Building Capacity to Evaluate Package of Essential Non-Communicable Disease Interventions (PEN) in Nepal - An Implementation Study - ABSTRACT
Non-communicable diseases (NCDs) are the leading cause of premature deaths and disease burden globally.
Sixty percent of the global deaths are caused by four major NCDs: cardiovascular diseases (CVD), cancers,
chronic respiratory diseases and diabetes. The world health organization (WHO) proposed a cost effective
Package of Essential Noncommunicable Disease Interventions (PEN) that includes population and individual
level strategies to address NCDs in low resource countries to reduce the NCD burden and improve the quality
of life and productivity in low resource settings. The Government of Nepal endorsed the PEN and has been
piloted in 16 districts with aims to expand and scale up the PEN throughout the country. However, initial
reviews suggest inadequate human resource capacity to implement, monitor and evaluate the PEN. The
implementation of the existing PEN program has not been assessed and evaluated systematically. Currently
no empirical information is available to rate the status of the program nor on the factors affecting its success or
failures. The proposed study will improve the capacity for NCD care by strengthening PEN implementation in
Nepal in three ways. Aim 1 will build capacity of Primary Health Care workers in implementing, monitoring and
evaluation of PEN through training of NCD health coordinators from the 16 pilot districts on implementation
science, focusing on the implementation, monitoring and evaluation of the PEN using real-time routine data.
Aim 2 will evaluate the implementation of PEN in the 16 pilot districts by estimating (a) Acceptability-
satisfaction on content, complexity, comfort, delivery and credibility of the PEN, by semi-structured interviews;
(b) Adoption: Uptake and initial implementation of the PEN, by administrative data; (c) Feasibility: coverage on
PEN screening and treatment, with health information system data (d) Fidelity - adherence to the PEN
protocol, using observation checklists; (e) Penetration: Level of institutionalization, using checklists and semi-
structured interviews; (f) Cost - marginal cost per primary health care center, using administrative data; and (g)
Sustainability - routinization and maintenance, using semi-structured interviews and checklists. Aim 3 will
identify facilitators and barriers to the PEN implementation at health system and community level through six
focus group discussions with the clients who seek NCD services at primary health care centers in Nepal; and
32 in-depth interviews with the health care workers. By building the capacity of district-level PEN leaders on
implementation research, it will sustainably strengthen the health system capacity for PEN implementation and
evaluation. By generating pilot data on acceptability, adoption, feasibility, fidelity, penetration, implementation
cost and sustainability, it will guide the Government of Nepal for scaling-up PEN. By identifying facilitators and
barriers to implementation from the provider’s and client’s perspective, it will suggest modifications to the
processes of NCD programs such as PEN across health systems, and hence on how this program could be
implemented nationwide across other contexts in south Asia and developing countries.
