The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion

Gene Bukhman, Ana O Mocumbi, Rifat Atun, Anne E Becker, Zulfiqar Bhutta, Agnes Binagwaho, Chelsea Clinton, Matthew M Coates, Katie Dain, Majid Ezzati, Gary Gottlieb, Indrani Gupta, Neil Gupta, Adnan A Hyder, Yogesh Jain, Margaret E Kruk, Julie Makani, Andrew Marx, J Jaime Miranda, Ole F Norheim, Rachel Nugent, Nobhojit Roy, Cristina Stefan, Lee Wallis, Bongani Mayosi†, for the Lancet NCDI Poverty Commission Study Group

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We live in an era of unprecedented global wealth. Nevertheless, about one billion people in low-income and lower-middle-income countries (LLMICs) still expe­rience levels of poverty that have long been described as “beneath any reasonable definition of human decency”, in the words of former World Bank president, Robert McNamara. This Commission was formed at the end of 2015 in the conviction that non-communicable diseases and injuries (NCDIs) are an important, yet an under-recognised and poorly-understood contributor to the death and suffering of this vulnerable population. The aims of the Commission were to rethink global policies, mend a great disparity in health, and broaden the global health agenda in the interest of equity.

Beginning in 2016, this Commission organised a team of 23 clinicians, researchers, and policy practitioners into four working groups with these objectives: to learn about the scale and pattern of the NCDI burden among the poorest; to identify priority interventions and delivery strategies to address this burden; to consider gaps and opportunities for NCDI financing in the countries where the poorest billion live; and to better understand the history and current state of NCDI framing and governance within key global institutions and at national levels.

This Commission has identified a set of cost-effective and equitable interventions to address NCDI Poverty. Although global initiatives have largely focused on health behaviours, the interventions we have identified also have to be delivered through the health sector, including at secondary facilities (such as, district hospitals) to treat established disease. In section 2—integrating NCDI Poverty in UHC—we describe these interventions and show how they can be implemented at scale…. We find that health-sector interventions to address NCDI Poverty are diverse and require integration both within and across levels of the health system. We introduce the concept that delivery of these interventions through integrated care teams can help drive trans­ formative change to improve the quality of services in health systems.

Malawi PEN-Plus Operational Plan

Malawi Ministry of Health and Population, Malawi PEN-Plus Stakeholder Group, NCDI Poverty Network Co-Secretariat/Center for Integration Science, Abwenzi Pa Za Umoyo/Partners In Health Malawi

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This operational plan was developed to guide scale-up and identify practical ways to implement PEN-Plus across the country. The plan draws from a large volume of stakeholder consultation across MOHP, clinical implementing partners, civil society, and other technical partners, building on the work of the NCDI Poverty Commission. The plan also draws from existing PEN-Plus experience in Malawi, including projects led by the MOHP with support from the World Diabetes Foundation and the Neno District MOHP team with support from Partners In Health and Helmsley Charitable Trust.

The PEN-Plus operational plan details the current situation for care for severe and complex chronic NCDs in Malawi. It then goes on to outline the model of care including the care continuum, staffing, interventions, training and mentorship, commodities, and M&E. We are confronted with critical next steps in governance, funding, human resource development, supply chain, and data systems, and we are confident that by building on existing systems and leveraging our substantial community of experts, advocates, academics, partners, and civil society we will make significant progress in addressing this critical burden of disease in Malawi.

National PEN-Plus implementation will require political will, partner engagement, funding, and a strong understanding of the NCDI burden we are addressing. The PEN-Plus consultation group is optimistic that together we can develop a pro-poor pathway in treating severe and chronic NCDs in Malawi, complementing existing NCD interventions within an inclusive agenda rooted in equity for a comprehensive NCD response in Malawi. This will help move us toward a brighter future for all present and future patients suffering from this wide array of conditions, ensuring no one is left behind.

Dr. Jones Masiye
Deputy Director of Clinical Services, NCDs & Mental Health
Malawi Ministry of Health & Population

Integrated Care Cascade Toolkit: an implementation guide to screening, treatment & follow-up for HIV & NCDs

Lemie Banda, Elizabeth Dunbar, Tafwirapo Chihana, Arnold Jumbe, Chiyembekezo Kachimanga, Lila Kerr, Joseph Lusaka, Bright Mailosi, Lawrence Nazimera, Basimenye Nhlema, Charles Phiri, and Emily Wroe

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The Integrated Care Cascade was developed in Neno District, Malawi over two years of collaboration between Partners In Health and the Ministry of Health (MOH).

PIH began working in Neno in 2007, and the HIV care program quickly blossomed, with active screening initiatives, treatment decentralized to all health facilities, and a robust system for tracking patients with missed appointments.3 At the end of 2014, 7,100 clients were enrolled in HIV care, representing an estimated 75% of HIV cases in the district.

Meanwhile, care for non-communicable disease (NCD) patients remained limited: case-finding was low, treatment was only available at the two hospitals, and there was no system to follow-up with missing patients. At the end of 2014, just 1% of estimated hypertension and diabetes cases were enrolled in care.

The Neno solution was to integrate care across screening, treatment and follow-up systems, leveraging the success of the HIV program to improve NCD outcomes. Through strategic leveraging of the strong HIV platform, including staff, space, and other resources, Neno was able to fully integrate NCD care. This toolkit highlight this success, including screening, treatment, and follow-up systems for our Integrated Chronic Care Clinic.

Communitisation of healthcare: peer support groups for chronic disease care in rural India

Yogesh Jain paediatrician and public health physician, Priyank Jain internal medicine physician

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The management of chronic diseases requires the sustained motivation of patients to engage in long term adherence and periodic review of the treatment plan. Given this, the assumed primacy of doctors and hospitals as providers of care is increasingly being challenged, and recognition is increasing that health outcomes are “co-produced” by healthcare systems and patients.

Peer support is support from people who have the same health condition as the patients they help—they experience the same challenges of living with the same chronic condition. In poorer countries, peer support groups have been used for mental illness and HIV but with relatively little research on benefits or about applicability to other chronic diseases. Patients in poorer settings are even more vulnerable because they also lack access to healthcare facilities, which can be a further demotivator to the long term engagement needed for optimal health outcomes.

In this essay we describe our experience of using on-to-face peer support groups for chronic disease management facilitated by community health workers in rural central India.

Embodied contradictions, structural power: Patient organizers in the movement for global health justice

Apoorva Gomber, Eunice Owino, Moses Echodu, Anu Gomanju, Paladie Mategeko, Lauren Brown, Jonathan D. Shaffer

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The current regime of global health governance ensures three things remain true. First, it ensures that the capital allocated to systems of effective caregiving remains deeply insufficient for the health needs of the vast majority of the people in the world. Indeed, at least half the world lack access to essential health services. Second, the fragmented caregiving systems that do exist are largely governed by global institutional philanthropy and their NGOs, usually from the U.S. or Europe, and deploy a logic of “cost-effectiveness”–a race to the bottom in terms of care quality in the name of “efficiency”. Third, this regime of frag- mented charity care in impoverished regions of the Global South often dampens the political aspirations of patients, healthcare providers, and Ministry of Health planners. Sights get narrowed; expectations are reined in because budgets are assumed to be fixed. Failures of imagination combine with deep socialization for scarcity such that substantive change feels insurmountable.

Where do we find hope given this bleak picture? We, the authors, find hope in the fights waged by our fellow patient-organizers. Patient organizers are people living with disease, and those who stand in solidarity with them, who choose to build organizing campaigns and power within a broader constituency to win shared goals. They are central in driving what sociologists have called embodied health movements.

Applying the Care Delivery Value Chain: HIV/AIDS Care in Resource Poor Settings

Joseph Rhatigan, Sachin Jain, Joia S. Mukherjee, Michael E. Porter

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The care delivery value chain (CDVC) is a framework that allows a systemic analysis of value creation across the myriad of activities that occur during the care of a patient for a specific medical condition. The CDVC looks at care as an overall system, not as a series of discrete interventions. It describes the discrete activities that are required to deliver care and illustrates their sequence and organization. As clinical care requires many interdependent activities, value is measured as a product of the entire care cycle. The CDVC is a tool that allows one to outline and analyze the process of care delivery for a medical condition in order to use this information to configure this process to maximize value for patients. Individual activities within the care delivery cycle contribute value but do so in relation to other activities in the cycle. Thus the value of any discrete activity can only be understood by considering its relation to other activities within the care delivery value chain. The CDVC also highlights activities such as patient access, external factors, patient information, and patient engagement that are crucial in resource poor settings.

Why there is new hope for the care of chronic diseases in Africa

Matshidiso Moeti, Ana Mocumbi, Gene Bukhman

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Over the past decade, with support from global non-governmental organisations, the ministries of health in Haiti, Liberia, Malawi, and Rwanda have refined an integrated healthcare delivery model called PEN-Plus that aims to alleviate the burden of non-communicable diseases on low income, rural communities by improving the accessibility and quality of care services.

In August 2022, the 47 countries that comprise WHO’s African region unanimously adopted PEN-Plus as the strategy to expand care for severe non-communicable diseases because it offers an efficient method for integrating services while ensuring ownership lies with each country’s health leaders. WHO is now mobilising ministries of health to support the implementation of PEN-Plus in 20 countries over the next three years. WHO is now mobilising ministries of health to support the implementation of PEN-Plus in 20 countries over the next three years. But to save lives, the strategy requires continued support and commitment.

The PEN-Plus Partnership: addressing severe chronic non-communicable diseases among the poorest billion

Gene Bukhman, Ana Mocumbi, Emily Wroe, Neil Gupta, Luwei Pearson, Raoul Bermejo, Jean Marie Dangou, Matshidiso Moeti

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PEN-Plus was designed to strengthen outpatient care for severe chronic NCDs at intermediate-level facilities such as district hospitals.PEN-Plus takes an equity-driven approach by first addressing severe conditions among the rural and urban poor. At the same time, PEN-Plus builds capacity to train, mentor, and supervise health workers at lower-level facilities, strengthening WHO PEN and chronic care decentralisation and integration for common NCDs.

In August, 2022, the 47 countries of WHO’s African Region approved a resolution and strategy to achieve high-levels of PEN-Plus coverage by 2030. 3 weeks later, a global PEN-Plus Partnership was launched as an initiative of the NCDI Poverty Network. This global partnership includes leading organisations focused on childhood heart disease, diabetes, and sickle cell disease working together with WHO and UNICEF to dramatically increase the number of the poorest children and young adults on high-quality treatment for these three conditions and other severe chronic NCDs by the end of the decade.

An investment case for the prevention and management of rheumatic heart disease in the African Union 2021–30: a modelling study

Matthew M Coates, Karen Sliwa, David A Watkins, Liesl Zühlke, Pablo Perel, Florence Berteletti, Jean-Luc Eiselé, Sheila L Klassen, Gene F Kwan, Ana O Mocumbi, Dorairaj Prabhakaran, Mahlet Kifle Habtemariam, Gene Bukhman

RHD Investment Case LGH Despite declines in deaths from rheumatic heart disease (RHD) in Africa over the past 30 years, it remains a major cause of cardiovascular morbidity and mortality on the continent. We present an investment case for interventions to prevent and manage RHD in the African Union (AU).

Increased coverage of interventions to control and manage RHD could accelerate progress towards eradication in AU member states. Gaps in local epidemiological data and particular components of the disease process create uncertainty around the level of benefits. In the short term, costs of secondary prevention and secondary and tertiary care for RHD are lower than for primary prevention, and benefits accrue earlier.

PEN-Plus Policy Brief – Decentralizing lifesaving care for severe NCDs

8-page policy brief presents PEN-Plus as a proven model for decentralizing care and treatment for type 1 diabetes, sickle cell diseases, rheumatic and congenital heart disease, and other severe NCDs that cause hundreds of thousands of avoidable deaths every year among the world’s poorest children and young adults.