Why the NCD Response Needs Universal Health Coverage
Why the NCD Response Needs Universal Health Coverage
This post originally appeared on The Lancet Global Health Blog.
Universal health coverage (UHC) and non-communicable diseases (NCDs) are high priorities in global health—just look at the proposed post-2015 development goals. The increasing burden of NCDs is widely recognised, and a growing list of countries have joined the UHC movement. But what’s less widely understood is why a UHC approach is necessary for an effective NCD response.
To be clear, UHC in itself won’t be the answer to the NCD epidemic. NCDs are uniquely responsive to social determinants of health: the circumstances and environments in which people live. These factors contribute heavily to NCD risk factors like unhealthy diet, physical inactivity, and tobacco and alcohol use. The health system alone cannot get to the root of these problems.
Nevertheless, UHC efforts offer unique strengths for confronting the NCD epidemic in low- and middle-income countries (LMICs). Today, the staggering rates of unnecessary death, disability, and illness from NCDs in these countries are signs that our health systems aren’t fit for purpose. Done right, UHC reforms can dramatically reshape these systems around the most pressing needs. In fact, UHC might be the only realistic path to closing the NCD services gap, arguably doing more for NCDs than for any other health area.
NCDs cause 8 million premature deaths in LMICs each year, many of which are preventable or treatable with proven health system interventions. A woman in North America has an 80 percent chance of surviving breast cancer; in a developing country she has @epidemiologysurveilance/documents/document/acspc-027766.pdf">less than 40 percent. And for a child in a LMIC who comes down with strep throat, there’s a serious concern that it could lead to rheumatic fever, followed by the onset of rheumatic heart disease, all because of a shortage of the standard drug penicillin.
This divide reflects an unconscionable gap between burden of disease and health spending. Despite the large and growing challenge of NCDs, governments and donors allocate minimal resources to this area. National governments in LMICs haven’t responded to the need. For example, in Nepal (one of the few countries for which data on NCD spending is available) a meagre 7 percent of the national health budget is devoted to NCDs, despite accounting for 60 percent of the disease burden. And donors haven’t picked up the slack: only 1 percent of all development assistance for health went to NCDs in 2011.
Contrary to common misconception, the greatest burden of NCDs—both in terms of health consequences and impoverishment—falls on the poor. And since a large and increasing share of the cost of NCD care comes from out-of-pocket payments, NCDs are a prime cause of catastrophic health expenditures and reinforce societal inequities.
In the Philippines, NCDs account for more than 30 percent of premature deaths. Recognising this large and growing problem, the country has set about providing a set of low-cost early screening and treatment services. These include assessments for risk factors like tobacco use and overweight; referrals for treatment of heart disease and high blood pressure; and inclusion of essential drugs for hypertension and diabetes.
This Package of Essential NCD Interventions (Phil PEN) is just a start, but it’s an important one. The programme is being provided through PhilHealth, a national health insurance scheme that covers the majority of the population. And that’s no surprise—like Rwanda and Mexico, the Philippines is demonstrating that a UHC programme is an efficient vehicle for scaling up NCD services.
Under a UHC agenda, countries must define a package of health services that will be covered by health insurance (or its equivalent). Often limited to start with, this list of services is expanded over time, as funding increases and health needs shift.
To define this essential package of services, governments and health officials consider various factors, including the primary causes of illness, and the effectiveness and affordability of interventions. This is where we can expect to see expansion of NCD services. As policymakers consider the highest-impact interventions their pool of funding can buy, it’s simply impossible to ignore the benefit of NCD services.
A good place for LMICs to start is with NCD “best buys”, a core set of NCD interventions recommended by WHO. They include cervical cancer screening, counselling and drug therapy for cardiovascular disease, and other high-impact interventions. Importantly, they cost between just US$1 and $3 per person to implement in LMICs—partly self-financed by revenue-generating interventions like tobacco taxation.
Such highly cost-effective interventions should be affordable even for most low-income countries, with the increased domestic financing and individual contributions that are built into UHC reforms. Countries can build on this core set of NCD services over time, especially as economic growth and political commitment generate more funding for UHC.
As we see it, UHC is the only option for scaling up towards comprehensive NCD services for everyone. The alternatives just won’t work. Freestanding public health programmes—say, to provide mammograms or to identify school children with asthma—can scale up a single service but don’t mean much without a strong health system behind them. Given the nature of NCDs—caused by shared risk factors, closely interconnected with other health conditions, and often requiring complex, long-term care—governments will never move the needle without a robust, fully functioning health system.
Neither can governments leave prevention and treatment to individual consumers and providers: out-of-pocket payment, which is the status quo in many LMICs, simply means people don’t seek care, or they risk their financial welfare paying for it. A household in India, for example, can expect to spend up to 34 percent of its income caring for a diabetic family member. Inaction on the gap in NCD services is inexcusable, exacerbating inequity and fuelling the epidemic.
So while we mustn’t overestimate the promise of UHC for NCDs—addressing NCDs requires many societal changes that UHC activities can’t plausibly encompass—we should recognise UHC’s importance to a future in which health systems respond effectively to the epidemic. That’s a healthier and more just future that we’d like to be part of.