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Prevention and control of non-communicable diseases 

Prevention and control of non-communicable diseases
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Prevention and control of non-communicable diseases
Author(s):

K. Srinath Reddy

DOI:
10.1093/med/9780199661756.003.0237
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date: 17 October 2019

Introduction to prevention and control of non-communicable diseases

In September 2011, the United Nations (UN) held a High-Level Meeting on Non-Communicable Diseases (NCDs), involving heads of state and other senior government functionaries from across the world. The only prior occasion that the UN had convened such a meeting on a health-related issue was in 2001, when a concerted global response to the HIV/AIDS epidemic was framed. It was clear from the political resolution adopted at the 2011 summit that the NCDs were being recognized as a similar grave threat to global health and development, warranting concerted global action for prevention and control (UN General Assembly 2011).

The transition between 2000 and 2015, in the framing of global development goals, also illustrates how NCDs have finally emerged on the radar screen of global health priorities. Action on NCDs, including tobacco control, did not feature in the Millennium Development Goals of 2000. This was despite the fact that NCDs had already become the leading cause of death globally towards the end of the twentieth century and tobacco had claimed about 100 million lives in that century. However, all of the groups working to draft the post-2015 Sustainable Development Goals (SDGs) have acknowledged the need to incorporate the prevention and control of NCDs within the ambit of any health goal proposed for inclusion among the SDGs (International Institute for Sustainable Development 2013; Leadership Council of the Sustainable Development Solutions Network 2013; UN 2013).

What are non-communicable diseases?

Despite all this attention, most people, many policymakers, and even some health professionals do not know what the term ‘NCDs’ means and includes. The descriptor emerged initially to indicate diseases which were considered to be non-infectious in origin and spread, at a time when global health was mainly concerned about infectious diseases. For the purpose of the UN high-level meeting, the World Health Organization (WHO) proposed to restrict the term to four major disease groups: cardiovascular diseases (CVDs, which include stroke), diabetes, cancers, and chronic respiratory diseases (such as asthma, emphysema, and chronic bronchitis). These four groups of disorders, though very different in their clinical profile, are linked by four common risk factors: tobacco, unhealthy diet, physical inactivity, and alcohol.

Many find the term ‘NCDs’ unsatisfactory for several reasons. First, some of the cancers (e.g. cervix, liver, and stomach) and some forms of heart disease (e.g. rheumatic heart disease) are linked to viral or bacterial infections. Second, in the socio-epidemiological understanding of disease causation, disease-causing agents like tobacco, alcohol, and unhealthy foods are marketed aggressively across countries and can be considered ‘communicable’. Behaviours too are vulnerable to change under the influence of cultural and commercial messages that are communicated to people. Third, where do mental illness, vision and hearing disorders, haemoglobinopathies like thalassaemia, musculoskeletal and gynaecological disorders, and some renal diseases fit in, if the term is restricted to four groups of diseases?

Other terms which have been used to describe NCDs are ‘chronic diseases’ and ‘lifestyle-related diseases’. These too are unsatisfactory. There is nothing ‘chronic’ in the clinical picture of acute myocardial infarction (heart attack), stroke (brain attack), or sudden cardiac death, even if the underlying pathology may have had an insidious growth. Labelling NCDs as ‘lifestyle-related diseases’ places the blame on individuals, without taking into account the social and economic factors that operate at the population level, influencing personal behaviours and often overriding informed choice as the main determinant.

Would it be better to choose a descriptor that is more directly linked to the common risk factors than to a disparate group of diseases? A term like ‘diet, inactivity, tobacco, and alcohol-related disorders’ (DITA disorders) will clearly spell out the causes that need to be countered to reduce the NCD burden and may shape the attitude of health professionals, policymakers, and people to emphasize prevention instead of focusing mainly on disease management as at present.

However, it must be recognized that the UN summit has now legitimized the term NCDs in the global health parlance. The nomenclature has finally been registered on the consciousness of national policymakers across the world and, therefore, has come to stay. Global public health must accept the term as indicative of four major disease groups which are partly but not wholly linked by four risk factors and their determinants, and not quibble about which diseases are in or out. Conditions like mental illness will surely need attention and action, as will injuries and disabilities, but the ambit of NCDs is now defined by the criteria set by the WHO and UN.

Global burden of non-communicable diseases

The WHO estimated that NCDs accounted for 36 million deaths in 2008, contributing to 63 per cent of the 57 million deaths from all causes worldwide (WHO 2011a). About 80 per cent of the NCD-related deaths occurred in the low- and middle-income countries (LMICs) which also accounted for 90 per cent of the 9 million NCD-attributable deaths that occurred below the age of 60 years (WHO 2011b). Even when deaths under 70 years of age are considered, 48 per cent of the NCD related deaths in LMICs occurred below that age in 2008, in comparison to 26 per cent in high-income countries (HICs). The Global Burden of Diseases study 2010 (GBD 2010) estimated that mortality due to NCDs increased from 57 per cent of total mortality in 1990 to 65 per cent in 2010, with a continued high burden of deaths in middle age in the LMICs (Lozano et al. 2013).

Comparisons of NCD mortality, across countries or regions, provide varying profiles, depending on which statistical measure is used. When absolute numbers of NCD-attributable deaths are considered, the LMICs account for the largest fraction because of their cumulative population size. The HICs presently have higher proportional mortality rates (NCD deaths as a percentage of all deaths, within countries) but these too are rising in the LMICs. The highest proportional mortality rates due to NCDs are presently seen in Eastern and Central Europe. Due to the large proportion of deaths occurring at a young age, LMICs have higher age-standardized mortality rates for NCDs, when compared to countries like the United States, Australia, or New Zealand. In every region of the world, other than sub-Saharan Africa, NCDs account for a higher proportion of deaths than the combined contribution of communicable diseases, pregnancy-related events, and nutritional deficiency. Even in sub-Saharan Africa, the age-standardized mortality rates of CVDs are higher than those in HICs but that burden is obscured by the overwhelming effect of HIV/AIDS, malaria, and tuberculosis on proportional mortality. Indeed, the highest rate of rise in NCD related mortality over the next two decades is projected for Africa (WHO 2011c).

Among the NCDs, CVDs are the most prominent, accounting for 48 per cent of all NCD-related deaths in 2008. This group features two dominant disorders, coronary heart disease (CHD) and cerebrovascular disease (stroke). In addition, there are several other cardiovascular disorders like rheumatic heart disease, cardiomyopathies, hypertensive heart disease, and peripheral vascular disease. Cancers contributed to 21 per cent of NCD deaths, chronic respiratory diseases to 12 per cent, and diabetes to 3.5 per cent. Since deaths in people with diabetes are often due to CHD or stroke, its contribution to NCD mortality is larger than the directly attributed fraction suggests.

Apart from mortality, disease burdens are also estimated in terms of disability-adjusted life years (DALYs). This is a summated measure of years of life lost due to death from a disease and a measure of ‘life years lost’ to years of disability accruing from the disease, weighted for the extent of disability. In 2010, NCDs contributed to 54 per cent of total DALYs lost globally due to all health disorders combined. This represents a substantial increase from the 43 per cent of DALY loss attributed to NCDs in 1990. In the two decades between 1990 and 2010, DALY loss from CVD rose by 22.6 per cent, cancer by 27.3 per cent, and diabetes by 69 per cent, while the DALY loss due to chronic respiratory diseases decreased by 2 per cent (Murray et al. 2013).

There are considerable variations across the world in the profile of NCDs. In Africa, China, Japan, South East Asia, and some countries of South America, stroke is the dominant form of CVD. In others like the United States, United Kingdom, Europe, and Australia, CHD is the dominant form of CVD. In others, both forms are co-dominant. In general, the early stages of the CVD epidemic are marked by haemorrhagic stroke and hypertensive heart disease as the major manifestations of high blood pressure. As societies move to high-fat diets and increased rates of smoking, thrombotic CVDs (CHD and thrombotic stroke) become prominent. In cancer too, there is considerable geographic variation in the types of cancers that are most frequent. This is related to variations in patterns of diet, tobacco consumption, alcohol use, and exposure to cancer-causing viruses.

Based on models of demographic and developmental transitions expected to occur over the coming two decades, the WHO estimates that the number of deaths attributable to NCDs would rise to 55 million by 2030, if urgent measures are not taken to contain the threat of these diseases. This will amount to 70 per cent of all global deaths that year. Action would be needed not only on timely diagnosis and treatment of manifest disease but, more importantly, on the prevention and control of risk factors before they result in disease.

NCDs also have an adverse impact on the economy, at national and global levels. This is due to the combined burden of healthcare costs and productivity losses resulting from deaths in working age and disease-related disability that curtails the ability to engage in fully productive work. A study conducted by the World Economic Forum and the Harvard School of Public Health estimated that the world would lose $47 trillion, during 2011–2030, due to NCDs and mental illness (Bloom et al. 2011). About $30 million of this would be due to CVD, cancers, diabetes, and chronic respiratory diseases. NCDs also result in catastrophic health expenditure and can push families into poverty because of unaffordable costs of technology-intensive medical care (Heeley et al. 2009).

Risk factors and determinants

Among the several risk factors associated with NCDs, three categories can be identified: biological, behavioural, and socioeconomic. Of these, the four behavioural risk factors identified by the WHO (unhealthy diet, physical inactivity, tobacco consumption, and harmful use of alcohol) are positioned centrally. They are influenced upstream by socioeconomic determinants like education and income that operate at the individual level, and societal factors like trade policies, urban design and transport, media and cultural influences that operate at the population level. Behaviours in turn have a substantial impact on biological risk factors like blood pressure, body weight, body shape (central obesity), blood lipids, and blood sugar which are the downstream mediators of risk.

While the four behavioural risk factors are indeed the main contributors to NCDs, becoming the critical link between social determinants and biological causes, there are other risk factors too which contribute to NCDs. These vary from viruses causing cancer, to indoor and outdoor air pollution causing respiratory diseases and CVDs. Family history plays a role too, but the focus of a public health strategy must be on modifiable risk factors.

The role that genetic factors play has not been sufficiently well defined to predict risk in many NCDs. Disorders like CHD and maturity-onset diabetes are polygenic and the variability explained by the identified genes so far is low. Study of gene–environmental interactions in NCDs suggests that the environment is the dominant determinant in the development of these conditions (Florez et al. 2006). However, genetic markers are more prominently associated with some cancers and help in risk prediction and targeted therapy. The role of epigenetics, wherein gene expression is altered by environmental exposures such as tobacco, diet, and chemical pollutants, is now coming to the fore. Similarly, the role of early life influences, of fetal and childhood nutrition and growth, is being invoked to explain adult susceptibility to NCDs (Barker et al. 2002). Further research in these areas may help to better identify population groups and individuals at a high risk of one or more of the NCDs.

The GBD 2010 supports this approach by revealing that the four major behavioural risk factors and high blood pressure account for the largest fraction of global deaths and disability (Lim et al. 2012). Global trends reveal that while tobacco consumption is declining in HICs, it is rising in LMICs. Similarly the population mean of systolic blood pressure has declined or stabilized in HICs but has risen and is now the highest in LMICs (Danaei et al. 2011). Overweight and obesity are continuing to rise in prevalence across all regions of the world. Diabetes too is escalating as a global epidemic, with LMICs dominating the league table of countries with the largest numbers of people with diabetes (International Diabetes Federation 2012).

Alongside the global transition, where NCD mortality rates are stabilizing or declining in HICs but rising in LMICs, there is also evidence of a progressive reversal of the social gradient as the epidemics mature. In the early stages of the NCD epidemics, harmful behaviours are more often associated with the higher disposable incomes of the rich, placing them in the high-risk category. However, as the epidemics advance, mediators of risk are mass produced for mass consumption and the ubiquitous presence of tobacco, alcohol, processed foods, labour saving devices, and motorized transport systems writes the prescription for mass epidemics. At a later stage, the affluent and educated sections benefit from their greater access to information, health services, healthy foods, and leisure time exercise to avoid or reduce the risk of NCDs. On the other hand, the poor and less educated sections have inadequate knowledge of NCDs and their risk factors, cannot afford regular purchase and consumption of fruit, vegetables, healthy oils, and fish, which are often costlier than unhealthy processed foods, and usually lead more stressful lives. In such a mature epidemic, the poor will be the most vulnerable victims and experience the highest burden of NCDs (Reddy et al. 2007). Across the world, different stages of this transition are evident in different regions, based on the level of economic and social development.

A comprehensive response

Health services are frequently confronted by the challenge of balancing a broad public health response focusing on the determinants which operate at the population level and a medical response which places emphasis on providing clinical care to individuals with manifest disease or at a high risk of developing it. This challenge is often exacerbated by the limited resources available to the health system, especially in LMICs.

However, the strategic approach is best guided by understanding how ‘risk’ operates even in individuals, with respect to risk factors like elevated blood pressure or blood cholesterol or smoking. For example, abundant evidence, gathered from both observational epidemiology and clinical trials, enables us to state the following principles of risk for CVD:

  1. 1. Risk operates in a continuous manner, and not across arbitrary thresholds. This is true of biological variables like blood pressure, blood cholesterol, blood sugar, body mass index, and even to the number of cigarettes smoked per day.

  2. 2. Most adverse events arise in a population in people in the mid-range of a risk factor distribution—while high levels of any risk factor place individuals at higher relative risk, the majority of people in a population have risk factor levels in the mid-range and, therefore, contribute to the largest number of events.

  3. 3. When multiple risk factors coexist, the overall risk is additive.

  4. 4. In all populations, the majority of the CVD events arise in people with concurrent elevation of many risk factors rather than in individuals with a high level of a single risk factor.

Based on this, we can derive the principles of prevention:

  1. 1. Small reductions in risk factor levels, when achieved across the whole population, result in a large reduction of CVD events.

  2. 2. Non-drug measures prevent risk across the whole population and reduce it in people who have already acquired a high-risk profile.

  3. 3. Drug therapy to reduce risk is most cost-effective in people who are at high risk of adverse events in the next 10 years.

  4. 4. Best results are achieved through a combination of population-based prevention and high-risk individual management approaches.

For example, half of all blood pressure-related deaths occur below the clinical threshold of 140/90 mmHg which defines hypertension. Since the risk of CVD rises progressively at levels above 110/70 mmHg in adults, it is inconceivable that a majority of the population should be treated with drugs. Healthy diet, regular physical activity, and avoiding harm from alcohol can not only help individuals to lower blood pressure, but can shift the population distribution of blood pressure to the left, with a lower mean. This will substantially reduce the burden of CHD and stroke in that population. Among those with ‘clinical hypertension’, the combination of risk factors will determine the overall ‘absolute risk’ of CVD and define the threshold for intervention with drug therapy. For further discussion, see Chapter 8.1.

While these principles are derived from CVD epidemiology, they are also applicable to other NCDs where behavioural risk factors translate into biological risk. They would hold true for the relationship of body mass index, central obesity, and physical inactivity to diabetes or the relationship of air pollution to chronic respiratory diseases. Similarly, the risk of cancer with tobacco exposure has a continuous relationship. This makes a strong case for population-based strategies to reduce risk exposure across a wide range, rather than focusing only on those at the highest level of exposure.

The fact that many biological risk factors are driven by a clustering of behaviours also provides the rationale for a strategy that focuses on the four behavioural risk factors identified by the WHO. Blood lipids, blood sugar, blood pressure, and obesity are influenced by diet, physical activity, and alcohol. Tobacco interactively amplifies the risk of each of these biological risk factors for NCDs. Action on these risk behaviours, therefore, will provide great benefits to populations as well as individuals by reducing the levels and effects of several biological risk factors.

In relation to the risk factors for NCDs, changing the behaviours of individuals is essential but is difficult and will take a concerted effort over a long time. More research is also required to ascertain the most effective ways in which this could be achieved, especially in the current global context where so much health-related information, and misinformation, is transmitted and shared through the Internet and social media networks, often on a peer-to-peer basis. It is critical, in parallel, to change environmental factors so as to create settings and environments that actively promote healthy behaviours and activities.

A comprehensive and integrated strategy should therefore encompass effective public health interventions to minimize risk factor exposure in the whole population and to reduce the risk of disease-related events in individuals at high risk. As this combination of the population approach and the high-risk approach is synergistically complementary, cost-effective, and sustainable, such an approach provides the strategic basis for early, medium-term, and long-term impact on NCDs.

The response to NCDs, therefore, requires concerted action at the level of policy, health systems, community action, and individual behaviours. Since the determinants of risk are driven by many social forces, including social inequalities that expose vulnerable segments of society to greater risks and reduced access to health promoting programmes, screening, and medical care, a comprehensive policy response is necessary, involving several sectors such as agriculture, food processing, urban design and transport, commerce, education, and communication. Tobacco control, for example, requires higher taxes on all tobacco products, a ban on tobacco advertising, effective health warnings, and smoke-free public and work places. Promotion of healthy diets would need availability of fruit, vegetables, and healthy oils at affordable prices and reduction of salt, sugar, and trans and saturated fats, in processed foods. Promotion of physical activity would require provision of safe pedestrian pathways, protected cycling lanes, community recreational facilities, green spaces, and mass transport systems that encourage walking to and from stations.

Health services must gear up capacity for early detection and treatment of NCDs and risk factors in primary healthcare, so that NCDs and their complications can be prevented and early therapy can be initiated when they do occur. At higher levels of care, more advanced diagnostic tests and treatments must become available at affordable cost.

Community level action, to promote good health and prevent disease, should involve schools, work sites, residential districts, associations of women, and young people. Apart from increasing health literacy, health-promoting environments must be created through smoke-free and exercise-friendly physical spaces, cafeterias serving healthy food, and group activities that reduce stress and engender well-being. Individuals too must learn to exercise healthy choices related to tobacco, diet, physical activity, and alcohol.

The World Health Organization’s global action plan

The UN meeting in 2011 identified a target of 25 per cent reduction in mortality due to NCDs, between the ages of 30 and 70 years, to be achieved globally by 2030. The World Health Assembly, in May 2013, approved a global action plan for prevention and control of NCDs, along with a set of voluntary targets and indicators linked to actions which will enable this goal to be achieved (WHO 2013).

This plan lists nine voluntary targets which are connected to 25 indicators (Table 11.2.1). To achieve these targets, WHO recommends the following actions.

Table 11.2.1 Voluntary global targets from the Action Plan for the Prevention and Control of Non-communicable Diseases 2013–2020

Mortality and morbidity

1.

Premature mortality from non-communicable disease

A 25% relative reduction in risk of premature mortality from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases

Behavioural risk factors

2.

Harmful use of alcohol

At least 10% relative reduction in the harmful use of alcohol, as appropriate, within the national context

3.

Physical inactivity

A 10% relative reduction in prevalence of insufficient physical inactivity

4.

Salt/sodium intake

A 30% relative reduction in mean population intake of salt/sodium

5.

Tobacco use

A 30% relative reduction in prevalence of current tobacco use in people aged 15+ years

Biological risk factors

6.

Raised blood pressure

A 25% relative reduction in the prevalence of raised blood pressure or contain the prevalence of raised blood pressure, according to national circumstances

7.

Diabetes and obesity

Halt the rise in diabetes and obesity

National system response

8.

Drug therapy to prevent heart attacks and strokes

At least 50% of eligible people receive drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes

9.

Essential non-communicable disease medicines and basic technologies to treat major non-communicable diseases

An 80% availability of the affordable basic technologies and essential medicines, including generics, required to treat major non-communicable diseases in both public and private facilities

Adapted with permission from World Health Organization, Sixty Sixth World Health Assembly; Follow-up to the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, Copyright © World Health Organization 2013, available from http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_R10-en.pdf.

Tobacco use

  • Implement the Framework Convention on Tobacco Control (FCTC).

  • Reduce affordability of tobacco products by increasing tobacco excise taxes.

  • Create, by law, completely smoke-free environments in all indoor workplaces, public places, and public transport.

  • Warn people of the dangers of tobacco and tobacco smoke through effective health warnings and mass media campaigns.

  • Ban all forms of tobacco advertising, promotion, and sponsorship.

Harmful alcohol use

  • Excise tax increases on alcoholic beverages.

  • Comprehensive restrictions and bans on alcohol advertising and promotion.

  • Restrictions on the availability of retailed alcohol.

  • Implement the WHO global strategy to reduce harmful use of alcohol.

Unhealthy diet and physical inactivity

  • Salt reduction through mass media campaigns/reduced salt content in processed foods.

  • Replacement of trans fats with polyunsaturated fats.

  • Public awareness programme about diet and physical activity.

Health system

  • Integrate highly cost-effective NCD interventions into the basic primary healthcare package to advance the universal health coverage (UHC) agenda.

  • Explore viable health financing mechanisms and innovative financing approaches, like tobacco and alcohol taxation, to generate resources to expand health coverage.

  • Improve availability of affordable basic technologies and essential medicines, including generics, required to treat major NCDs in both public and private facilities.

  • Scale-up early detection and coverage starting with very cost-effective, high-impact interventions.

  • Strengthen and reorient health systems to address NCDs and risk factors through people-centred primary healthcare and UHC.

Cardiovascular disease and diabetes

  • Multidrug therapy (including glycaemic control for diabetes mellitus and control of hypertension through a total risk management approach) to individuals who have had a heart attack or stroke, and to people with high risk (≥ 30 per cent) of a fatal and non-fatal cardiovascular event in the next 10 years.

  • Acetylsalicylic acid for acute myocardial infarction.

  • Multidrug therapy (including glycaemic control for diabetes mellitus and control of hypertension through total risk approach) to individuals who have had a heart attack or stroke, and to people with moderate risk (≥ 20 per cent) of a fatal and non-fatal cardiovascular event in the next 10 years.

  • Acetylsalicylic acid, atenolol, and thrombolytic therapy (e.g. streptokinase) for acute myocardial infarction.

  • Treat congestive cardiac failure with an angiotensin-converting enzyme inhibitor, beta-blocker, and diuretic.

  • Cardiac rehabilitation post myocardial infarction.

  • Secondary prevention of rheumatic fever and rheumatic heart disease.

  • Anticoagulation for medium- and high-risk non-valvular atrial fibrillation and for mitral stenosis and atrial fibrillation.

  • Low-dose acetylsalicylic acid for ischaemic stroke.

  • Care of acute stroke and rehabilitation in stroke units.

  • Interventions for foot care; educational programmes, access to appropriate footwear; and multidisciplinary clinics.

Diabetes

  • Lifestyle interventions for preventing type 2 diabetes.

  • Influenza vaccination.

  • Preconception care among women of reproductive age (includes patient education and intensive glucose management for gestational diabetes).

  • The early detection of diabetic retinopathy by regular dilated eye examination followed by appropriate laser photocoagulation therapy to prevent blindness.

  • Enalapril to prevent progression of renal disease.

Cancer

  • Prevention of liver cancer through hepatitis B immunization.

  • Prevention of cervical cancer through screening (visual inspection with acetic acid) linked with timely treatment of pre-cancerous lesions.

  • Vaccination against human papillomavirus, as appropriate if cost-effective and affordable, according to national programmes and policies.

  • Population-based cervical cancer screening linked with timely treatment.

  • Population-based breast cancer mammography screening (50–70 years) linked with timely treatment.

  • Population-based colorectal cancer screening at ages over 50 years, linked with timely treatment.

  • Oral cancer screening in high-risk groups (e.g. tobacco users) linked with timely treatment.

  • Palliative care; using cost-effective treatment modalities including opioid analgesics for pain relief.

Chronic respiratory disease

  • Access to improved stoves and cleaner fuels to reduce indoor air pollution.

  • Cost-effective interventions to prevent occupational lung diseases, that is, exposure to silica, asbestos.

  • Treatment of asthma based on WHO guidelines.

  • Influenza vaccination for patients with chronic obstructive pulmonary disease.

Research and surveillance

  • Develop and implement a prioritized national research agenda for NCDs.

  • Strengthen research capacity through cooperation with research institutes.

  • Implement other policy options to promote and support national capacity for high-quality research and development.

  • Develop national targets and indicators based on global monitoring framework.

  • Establish/strengthen a comprehensive NCD surveillance system, including reliable registration of deaths by cause, cancer registration, periodic data collection on risk factors, and monitoring national response.

  • Integrate NCD surveillance/monitoring into national health information systems.

  • Monitor trends and determinants of NCDs and evaluate progress in their prevention and control.

These recommendations for national and global actions are based on evidence of high impact on population-attributable risk and cost-effectiveness of the interventions (Beaglehole et al. 2011; WHO 2011d; Bonita et al. 2013). They combine policy and community level interventions which impact on behaviours across the population and health service interventions which enable risk reduction in individuals at high risk of NCD-related death or disability. While many of these are steered by the health system, they will require multi-sectoral actions to influence the determinants of NCDs. Together, they provide a comprehensive framework for prevention and control of NCDs.

Health system challenges

Implementation of the various measures proposed in the WHO’s Global NCD Action Plan (as discussed earlier) will pose several challenges to national health systems, especially those in the LMICs. These include: health financing; human resources for health; access to essential drugs and technologies and information systems, apart from infrastructure and governance.

Even as escalating costs of healthcare are straining health systems across the world, there is the imminent danger of the expanding NCD epidemics loading unaffordable costs on health budgets. Most LMICs have to contend with competing priorities, with continued commitment to funding programmes for maternal and child health, control of infectious diseases, and nutrition along with fresh commitments to programmes for NCD prevention and control. It should be noted that some key policy measures such as for the control of tobacco and alcohol use will not demand many resources.

Indeed, higher taxes on tobacco and alcohol will yield additional revenues which can be allocated to NCD-related health programmes. Each measure like downward regulation of salt, sugar, and saturated and trans fats in processed foods would not incur expenditure for the government.

However, programmes for clinical care will entail substantial additional costs to the health budget. This can be contained by integrating NCD prevention into existing health programmes (like tobacco control, maternal and child health, and HIV/AIDS programmes) and investing more in primary care than in tertiary care.

As many countries move towards implementation of UHC, NCD-related services should be included so that essential healthcare is provided in an accessible, affordable, and equitable manner to all who need it. The growing global momentum for UHC coincides with the increasing recognition of NCDs as a major health priority, indicative of a convergence that accommodates NCDs in UHC (Frenk and de Ferranti 2012).

Most LMICs have severe shortages in their healthcare workforce, at various levels (specialist doctors, primary physicians, nurses, allied health professionals, and community health workers). Even as capacity is progressively scaled up at each of these levels, ‘task shifting’ and ‘task sharing’ can enhance the outreach and effectiveness of NCD programme delivery. Non-physician healthcare providers like nurses and community health workers have been shown to detect and manage diabetes, hypertension, and asthma efficiently with good health outcomes (Coleman et al. 1998; Abegunde et al. 2007; Farzadfar et al. 2012). Health workers in different health programmes can be multiskilled to perform some functions related to NCD prevention and control, in addition to their primary functions. Specific programmes for NCD prevention and control would also need a multilayered work force with competencies attuned to the programme. Training programmes need to be developed for this purpose. Public health education too must be strengthened to increase public health expertise for policy and programme design, delivery, and evaluation.

Provision of essential drugs and access to needed technologies are also priorities which the health system must address. Since NCDs usually require long-term and often lifelong care for chronic conditions, the availability and affordability of drugs becomes a major concern to affected individuals and families. This is true of drugs for the treatment of hypertension and diabetes, where the cost of drugs in several LMICs amounts to a large fraction of the average monthly wage (Van Mourik et al. 2010). With respect to cancer, treatment for curable cancers is often out of reach, because of the prohibitive cost of drugs. In several countries, palliative pain-relief therapy is unavailable to cancer patients. Even inhalers for asthma therapy are not universally available.

There is a great need for increasing the production and availability of generic drugs. Countries with high manufacturing capacity for such drugs (such as China, India, and Brazil) must supply not only their domestic markets but also other needy markets. Pooled procurement, at national and global levels, will help keep costs under control. The WHO is examining mechanisms for such global procurement and distribution of essential NCD-related drugs. At the national level, it must ensure that frequently needed NCD drugs of proven efficacy should be entered into the Essential Drug List (EDL). Measures to ensure affordability and access, including price control and public provision of life-saving cancer drugs, should also be considered by governments.

Access to technologies is also vital for NCD prevention and control. While high-cost technologies should be judiciously used, based on rational guidelines, low-cost technologies can greatly advance primary care. Point-of-care diagnostics need to be promoted, to enable early detection of risk factors. Use of information technology and mobile phones offer a potentially powerful health system innovation that can transform primary care for NCDs (Krishna et al. 2009). They can also help in strengthening surveillance systems, enabling programme managers to acquire real-time data from sentinel sites across the country and provide a rapid response.

Health services too must be reconfigured to provide chronic care and emergency care for NCDs. Presently, the health systems of most LMICs are designed to deliver acute episodic care, rather than continuous care involving periodic reviews and monitoring. Integration of primary with secondary and tertiary services, with clearly defined and dependable systems for bi-directional referral and follow-up, is also a requirement of NCD-related care. Emergency care services too need to be geared up, to save lives through early intervention in cases of acute coronary or cerebrovascular events.

Conclusion

Prevention and control of NCDs will be the dominant health challenge of the twenty-first century. While it would be unrealistic to expect that all NCDs can be prevented, a large fraction of them can be prevented from occurring or affecting people in young and middle ages. Prevention of premature mortality and reduction of NCD-related morbidity and disability are goals that every national health system must pursue and all global partnerships must support. That these are achievable has been demonstrated in many HICs. Success does not derive only from costly clinical care. Prevention, through policies which create conducive environments in which people can make and maintain healthy living choices without formidable barriers, has contributed to most of the decline in NCDs that has been observed in HICs. Tobacco control is a prime example of how NCD mortality rates decline in response to policy and community-led initiatives (Unal et al. 2004). Countries like Finland and Poland have demonstrated how policies and community-based programmes influencing dietary choices can put brakes on the CVD epidemic (Zatonski and Willett 2005; Puska 2013).

The decline of cervical cancer, with organized screening and treatment (Mathew and George 2009), and the decline in lung cancer mortality, due to falling smoking rates in HICs, offer lessons for LMICs. It has also been observed that risk factor reduction explains 44–76 per cent of declining mortality in the United States, with improvements in clinical care contributing to the rest (Ford and Capewell 2011). LMICs can learn from the global experience of countries which have already experienced the NCD epidemics in full tide. At the same time, they will have to prioritize prevention and primary care over high-cost tertiary and terminal care, if their health systems are to successfully cope with the demands of multiple health burdens in a resource-constrained situation. Fortunately, knowledge related to effective prevention and lifesaving clinical care is available. It is now time to translate that abundant knowledge into effective action, if the ambitious but achievable goal of ‘25 by 25’is to be realized.

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