An emerging strategy to tackle chronic disease

The largest hospital in Africa has a first-class trauma center, a burns unit and top-notch specialized care. But the Chris Hani Baragwanath Hospital in Soweto, South Africa, also spends a lot of time treating colds, flus and other more typical ailments that could be treated at simple clinics. They are not alone.

In many countries around the globe, both developed and developing, tertiary hospitals in city centers are overwhelmed by an influx of patients who might be better served with preventative or primary medical care.

The mismatch is symptomatic of a growing shift in global health, away from infectious diseases and toward noncommunicable diseases such as cancer and heart disease. NCDs are likely to be the key challenge of the future, and for now they are being treated in a system that wasn’t built to address them.

Experts and practitioners are now beginning to piece together a strategy. Addressing NCDs will require different solutions and far stronger and more integrated health systems, they say.

“Where we are now on NCDs is not far from where we were 20 years ago on communicable diseases,” Isabelle Torres, global head of access to medicines at Takeda Pharmaceutical Co., told Devex at an event hosted by the company in Geneva to bring together government, NGO and private sector leaders to discuss a roadmap for NCDs.

Public health experts described an emerging consensus around actionable steps that can help countries and that the global health community can take to address this evolving reality. Tackling NCDs will require policy adjustments, reformed health system structures and effective partnerships that break down silos.

A transition in priorities

Sub-Saharan Africa offers a glimpse of the transition underway. Just a few years ago, NCDs were not an issue, said Dr. Joseph Kibachio, the head of the division of NCDs at Kenya’s ministry of health. Today however, his government sees NCDs as a growing and immediate concern.

“We have not cleared infectious disease and now we have a more sinister thing to deal with — NCDs,” he said.

The urgency to address NCDs stems in part from their growing impact on society. Countries are losing productive workers at peak age, from age 30 to 69. These “slow motion” diseases can be expensive to treat and don’t respond to the type of rapid mobilization that pandemics or other issues do.

Analysts say NCD policies must reflect critical needs, including building and retaining talent, providing services to the poor, improving health systems functioning and finding ways for better regional cooperation.

Many countries will also need to build up their supplies of specialists and equipment. Some countries have only a handful of oncologists and cardiologists, in addition to lacking specialized medical devices.

Retaining talent is a key challenge. In addition to training more local practitioners, governments must find ways to prevent skilled workers from leaving, particularly in far-flung areas. Many doctors and other health care professionals prefer to live in cities or other areas with better payment or working conditions, Kibachio said.

A better working environment also includes hiring and training more mid-level staff and shifting tasks to them, so doctors are focused on treating the most serious cases. Much of diabetes care management, for example, can be done by health workers under the supervision of a specialist, Kibachio said.

Policy changes will require more investment — countries will need to increase expenditure on health care, said Dr Githinji Gitahi, group chief executive officer of Amref Health Africa. He advocates for countries to consider universal health coverage systems and insurance to spur much-needed to improve health systems.

Rethinking health system structures

Pressure on tertiary institutions such as the Chris Hani Baragwanath Hospital indicates the need to shift more care to secondary hospitals and local community health clinics, health experts told Devex. That will require building trust in the local institutions; many patients turn to hospitals because they are assumed to provide better care. It will also mean expanding and investing in primary or community health care.

“First build community health level infrastructure,” Gitahi said. In addition to specialized centers, politicians will have to work for less visible, local-level change. Rwanda, for example, has simultaneously expanded primary care and built centers of excellence for cancer and surgery, Gitahi said.

Preventative care at the local level should help reduce pressure on specialized facilities by improving early detection and prevention. An effective referral system can move patients up the chain of care when needed.

The referral system is a key deficiency in Kenya, Gitahi said. Many local health clinics lack the proper staff and infrastructure to treat primary health care concerns, so patients seek care at specialized facilities.

Building effective partnerships

Kenya’s recently completed cancer strategy was crafted in partnership with professional organizations and civil society — part of a shift toward collaboration in tackling NCDs. While it has worked for funds and efforts to tackle individual infectious diseases, health experts say that system will not work for chronic conditions.

“Policymakers are important but the best NCD policy is made by bringing brilliant minds together,” Kibachio said. With NCDs costing developing countries about 5 percent of gross domestic product according to the World Economic Forum, governments “can’t afford to just look at the health issue,” Kibachio said.

New kinds of partnerships, across sectors and diseases, are necessary, experts told Devex. In addition to the health sector, these might include experts from education and marketing to food and urban design.

A number of private actors are looking at how to partner on NCDs and help the process from disease awareness, to screening, to treatment. Takeda, for example, is working with small NGOs at the lower rungs of health care, and they have seen improvements in rates of cancer screening, Torres said. Takeda also helped create a cancer partnership that will create a center of excellence for cancer treatment in Nairobi.

Novartis has made deals with ministries to provide a bundle of medications to treat leading NCDs for $1 per month per treatment. Roche has been working to help train health care workers and improve diagnostic capacities.

Much of this is new territory. While there is ample information about the goals, there is no clear roadmap for how to reach them. The response moving forward will have to be responsive and flexible. All partners have a responsibility to investigate why something is working so that solutions can be scaled.

Torres’ philosophy is that you “have to be a little bit loose” with partnerships so that you can figure out what will work best to achieve your goals in an integrated way, she told Devex.  

Editor’s note: The reporter traveled to Geneva with the support of Takeda. Devex retains full editorial independence and responsibility for this content.

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