Improving responsiveness of health systems to non-communicable diseases

Abstract

In almost all countries, development of health systems that are responsive to the challenge of prevention and treatment of non-communicable diseases (NCDs) is a priority. NCDs consist of a vast group of conditions, but in terms of premature mortality, emphasis has been on cardiovascular disease, cancer, diabetes, and chronic respiratory diseases—diseases that were also the focus of the UN high-level meeting on NCDs, held in 2011. In 1990, there were 26·6 million deaths worldwide from NCDs (57·2% of 46·5 million total deaths), increasing in 2010 to 34·5 million (65·5% of 52·8 million deaths) as the leading cause of death in all regions apart from sub-Saharan Africa and south Asia. Similarly, the global burden of NCDs has increased from 43% (1·08 billion of the total 2·50 billion) in 1990, to 54% (1·34 billion of 2·49 billion) of the total number of disability-adjusted life-years in 2010. The global economic burden of NCDs is large, estimated at US$6·3 trillion in 2010, rising to $13 trillion in 2030. A 10% rise in NCDs leads to a 0·5% decrease in gross domestic product. The projected cumulative global loss of economic output due to NCDs for 2011–30 is estimated at $46·7 trillion, with around $21·3 trillion (46%) in low-income and middle-income countries. The growing burden of NCDs in low-income and middle-income countries will compound the poverty and economic hardship created by communicable diseases and hold back development. Yet, few such countries have the fi scal strength to meet the future health, economic, and social burden that NCDs will impose, which raises concerns of economic instability, arrested development, and government fragility—with implications for global security as well as foreign policy. An ageing society, alongside improving health care, means that health systems have to manage not only diseases such as heart disease, stroke, and cancer, but also individuals with multiple chronic disorders. Multimorbidity disproportionately aff ects those who are poorest. Furthermore, around 9 million people in lowincome and middle-income countries now benefi t from antiretroviral treatment (ART), with remarkably im proved survival, but with new comorbidities such as diabetes or cardiovascular disease. Health systems also have to manage patients with new comorbid disease patterns, in which infectious diseases combine with NCDs. Management of people with NCDs and multimor bidity will be particularly challenging in low-income and middle-income countries with weak health systems characterised by fragmented health-care services, which are still designed to respond to single episodes of care, or the long-term prevention and control of infectious diseases such as HIV, tuberculosis, and neglected tropical diseases. These health systems are ill prepared to manage changing disease patterns with a growing burden of NCDs and multimorbidity. To achieve the World Health Assembly target of 25% reduction in preventable deaths from NCDs by 2025, health systems need to be transformed to provide person-centred care with improved outreach and selfmanagement to eff ectively manage risk factors, illness episodes, and multimorbidity over many years. Along with outreach and community-based services, health facilities in low-income and middle-income countries need to be strengthened to develop reliable individual records that enable assessment and management of risks of individuals under their care. Yet, in many such countries, long-term care and risk management that includes follow-up at clinic and repeat prescriptions are a new idea for many patients and health staff . However, existing service delivery platforms can be used to address chronicity, the emerging NCD epidemic, and multi morbidity. Resource constrains imposed by the worldwide economic crisis means that sustaining increases in global health fi nancing will be a challenge. There is an imperative to fi nd solutions that create synergies among investments in low-income and middle-income coun tries for diff erent diseases, especially HIV and tuber culosis, which have substantially benefi ted from international fi nancing and have clear links with NCDs. In this paper we provide examples of how HIV and tuberculosis investments have been used to strengthen health systems and opportunities to integrate NCD prevention and control with HIV and other programmes. We describe the importance of building health services that profi le the risks of NCDs and multimorbidity in their population. Finally, we propose a stepwise approach to scale up health systems by building on existing programmes to tackle NCDs and multimorbidity.