Implementing WHO PEN in primary health in Moldova: a qualitative evaluation of barriers, enablers, and lessons for scale-up

Background: The WHO Package of Essential Noncommunicable (PEN) disease interventions is promoted to strengthen NCD prevention and management in primary health care (PHC), particularly in low-resource settings. Moldova initiated PEN implementation in 2017. Prior quantitative monitoring showed mixed performance across sites. Objective: To identify practical strategies to improve implementation and inform national scale-up. Methods: We conducted a qualitative study (June–August 2018) in five family medicine centers purposively selected for prior PEN performance (two high, one medium, two low). Two trained interviewers per site conducted semi-structured, face-to-face interviews with clinicians. Interviews were audio-recorded, transcribed verbatim (Romanian), anonymized, and analyzed using the framework analysis approach by a six-member team. Findings were discussed iteratively with the evaluation team. Results: Twenty-eight participants were interviewed (15 doctors, including five managers and 13 nurses). Participants valued PEN for structuring consultations and clarifying team roles. Implementation barriers included staff shortages and workload, duplicate documentation, limited ongoing training (especially for risk communication and motivational interviewing), inconsistent use of cardiovascular risk to guide treatment, referral bottlenecks, and patient-level barriers (costs, limited preventive care use among working-age men, migration). Enablers included joint doctor-nurse training, clear role delineation, simple embedded tools (checklists), local reorganization of patient flow, and leadership engagement. Conclusions: To sustain impact during scale-up, national efforts should streamline documentation, institutionalize refresher training focused on counseling and risk-based care, address access and referral gaps, and deliver community outreach to under-reached groups. These actions can strengthen PHC and advance national NCD goals.