• health policy
• public health

On 10 December 2019, the WHO launched the ‘It’s time to walk the talk: WHO independent high-level commission on non-communicable diseases’ report.1 This was the second report of the commission convened in 2017 by the director general of the WHO to address the global burden of non-communicable diseases (NCDs) in innovative ways. The current report highlights that given the current measures in place the 2030 sustainable development goal (SDG) target 3.4 of reducing by ‘one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being’ will not be met.2 Whereas the first report proposed recommendations for heads of state, governments, civil society and the private sector, the proposals put forward in this report were targeted at the WHO. The eight recommendations include: encouraging heads of state and governments to take the lead in the NCD response; supporting countries to ensure healthy lifestyles for their populations; proposing investments in mental health; including prevention in universal health coverage (UHC); introducing social and financial protection measures to prevent people falling into poverty due to NCDs; engaging with businesses and member states to address NCDs and mental health; encouraging interactions between governments and civil society; and advocating for a ‘multi-donor trust fund to support countries in activities to reduce NCDs and promote mental health’.3

As a group of humanitarian actors, clinicians and academics active in the area of NCDs in low/middle-income countries (LMICs) and humanitarian settings, we welcome the launch of this report. The report rightly addresses many of the determinants driving the NCD epidemic and offers concrete actions for the WHO to move progress forward with governments, civil society and the private sector.

However, we feel that the important concept of inequality is largely missing from the report. By inequality we refer to the disparities in access to healthcare and services which are ‘unnecessary’, ‘avoidable’ and ‘unfair and unjust’.4 This is essential to align with the SDG 2030 agenda of ‘leaving no one behind’,5 also quoted in the report.1 We see three components that are essential to tackling the inequalities that exist for NCDs: functioning and fully supported health systems, access to medicines and technologies and addressing NCDs in humanitarian settings.

Although the report does mention health systems and provides a focus on primary healthcare (PHC), much stronger recommendations are needed to ensure appropriate investment in strengthening and improving the quality of health systems, especially at PHC level.6 To date, PHC is not equipped in many settings to address the needs of populations in managing NCDs and to do this strong government involvement and investment are required.7 8 This also needs to be supported by the global community as a priority. Beyond this, a shift in paradigm is needed, focusing on how health systems respond to the complex needs of the populations they serve,6 especially those with NCDs. This focus on health systems does not preclude active support to essential population-wide prevention strategies. On the contrary, it will reinforce these by having prevention measures tailored to the context where people live.9

With regards to access to medicines and technologies, including diagnostic tools, many studies have found that availability and affordability of NCD medicines and technologies is much lower in LMICs than in high-income countries (HICs).10 Insulin is a striking example in that despite having been discovered 100 years, there are marked disparities and gaps in global insulin access.11 Governments, the private sector and other actors all need to be involved in finding sustainable solutions to ensure access to medicines and technologies within functioning health systems.

Lastly, as the report acknowledges, it fails to contextualise NCDs in humanitarian settings. Currently, the world is seeing an unprecedented number of individuals facing humanitarian emergencies with 125 million people affected,12 almost equivalent to the population of Japan. These individuals face many barriers to accessing care and medicines and are often reliant on external interventions to ensure their survival. Many of the authors of this comment are involved in a working group that establishes principles and guidelines for the management of NCDs in humanitarian settings, which have only recently started to be addressed in a systematic way.

Despite high-level meetings at the United Nations, the WHO’s global action plan for the prevention and control of non-communicable diseases and two reports from the high-level commission on NCDs, the global NCD response has failed to materialise. There are some positive tangible results, such as a renewed call for the importance of PHC during the 40th Anniversary of the Alma-Ata Declaration, plans for inclusion of insulin in the WHO’s prequalification programme and the WHO’s development of an emergency health kit of key NCD medicines and technologies, which all help address inequalities on the NCD agenda.

For NCDs, embracing prevention, addressing risk factors and improving access to care require different approaches and policies.13 Addressing risk factors requires strong policies, multi-sectoral involvement and global conventions and guidance as has been developed for tobacco. For provision of care, a solid health system response needs to be locally driven with a focus on national and subnational policies. Globally, in HICs, LMICs and humanitarian settings, the delivery of chronic care needs to adapt to the complexity of managing NCDs and their associated multi-morbidities, with a focus on PHC and involvement of local communities, as one size does not fit all. This is even more relevant given the current COVID-19 pandemic as people with NCDs are more vulnerable and need resilient health systems providing population-wide prevention, continuous access to care and referrals. While the pandemic’s consequences are truly global, people with NCDs in countries affected by humanitarian crises with overcrowded camps, places of detention and communities that are already highly vulnerable, where health and other systems are weak and under-resourced, will bear the brunt of the current and future impact of the pandemic. COVID-19 will exacerbate existing inequalities and possibly create new ones given the wide social and economic challenges that the pandemic has created and people with NCDs will be among those most vulnerable to these inequalities.

In all contexts allocation of resources needs to optimise access for long-term care and treatment, paired with population-wide prevention efforts in order to guarantee UHC. The UHC agenda places strong emphasis on equality in access to services, medicines, including in humanitarian settings. While the report invites us ‘to walk the talk’ proposing ‘bold’ recommendations, for political commitment on NCDs we contend that these could have been stronger to also address inequalities in access to NCD care and medicines for the millions of people already with NCDs.14 Any recommendation for NCDs must guarantee equal access to NCD prevention, treatment, care and rehabilitation for all in need, in order to truly leave no one behind.