From siloes to synergies: Ensuring everyone living with chronic diseases has access to essential healthcare

COVID-19 has intensified the need to ensure people in low- and middle-income countries can more easily access simultaneous services that prevent and treat both infectious diseases such as HIV, tuberculosis (TB) and malaria, and noncommunicable diseases such as cardiovascular diseases, cancers, respiratory diseases, and diabetes, finds a new report launched by the Noncommunicable Disease Alliance (NCD Alliance) today.

The report by The George Institute for Global Health, From siloes to synergies: Integrating noncommunicable disease prevention and care into global health initiatives and universal health coverage, argues that decade-long political commitments to integrate noncommunicable disease (NCD) services with services for priority groups for major global health initiatives such as HIV/AIDS, TB, malaria and maternal and child health have not translated into reality on the ground in low- and middle-income countries (LMICs). Healthcare in many LMICs does not yet respond to the needs of people living with NCDs, which have come to be the leading causes of death and disability worldwide.

LMICs are experiencing a rapid transition from population disease profiles shaped by communicable diseases and conditions impacting mothers and their children, to those dominated by NCDs and injuries. Today, 85% of people dying from NCDs between ages 30 and 70 are in LMICs.

“The funding to low- and middle-income countries for priority population health initiatives, such as HIV/AIDS, malaria, TB and maternal and child health has been pivotal in achieving substantial health gains over the past decade,” said Dr Gill Schierhout from the George Institute for Global Health, lead author of the report. “Many LMIC health systems continue to be influenced by global health funding and the shape of this has critical impacts on the health care available – or not available – for the growing number of people who are living with NCDs in LMICs.”

The new face of comorbidities

COVID-19 has brought about a greater recognition that the long-held distinctions between infectious and noncommunicable diseases are not as clear cut as once thought – those with chronic conditions have a significantly higher risk of hospitalisation or death from the virus. The vast majority of the millions of people to date who have lost their lives or became seriously ill with COVID-19 were living with underlying health conditions, most commonly hypertension, cardiovascular disease and diabetes. Longstanding inaction on NCDs has amplified the human and economic cost of COVID-19.   Similarly, with NCDs becoming more common in LMICs, comorbidities are now increasingly threatening the gains made against diseases such as TB and HIV.

“We urgently need a reset of healthcare delivery in poorer countries that actually reflects the needs of those who need it most,” said Katie Dain, CEO of the NCD Alliance. “Integrated care is the future of healthcare. The reality today is that ever more people are living with multiple chronic conditions. This needs to be better recognised in health systems. People living with HIV have a significantly higher risk of cardiovascular disease and some cancers. People living with TB are much more susceptible to diabetes and vice-versa. Hypertensive disorders and gestational diabetes affect many pregnancies, risking potential lifelong health impacts for both mother and child if not effectively treated.”

Cardiovascular diseases account for most NCD deaths, or 17.9 million people annually, followed by cancers (9.3 million), respiratory diseases (4.1 million), and diabetes (1.5 million). These four groups of diseases account for over 80 percent of all  NCD deaths before the age of 70.

“Health centres that reflect this changing epidemiology are the future,” said Dain. “But this will also mean that we have to change the way we do business. The COVID-19 pandemic has been catastrophic for people living with NCDs and it is clear we need a health infrastructure in LMICs that is fit for purpose if we are to build back better.”

It is more than a decade since Ministers of Health at the first UN High-Level Meeting on NCDs resolved to “encourage the development, integration and implementation of vertical programmes, including disease-specific programmes, in the context of integrated primary health care”. This approach is based on the idea that health systems need to adapt to a clearer focus on the person and their health throughout the life course, not only on the single health crisis or condition that leads them to seek care. However, progress in this area has been patchy at best. World leaders have recently reaffirmed the need to provide more integrated services to include NCDs, notably in the ground-breaking commitment at the United Nations High-Level Meeting on AIDS in June 2021, which commits governments to ensure 90 percent of people living with and at risk of HIV can access NCD and mental health care by 2025.

Case studies

The From Siloes to Synergies report surveyed LMIC health experts to identify why political commitments to integration of NCD services into global health programmes have not yet been widely achieved, sets out the empirical case for integration, and identifies constructive examples and key enablers of MNCH programmes, HIV programmes and other disease-specific programmes which are effectively integrating one or more NCD services either into their care packages or into primary healthcare:

• Kenya: Integrating HIV/AIDS and diabetes care in Western Kenya. Kenya Ministry of Health, Moi University, Moi Teaching and Referral Hospital, AMPATH consortium of North American Universities and Health Centres, with support from the World Bank, USAID, US National Institutes of Health, US Centres for Disease Control and Prevention, Bill and Melinda Gates Foundation, AstraZeneca, Boehringer Ingelheim, Eil Lilly and Company, Merck, Pfizer and Takeda.
• Malawi: Integrated Chronic Care Clinic in Neno District. Malawi Ministry of Health supported by Partners in Health and the Global Fund to Fight AIDS, TB and Malaria.
• Zambia: Cervical Cancer Prevention Programme. Zambia Ministry of Health and Center for Infectious Disease Research, supported by PEPFAR, US Centres for Disease Control and Prevention and the University of Zambia.

Recommendations

The report identifies key benefits of integration, which include improved health outcomes for target groups and wider populations, improved equity of access, cost effectiveness and increased user satisfaction and trust in health services. The report proposes three key ways forward and eight enablers to achieve NCD integration, and concludes with a set of recommendations for the global health community, national governments, health advocates and researchers:

DONORS AND DEVELOPMENT PARTNERS

• Leverage new and existing programmes and platforms to make them more integrated
• Include person-centred care indicators in funding requirements
• Create horizontal funding opportunities to promote an integrated agenda and stop/reduce initiatives which create separate data systems and supply chains
• Develop initiatives which take into account the care cascade (find-link-treat-retain) in integration efforts
• Build disease prevention into funding opportunities 
• Help generate evidence about integration and invest in evaluation.

GOVERNMENTS

• Provide leadership on integration and encourage coordination among stakeholders working across disease areas, ensuring that the full care cascade is prioritised
• Ensure people living with NCDs are meaningfully engaged in decision making and priority setting
• Collect multimorbidity data and incorporate into planning processes
• Take into account capacities and priorities of sub-national health service providers
• Promote the transition to UHC in a phased and context-specific way
• Actively seek integrated funding opportunities.

NCD ADVOCATES AND RESEARCHERS

• Actively build relationships with advocates from other global health priorities
• Amplify the voice of people living with NCDs by giving them a platform to share their experiences and ensure their meaningful involvement in integration design processes 
• Call for the inclusion of NCDs in UHC and advocate to abolish user fees for health care
• Share successes and lessons learned about integration
• Generate evidence about integration for programme designers.