The move towards universal health coverage (UHC) has been spurred on by the risk of a pandemic and the premise of the sustainable development agenda. But, as countries move towards UHC, their frame of reference often converges around services focused on maternal and child health and infectious diseases. This is likely to be because of the programmes that were established in the era of the millennium development goals.
Non-communicable diseases (NCDs) must be part of UHC frameworks—they are the world’s biggest killers and the leading cause of preventable morbidity and disability. This does not mean a vertical solution. Opportunities exist to negotiate policy space for NCDs in each health systems’ six “building blocks,” and therefore in UHC plans.
In terms of service delivery and financing, where free at the point of delivery measures are being adopted in order to achieve UHC, it is important to also have NCD services included in UHC entitlements. Where insurance schemes are being used to finance UHC, NCDs must be included in the public benefits package. And where social protection programmes are the UHC instrument, they must acknowledge that much of the risk of catastrophic health expenditure is derived from NCDs.
Primary healthcare must be reoriented towards chronic care. This can be done readily in settings where HIV chronic care platforms have been established, as these provide an opportunity to jumpstart nascent NCD programmes. A recent partnership between the US President’s Emergency Plan for AIDS Relief and AstraZeneca, aimed at offering HIV/AIDS and hypertension services in an integrated manner, is a step in the right direction. Recent initiatives, such as the Defeat NCD partnership and Resolve, can help accelerate the integration of NCDs into primary healthcare.
Drugs for NCDs should be included in national essential drug lists and national drug procurement systems. Access to disease preventing vaccines is a key component of UHC. The human papillomavirus (HPV) vaccine, as an example, represents a cost effective measure to prevent cervical cancer, an NCD that needlessly kills over 270 000 women each year. HPV vaccination is being rolled out from Australia to Rwanda. Coupled with increased screening, HPV elimination is now feasible and, with support from countries and organisations like GAVI, the Vaccine Alliance, the vaccine can be accessible across the globe. Similarly, the hepatitis B virus (HBV) is the cause of 43% of deaths from liver cancer globally. Liver cancer rates tend to be highest in countries with minimal immunisation programmes. If administered early, the HBV vaccine can save lives.
The complexities in the diagnosis of NCDs at a population level necessitate surveillance of risk factors rather than diseases. Risk factor surveillance can be integrated with existing population based surveys such as the Living Standards Measurement Survey, Demographic Health Survey, or the Multiple Indicator Cluster Survey. These are routinely conducted in over 100 countries. Integration of NCD surveillance with these surveys would mean there was no need for standalone NCD surveys. This can be supplemented with cancer registries and NCD-sensitive metrics in service management information systems.
The inclusion of NCD training modules into the curriculums of ongoing education for health workers can help prime professionals in the new realities in public health. Community health workers and nurses have a critical role in giving lifestyle advice and support in reducing stigma and discrimination, which is especially important when it comes to mental health. Partnerships with the nursing community can be rewarding. The Nursing Now project is looking at ways to further leverage their strengths, including collaboration with the NCD community.
Technological innovations ranging from telemedicine and mobile health to artificial intelligence and the internet of medical things, as well as personalisation and on-demand healthcare, are largely drawn on NCDs. As health systems of the future are shaped with these changes, and UHC plans draw on them to make health systems more efficient and effective, the integration of NCD care will become more feasible. But there must be political will to do so.
NCD and UHC integration is critical for closing the NCD services gap and tackling the rates of unnecessary deaths, disability, and illness from NCDs. While essential, however, it is not enough. NCDs are uniquely responsive to changes in the environments in which people live. Factors that contribute heavily to NCD risk factors, like unhealthy diet, physical inactivity, tobacco and alcohol use, and air pollution, are beyond the purview of the health system, hence the urgent need for multisectoral action.
Prevention strategies, such as the WHO recommended “Best Buys,” and more recent initiatives, such as WHO’s move to remove trans fats from the global food chain, are critically important in tackling NCDs. They could help us save 8 million lives by 2030. To be successful, governments must unbundle the term “multisectoral.” More broadly, an overarching change is needed so that governments choose to prioritise long term sustainability over short term gratification, and calculate the true cost borne by societies in the future instead of just the price of actions and policies today.
The global community has a responsibility to facilitate this transformation. Countries have become accustomed to the politically attractive clear “asks,” fiscal envelopes, and hand holding of the millennium development goal era. There should be no escaping a strong global push to tackle NCDs. A strong institutional base, a clear strategy, and adequate funding are critically needed.
NCDs will be profiled at the United Nations General Assembly high level meeting in September. Never has there been a wider chasm in public health between, on the one hand, our knowledge about the burden of disease coupled with evidence of what works, and inaction on the other. We must act decisively to bridge that. The future will hold us accountable for our actions. Words are not enough.
Sania Nishtar is the co-chair of the WHO Independent High-level Commission on NCDs
Competing interests: None