OPTIMIZING CARE PATHWAYS AND QUALITY OF CARE FOR MODERATE-TO-SEVERE HYPERTENSION, DIABETES AND COMMON MENTAL HEALTH MULTIMORBIDITY IN MOZAMBIQUE

Descripción del proyecto

Vincular la atención primaria y la atención a nivel de distrito para mejorar el tratamiento de múltiples afecciones crónicas

Las enfermedades no transmisibles, como la hipertensión, la diabetes y los problemas de salud mental, están aumentando en los países de rentas medias y bajas, lo que supone una gran carga para los sistemas sanitarios, los enfermos y sus familias. Las personas con varias enfermedades crónicas suelen recibir una atención fragmentada y poco coordinada, lo que pone de manifiesto la necesidad urgente de enfoques más integrados. Teniendo esto en cuenta, el proyecto PEN-CONNECT, financiado con fondos europeos, combina dos estrategias efectivas de la Organización Mundial de la Salud (WHO PEN para atención primaria y PEN-Plus para atención a nivel de distrito) en un marco integrado a fin de mejorar la atención centrada en la persona para pacientes con múltiples afecciones crónicas. Al abordar importantes brechas del conocimiento, se espera que PEN-CONNECT aporte información precisa sobre aspectos clínicos, de implementación y económicos que sirva de guía para las políticas y estrategias sanitarias a nivel mundial, ofreciendo un modelo escalable y adaptable para mejorar la atención y los resultados en salud.

Objetivo

Non-communicable diseases (NCDs) like hypertension, diabetes, and mental health conditions are a growing crisis in low- and
middle-income countries (LMICs) such as Mozambique, straining healthcare systems and undermining national productivity.
Individuals with multiple long-term conditions (MLTCs) face fragmented, poorly coordinated care, highlighting the urgent need for
integrated solutions. PEN-CONNECT pioneers the integration of two WHO evidence-based strategies—WHO PEN (primary care) and PEN-Plus (district-level care)—into a unified framework to address these gaps. Already implemented in many countries WHO-PEN and PEN-Plus serve as a foundation for bridging primary and district healthcare levels to deliver timely, coordinated, patient-centred care for
patients with MLTCs. The project develops integrated care pathways, leveraging digital health tools, and supported by implementation strategies co-created with stakeholders. PEN-CONNECT builds on the premise that strengthening the integration of PEN and PEN-Plus will be more effective than when addressed in isolation. By addressing critical knowledge gaps and contributing new theoretical frameworks, PEN-CONNECT advances the state-of-the-art for integrated MLTC care. PEN-CONNECT generates robust clinical, implementation, and economic evidence to inform global policy and practice, offering a scalable, adaptable model for LMICs to improve care and health outcomes. Its Roadmap including Implementation Toolkit offers actionable guidance, training materials, and decision-support tools for healthcare providers and policymakers, ensuring sustainability and scalability. The project aligns with SDG 3 and EU's commitment to global health equity. By strengthening healthcare delivery and reducing costs, PEN-CONNECT improves patient outcomes and quality of life for individuals with MLTCs while transforming NCD care in Mozambique and beyond. This collaborative initiative creates a benchmark for addressing NCD challenges in LMICs.