PEN-PLUS: African Health Ministers announce ‘pivotal’ new strategy to combat communicable diseases

24 August, 2022

[Note from HIFA moderator, NPW: 'With the burden of cardiovascular disease, mental and neurological disorders and diabetes rising in the region, African health ministers on Tuesday, endorsed a new strategy to boost access to the diagnosis, treatment and care of severe noncommunicable diseases.

The health ministers, gathering for the seventy-second session of the UN World Health Organization (WHO) Regional Committee for Africa in Lomé, Togo, adopted the strategy, known as PEN-PLUS. That plan will be implemented as a regional strategy to address severe noncommunicable diseases at first-level referral health facilities. The strategy supports building the capacity of district hospitals and other first-level referral facilities to diagnose and manage severe noncommunicable diseases... ]

The report on PEN-PLUS may be of interest to HIFA readers. I have pasted a few paragraphs. Interestingly, perhaps, HICs might benefit from more nurse

and patient led initiatives - especially health literacy, shared personal health data, clinical knowledge and skills and community engagement?

Community Engagement: - Enhance health literacy and empower communities for NCD prevention and control Report on Regional Consultation - Engage

community leadership, thought leaders and community structures in NCD work - Have ongoing awareness campaigns with relevant materials and harmonized

messaging - Educate appropriate teachers, including traditional healers.

National Commissions have often focused on severe NCDs as typically the services for these diseases are not reaching poor or rural communities,

instead are highly centralized in capital cities and other larger urban areas with extremely low coverage of services at first-level hospitals.

Dr. Bukhman presented that WHO PEN and the draft PEN-Plus strategy should be part of the same cohesive strategy. PEN-Plus will push decentralization

of more severe, lower prevalence diseases to first-level referral hospitals in order to better treat conditions that have a narrow therapeutic window

and more advanced medication management that must be precise to avoid harm to the patient. PEN-Plus will require targeted training of mid-level health

providers given human resource challenges faced by Member states, to be able to respond to conditions including, but not limited to: type 1 diabetes, cardiomyopathies, malignant hypertension, heart failure management, sickle cell disease. These conditions are of significance due to the higher burden of both Years of Life Lost (YLL) and Disability-Adjusted Life Years (DALYs) and their impact among children and young adults.

In addition, some questions were raised about prevention of NCDs and how this could be built in further to PEN-Plus efforts. The panelists recognized the crucial role of prevention, particularly for common NCDs, but emphasized that there is no prevention possible with many severe NCDs such as type 1 diabetes, and therefore high-quality treatment should be available at first-level hospitals while preventative measures should be focused at primary health centers. The panel also discussed health system structure and the need to shift care for common NCDs to health centers. By preserving referral and district hospitals for more severe conditions and shifting care for common NCDs to health centers, the cost of care is kept low, and ensures that patients with severe NCDs are able to access the care they need.

Final discussion points centered on training, and the need to engage professional societies and Ministries of Education in structured planning, as what each health professional islicensed to do will differ per country. There will also need to be a strong understanding among and between healthcare workers of what their role is on an integrated care team, and who is responsible for each step of the care cascade.

Dr. Ndayisaba emphasized the crucial role of task shifting. NCD nurses in Rwanda were cross-trained in care for severe, chronic NCDs to lead PEN-Plus

clinics as well as one GP per clinic who will be supervising this care. The skills that are shifted to nurses have included simplified echocardiography, anti-coagulation and insulin management. The success of this program relies heavily on a structured mentorship program, with

hands-on supervision and oversight. The success of this program has led to patients in rural areas now able to access high quality care without

traveling to Kigali, as the necessary equipment and medicines have also become more readily available.

Finally, Dr. Ndayisaba discussed language barriers in Rwanda, and the need to better inform patients and end stigma surrounding chronic diseases.

Finally, Dr. Kateera noted that data systems have been a key point of focus. Data systems have continued to be updated and improved, and now the

entire country of Rwanda uses the OpenMRS Platform. In order to ensure the continued success of this national program, colleagues from IMB continue to

meet with the Ministry regularly to discuss district and national matters, and work closely together to achieve shared goals. Following these

presentations, Dr. Gene Bukhman moderated a discussion with Dr. Gilles Ndayisaba and Dr. Fred Kateera. Key questions that emerged from the

discussion touched on how to produce relevant training materials and protocols for both clinicians and patients, and who is responsible for

overseeing ongoing clinical supervision and mentorship. Dr. Kateera described the success of the training model in Rwanda – by identifying and

investing in NCD nurse champions during training, they can become leaders in training Report on Regional Consultation others.

To conclude the third day, all participants were invited by the Rwanda Ministry of Health to visit one of three first-level hospitals near Kigali

in Masaka, Rutongo and Nyatanga. Each group, comprised of 18-20 participants, had the opportunity to speak with the Director General of the

hospital and the NCD nurse lead from the respective NCD PEN-Plus clinic.

Visits were well received, with positive feedback from each of the participating member states. Meeting participants enthusiastically reviewed

sample forms, protocols and guidelines and had engaging conversations with district hospital staff about Rwanda’s model of care for severe NCDs. There

was strong recognition of how much nurses were able to do independently in Rwanda, and the strength of the mentorship program to WHO PEN providers was

applauded. A resounding theme from each visit was that outpatient care for severe NCDs is feasible and plausible, even in rural district hospitals,

with sufficient financial resources, human resources and partnership.

HIFA profile: Richard Fitton is a retired family doctor - GP. Professional interests: Health literacy, patient partnership of trust and implementation of healthcare with professionals, family and public involvement in the prevention of modern lifestyle diseases, patients using access to professional records to overcome confidentiality barriers to care, patients as part of the policing of the use of their patient data Email address: richardpeterfitton7 AT