Non Communicable Diseases: Not Just for the Rich

On September 19-20, 2011, the UN General Assembly will convene a high-level meeting on non-communicable diseases (NCDs), an affirmation that prevention and control of NCDs is finally reaching the global public health agenda. Often thought of as “diseases of the rich”, NCDs comprise about 60% of global mortality, with approximately 80% of the deaths occurring in low and middle income countries. In fact, current projections show that by 2030, NCDs will overtake communicable diseases as the leading cause of death in rich and poor nations alike as an aging populations and lifestyle changes linked with economic development increase the risk factors for illnesses such as heart disease, cancer, chronic obstructive pulmonary disease and diabetes.

How are different actors - both public and private - within developing nations dealing with the shifting burden of disease? To address this issue, the Center for Strategic International Studies (CSIS) hosted a panel discussion focused on the developing nation response to the emergence of NCDs as a major public health concern.

To kick off the discussion, Rebecca Firestone of Population Services International (PSI) shared a number of often overlooked statistics to conclusively defeat the “diseases of the rich” misconception. Although NCDs account for a greater percentage of total deaths in higher-income countries, the NCD death rate per 100,000 is actually higher in many developing nations. Furthermore, risk factors such as smoking disproportionately affect the poor; in Laos, for example, the prevalence of smokers among the lowest quintile is close to 50%, compared to about 20% of the wealthiest quintile.

How is the international community reacting to these statistics? The unfortunate answer is that the response is still lagging. In 2007, only 3% of all donor assistance for health went to NCDs, amounting to approximately $.78/DALY attributable to NCDs, compared to $23.9/DALY attributable to HIV, malaria, and TB. One of the likely reasons for this lackluster response is the overwhelming perception that NCDs are just too complicated to prevent and treat in low-resource settings.

Still, there is reason to be optimistic. Gina Lagomarsino, Managing Director and CHMI lead at Results for Development, shared a number of approaches that are being employed to make NCD care accessible and affordable to the poor. Several innovative initiatives have been identified over the last year by CHMI partner organizations that attempt to address one or more segments of the NCD continuum of care, from mobile clinics that engage in prevention, diagnosis and monitoring of chronic diseases in rural and remote geographies, to private chains that are paid for through government contracts that engage in long-term disease management, and super-specialty hospitals that provide the full continuum of care at a lower cost, often through government insurance or cross subsidization.

Brazil and India appear to be two of the countries leading the way toward making NCD care affordable for lower income populations.

• In Brazil, Nefrocare has established a network of independent low-cost dialysis clinics that take advantage of scale to reduce the cost of service. Nefrocare currently operates 11 clinics in Brazil and 1 in Angola; approximately 90% of its patients are covered through Brazil’s Unified Health System (SUS).
• Narayana Hrudayalaya (NH), the largest provider of heart surgeries in India (and one of the largest in the world), uses a high volume-low cost delivery model and cross subsidization to provide reduced-fee or free care to about 60% of its patients.
• Furthermore, a number of technology providers are developing and rolling out mobile-phone adapted software (see GlicOnline, Mobile Phones for Health Monitoring, MediNet) to help patients better manage conditions such as diabetes and cardiovascular diseases.

Though it’s evident that a number of independent pro-poor initiatives are indeed tackling NCD care in the developing world, an important issue remains – how does the global health community ensure that these efforts are plugged into a wider support system, one that aids the acquisition of low-cost quality drugs and encourages compliance with established operational and quality standards? Nikki Charman, PSI’s Global Service Marketing Manager, discussed how the social franchising model – already widely used for family planning and the diagnosis and treatment of infectious diseases such as HIV/AIDS, Malaria and TB – can be applied to the prevention and control of NCDs. In Myanmar, Sun Quality Health is beginning to offer low cost cervical cancer screenings and cryotherapy (the use of cold temperatures to destroy abnormal tissue) through its network of franchised clinics. Similar initiatives are underway in Kenya and Uganda. Although several aspects of these models appear promising, a host of unanswered questions remain. How can providers be incentivized to deliver long-term care? How does a social franchise network coordinate across the continuum of care? How would social franchising address the steep cost of NCD care?

Ensuring that countries are prepared to meet the shifting burden of diseases will require collaboration between both the public and private health sectors, as well as cross-sectoral support and assistance from the international community. Are we up to the challenge?