Qualitative evaluation of WHO PEN implementation in Moldova identified that staff shortages, duplicate documentation, and limited counseling training were key barriers, while joint doctor-nurse training, clear role delineation, and embedded checklists were key enablers for scale-up.
Key Findings
Results
Healthcare staff valued the WHO PEN intervention for structuring consultations and clarifying team roles in primary health care.
Twenty-eight participants were interviewed across five family medicine centers, including 15 doctors (five of whom were managers) and 13 nurses.
Sites were purposively selected based on prior PEN performance: two high-performing, one medium-performing, and two low-performing centers.
Participants expressed that PEN helped organize the clinical encounter and delineated responsibilities between doctors and nurses.
Interviews were conducted in Romanian, audio-recorded, transcribed verbatim, anonymized, and analyzed using framework analysis by a six-member team.
Results
Staff shortages and high workload were identified as major barriers to PEN implementation.
This barrier was reported across sites regardless of performance level.
Workload issues contributed to difficulties in consistently applying PEN protocols during routine consultations.
Staff shortages were noted as a systemic constraint in primary health care settings in Moldova.
The study was conducted in June–August 2018, approximately one year after Moldova initiated PEN implementation in 2017.
Results
Duplicate documentation requirements created an implementation burden for clinicians.
Participants across sites identified redundant paperwork as a practical obstacle to smooth PEN integration.
Duplicate documentation was flagged as a target for streamlining in national scale-up recommendations.
This finding informed the conclusion that national efforts should streamline documentation to sustain impact during scale-up.
Results
Limited ongoing training, particularly in risk communication and motivational interviewing, was a significant implementation barrier.
Clinicians reported insufficient training in counseling skills needed to support patient behavior change.
Specific gaps were identified in risk communication and motivational interviewing techniques.
The authors recommended institutionalizing refresher training focused on counseling and risk-based care as a national scale-up priority.
Initial joint doctor-nurse training was identified as an enabler, suggesting that training format mattered alongside training content.
Results
Inconsistent use of cardiovascular risk scores to guide treatment decisions was identified as a clinical implementation gap.
Participants indicated that cardiovascular risk stratification, a core component of WHO PEN, was not consistently applied to inform treatment.
This inconsistency was identified across performance levels, suggesting it was a widespread rather than site-specific issue.
The finding informed recommendations to institutionalize training in risk-based care approaches during scale-up.
Results
Referral bottlenecks limited the effectiveness of PEN protocols that required specialist involvement.
Participants reported that patients identified through PEN screening encountered delays or difficulties accessing specialist referral services.
Referral bottlenecks were identified as a system-level barrier beyond the control of individual family medicine centers.
Addressing access and referral gaps was included among the key national scale-up recommendations.
Results
Patient-level barriers including out-of-pocket costs, low preventive care utilization among working-age men, and migration impeded PEN reach.
Clinicians identified financial costs as deterrents to patients following through with recommended care.
Working-age men were specifically identified as an under-reached group with limited engagement in preventive care.
Migration was noted as a population-level barrier relevant to Moldova's demographic context.
These findings led to recommendations for community outreach to under-reached groups as part of scale-up efforts.
Results
Joint doctor-nurse training, clear role delineation, embedded checklists, local patient flow reorganization, and leadership engagement were identified as key enablers of PEN implementation.
Joint training of doctors and nurses together was reported to facilitate shared understanding and coordinated implementation.
Simple tools embedded in clinical workflows, such as checklists, supported consistent protocol adherence.
Local reorganization of patient flow allowed centers to adapt PEN to existing infrastructure and staffing patterns.
Leadership engagement at the family medicine center level was associated with higher implementation performance.
These enablers were identified through comparison across sites with varying prior PEN performance levels.
Conclusions
The study concluded that national scale-up of WHO PEN in Moldova requires streamlined documentation, institutionalized refresher training, improved referral systems, and community outreach to under-reached populations.
Findings were synthesized from qualitative interviews conducted approximately one year after Moldova's 2017 PEN initiation.
Prior quantitative monitoring had shown 'mixed performance across sites,' motivating the qualitative evaluation.
The framework analysis approach was used with iterative discussion among a six-member analysis team.
Recommendations were framed as necessary to 'sustain impact during scale-up' and 'advance national NCD goals.'
What This Means
This research examines how a World Health Organization program called the Package of Essential Noncommunicable Disease Interventions (PEN) was being implemented in Moldova's primary healthcare clinics about a year after it launched in 2017. Researchers interviewed 28 healthcare workers — doctors and nurses — at five clinics that had varying levels of success with the program, in order to understand what was working and what was getting in the way. The study found that while healthcare workers appreciated how the program helped organize patient visits and clarified who was responsible for what tasks, a number of practical problems were slowing things down, including staff shortages, excessive paperwork, gaps in training for patient counseling, inconsistent use of heart disease risk scores to guide care, difficulties getting patients referred to specialists, and patient-level challenges like costs and the fact that working-age men rarely seek preventive care.
On the positive side, the research identified several factors that helped clinics implement the program more effectively: training doctors and nurses together, giving each role clear responsibilities, using simple checklists built into existing workflows, reorganizing how patients moved through the clinic, and having engaged local leadership. These enablers were more consistently present in the higher-performing sites.
This research suggests that for Moldova to successfully expand this program nationally, policymakers and health administrators should focus on reducing redundant paperwork, regularly updating staff training — especially on how to communicate health risks and support patients in changing behaviors — fixing bottlenecks in the referral system, and reaching out to communities and groups that currently underuse preventive health services, such as working-age men and populations affected by migration. The findings offer practical lessons not just for Moldova but for other low- and middle-income countries implementing similar NCD prevention programs in primary care.
V. Salaru, Yelena Tarasenko, Angela Ciobanu, T. Laatikainen, Diana Chiosa, Angela Anisei, et al.. (2026). Implementing WHO PEN in primary health in Moldova: a qualitative evaluation of barriers, enablers, and lessons for scale-up. BMC Primary Care. https://doi.org/10.1186/s12875-026-03252-2