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

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.

PEN-Plus – Bringing Care for Severe NCDs to the World’s Poorest Children and Young Adults

Short (6-minute) video introduces the PEN-Plus model for decentralizing integrated chronic care services for type 1 diabetes, sickle cell disease, rheumatic heart disease, and other severe NCDs that cause tens of thousands of avoidable deaths every year among the world’s poorest children and young adults. Video includes statements of support from leaders of WHO/AFRO, which has adopted a regional strategy to implement PEN-Plus continent-wide, UNICEF, WHO headquarters, the World Bank, and the Helmsley Charitable Trust.

Addressing severe chronic NCDs across Africa: measuring demand for PEN-Plus

Chantelle Boudreaux, Prebo Barango, Alma Adler, Patrick Kaobre, Amy McLaughlin, Mohamed Ould Sidi Mohamed, Paul H. Park, Steven Shongwe, Jean Marie Dangou, Gene Bukhman
Health Policy and Planning 2022

Addressing severe chronic NCDs across Africa:
measuring demand for the Package of Essential Non-communicable Disease Interventions-Plus (PEN-Plus)

Severe chronic non-communicable diseases (NCDs) pose important challenges for health systems across Africa. This study explores the current availability of and demand for decentralization of services for four high-priority conditions: insulin-dependent diabetes, heart failure, sickle cell disease, and chronic pain. Countries reported widespread gaps in service availability at all levels. We found that just under half (49%) of respondents report that services for insulin-dependent diabetes are generally available at the secondary level (district hospital); 32% report the same for heart failure, 27% for chronic pain and 14% for sickle cell disease. Reported gaps are smaller at tertiary level (referral hospital) and larger at primary care level (health centres). Respondents report ambitious plans to introduce and decentralize these services in the coming 5 years. Respondents from 32 countries (86%) hope to make all services available at tertiary hospitals, and 21 countries (57%) expect to make all services available at secondary facilities. These priorities align with the Package of Essential NCD Interventions-Plus. Efforts will require strengthened infrastructure and supply chains, capacity building for staff and new monitoring and evaluation systems for efficient implementation. Many countries will need targeted financial assistance in order to realize these goals. Nearly all (36/37) respondents request technical assistance to organize services for severe chronic NCDs.

PEN-Plus: Decentralizing life-saving care for the poorest billion

This 11-minute video shows how decentralizing and integrating chronic care services for type 1 diabetes, sickle cell disease, rheumatic and congenital heart disease, and other severe NCDs has brought lifesaving care to poor rural communities in Rwanda, Malawi, and Haiti … and how this PEN-Plus model is now expanding to other lower-income countries in Africa and South Asia.


Integration of NCDI Services Policy Brief

Progressive Decentralization and Integrated Care Teams –
Keys to Bridging the Gap in Services for NCDs and Injuries

Non-communicable diseases and injuries (NCDIs) account for a large and growing proportion of the burden of disease in all World Health Organizations (WHO) regions, including in low- and lower-middle-income countries (LLMICs). Among the world’s poorest billion people, NCDIs cause almost 800,000 deaths under the age of 40 every year – more than HIV, tuberculosis, and maternal deaths combined.

Proven, cost-effective, and equitable NCDI interventions exist that could save millions of lives each year, if scaled to reach everyone in need. But in many LLMICs, these interventions are available only at referral hospitals in capital cities, which makes them inaccessible and unaffordable for the rural poor.

The key to achieving both Universal Health Coverage and Sustainable Development Goal targets for reducing mortality from NCDIs is to develop and implement strategies for progressive decentralization and integrated service delivery that can deliver these interventions, with quality, at lower levels of the health system and in rural areas.

Integration and PEN-Plus policy brief_w_CIS&Network_logos