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.

Rural Zambian Oral Health Transition: A Long-Term Retrospective Examination of an Outreach Program’s Progress and Impact

Morgan JP, Marino ON, Finkelman M, Mourão CF, Flubinda FS

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This study aimed to (a) describe an annual prevention-focused, community-based oral health outreach program in rural Zambia, (b) assess its oral health outcomes using demographic and oral health variables, and c) identify milestones resulting from program activities.

A retrospective analysis of demographic and oral health data from a single site between 2007–2014 and 2018–2019 was conducted. 

Data from 5,791 subjects were analyzed. The prevalence of pain, untreated caries, and highest treatment urgency category decreased consistently across year categories. Both bivariate and multivariable analyses showed statistically significant differences in clinical outcomes between year categories (p < 0.001). In addition, the percentage of male participants and younger age categories increased during the study period. Key program milestones included the installation of two boreholes for clean water, the development of a local community oral health volunteer program, the establishment of an educational pipeline by the Dental Training School for residents, and the construction of a maternal/oral health center with district and ministry oversight.

The observed decrease in treatment urgency scores, presence of pain, and untreated caries are consistent with the prevention-seeking behavior of program participants. The increasing participation and changing demographic patterns over time suggest a growing demand for oral health services among males and younger individuals. The positive oral health outcomes and development of a maternal child/oral health facility exemplify a program design aligned with community needs and appropriate care delivery.

Economic evaluation of integrated services for non-communicable diseases and HIV: costs and client outcomes in rural Malawi

Emily B Wroe, Bright Mailosi, Natalie Price, Chiyembekezo Kachimanga, Adarsh Shah, Noel Kalanga, Elizabeth L Dunbar, Lawrence Nazimera, Mahlet Gizaw, Chantelle Boudreaux, Luckson Dullie, Liberty Neba, Ryan K McBain

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We quantified the annualised total and per capita economic cost of integrated chronic care at primary and secondary level health facilities in Neno District, Malawi, using activity-based costing from a health system perspective. We also measured enrolment, retention and mortality over the same period. Furthermore, we measured clinical outcomes for HIV (viral load), hypertension (controlled blood pressure), diabetes (average blood glucose), asthma (asthma severity) and epilepsy (seizure frequency).

The annualised total cost of providing integrated HIV and NCD care was $2 461 901 to provide care to 9471 enrollees, or $260 per capita. This compared with $2 138 907 for standalone HIV services received by 6541 individuals, or $327 per capita. Over the 12-month period, 1970 new clients were enrolled in IC3, with a retention rate of 80%. Among clients with HIV, 81% achieved an undetectable viral load within their first year of enrolment. Significant improvements were observed among clinical outcomes for clients enrolled with hypertension, asthma and epilepsy (p<0.05, in all instances), but not for diabetes (p>0.05).

Integrated Chronic Care Clinics (IC3) is one of the largest examples of fully integrated HIV and NCD care. Integrating screening and treatment for chronic health conditions into Malawi’s HIV platform appears to be a financially feasible approach associated with several positive clinical outcomes.

A household-based community health worker programme for non-communicable disease, malnutrition, tuberculosis, HIV and maternal health: a stepped-wedge cluster randomised controlled trial in Neno District, Malawi

Emily B Wroe, Basimenye Nhlema, Elizabeth L Dunbar, Alexandra V Kulinkina, Chiyembekezo Kachimanga, Moses Aron, Luckson Dullie, Henry Makungwa, Benson Chabwera, Benson Phiri, Lawrence Nazimera, Enoch P L Ndarama, Annie Michaelis, Ryan McBain, Celia Brown, Daniel Palazuelos, Richard Lilford, Samuel I Watson

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Community health worker (CHW) programmes are a valuable component of primary care in resource-poor settings. In this study, we evaluated expanding an existing HIV and tuberculosis (TB) disease-specific CHW programme into a polyvalent, household-based model that subsequently included non-communicable diseases (NCDs), malnutrition and TB screening, as well as family planning and antenatal care (ANC).

We conducted a stepped-wedge cluster randomised controlled trial in Neno District, Malawi.

The intervention resulted in a decrease of approximately 20% in the rate of patients defaulting from chronic NCD care each month (−0.8 percentage points (pp) (95% credible interval: −2.5 to 0.5)) while maintaining the already low default rates for HIV patients (0.0 pp, 95% CI: −0.6 to 0.5). First trimester ANC attendance increased by approximately 30% (6.5pp (−0.3, 15.8)) and paediatric malnutrition case finding declined by 10% (−0.6 per 1000 (95% CI −2.5 to 0.8)). There were no changes in TB programme outcomes, potentially due to data challenges.

Novel approaches to screening for noncommunicable diseases: Lessons from Neno, Malawi

Chiyembekezo Kachimanga, Katie Cundale, Emily Wroe, Lawrence Nazimera, Arnold Jumbe, Elizabeth Dunbar, Noel Kalanga

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As Malawi continues to suffer from a large burden of noncommunicable diseases (NCDs), models for NCD screening need to be developed that do not overload a health system that is already heavily burdened by communicable diseases.

This descriptive study examined 3 screening programmes for NCDs in Neno, Malawi, that were implemented from June 2015 to December 2016. The NCD screening models were integrated into existing platforms, utilising regular mass screening events in the community, patients awaiting to be seen in a combined NCD and HIV clinic, and patients awaiting treatment at outpatient departments (OPDs). Since the initiation of the screening programmes, the number of patients ever enrolled for NCD care every 3 months has nearly tripled, from 40 to 114.

The screening models have shown that it is not only feasible to introduce NCD screening into a public system, but screening may have also contributed to increased enrolment in NCD care in Neno, Malawi.

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.

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.

What women want: A mixed-methods study of women’s health priorities, preferences, and experiences in care in three Rwandan rural districts

A.J. Adler, T. Randall, L.N. Schwartz, L. Drown, S. Matthews, L.E. Pace, C. Mugabo, F. Kateera, G. Bukhman, E. Baganizi, L.M. Ng’ang’a

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Objective: To explore Rwandan women’s experiences, priorities, and preferences in accessing health care for non-pregnancy-related conditions and inform development of healthcare services related to these conditions among women of reproductive age at district hospitals and health centers in Rwanda.

Results: Seventeen interviews and 150 surveys were conducted. Women identified conditions including back pain, gynecologic cancers, and abnormal vaginal bleeding as concerns. They generally reported positive experiences while accessing health care and knowledge of accessing health care. Barriers to care were identified, including transpor- tation costs and inability to miss work. Women expressed a desire for more control over their care and the importance of maintaining their dignity while accessing health care.

Conclusion: The reported end-user health concerns, barriers to care, and diminished control over their care point to a need to evolve health systems around user-tailored needs and design interventions optimizing access whilst promoting dignified care.

Realigning noncommunicable disease monitoring with health systems priorities in the Africa region

Chantelle Boudreaux, Devashri Salvi, Alma J. Adler, Emily B. Wroe, Matthew M. Coates, Maia Olsen, Yogesh Jain, Ana O. Mocumbi and Gene Bukhman

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The African region of the World Health Organization (WHO) recently adopted a strategy aimed at more comprehensive care for noncommunicable diseases (NCDs) in the region. The WHO’s World Health Assembly has also newly approved several ambitious disease-specific targets that raise the expectations of chronic care and plans to revise and update the NCD-Global Action Plan. These actions provide a critically needed opportunity for reflection and course correction in the global health response to NCDs. In this paper, we highlight the status of the indicators that are currently used to monitor progress towards global goals for chronic care. We argue that weak health systems and lack of access to basic NCD medicines and technologies have prevented many countries from achieving the level of progress required by the NCD epidemic, and current targets do little to address this reality. We identify gaps in existing metrics and explore opportunities to realign the targets with the pressing priorities facing today’s health systems.

Non-communicable disease burden among inpatients at a rural district hospital in Malawi

Peter Olds, Chiyembekezo Kachimanga, George Talama, Bright Mailosi, Enoch Ndarama, Jodie Totten, Nicholas Musinguzi, Dickson Hangiwa, Gene Bukhman and Emily B. Wroe

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The goal of this study was to understand the burden of NCDs among inpatients in a rural district hospital in Malawi. We broadened our definition of NCDs beyond the tradi- tional 4 × 4 set of NCDs, and included neurological disease, psychiatric illness, sickle cell disease, and trauma. We conducted a retrospective chart review of all inpatients who were admitted to the Neno District Hos- pital between January 2017 and October 2018. We broke patients down by age, date of admission, type, and number of NCD diagnoses, and HIV status, and constructed multivariate regression models for length of stay and in-hospital mortality.

We found two distinct populations of NCD patients. The first were patients 40 years and older with primary diagnoses of hypertension, heart failure, cancer, and stroke. The second were patients under 40 years old with primary diagnoses of mental health conditions, burns, epilepsy, and asthma. We also found significant trauma burden, accounting for 40% of all NCD visits.

There is a significant burden of NCDs in a rural hospital in Malawi, including those outside of the tradi- tional 4 × 4 set. We also found high rates of NCDs in the younger population (under 40 years of age). Hospitals must be equipped with adequate resources and training to meet this burden of disease.