Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Health Care in Low-resource Settings
(2010; 66 pages)


As low- and middle-income countries (LMIC) begin to make gains in combating infectious disease and malnutrition and garner the benefits of economic development, they have become increasingly vulnerable to the impact of noncommunicable diseases (NCDs). NCDs such as cardiovascular disease (CVD), cancer, respiratory disease and diabetes are already the leading causes of death in all LMIC except those in sub- Saharan Africa. Projected data indicate that there will be a rapid increase in NCDs over the next seven years, including in sub-Saharan Africa. The economic impact of this increase will be substantial because working-age adults account for a high proportion of the NCD burden.

Effective approaches to reduce the NCD burden in LMIC include a mixture of population-wide and individual interventions. Such cost-effective interventions are already available and include methods for early detection of NCDs and their diagnoses using inexpensive technologies, non pharmacological and pharmacological approaches for modification of NCD risk factors and affordable medications for prevention and treatment of heart attacks and strokes, diabetes, cancer and asthma. These low technology interventions, if effectively delivered, can reap future savings in terms of reduced medical costs, improved quality of life and productivity. However, due to weak health systems, there are substantive gaps in their implementation particularly in LMIC.

Efficient use of limited health care resources, sustainable health financing mechanisms, access to basic diagnostics and essential medicines and organized medical information and referral systems are imperative for provision of equitable care for people with and at risk of NCDs. They require long-term care that is proactive, patient centered, community based and sustainable. Such care can be delivered equitably only through health systems based on primary health care (PHC).

Further, two billion people in the world are living below the poverty line and poverty and NCDs are linked through many pathways. Although providing good quality care for the poor is an ethical imperative, due to weak health systems and inadequate health-care expenditure of many countries, the poor do not have access to services at all or receive substandard services. Furthermore, out-of-pocket expenditure is unacceptably high in many LMIC. Countries need to transform and regulate health systems for universal access and social protection . This transformation will take several years given the global financial status and wide disparities in domestic resources between countries. In the meantime, Ministries of Health (MoHs) need to take steps to improve health outcomes and to reduce rising health-care costs due to NCDs and their preventable complications.

The WHO Package of Essential Noncommunicable Disease Interventions (WHO PEN) for primary care in low-resource settings is an innovative and action-oriented response to the above challenges. It is a prioritized set of cost-effective interventions that can be delivered to an acceptable quality of care, even in resource-poor settings. It will reinforce health system strengthening by contributing to the building blocks of the health system. Cost effectiveness of the selected interventions will help to make limited resources go further and the user-friendly nature of the tools that are been developed, will empower primary care physicians as well as allied health workers to contribute to NCD care. It should not be considered as yet another package of basic services but, rather, an important first step for integration of NCD into PHC and for reforms that need to cut across the established boundaries of the building blocks of national health systems. WHO PEN is the minimum standard for NCDs to strengthen national capacity to integrate and scale up care of heart disease, stroke, cardiovascular risk, diabetes, cancer, asthma and chronic obstructive pulmonary disease in primary health care in low resource settings. Most importantly, it defines a minimum set of essential NCD interventions for any country that wishes to initiate a process of universal coverage reforms to ensure that health systems contribute to health equity, social justice, community solidarity and human rights.

WHO PEN will be further developed to provide guidance and tools to assess needs and capacity, implement essential NCD interventions, evaluate impact, strengthen health systems and human resource capacity in PHC with a special focus on primary care (first contact) level. The components been developed and validated include protocols for clinical diagnosis and treatment, tools for risk prediction of heart attacks and strokes, guidance on minimum requirements for essential medicines and affordable technologies, standards and indicators to measure progress of implementation and impact of WHO PEN.

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