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

Click on image to access full Lancet Commission booklet

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

Click on image to access full operational plan

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

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

Click image to access full article

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.

Leveraging School Health Programs in Africa: Integrated Screening for Rheumatic Heart Disease and Dental Caries

Euridsse Sulemane Amade, Edna Luchucha, Zakir Ossman, Keila Jamal, Adjine Mastala, Lene Thorup, Carlos José Soares, Rolan Aka N’gueta, Ana Mocumbi

Click on image to access full article.

Rheumatic heart disease (RHD) and dental caries (DC) disproportionately affect children and young adults in sub-Saharan countries, with major impact on schoolchildren’s health and education. DC in children with RHD constitutes an important risk for fatal complications. Our study aimed at assessing the feasibility of simultaneous RHD and DC screening in school environment.

March 20–24, 2022, we performed an observational descriptive study of schoolchildren in a public school in Maputo City, Mozambique. A total of 954 students (median age 9; range 6–15) were screened. One hundred and twenty-five participants were eligible for a rapid antigen test, of which 6 (4.8%) tested positive. On clinical evaluation 52 children (5.3%) presented a heart murmur. Echocardiography on 362 children showed borderline RHD in 35 children and definite RHD in 2 (0.6%); 1 child had a ventricular septal defect. Dental cavities were present in 444 (48.4%), despite 904 out of 917 students reporting brushing of their teeth once to three times daily (98.6%).

School-based integrated oral and cardiovascular screenings and use of rapid tests for GAS carriage provide crucial information to create customized preventive strategies for rheumatic fever (RF) and RHD in low- and middle-income countries (LMICs), in addition to detecting children at very high risk of bacterial endocarditis. The sustainability of such interventions and acceptability by health providers needs to be assessed.

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

Click on image to access full article.

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

Click on image to access article.

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

Click on image to access full article

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.

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

Click on image to access and download toolkit

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

Click image to access full essay

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

Click image to access full opinion article.

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.