The WHO PEN-Plus: A Framework to promote Equitable Chronic Disease Coverage in Private Health Insurance

By Solange Dabou, Nji Seraphin Ombel Musa, Constantine Asahngwa & Ronald Gobina

Executive summary

Chronic diseases are driving catastrophic health expenditures in Cameroon, where out‑of‑pocket payments dominate. Despite the existence of private health insurance, long‑term conditions are rarely covered. The WHO PEN‑Plus strategy offers a practical solution by reducing costs and uncertainties that currently discourage insurers from providing coverage. Implementing PEN‑Plus nationwide would strengthen early diagnosis, improve service quality, and create predictable conditions that make chronic disease benefits more feasible for private health insurance. To realize these gains, Cameroon must align PEN‑Plus rollout with reforms in regulation, financing, and data systems to expand equitable and sustainable financial protection against the cost of chronic disease care.

Context

In sub-Saharan Africa (SSA), one in six households experience financial catastrophes when seeking healthcare. Catastrophic health expenditures (CHE) occur as a result of out-of-pocket (OOP) payments for health services at the point of care, and can be defined as more than 10% of total household expenditure spent on healthcare. Recent data reveal that when the expenses relate to the provision of care for chronic Non-Communicable Diseases (NCDs), the proportion of households facing CHE can exceed 95%. The burden of NCDs disproportionately affects populations in SSA, where health systems are challenged by the double burden of disease: High rates of persistent infectious diseases and rising incidence of NCDs. It is projected that by 2030, NCDs will surpass communicable, maternal, neonatal, and nutritional disorders cumulated as the leading cause of death in the region.

While considerable public health efforts have been made towards prevention and control of NCDs in SSA, their direct financial burden on households or individuals remain unaddressed, especially in countries like Cameroon with high out-of-pocket payments. Cameroon provides a particularly relevant case for examining the financial burden of NCDs on populations. NCDs account for about 38% of all deaths in the country, yet financial protection mechanisms remain weak and fragmented. With limited health insurance coverage, OOP represent more than 65% of total health expenditure. This heavy reliance on out-of-pocket financing is particularly problematic for NCDs, which require long-term, continuous, and often costly care. For example, the mean annual expenditure for different cardiovascular diseases ranges from 695 to up to 2500 USD per patient, while the average cost for treating type 2 diabetes is 720 USD yearly according to a study in the Northwest region. Despite government efforts, including the first phase of the universal health coverage (UHC) program, NCDs remain a major burden for most Cameroonians, for UHC at its current state only covers dialysis treatment. Public financing and service coverage are still insufficient to meet the long-term needs of people living with chronic conditions, putting many households at risk of CHE. In this context, health insurance, particularly private health insurance, has the potential to complement public initiatives by improving financial protection and access to sustained NCD care.

However, chronic NCDs care is usually excluded from PHI coverage in Cameroon, because long-term conditions are seen as financially risky and difficult to manage. Health system weaknesses further worsen the situation through under-diagnosis and poor control of NCDs, reinforcing insurers’ reluctance to cover them. In this context, strengthening prevention, quality of care, and surveillance could reduce this risk. A major effort to achieve this in Africa is the PEN-Plus strategy designed by the World Health Organization (WHO). WHO PEN-Plus complement the WHO PEN (Package for Essential Non-communicable diseases interventions), an innovative and practical set of cost-effective interventions designed for low-resource settings. The WHO PEN-Plus strategy offers a promising pathway by standardizing and decentralizing NCD care, creating conditions for more equitable and feasible insurance coverage. In this brief, we explore how full implementation of WHO PEN-Plus in Cameroon, could support equitable coverage of chronic diseases through PHI.

Challenges of chronic diseases insurance coverage

Despite the high and growing financial burden of non-communicable diseases (NCDs) on households, multiple constraints continue to limit their effective insurance coverage, especially in low-and-middle income countries. Pre-existing conditions, which are illnesses diagnosed before enrollment and chronic diseases such as diabetes and hypertension generate predictable, high-cost claims, leading insurers to exclude them. Without risk sharing and cost stabilization mechanisms, insurers tend to restrict benefits for individuals with NCDs, leading to exclusions, long waiting periods, or premium loadings that limit coverage.

In Cameroon, NCDs and their risk factors are underdiagnosed and inadequately managed. This is mainly due to health system challenges such as uneven distribution of health facilities, shortage of skilled healthcare workers and lack of adequate infrastructure. The poor management of NCDs in the country further contributes to insurers’ reluctance to offer coverage to patients which are usually excluded from PHI schemes.

The WHO PEN-Plus as a pathway to equitable chronic disease insurance coverage

Overview of the PEN-Plus strategy

The PEN-Plus package is a health systems strategy designed to foster equitable access to care for severe and chronic non-communicable diseases (NCDs) by decentralizing integrated care to first-level referral facilities such as district hospitals. PEN-Plus focuses on increasing access to integrated, decentralized outpatient services to tackle the burden of severe chronic diseases among undeserved communities in the African Region. Priority diseases include type 1 diabetes, sickle cell disease, rheumatic and congenital heart disease, and complicated hypertension.

With this model, middle level clinicians (nurses, clinical officers) are trained with  advanced skills to diagnose, manage, and follow-up on severe NCDs in outpatient settings, thereby improving proper medication management, diagnostics, psychosocial support and referral pathway to specialist care. This capacity enhancement strategy contributes to reducing delays in treatment, thus improving disease outcomes. PEN-Plus also enhances connection to primary and tertiary services using standardized protocols, mentorship and supervision to foster continuity of care.

The state of PEN-Plus Implementation in Cameroon

Since the adoption of the WHO PEN-Plus regional strategy in 2022, Cameroon is one of the 20 Member States that have recorded some improvement in implementing the package. The WHO mid-term review indicates that Cameroon has adjusted and incorporated standardized management procedures in national health policies and strategies. Cameroon has also developed a national operational plan on the management of chronic and severe NCDs in district hospitals, which places the country among the 42.5% of African Member States that have achieved this by the year 2024.

However, as of the end of 2024, Cameroon just like other countries in the region had not met any of the PEN-Plus 2025 milestones, highlighting systematic obstacles. These setbacks are largely due to limited financial resources, little or no political commitment, weak health systems and lack of engagement to invest in scaling up efforts. These problems are augmented by excessive out-of-pocket payments for NCDs care and flimsy risk-pooling systems to take care of chronic diseases. Addressing these systemic barriers is thus a prerequisite to transforming PEN-Plus-which remains only a policy commitment-into the equitable and functional NCDs care mechanism strongly needed in Cameroon.

Opportunities for equitable chronic disease coverage through private health insurance

While major barriers persist in WHO PEN-Plus implementation, its potential effects on health system offers important opportunities to reduce the financial burden of NCDs through private health insurance.

With cost-effective and clearly defined service packages, WHO PEN-Plus provides standardized frameworks for adequate management of priority NDCs accessible within primary healthcare services. This standardization of NCDs care can inform and support the design of adapted PHI benefit packages, thus reducing uncertainty and information asymmetry between insurers, healthcare providers and policy holders. In addition, standardized monitoring and evaluation of PEN-Plus indicators and NCDs surveillance offer reliable and continuously available health data to support PHI packages design.

The PEN-Plus strategy also focuses on decentralization of health services for severe NCDs from tertiary level to district level and primary level facilities, supported by capacity strengthening for different categories of healthcare workers. These measures will improve early diagnosis thus lowering the risk of costly complications. The availability of services at primary and district levels will also ensure continuity of care and reduce its cost and complexity. In this scenario, the high risk associated with NCDs coverage for insurers could be significantly reduced, allowing for more predictability of cost, informing actuarial models of affordable premiums for patients.

Policy pathways

While PEN-Plus provides a strong clinical and service-delivery foundation, its full potential will only be realized if it is embedded within a broader reform agenda for financial protection against NCDs. There is a need for a holistic policy approach that links PEN-Plus implementation with complementary financing and regulatory mechanisms to build a sustainable and equitable system for chronic disease coverage.

Scientific literature emphasizes the need for risk pooling and risk sharing mechanisms to mitigate insurers’ incentives to avoid high-cost chronic patients and to reduce uncertainty in coverage markets. A model combining high risk pooling with risk equalization has been proposed. High-risk pools and risk equalization helps insurers to cover people with chronic diseases by sharing costs and providing extra support for high-risk enrollees. Central funds or government subsidies compensate insurers, making coverage of NCDs financially viable.

Besides, according to global experts, sustainable health insurance coverage for NCDs in low-resource settings relies on micro-insurance schemes. These schemes are based on integrated and innovative approaches such as public-private partnerships for subsidized benefits, digital tools for enrollment and claims, integrated prevention and chronic care programs, and simple, affordable insurance products for first-time users.

Conclusion and Recommendations

In Cameroon like in other low-resource settings, chronic diseases still receive poor coverage by PHIs because of their high, predictable, and long-term costs, weak risk-sharing mechanisms, and fragile service delivery systems. By strengthening decentralized care for severe chronic diseases through standardized packages, trained teams, and more predictable financing, the WHO PEN-Plus framework can reduce uncertainty around NCDs management and create conditions that make equitable insurance coverage more feasible in Cameroon. Accelerating PEN-Plus implementation within a broader reform agenda thus sets the stage for actionable policy solutions, which are outlined in the following recommendations.

The Cameroon government essentially through the Ministry of Public Health in the short term should:

• Accelerate the WHO PEN-Plus strategy implementation across the country, in line with the call for action following the 2nd International Conference on PEN-Plus in Africa (ICPPA 2025).
• Ensure rigorous tracking and public availability of PEN-Plus monitoring and evaluation indicators as well as NCDs related de-identified health data, to inform public or private initiatives promoting NCDs health financial protection.
• Reinforce PHI regulatory mechanisms to assess their current contribution to NCDs coverage, identify challenges and design sustainable models that can leverage opportunities offered by the PEN-Plus strategy.

In the medium term it is also essential to:

• Initiate implementation research on NCDs financial protection models best suited for the Cameroon context, leveraging PEN-Plus indicators. Such initiatives could be carried out by civil society organizations or research centers and supported by the government and development partners.
• Integrate PHI and NCDs financial protection into the broader universal health coverage agenda to avoid fragmentation of efforts, expand coverage, improve risk pooling and risk sharing and reduce the risk of widening disparities within the population.