Bringing severe non-communicable disease care to district-level hospitals in Nepal: PEN-Plus experience and regional policy implications.

Severe non-communicable diseases (NCDs) such as type 1 diabetes mellitus (T1DM), sickle cell disease (SCD), thalassaemia and congenital heart conditions are prevalent in low-resource settings but remain largely unaddressed in the primary care system. Nepal's Package of Essential NCD Interventions-Plus (PEN-Plus) initiative demonstrates how peripheral provincial hospitals (former district hospitals) can effectively deliver decentralised, equitable care for childhood-originated NCDs such as T1DM, SCD, thalassaemia, rheumatic and congenital heart diseases, epilepsy and childhood asthma. Led by the Ministry of Health and Population, Epidemiology and Disease Control Division in partnership with key stakeholders, the programme has been implemented in six districts of Nepal, offering early diagnosis, treatment, social protection and follow-up care. Early implementation demonstrates feasibility, with 3278 patients receiving care through PEN-Plus clinics over 2 years using modest investments and existing district hospital resources. Scalability is supported by the expansion from two to six districts and by government policy commitments, including provincial budget allocations for further rollout. This paper presents an overview of the PEN-Plus programme in Nepal, its design, implementation and early outcomes, illustrating how this approach offers a scalable solution for severe NCD care in resource-constrained settings. The PEN-Plus model provides critical policy insights and valuable lessons for other South Asian countries and low- and middle-income countries seeking to strengthen equitable NCD care through decentralised health systems.