Package of Essential Noncommunicable (PEN) disease interventions in Nepal

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Non-communicable diseases are a major public health problem in Nepal accounting for around 60% of the total annual deaths in 2014 (WHO). The Package of Essential Non-communicable Diseases (PEN) has been introduced to screen, diagnose, treat and refer Cardio Vascular Diseases, COPD, cancer, diabetes, and mental health at health posts, primary health care centres and district hospitalhospitals  for early detection and management of chronic diseases within the community.

Related services available at health facilities:

Health FacilitesServicesBasic diagnostics
Health PostDetect hypertension, diabetes, assess CVD risks, counseling, referral, follow up of low risk patients,  refill drugs, health promotionBlood pressure measurement device,  Glucometer, Urine protein test strips, Urine ketone test strips, Stethoscope, Measurement tape, Digital weighing scale, Stadiometer, CVD risk charts
Primary Health Care CentersConfirm diagnosis of diabetes, hypertension, manage, follow up high risk patients, refer complicated cases to district hospitalBlood pressure measurement device,  Glucometer, Cardio check, Urine protein test strips,  Urine ketone test strips, Stethoscope, CVD risk charts, Measurement tape, Digital weighing scale, Stadiometer

 

 

 

 

 

Source of info: Ministry of Health

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.
Source : * Reference: World Health Organization Package of essential noncommunicable (PEN) disease 
interventions for primary health care in low-resource settings, World Health Organization, 2010.:Introduction 
(Page No.8)

WHO PEN for primary care in low-resource settings overview*

Goals
To close the gap between what is needed and what is currently available to reduce the burden, health-care costs and human suffering due to major NCDs by achieving higher coverage of essential interventions in LMIC.

  • To achieve universal access to high-quality diagnosis and patient-centred treatment
  • To reduce the suffering and socioeconomic burden associated with major NCDs
  • To protect poor and vulnerable populations from heart disease, stroke, hypertension cancer,
    diabetes, asthma and chronic respiratory disease
  • To provide effective and affordable prevention and treatment through primary care
  • To support early detection, community engagement and self-care

Objectives
Equity and efficiency objectives
Improve the efficiency of care of major NCD in primary care through:

  • enhanced implementation of human rights standards;
  • provision of cost effective interventions based on need rather than ability to pay;
  • targeting limited resources to those who are most likely to benefit due to high risk;
  • standardization of diagnostic and investigation procedures and drug prescription;
  • formulation of referral criteria for further assessment or hospitalization;
  • definition of parameters for planning and budget;
  • selection of monitoring and evaluation indicators.

Quality of care objectives
Improve the quality of care of major NCD in primary care through:

  • cost effective case management;
  • appropriate referral and follow-up;
  • prevention, early detection and cost effective case management
  • management of exacerbations and emergencies;
  • follow-up of long-term treatment prescribed by the specialist.

Health impact objectives
Have a beneficial impact on health through:

  • reduction of tobacco consumption in NCD patients;
  • reduction of the average delay in the diagnosis of NCD by the health services;
  • reduction of the risk of heart attacks, strokes, amputations and kidney failure;
  • reduction of case fatality of major NCDs;
  • prevention of acute events and complications;
  • prolongation of the duration of stable clinical periods for CVDs, diabetes, asthma and COPD
    patients.

* Reference: World Health Organization Package of essential noncommunicable (PEN) disease interventions for primary health care in low-resource settings, World Health Organization, 2010.

WHO PEN Protocol 2
Health Education and Counseling on Healthy Behaviours (to be applied to ALL)

Educate your patient to

  • Take regular physical activity
  • Eat a “heart healthy” diet
  • Stop tobacco and avoid harmful use of alcohol
  • Attend regular medical follow-up

Take regular physical activity

  • Progressively increase physical activity to moderate levels (such as brisk walking); at least 150 minutes per week
  • Control body weight and avoid overweight by reducing high calorie food and taking adequate physical activity

Eat a heart healthy diet

Salt (sodium chloride)

  • Restrict to less than 5 grams (1 teaspoon) per day
  • Reduce salt when cooking, limit processed and fast foods

Fruits and vegetables

  • 5 servings (400-500 grams) of fruits and vegetable per day
  • 1 serving is equivalent to 1 orange, apple, mango, banana or 3 tablespoons of cooked vegetables

Fatty food

  • Limit fatty meat, dairy fat and cooking oil (less than two tablespoons per day)
  • Replace palm and coconut oil with olive, soya, corn, rapeseed or safflower oil
  • Replace other meat with chicken (without skin)

Stop Tobacco and avoid harmful use of Alcohol:

  • Encourage all non-smokers not to start smoking
  • Strongly advise all smokers to stop smoking and support them in their efforts
  • Individuals who use other forms of tobacco should be advised to quit
  • Alcohol abstinence should be reinforced.
  • People should not be advised to start taking alcohol for health reasons
  • Advise patients not to use alcohol when additional risks are present, such as:
    ■ driving or operating machinery
    ■ pregnant or breast feeding
    ■ taking medications that interact with alcohol
    ■ having medical conditions made worse by alcohol
    ■ having difficulties in controlling drinking

Adherence to treatment

  • If the patient is prescribed a medicine/s:
    ■ having medical conditions made worse by alcohol
    ■ having difficulties in controlling drinkingteach the patient how to take it at home:
    ■ explain the difference between medicines for long- term control (e.g. blood pressure) and medicines for quick relief (e.g. for wheezing)
    ■ tell the patient the reason for prescribing the medicine/s
  • Show the patient the appropriate dose
  • Explain how many times a day to take the medicine
  • Label and package the tablets
  • Check the patient’s understanding before the patient leaves the health centre
  • Explain the importance of:
    ■ keeping an adequate supply of the medications
    ■ the need to take the medicines regularly as advised even if there are no symptoms

World Health Organization Package of essential noncommunicable (PEN) disease interventions for primary health care in low-resource settings, World Health Organization, 2010.

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Nepal Health Minister launches the WHO NCD PEN package
As a follow up of the commitment of the 69th Session of the WHO Regional Committee for South-East Asia 
and the Colombo Declaration on “Strengthening health systems to accelerate delivery of noncommunicable 
services at the primary care level”, H.E. Minister of Health Mr. Gagan Kumar Thapa launched the WHO NCD 
PEN package in Kailali district on 5th October 2016.  WHO NEPAL
PEN Program was piloted in 2 districts. (Kailali & Ilam). Government planned to expansion of the 
PEN program in following eight districts ; Palpa, Baglung, Myagdi, Achham, Bardiya, Surkhet, 
Makawanpur and Rautahat in FY 2073/74 & 20 more districts in FY 2074/75.
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