Elsevier

The Lancet

Volume 376, Issue 9754, 20–26 November 2010, Pages 1785-1797
The Lancet

Series
Prevention and management of chronic disease: a litmus test for health-systems strengthening in low-income and middle-income countries

https://doi.org/10.1016/S0140-6736(10)61353-0Get rights and content

Summary

National health systems need strengthening if they are to meet the growing challenge of chronic diseases in low-income and middle-income countries. By application of an accepted health-systems framework to the evidence, we report that the factors that limit countries' capacity to implement proven strategies for chronic diseases relate to the way in which health systems are designed and function. Substantial constraints are apparent across each of the six key health-systems components of health financing, governance, health workforce, health information, medical products and technologies, and health-service delivery. These constraints have become more evident as development partners have accelerated efforts to respond to HIV, tuberculosis, malaria, and vaccine-preventable diseases. A new global agenda for health-systems strengthening is arising from the urgent need to scale up and sustain these priority interventions. Most chronic diseases are neglected in this dialogue about health systems, despite the fact that non-communicable diseases (most of which are chronic) will account for 69% of all global deaths by 2030 with 80% of these deaths in low-income and middle-income countries. At the same time, advocates for action against chronic diseases are not paying enough attention to health systems as part of an effective response. Efforts to scale up interventions for management of common chronic diseases in these countries tend to focus on one disease and its causes, and are often fragmented and vertical. Evidence is emerging that chronic disease interventions could contribute to strengthening the capacity of health systems to deliver a comprehensive range of services—provided that such investments are planned to include these broad objectives. Because effective chronic disease programmes are highly dependent on well-functioning national health systems, chronic diseases should be a litmus test for health-systems strengthening.

Introduction

The burden of disease attributable to chronic disorders, such as cardiovascular disease, diabetes, cancers, and respiratory disease, is higher in low-income and middle-income countries than it is in high-income countries, and continues to rise.1 Non-communicable diseases (most of which are chronic) will account for 69% of all global deaths by 2030 with 80% of these deaths in these countries.2 This mirrors the globalisation of risk factors such as tobacco, the combination of increased calorie intake and reduced exercise, and the ageing of populations.3, 4, 5

The chronic characteristics of non-communicable diseases contrast with the predominantly acute nature of infectious diseases (although inevitably there are exceptions, such as HIV, tuberculosis, and leprosy). Chronic illness demands a complex health-systems response that needs to be sustained across a continuum of care. Evidence-based interventions should be delivered by health professionals with diverse skills. Appropriate technologies, dependable pharmaceutical supplies, and clean, accessible health facilities need to be brought together over a sustained period. These efforts should also be complemented by effective public policies to tackle major risk factors. Such interventions are possible only with a functioning health system, which can deliver disease prevention and education services alongside integrated care and intersectoral collaboration that extends beyond the health sector.6

Key messages

  • Many cost-effective interventions exist to address the growing burden of chronic diseases in low-income and middle-income countries; however, weak national health systems often make it impossible to deliver and sustain interventions effectively and equitably.

  • Constraints on the capacity of countries to respond to the challenge of chronic diseases exist across each of the six key health-systems components of health financing, governance, health workforce, health information, medical products and technologies, and health service delivery.

  • Efforts to scale-up interventions for chronic diseases in low-income and middle-income countries tend to focus on one disease and its causes, and are often fragmented and vertical. These efforts represent missed opportunities to leverage the health-system reforms that are needed.

  • Global dialogue about health-systems strengthening neglects most chronic diseases.

  • Advocates for action on chronic diseases are not paying enough attention to the interface between chronic disease responses and health systems. Increased focus and understanding on the dimensions of health systems is needed if countries are to address the challenge of chronic diseases.

  • Interventions for responding to chronic diseases can lead to overall improvements in health systems in low-income and middle-income countries, provided that such investments are planned to include these broad objectives from the outset.

  • Chronic disease interventions depend on well-functioning national health systems since long-term coordinated and intersectoral responses are needed across a continuum of care. Reduction of mortality and morbidity that is associated with chronic diseases will be an important measure for assessment of efforts to strengthen health systems.

However, most low-income and middle-income countries have fragile health systems that are under-resourced and in need of structural and policy reform.7 The rapid transition in disease burden to chronic diseases is an enormous challenge for these weak systems. Cost-effective interventions to address chronic diseases exist, although progress is being stalled by shortfalls in the ability of health systems to ensure the effective and equitable delivery of these interventions.

We aim to assess the challenges involved in the delivery of services for chronic diseases in low-income and middle-income countries from a health-systems perspective; explore whether interventions to address chronic conditions can contribute to improving the capacity of health systems to deliver comprehensive health services; and assess whether the rapid emergence of a global agenda for health-systems strengthening, focused mainly on specific infectious diseases, is taking account of the growing need for services that can meet the challenge of chronic diseases in these countries.

Section snippets

Methods

We undertook an extensive review of published work from the past 10 years (1999 to present) in the Cochrane and PubMed databases. The search was done to identify health-systems aspects of prevention, diagnosis, treatment, monitoring, and management of chronic diseases in low-income and middle-income countries. Key search terms were: “chronic disease”, “developing country”, “low-income”, “health system”, “monitoring”, “prevention”, “screening”, “risk assess*”, “diagnosis” “medical test”,

Background

The prevention, treatment, and management of chronic diseases, whether in low-income, middle-income, or high-income countries, entails a core range of interventions—ie, primary prevention, proactive case finding (eg, assessment of risk factors and screening), education of both the public and health-care workers, efficient referrals, pharmacological and psychosocial interventions, long-term surveillance, and monitoring and assessment of quality of care.6 Although such interventions might be the

Global political commitments to chronic diseases and to health-systems strengthening

The political priority that is afforded to different aspects of global public health is communicated through the wide range of political commitments that are made by national health leadership and by development partners.66 Such commitments are formally expressed through resolutions and other statements of intent from relevant bodies and organisations. We did a wide search of the recent documentation of resolutions and statements about chronic diseases, and about health-systems strengthening.

Emerging issues

Our analysis shows many recurring themes. First is that chronic disease programmes are highly dependent on well functioning and equitable health systems—arguably more so than some other population-health interventions. Such a dependency results from the need for long-term and sustained coordination between sectors and at all levels across a continuum of prevention and care. Therefore, delivery of a comprehensive package of interventions for chronic diseases places substantial operational

Conclusion

Every effort must now be made to embed the discourse on chronic diseases firmly within the emerging agenda for health-systems strengthening, and to promote the needs of health systems to chronic disease advocates. A shared agenda will aim, from the outset, to build national health systems which can respond to the full spectrum of evolving population-health needs in low-income and middle-income countries. From this shared global vision will follow policy reforms that can encourage greater

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