Noncommunicable diseases: A policy success but implementation failure

KIGALI, Rwanda — This could be an important year for defining priorities around noncommunicable diseases, or NCDs — an often overlooked area in global health. In September, when world leaders meet at the United Nations General Assembly in New York City, they will participate in a high-level meeting focused on how the world should tackle the growing burden of NCDs. NCDs, such as heart disease, cancer, diabetes, and respiratory illness, killed at least 43 million people in 2021, which equated to 75% of nonpandemic related deaths that year — with the majority of premature deaths from NCDs happening in low- and middle-income countries. In five years, NCDs are slated to surpass HIV/AIDS, tuberculosis, and maternal mortality as the leading cause of death in sub-Saharan Africa. “These numbers dwarf many other health issues combined, and yet they are neglected and under-prioritized politically,” said Katie Dain, chief executive officer of the NCD Alliance. A combination of factors are driving this, such as trends towards urbanization, increasing levels of pollution and tobacco use, as well as the proliferation of processed foods at supermarkets. And the issue is exacerbated by the fact that many people must pay out-of-pocket for expensive treatments such as chemotherapy or dialysis. In the lead-up to this high-level event, experts, advocates, policymakers, and nongovernmental organizations gathered in Kigali for the Global NCD Alliance Forum this month to start defining their priorities. This is the first time the alliance has held its forum in Africa — previous iterations were in the United Arab Emirates. People from 89 countries attended the forum. The high-level meeting in September will be an opportunity to take stock of where the world stands in tackling these diseases. In 2012, governments set a target of reducing premature mortality from noncommunicable diseases by 25% by 2025. At this time, they also included a set of specific targets in areas including tobacco use, diabetes, high blood pressure, and physical inactivity, among others. “Progress against all of these targets are essentially falling short,” Dain said at the forum. “When we take a step back and actually look at progress on NCDs, it's very clear that we are significantly off track.” For the last century, public health has focused on fighting infectious diseases, said Dr. Mary-Ann Etiebet, president and CEO of Vital Strategies. “We did a good job at it: vaccines, sanitation, antiretrovirals, antibiotics, and the programs to get them to communities that needed them. It changed the game,” she said. “But today, the playing field has changed. We are facing a different set of challenges.” Dain said the September high-level meeting will serve as an opportunity to review progress and make new commitments at the highest political level — a way to reset the agenda. This will be the fourth high-level meeting focused on NCDs. And it will be an opportunity to start crafting new goals. In 2013, the World Health Assembly adopted 25 indicators and nine global targets around reducing premature mortality from noncommunicable diseases by 2025. There will be a process around creating new targets for the next 10 to 15 years through a global monitoring framework on NCDs that will come after the high-level meeting, Dain said. The World Health Organization will establish a group of experts around setting these targets and there will be a country-level meeting after UNGA to agree upon new goals. The new framework will then be presented to the World Health Assembly in May 2026. The wish list The NCD Alliance has five priorities for the September meeting, Dain said, including: 1. Accelerating implementation of goals around tackling NCDs. She said the last decade was a policy success for NCDs, but an implementation failure. “We haven't seen enough progress at the national level on what we know works in terms of primary prevention, as well as access to care and treatment,” she said. 2. Mobilizing investment around sustainable financing. “The most important part of the financing agenda, from our perspective, is actually domestic resource mobilization,” she said. And there’s a need for financial risk protection for people paying out-of-pocket for NCD services. 3. Breaking down silos so that NCDs are better integrated into other parts of global health. Some success stories around this include progress around linking NCDs with HIV services at primary health care levels, she said. But this can expand to integrating NCDs into work on climate change and universal health coverage. 4. Creating new concrete global targets around NCDs and ensuring there are accountability frameworks around reaching these goals. 5. Community engagement to ensure the lived experiences of patients and civil society engagement are integrated into the NCD response. In the lead-up to the meeting, experts need to figure out which targets make sense, Vital Strategies' Etiebet said. “What are the targets that people feel are concrete, actionable, and that you can see movement with so that they actually incentivize ongoing action,” she said. Ariella Rojhani, director of the Partnership for Healthy Cities at Vital Strategies, also said it’s imperative that at the high-level meeting and its aftermath, there’s not a “backslide from the language that has been agreed in the previous three meetings.” She said that given this is a political process, there are geopolitical issues that will find their way into these dialogues. This includes discussions around intellectual property and the rules that govern whether or not people can access generic medications at affordable rates to treat their NCDs. This may include “big fights around commercial determinants of health” — which include corporate influence such as aggressive marketing of unhealthy products, she said. And there will also be discussions around what place the private sector and commercial producers have in discussions around NCDs and their prevention, she said. “As civil society, we want to make sure that we have really strong protections against these industries that seek to only make people sicker through their products,” Rojhani said. Prisca Githuka, chairperson of the Cancer Survivors Association of Kenya, said her priority is working to ensure there’s availability of quality, affordable, and timely treatment. “People who have been diagnosed are dying because of lack of access to these medicines,” she said. And in the lead-up to the high-level meeting, there are expected to be challenges in getting enough attention on NCDs, experts said. The global health conversation is currently dominated by the U.S. Trump administration’s dismantling of the U.S. Agency for International Development. While USAID hasn’t played a significant role in funding the response to NCDs, the major halt in funding is expected to have a ripple effect on many health issues, Dain said, adding that it could also set back efforts to integrate NCD services into other areas of health care, with a return to a siloed approach. And within the broader global financing ecosystem there will be challenges in figuring out how to plug funding gaps, Etiebet said. “The abrupt halt of that financing is actually threatening lives,” she said. “I do worry that the conversation again on NCDS will be overtaken by other current events.” What’s worked Country, regional, and global-level successes were on display at the Kigali forum. This includes the implementation of the World Health Organization’s package of essential noncommunicable disease interventions for primary health care in low-resource settings, known as PEN. They were first introduced in 2010 “as a prioritized set of cost-effective interventions able to deliver an acceptable quality of care, even in resource-limited settings.” They include services for hypertension, Type 2 diabetes, and chronic respiratory disease, as well as early detection of breast and cervical cancer. Several African countries have piloted and scaled WHO’s PEN. But these efforts were expanded with “PEN-Plus,” which is an approach to address severe NCDs through an integrated outpatient service at first-level hospitals, which includes Type 1 diabetes, advanced rheumatic and congenital heart disease, and sickle cell disease, among others. Rwanda wasn’t randomly chosen to host this conference — it’s seen as a success story in tackling NCDs, including scaling these WHO programs. In Rwanda, PEN-Plus is implemented at 39 district hospitals and four provincial hospitals, and PEN is implemented at health centers, health posts, and by community health workers. The country is also working to reduce the burden of out-of-pocket payments for health care for its citizens. It has a community-based insurance system that charges annual premiums based on a person’s socioeconomic status. This insurance includes access to NCD care, such as cancer medications, said Francois Uwinkindi, manager of the NCD division in Rwanda Biomedical Centre at the country’s Ministry of Health. The country has also worked to build up its surgery capacity. Cardiac surgery, for example, initially was conducted by foreign health missions but now these operations are conducted by local surgeons at King Faisal Hospital in Kigali. Francois said they’ve also included NCD screenings into the package of services community health workers offer. They screen people within their communities and refer them to health facilities. “This approach is helping us to detect people on time, but also be able to initiate the treatment on time,” he said. An early diagnosis can mean a less complicated, and less costly, treatment. “Rwanda has really stood out over the last two decades as being very much a leader in public health, universal health coverage, and NCDs specifically,” Dain said. Twice a month, Kigali also has days where cars are banned, which encourages people to go out and exercise. They can also have their blood sugar and blood pressure checked on those days. The country also recently increased taxes on alcohol and tobacco. Editor’s note: The NCD Alliance facilitated travel for this reporting. Devex retains full editorial independence.