Study Shows Medicine and Equipment Gaps in Advance of PEN-Plus
The research assessed facilities’ capacity for medicines and equipment prior to PEN-Plus implementation.
Joyce Apolot, a senior nursing officer at the PEN-Plus clinic at Atutur General Hospital in Uganda, prepares medical supplies on a Tuesday, the designated clinic day for people living with sickle cell disease. This photo—taken in March 2024, two years after NCDI Poverty Network partners gathered data included in the recently published study on facility readiness—shows a clinic no longer lacking in the medicine and equipment needed to treat people living with severe noncommunicable diseases. (Photo: © Badru Katumba/World Health Organization)
A newly published study found that only two of 16 health facilities assessed in nine lower-income countries had all the functional equipment needed to diagnose and manage care for people living with type 1 diabetes. Two of the facilities had none of the necessary equipment.
Researchers assessed the first-level facilities in March 2022, before implementation of the groundbreaking model of care known as the Package of Essential Noncommunicable Disease Interventions–Plus, or PEN-Plus.
The study also found that only two facilities carried both of two medications considered essential for treating sickle cell disease. Seven of the facilities had just one of the essential medicines, and five had neither. (Ethiopia has a low prevalence of sickle cell disease, so its two facilities were not assessed for the medicines.)
Only one of the assessed facilities had functioning ultrasound equipment with cardiac probes needed for performing echocardiography, which creates detailed images of the heart.
These were just a few of the many gaps in equipment, supplies, and medicine needed to treat severe, chronic noncommunicable diseases (NCDs) that the research team identified. The study, “Facility Readiness for Decentralized Package of Essential Noncommunicable Disease Interventions–Plus (PEN-Plus) Care in Nine Lower-Income Countries,” was published April 24 in PLOS Global Public Health.
The Center for Integration Science in Global Health Equity at Brigham and Women’s Hospital conducted the study in collaboration with governments and implementing partners in nine countries in sub-Saharan Africa and South Asia. The center is the U.S. co-secretariat of the NCDI Poverty Network, in tandem with the co-secretariat in Mozambique.
The study assessed facilities’ baseline readiness to provide care for people living with severe, chronic NCDs—particularly type 1 diabetes, sickle cell disease, and rheumatic and congenital heart disease—before implementation of PEN-Plus. This proven, integrated, and cost-effective strategy brings care closer to home for people living with severe NCDs in rural areas of low- and lower-middle-income countries.
The 16 assessed facilities serve a combined total of nearly 5.3 million people.
Although those were not the only health facilities serving the mostly rural populations, nearly all the assessed facilities represented first-level care, such as district hospitals. A lack of equipment, medicine, and trained providers at those facilities means that, in the absence of strategic integration to improve health systems, many of those millions of people would need to travel significant distances to higher-level facilities, such as national hospitals, for diagnosis and management of severe, chronic NCDs.
Gathering data to help identify and ultimately bridge those gaps—and track the effectiveness of improvements in equipment, medicine, and training for health care providers—was exactly the study’s intent.
“These findings highlight the need for tailored, context-driven implementation approaches to address gaps in readiness for severe, chronic NCD care in low-to-lower-middle-income countries,” the study’s authors wrote. “Baseline results will guide ongoing implementation and evaluation of the PEN-Plus clinics.”
The research team conducted the baseline assessments at the beginning of a three-year funding cycle that brought PEN-Plus to facilities in Ethiopia, Kenya, Mozambique, Nepal, Sierra Leone, Tanzania, Uganda, Zambia, and Zimbabwe.
Dr. Alma Adler, director of research for the Center for Integration Science, said the assessments revealed gaps in care and capabilities that are spurring PEN-Plus implementation.
“Our findings underscore the need for PEN-Plus,” Dr. Adler said. “We went into these facilities before implementing PEN-Plus and discovered they were lacking even basic necessities, particularly for sickle cell disease.”
The study is the first of several rooted in the 2022 facility assessments. The team is also examining the facilities’ staffing levels and capacity as well as health information systems.
Dr. Gene Bukhman, executive director of the Center for Integration Science and co-chair of the NCDI Poverty Network, said the multifaceted research effort has brought together many of the network’s implementing partners.
“Every country involved in the study served on the working group and contributed to both the research and the manuscript,” Dr. Bukhman said. “This collaborative effort reflected the spirit of partnership that has been forming around PEN-Plus.”
Now at the end of the collaboration’s first three-year funding cycle, the Center for Integration Science and its partners also have completed endline assessments at all 16 facilities, to enable tracking of changes and improvements since the baseline assessments in 2022.
The newly published study noted that areas for improvement varied widely across the facilities—and across NCDs. Availability of diagnostic equipment for type 1 diabetes was notably low in many facilities, for example, but higher for sickle cell disease. Conversely, availability of medicine for type 1 diabetes was highest overall, at 75 percent, but lower for sickle cell, at about 40 percent. Gaps were found across facilities in availability of essential medicines, including medium- and long-lasting insulins, hydroxyurea, and anticoagulants.
The PEN-Plus model is designed to provide a standard method that applies across different health systems, resources, and capabilities.
“Participating hospitals vary greatly in existing service delivery, staffing, and overall systems at baseline, and implementation approaches vary,” the study’s authors wrote. “However, all sites share operational plans and technical resources for PEN-Plus implementation, which involves training of midlevel providers and ensuring availability of equipment and medicines for appropriate diagnosis and treatment of severe, chronic NCDs.”
PEN-Plus implementation involves many components, including hiring, supervising, and supporting clinical and auxiliary staff; increasing staff training and mentorship; establishing a strong supply chain for essential medicines, equipment, and materials; expanding or upgrading the infrastructure for clinic space; and facilitating systems development.
Dr. Adler said publication of the study adds to the growing body of data that shows the impact of PEN-Plus over the past several years—and could potentially expand its implementation.
“We want to reach new audiences,” Dr. Adler said, “and we want to get the word out to countries that could benefit from PEN-Plus.”