Priorities and Targets (2025–2028)
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.
The 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. (1) 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 member organizations of the NCDI Poverty Network focus their efforts to ensure that PEN-Plus adoption maintains momentum, delivers quality care across healthcare systems, elevates the power and leadership of people living with these conditions in PEN-Plus countries, and reaches even the least-resourced communities.
Over the next three years, we will build on our collective achievements to date as a springboard for action to reach new heights, focusing on three priorities to ensure the PEN-Plus promise is realized: Equity, Quality, and Financing.
Priority 1: Equity
2028 Global Target: Ensure that PEN-Plus services are accessible to a combined catchment area of 51 million people living in lower-income countries (2024 baseline: 25 million)
Equity is the driving force behind all we do, just as equity in health outcomes for people living with severe, chronic NCDs across higher-income and lower-income countries is the core premise underpinning PEN-Plus.
The NCDI Poverty Network channels and mobilizes more resources toward countries and districts with the least funding, tailoring country partnerships to accelerate sustainable care provision as quickly as possible. We work with our government partners to ensure equity of services within populations, using a person-centered approach to enable favorable outcomes for the most vulnerable patients.
Over the next three years, the Network will provide targeted support to healthcare workers and policymakers in the 15 countries with operational PEN-Plus clinics. This support will facilitate the path for the countries to scale services to benefit even more patients. We will also provide technical support to at least 11 new countries in the process of planning for and initiating PEN-Plus services.
Priority 1 Strategies
1a. Provide technical assistance and financial support to lower-income countries
In countries already implementing PEN-Plus—Bangladesh, Ethiopia, Haiti, India (Chhattisgarh State), Kenya, Liberia, Malawi, Mozambique, Nepal, Rwanda, Sierra Leone, Tanzania, Uganda, Zambia, and Zimbabwe—the NCDI Poverty Network will accompany health sector leaders to address barriers to scale and provide additional capacity-building and financing to facilitate progressive expansion of PEN-Plus services. One area of focus across many countries will be to identify new ways to leverage the PEN-Plus platform to improve the entire continuum of care, from primary-level early case findings of severe 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
Working closely with local clinical teams, the NCDI Poverty Network will cultivate hyperlocal patient leadership to increase psychosocial support, reduce stigma, and build solidarity across the type 1 diabetes, sickle cell, and childhood heart disease communities. This grassroots-level organizing is crucial for shifting narratives of power and resources from the ground up. To be effective, this work must be decentralized and responsive to a range of contexts while providing tangible value to people living with severe NCDs and their families. (2)
We will be driven by the expertise of disease-specific advocates living and working in PEN-Plus countries to move toward developing a supportive community and collective power for PEN-Plus patients. This work has already started through the Voices for PEN-Plus, a group of advocates from PEN-Plus countries who are using their lived experience with severe NCDs and advocacy expertise to foster connection and solidarity among people with NCDs. In Zimbabwe, for example, one of those advocates is collaborating with SolidarMed, a Swiss nongovernmental organization, to grow the peer-support infrastructures within communities served by PEN-Plus clinics.
1c. Ensure access to care through robust social support
Social determinants of health are well-documented critical components of good health, especially for people living with chronic disease. For many PEN-Plus patients, especially those living in extreme poverty, the monthly provision of funds for food and transportation can make the difference between sickness and health. In the pursuit of health equity, these are not nice-to-haves but must-haves.
NCDI Poverty Network members will work to ensure PEN-Plus clinics are integrated into existing social support frameworks as they accompany government partners through planning and implementation. We will also supplement these frameworks to alleviate additional financial burdens borne by people living with severe NCDs and their families.
Enabling Environment
In addition to aligning with each country’s priority frameworks, the Network’s Equity Priority aligns with Sustainable Development Goal Target 3.4. This goal calls for a reduction by one-third of premature mortality from NCDs by 2030 through the prevention and treatment of NCDs and the promotion of mental health and well-being, as measured against a 2025 baseline. The equity focus also corresponds with the meaningful engagement framework established by the WHO Global Coordination Mechanism. (3)
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 patient care and operational processes (2024 baseline: currently being aggregated)
Multiple countries and stakeholders are now expanding components of PEN-Plus programming nationally. At the same time, challenges are becoming apparent in supply chains, data systems, and human resources. There is now an increasing need for innovations that can solve these problems at scale.
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. These cross-cutting projects will pave the way for countries to take advantage of economies of scale made possible by the expansion of PEN-Plus interventions to date
Priority #2 Strategies
2a. Coordinate nationally and regionally to achieve key performance indicators
Accurate and timely data are essential for both clinical management and operational decision-making. They are also the basis of research insights and public health surveillance, which can influence resource investments and policy.
The NCDI Poverty Network has developed a standard list of key performance indicators for tracking clinical and operational progress in PEN-Plus clinics, including enrollment and cohort sizes, age and gender breakdowns, and clinical process and outcomes metrics. (4) The 15 countries implementing PEN-Plus use standardized data collection tools and reporting forms to track these indicators.
Over the next three years, the Network will continue to make key performance indicators and tools accessible to key decision-makers. The Network will also work with partners to establish routine data systems for PEN-Plus, including national health information systems and regional data systems through the WHO African Region and the Africa CDC.
2b. Analyze and tackle supply chain challenges and systemic market failures affecting essential medicines and supplies
Regulatory challenges and dysfunctional international markets—which raise prices and cause stockouts—remain systemic barriers to care for many people living with severe NCDs. Essential medicines and supplies for treating these conditions, such as insulin and hydroxyurea, have been left out of the major global 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 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 dissemination of the most effective medicines and technologies—such as analogue insulin—to the least-resourced settings.
2c. Provide ongoing clinical training, mentorship, and continuing medical education
While countries establish their own training capabilities as part of the initiation of PEN-Plus services, the NCDI Poverty Network’s regional advisors provide ongoing support and accountability for PEN-Plus clinical teams as operations unfold.
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 clinicians—from in-country specialists and trainers to frontline providers and implementers—to draft, refine, and validate training and protocols. These expert groups also identify gaps in PEN-Plus programmatic standards, discuss potential solutions to implementation challenges and advocacy priorities, foster cross-country learning, and share best practices within each clinical discipline.
These touchpoints provide channels for the sharing of decades of accumulated knowledge of these conditions. The touchpoints also nurture a shared culture of person-centered care that is responsive to the lived experience of people with severe NCDs.
Over the next three years, the Network will build on this relationship-driven set of supports to aid countries in developing more formal mechanisms for credentialing and certification for individual clinicians 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 better 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; (5) and
Longitudinal studies of PEN-Plus services to document their efficacy and acceptability to patients and providers over time.
Enabling Environment
The NCDI Poverty Network coordinates with PEN-Plus countries to ensure their data management systems can monitor care expansion and fidelity to quality standards. The Network encourages the integration of PEN-Plus indicators into national health information systems, supports WHO initiatives for standardized NCD data reporting, and aligns with the efforts of the Africa CDC to establish stronger regional surveillance mechanisms for NCDs.
Rwanda and Malawi, both of which operate PEN-Plus on a national scale, are key partners in identifying and guiding next-level inputs in monitoring, evaluation, procurement, training, and credentialing to strengthen national PEN-Plus programs.
In addition, the type 1 diabetes, sickle cell disease, and childhood heart disease communities have recognized supply chain challenges and developed robust policy platforms around access to medicines and supplies.
Priority 3: Financing
2028 Global Target: Unlock an estimated $40 million annually in support of PEN-Plus interventions across public sector, official development assistance, and philanthropic financing streams (2024 baseline: approximately $20 million annually)
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 assistance allocated to caring for people living with severe NCDs in lower-income countries.
3b. Cultivate new opportunities for private philanthropy
The expansion of PEN-Plus is an intersectional effort that touches on philanthropic priorities across a variety of spectrums, offering room for leadership in projects that save lives and streamline systems. The PEN-Plus model can also be an effective tool for moving health systems progressively toward Universal Health Coverage. Catalytic philanthropic investments can unlock new systemic efficiencies, provide proof of concept in specific locations, and deliver immediate relief to people living with severe NCDs in PEN-Plus countries. Over the next three years, the Network will collaborate with the philanthropic community to identify areas of mutual interest and high impact that will advance us toward the targets outlined in this plan.
3c. Provide support to PEN-Plus countries in facilitating favorable national-level policies and resource allocations
Drawing on the strength of local disease-specific advocacy organizations operating in PEN-Plus countries, the NCDI Poverty Network will establish an organizing infrastructure and policy agenda in key markets where opportunities exist to influence official development assistance, budget allocations, and development bank initiatives. Through this organizing work, advocates will be positioned to increase 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
NCDI Poverty Network members will leverage their own global platforms and expertise to keep the needs 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 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 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 persistent global issues through smart solutions and engaged partnerships.
With its reach currently spanning 23 countries, the NCDI Poverty Network represents multiple avenues to seed, grow, and support PEN-Plus interventions while accruing significant efficiencies in sharing lessons learned and building a global community of practice. The Network’s decentralized, comprehensive approach to addressing the needs of people living with severe NCDs offers multiple entry points for international partners to engage new resources to meet compelling needs while respecting each participating country’s ownership and accountability.
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.
Endnotes
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.
World Health Organization. Framework on integrated, people-centred health services. Report by the Secretariat. 2016.
World Health Organization. WHO framework for meaningful engagement of people living with noncommunicable diseases, and mental health and neurological conditions. 2023.
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.
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.. Global Heal Sci Pract 2021;9:3:1–14.