Background:
Implementation research (IR) integrates research directly into health system decision-making by embedding studies within existing programs, engaging key decision-makers and implementers throughout, and aligning with implementation cycles. This approach tackles relevant questions, secures buy-in, and increases the chances that evidence shapes policies and programs. Delivered cost-effectively and within tight timelines, IR fits within routine monitoring and evaluation. Local research teams work closely with implementers to rapidly identify and analyze challenges. UNICEF, collaborating with local and global partners, has successfully used IR to produce actionable insights worldwide.
Non-communicable diseases (NCDs) contributes about 66% of deaths in Nepal. The Package of Essential Noncommunicable Disease Interventions—Plus (PEN Plus) is an integrated care model targeting severe NCDs like type 1 diabetes, rheumatic and congenital heart diseases, and sickle cell by improving access to quality care at district-level hospitals, strengthening referral systems, and protecting poor families from financial hardship. In the PEN Plus model, mid-level clinicians in intermediary facilities in low and lower middle income countries are trained to provide integrated care for conditions where services traditionally were only available at tertiary referral facilities.[1] The first two PEN Plus clinics opened in 2021 in Damak and Bardiya; four more followed in 2022 in Lahan, Dailekh, Bajhang, and Gulmi. A national operations plan is underway to support nationwide rollout.
A National Operation Plan for PEN Plus is being developed to support its scale-up across Nepal. As a new program, implementers have highlighted challenges such as integration into hospital services, retention of medical staff, supply chain issues for equipment and medicines, and community access. IR can help identify and address these barriers in real-time, supporting improvements at all levels of the health system.
Purpose and Objectives
UNICEF, in collaboration with EDCD/MoHP and partners, aims to understand and explore challenges and enablers to the operationalization/implementation of PEN Plus interventions within the broader health system.
General Objective
- Conduct implementation research in two priority topics mentioned in the scope of work
- Generate actionable evidence and recommendations.
- Support packaging and dissemination of findings to key stakeholders.
Specific Objectives
- Support IR based on the priority learning/research questions to tackle the evidence gaps, identify potential solutions, and ensure service utilization by children and young people affected by NCDs
- Support better packaging of evidence generated from IR projects tailored to users and disseminate (including manuscript for publications) with relevant stakeholders to ensure timely and rigorous use of the evidence for PEN Plus implementation and scale up.
 Scope of Work
PHRD Nepal will support in conducting implementation research on two research topics as outlined below:
- PEN Plus supply chain management
PHRD Nepal will assess the PEN Plus that requires additional medical equipment, laboratory equipment and reagents, and medicines which are required for service delivery of NCD conditions like type 1 diabetes, rheumatic heart disease, congenital heart disease, asthma, hemoglobinopathies, and many other conditions. The challenge is establishing a supply chain at the PEN Plus clinic at the beginning of the program, followed by transitioning the supply chain mechanism to routine government supply chain mechanisms. PHRD Nepal will address the following specific questions as stated in the ToR:
- What are the barriers of the current supply chain management systems in Nepal, including supplies and procurement of PEN Plus-related commodities and medicines?
- What are the most effective procurement practices in place across the PEN Plus intervention districts?
- Which strategy works best and why? What are the optimal strategies to scale up an effective supply chain management system to ensure implementation of PEN Plus interventions in Nepal?
- PEN Plus Service delivery
As PEN Plus clinics are set up in first-level referral hospitals (previously known as district hospitals) with a trained medical doctor/MDGP (MD in general practice) and a staff nurse to provide extensive PEN Plus services. One of the challenges is ownership and retention of the above technical human resource, especially in district-level hospitals by the Government, as PEN Plus expands for national scale-up. PHRD Nepal will address the following IR questions:
- How can the delivery of PEN Plus services be integrated into the overall health system in Nepal? What are the enablers and barriers to integrating PEN Plus service delivery into the overall district health systems in Nepal?
- What are the means and ways to integrate and collaborate PEN Plus human resources as part of the overall hospital HR (doctors, nurses, and lab technicians)?
PHRD Nepal will further refine the proposed research questions, tailoring them to the proposal process and providing clear justifications, while maintaining the core concepts intact. Such well-considered revisions will demonstrate their technical capabilities.
PHRD Nepal will also encompass several key tasks i.e.,
- reviewing existing knowledge and data on the research topics;
- developing comprehensive research protocols and data collection tools;
- securing ethical approval from the Nepal Health Research Council;
- conducting data collection and analysis; and
- producing detailed reports, policy briefs, and presentations on findings.
PHRD Nepal will also organize a dissemination seminar to share results with relevant stakeholders, develop an implementation plan for the recommendations, and prepare at least two manuscripts for submission to peer-reviewed journals. Once the contract is signed, the PHRD Nepal will be responsible for managing the entire implementation research process. UNICEF’s involvement will be limited to facilitating coordination with partners as needed, without assuming any additional responsibilities.
Research Area
The implementation research for the PEN Plus program in Nepal will focus primarily on six existing PEN Plus sites (six districts):
- Provincial Hospital Lahan,
- Dailekh Hospital,
- Bajhang Hospital,
- Gulmi Hospital,
- Damak Hospital, and
- District Hospital Bardiya.
Duration: November 2025 to October 2026
Study Team: Dr. Abhinav Vaidya, Dr. Abha Shrestha, Dr. Deependra Thapa, Dr. Janak Thapa, Ms. Pabitra Balapaki, Mr. Sagar Dahal, And Mr. Yagya Badu