Richard Smith: How well are countries doing in responding to the NCD pandemic?

richard_smith_2014A pandemic of NCD (non-communicable disease) is sweeping across the world, particularly in poor countries, causing much suffering and premature death and swamping health systems. NCD (cardiovascular disease, diabetes, chronic obstructive pulmonary disease, and common cancers) accounts for 63% of global deaths (37 million annually), with 80% occurring in low and middle income countries. Almost a third of deaths from NCD in poor countries are in those under 60.

Recognising the scale of the problem and that deaths from NCD are expected to increase by 15% between 2010 and 2020, the United Nations held a high level meeting in 2011 and produced plans on how to reduce the growing burden from NCD. Afterwards the World Health Organization (WHO) set a range of targets, including reducing deaths from NCD in those under 70 by 25% by 2025. But how well are countries doing? A letter in this week’s Lancet gives high level results of a study, and a website launched today gives much more detail plus priorities for action.

The study looked at governance, risk factors, surveillance and research, and health systems in 23 mostly low and middle income countries (including China and India). The overall results show that most countries have a long way to go with mounting a comprehensive response to NCD, although there is considerable variation. There is a strong correlation between adequacy of response and per capita income, which is not surprising as richer countries have long had a high prevalence of NCD and poorer countries have been concentrating on reducing infectious disease and improving maternal and child health. Indeed, it is successes with this work that has left people alive to develop NCD. The pandemic has moved very fast: in Matlab in Bangladesh, for example, a closely monitored population has seen deaths from NCD increase from 10% of all deaths in 1986 to 80% of deaths by 2006.

Countries, even high income ones, are doing particularly poorly at reducing the risk factors for NCD (tobacco use, poor diet, physical inactivity, and the harmful use of alcohol). Most are also not doing well in researching local responses to NCD and measuring levels of disease and risk factors. Surveillance may be boring, but without good surveillance it’s impossible to know if policies and actions are working.

Governance is the strongest area, which is to be expected as countries must begin by recognising the problem, setting up teams and programmes, and developing plans and policies. Heath systems in high income countries are generally doing well in responding to NCD, but they may well find themselves overwhelmed. Health systems in some poor countries—particularly India, Kenya, and Guatemala—are not able to respond adequately, lacking staff, guidelines, and treatments.

The study has been undertaken by GRAND [Global Research Against NCD] South, a network of 11 centres in low and middle income countries doing research, building capacity, and advising on policy in relation to NCD. A two stage Delphi process identified 51 indicators, and field workers in each country then questioned people from government (not just from health but also finance and other departments), civil society, and academia. Many of the indicators are qualitative, as quantitative data is often unavailable or unreliable in low and middle income countries.

One hypothesis was that people from different sectors might give different answers, with perhaps government officials exaggerating the effectiveness of the response and academics being sceptical; but in most countries answers were similar. Respondents answered the questions on a four point scale (0-3), and an overall score was calculated for each indicator by dividing the total score by the total possible score and presenting the result as a percentage.

The website gives the high level scores and for each country the detailed responses to each indicator for all the sectors. Each country has downloadable PDF executive and full reports that include strengths and priorities for action. Most countries have a commentary, and results, reports, and commentaries are included in the local language as well as English.

Results for China, for example, show that the country is doing better than most other upper middle income countries with governance, surveillance and research, and health system response, but poorly—like comparable countries—with reducing risk factors. Strengths in China are vaccinating children against hepatitis B, reducing salt intake (very high in Northern China), and developing a national system for measuring physical activity. Priorities might be reducing sugar intake, banning trans fats, developing a national monitoring and surveillance system for NCD, and including the HPV vaccine in a national immunisation programme. “We need to face up to the deficiencies revealed by the scorecard [which shows] that the control of major risk factors and the health system reform in response to NCDs are relatively weak,” said Professor Yangfeng Wu, from the China International Center for Chronic Disease Prevention.

The hope is that the results will reach policy makers, campaigners, and others and spur greater and smarter action to counter the pandemic of NCD. GRAND South will be conducting an evaluation of the impact of the NCD Scorecard, and if the results show that policy makers and others find the results useful then GRAND South will seek funding to repeat the exercise. Regular, credible, useful, and actionable monitoring of progress (or the lack of it) is important for making countries accountable and helping them respond to the growing burden of NCD.

Richard Smith was the editor of The BMJ until 2004. He is now chair of the board of trustees of icddr,b [formerly International Centre for Diarrhoeal Disease Research, Bangladesh], and chair of the board of Patients Know Best. He is also a trustee of C3 Collaborating for Health.

Competing interest. RS is one of the authors of the Lancet letter and was employed by and still has shares in UnitedHealth Group, and the UnitedHealth Foundation (UHF) funded the early stages of this research. UHF did not prepare, review, or validate the content of the Lancet publication, this blog, or the website. The content and opinions expressed are those of the authors and do not represent the position of UHF.