People-Centered Healthcare for Tsirang and Punakha: PEN HEARTS Initiatives

At the Fifth Biennial Health Conference (BHC), convened by the Ministry of Health under the theme “Enhancing Integrated People-Centered Health Services”, I presented on “Transforming NCD Care by Keeping People at the Heart of Care: PEN HEARTS Initiatives in Tsirang and Punakha.” The presentation highlighted the shift from the former PEN programme—marked by limited recall, referral, and follow-up—to the people-centered PEN HEARTS model, emphasizing continuity, coordination, and comprehensiveness in chronic disease care.

Through real-world examples, district-level innovations, and community outreach activities, the talk illustrated how improved recall/reminder systems, medicine refills at Basic Health Units (BHUs), mentoring, and active doctor engagement enhanced outcomes for patients with hypertension and diabetes while also strengthening health systems and staff morale.

• Implications & Recommendations:
  • Reduce treatment interruptions for NCD patients through structured recall and reminder systems.
  • Minimize travel costs and time by enabling refills and outreach care at BHU level.
  • Strengthen team-based care and health system leadership through mentoring and supportive supervision.
  • Scale up PEN HEARTS as a national program to standardize chronic care across Bhutan.
  • Extend people-centered approaches to other services (communicable diseases, maternal & child health, mental health).
  • Ensure transport and logistics systems are formalized to support community medicine refills.

📖 Learn more:

• People-centred model supported by WHO’s PEN package improves access to noncommunicable disease healthcare in Bhutan

• Evolving a people-centred approach to noncommunicable disease (NCD) services in Bhutan

• Powerpoint Slides

🙏 With gratitude to the health workers of Punakha and Tsirang Dzongkhags for pioneering this initiative.