NCDI Poverty Network have already made significant progress in solving one of the world’s starkest health inequities. We invite you to join us in this ambitious work. The PENPlus model represents both an opportunity to dig deep into issues that matter to your mission and an outsized impact as part of the joint work of Network members.

Clinical experts bring their deep knowledge

meet minimum viable standards for human health

of specific diseases—such as type 1 diabetes,

and thriving. These policymakers are critical to

sickle cell disease, and rheumatic and congenital

ensuring these decisions address the needs of

heart disease—to refine clinical protocols, iden-

people living with severe NCDs.

tify referral pathways, and train and mentor lower-level providers.

severe NCDs in PEN-Plus countries to motivate,

Nongovernmental organizations—especially

inspire, and raise the bar for all stakeholders. In

those that serve as PEN-Plus implementing part-

telling their stories, they provide powerful re-

ners—are critical players in the expansion of PEN-

minders of the costs of inaction to people living

Plus. They bring operational prowess and creative

with severe NCDs, their families, and society.

thinking about how to integrate new clinical capaci-

Philanthropists provide catalytic capital to

ties into existing public health systems. Their place-

a variety of stakeholders to fund innovative ap-

based expertise and network of in-country relation-

proaches to care, strengthen local institutions

ships facilitate on-the-ground changes in care and

critical in care delivery, and meet near-term

holistic support for patients and their families.

humanitarian needs. Their networks and influ-

Academic institutions provide the evidence base critical to ensuring quality and action. Care de-

ence are valuable assets in change management across stakeholders.

livery for people living with severe, chronic NCDs in

Industry shapes and is shaped by markets.

low-resource settings has never been tackled at this

Pharmaceutical and medical-device companies

scale. Research is essential for understanding and

produce essential medicines and supplies. In col-

validating the impact of PEN-Plus and related inter-

laboration with pooled purchasing mechanisms

ventions in clinical, economic, and operational terms.

and governments, they also have a critical role to

Global policymakers set the standard for de-

play in reshaping markets to better work for the

termining where global resources should focus to

Contact Us 22

Advocates share their lived experiences with

poorest countries and populations.

Explore how you can leverage your expertise and resources as part of the NCDI Poverty Network: Rachel Gasana, Senior Director of Advancement, rgasana@bwh.harvard.edu

PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

NCDI POVERTY NETWORK members gather on the photo stage at the first International Conference on PEN-Plus in Africa, hosted by the World Health Organization Regional Office for Africa in Dar es Salaam, Tanzania, in April 2024.

A Truly Global Network, Working to Expand PEN-Plus The NCDI Poverty Network collaborates with and coordinates among influential organizations making significant contributions to advancing PEN-Plus around the world. Major partners include: Africa CDC

Mathiwos Wondu – YeEthiopia Cancer Society (Ethiopia)

African Society for Pediatric and Adolescent

Mozambique Institute for Health Education and Research (Mozambique)

Endocrinology American Heart Association American Society of Hematology Beyond Type 1 Breakthrough T1D Centre for Infectious Diseases Research in Zambia Chaupal Gramin Vikas Prashikshan Evam Shodh Sansthan (Chhattisgarh State, India) Clinton Health Access Initiative Doctors with Africa CUAMM East Africa Diabetes Study Group Foundation for Cardiovascular Care in Africa Global ARCH Global Sickle Cell Disease Network Harvard Medical School (USA) The Leona M. and Harry B. Helmsley Charitable Trust ICDDR,B (Bangladesh) International Pediatric Association International Society for Pediatric and Adolescent Diabetes Kathmandu Institute of Child Health (Nepal) Mass General Brigham (USA)

National Institute for Medical Research (Tanzania) Non-Communicable Diseases Alliance Kenya Norwegian Agency for Development Cooperation Partners In Health REDAC Network–Sickle Cell Disease Research Network Africa St. Jude Children’s Research Hospital (USA) Sangwari (Chhattisgarh State, India) The Scottish Government Sickle Africa Data Coordinating Center Sickle Cell Aid Foundation (Nigeria) Sickle in Africa Consortium SolidarMed (Zimbabwe) The Sonia Nabeta Foundation Uganda Initiative for Integrated Management of Non-Communicable Diseases UNICEF Universidade Eduardo Mondlane (Mozambique) World Diabetes Foundation World Health Organization World Health Organization Regional Office for Africa

PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

23

About the NCDI Poverty Network The NCDI Poverty Network works to bring lifesaving care to children, adolescents, and young adults doubly burdened with chronic noncommunicable diseases and extreme poverty. The Network represents a coalition of technical, policy, funding, and advocacy partners collaborating with governments to solve one of the world’s starkest inequities. Each organization brings its expertise to different aspects of the systemic change needed to ensure that people living with severe NCDs can access care close to home.

The Network directly oversees clinical care, capacity-building, and research to advance PEN-Plus through two co-secretariats: the Center for Integration Science in Global Health Equity at Brigham and Women’s Hospital in Boston, Massachusetts, USA, and Universidade Eduardo Mondlane in Maputo, Mozambique.

The Network also coordinates investments in PEN-Plus interventions made independently by partner organizations from around the world. This coordination is managed both formally, through memoranda of understanding and other partnership agreements, and informally, through working groups, technical assistance, and other communication mechanisms. Resources flowing through these multiple organizations, whether financial or in-kind, leverage the infrastructure of public health systems in PEN-Plus countries to move the world collectively toward universal access to care for people living with severe NCDs. A steering committee governs the Network, providing oversight for its strategy, structure and composition, activities, and partnerships. The committee members represent decades of expertise in management, research, clinical operations, and lived experience with severe, childhood-onset NCDs.

Steering Committee Members Gene Bukhman, MD, PhD (Co-Chair) Center for Integration Science in Global Health Equity, Brigham and Women’s Hospital, and Harvard Medical School, USA Ana Olga Mocumbi, MD, PhD, FESC (Co-Chair) Division of Noncommunicable Diseases, Instituto Nacional de Saude, and Universidade Eduardo Mondlane, Mozambique Salmane Ariyoh Amidou, MD, MPH, PhD Ministry of Health, Benin Mary Amuyunzu-Nyamongo, PhD African Institute for Health and Development, Kenya Moses Echodu Uganda Child Cancer Foundation and Voices for PEN-Plus, Uganda Anu Gomanju, MA, MPH Kathmandu Institute of Child Health and Voices for PEN-Plus, Nepal Yogesh Jain, MD Sangwari, Chhattisgarh, India

24

PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

Lucy Johnbosco, MA Diabetes Consciousness for Community and Voices for PEN-Plus, Tanzania Biraj Karmacharya, MBBS, MSc, PhD Dhulikhel Hospital and Kathmandu University School of Medical Sciences, Nepal Aimée Lulebo, MPH, PhD University of Kinshasa School of Public Health, Democratic Republic of the Congo Julie Makani, MD, PhD, FRCP Muhimbili University of Health and Allied Sciences, Tanzania Jones Masiye, MD, MPH East, Central and Southern Africa Health Community, Tanzania Eunice Owino Sickle Cell Uhuru Trust and Voices for PEN-Plus, Kenya Santigie Sesay, MD Ministry of Health and Sanitation, Sierra Leone Alfred Edwin Yawson, MD, FWACP, FGCP University of Ghana Medical School, Ghana

ANNA MAZIVA, 74, shares a lighthearted moment with her grandchildren at her homestead in Masvingo, Zimbabwe. Maziva receives treatment at the nearby PEN-Plus clinic for her hypertensive heart disease.

Endnotes 1. Gregory G, Robinson TIG, Linklater SE, et al.

Global incidence, prevalence, and mortality of type 1 diabetes in 2021 with projection to 2040: a modelling study. Lancet Diabetes Endocrinol 2022;10(10):741–760.

8. Tapela N, Habineza H, Anoke S, et al. Diabetes in rural Rwanda: high retention and positive outcomes after 24 months of follow-up in the setting of chronic care integration. Int J Diabetes Clin Res 2016;3:1–6.

2. Breakthrough T1D. Type 1 Diabetes Index. (https:// t1dindex.shinyapps.io/dashboard)

9. Eberly LA, Rusangwa C, Ng’ang’a L, et al. Cost of integrated chronic care for severe non-communicable diseases at district hospitals in rural Rwanda. BMJ Glob Health 2019;4(3):e001449.

3. Modell B and Darlison M. Global epidemiology of haemoglobin disorders and derived service indicators. Bull World Health Organ 2008;86(6): 480–487.

4. Hewitson J and Zilla P. Children’s heart disease in sub-Saharan Africa. SA Heart J 2010;7(1):18–29.

5. Bukhman G, Mocumbi AO, Atun R, et al. The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion.

Lancet 2020;396(10256):991–1044.

6. Niyonsenga SP, Park PH, Ngoga G, et al. Implementation outcomes of national decentralization of integrated outpatient services for severe non-communicable diseases to district hospitals in Rwanda. Trop Med Int Health 2021;26(8): 953–61.

7. Eberly LA, Rusingiza E, Park PH, et al. 10-Year Heart Failure Outcomes From Nurse-Driven Clinics in Rural Sub-Saharan Africa. J Am Coll Cardiol 2019;73(8):977–80.

10. Ruderman T, Chibwe E, Boudreaux C, et al.

Training mid-level providers to treat severe non-communicable diseases in Neno, Malawi through PEN-Plus strategies. Ann Glob Health 2022;88:69.

11. Gupta N, Mocumbi AO, Arwal S, et al. Prioritizing Health-Sector Interventions for Noncommunicable Diseases and Injuries in Low- and Lower-Middle Income Countries: National NCDI Poverty Commissions. Global Heal Sci Pract 2021;9:3:1–14.

12. World Health Organization. PEN-Plus: A regional strategy to address severe noncommunicable diseases at first-level referral health facilities.

AFR/RC72/4. WHO Regional Office for Africa.

Brazzaville. 2022.

13. Moeti M, Mocumbi AO, Bukhman G. Why there is new hope for the care of chronic diseases in Africa. BMJ 2023;383:2382.

14. Boudreaux C, Barango P, Adler A, et al.

Addressing Severe Chronic NCDs Across Africa: Measuring Demand for the Package of Essential Noncommunicable Disease Interventions-Plus (PEN-Plus). Health Policy Plann 2022;37:452–460.

15. World Health Organization. Framework on integrated, people-centred health services. Report by the Secretariat. 2016.

16. World Health Organization. WHO framework for meaningful engagement of people living with noncommunicable diseases, and mental health and neurological conditions. 2023.

17. Adler AJ, Wroe E, Atzori A, et al. 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. BMJ Open 2024; 14:e074182.

18. Gomber A, Valeta F, Coates MM, et al. Feasibility of continuous glucose monitoring in patients with type 1 diabetes at two district hospitals in Neno, Malawi: a randomised controlled trial. BMJ Open 2024;14:e075554.

Photo Credits © Michael Duff/WHO (inside front cover and pp. 10 and 20); © Badru Katumba/WHO (pp. 1, 7, and 14); Neil Gupta (p. 8); Karin Schermbrucker/ Slingshot Media for Partners In Health (p. 9); © Tafadzwa Ufumeli/WHO (p. 13 and inside back cover); courtesy of UNICEF (p. 16); courtesy of Partners In Health (p. 18); © Ivan Simone Congolo/WHO (p. 19); courtesy of WHO (p. 23)

An Expanded Strategic Plan Visit the online version of the PEN-Plus Partnership Strategic Plan to gain access to a range of appendices and updated material, including photo captions and credits for the front and back covers.

PEN-PLUS PARTNERSHIP STRATEGIC PLAN | 2025–2028

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NCDI POVERTY NETWORK CO-SECRETARIATS Center for Integration Science Universidade Eduardo Mondlane in Global Health Equity Maputo, Mozambique Brigham and Women’s Hospital Boston, Massachusetts, USA www.ncdipoverty.org