Portal de Periódicos da CAPES

The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion

2020; Elsevier BV; Volume: 396; Issue: 10256 Linguagem: Inglês

10.1016/s0140-6736(20)31907-3

1474-547X

Gene Bukhman, Ana Olga Mocumbi, Rifat Atun, Anne E. Becker, Zulfiqar A Bhutta, Agnès Binagwaho, Chelsea Clinton, Matthew M Coates, Katie Dain, Majid Ezzati, Gary Gottlieb, Indrani Gupta, Neil Gupta, Adnan A. Hyder, Yogesh Jain, Margaret E. Kruk, Julie Makani, Andrew Marx, J. Jaime Miranda, Ole Frithjof Norheim, Rachel Nugent, Nobhojit Roy, Daniela Cristina Stefan, Lee Wallis, Bongani M. Mayosi, Kafui Adjaye-Gbewonyo, Alma J Adler, Fred Amegashie, Mary Kigasia Amuyunzu-Nyamongo, Said Habib Arwal, Nicole Bassoff, Jason Beste, Chantelle Boudreaux, Peter Byass, Jean Roland Cadet, Wubaye Walelgne Dagnaw, Arielle Wilder Eagan, Andrea B Feigl, Gladwell Gathecha, Annie Haakenstad, Abraham Haileamlak, Kjell Arne Johansson, Mamusu Kamanda, Biraj Karmacharya, Noel Kasomekera, Alex Kintu, Bhagawan Koirala, Gene F. Kwan, Nancy Charles Larco, Sarah Maongezi, Jones Masiye, Mary Mayige, Amy McLaughlin, Solomon Tessema Memirie, Humberto Muquingue, Kibachio Joseph Mwangi, Gilles Ndayisaba, Christopher Noble, Bashir Noormal, Maia Olsen, Paul Park, Gisela Robles Aguilar, Osman Sankoh, Akshar Saxena, Leah N. Schwartz, Dan Schwarz, Jonathan Shaffer, Andy Sumner, Zoe Taylor Doe, Senendra Raj Upreti, Stéphane Verguet, David Watkins, Emily Wroe,

Global Health Care Issues

"As we embark on this great collective journey, we pledge that no one will be left behind. Recognizing that the dignity of the human person is fundamental, we wish to see the goals and targets met for all nations and peoples and for all segments of society. And we will endeavour to reach the furthest behind first."Transforming our world: the 2030 agenda for sustainable development1Transforming our world: the 2030 Agenda for sustainable developmentResolution adopted by the General Assembly on 25 September 2015. United Nations, New York, NY2015Google Scholar We live in an era of unprecedented global wealth.2Alveredo F Chancel L Piketty T Saez E Zucman G World Inequality Report 2018. Harvard University Press, Cambridge, MA, USA2018Crossref Google Scholar Nevertheless, about one billion people in low-income and lower-middle-income countries (LLMICs) still experience levels of poverty that have long been described as "beneath any reasonable definition of human decency", in the words of former World Bank president, Robert McNamara.3World BankWorld Development Report 1978. World Bank, Washington, DC1978Crossref Google Scholar, 4Poverty and Shared Prosperity 2018. World Bank, Washington, DC2018Google Scholar, 5Hallegatte S Rozenberg J Climate change through a poverty lens.Nature Clim Change. 2017; 7: 250-256Crossref Scopus (0) Google Scholar This Commission was formed at the end of 2015 in the conviction that non-communicable diseases and injuries (NCDIs) are an important, yet an under-recognised and poorly-understood contributor to the death and suffering of this vulnerable population.6Bukhman G Mocumbi AO Horton R Reframing NCDs and injuries for the poorest billion: a Lancet Commission.Lancet. 2015; 386: 1221-1222Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar The aims of the Commission were to rethink global policies, mend a great disparity in health, and broaden the global health agenda in the interest of equity. There are ways, with demonstrated effectiveness in real-world conditions, to address the constellation of afflictions known as NCDIs. We have found, however, that the world's poorest billion are being systematically deprived of those life-saving and life-changing interventions. This unfair exclusion stems both from a lack of global solidarity with the poorest of the poor, and from inadequate descriptions and comprehension of the problem. NCDIs are commonly represented as complications of ageing and development. In fact, they also constitute a large and diverse burden of illness among children and young adults, who make up the largest proportion of people living in extreme poverty around the world. Public health discourse and global solutions have generally focused on preventing NCDIs through changes in human behaviours, and not on addressing the inadequate resources available for the poor to be properly nourished, live safely, and to access health care. Meanwhile, treatments for NCDIs account for the largest gap in health financing for LLMICs, making a mockery of international commitments to universal health coverage (UHC). Many of the established global initiatives and frameworks for health equity are relevant for the heterogeneous set of conditions that comprise NCDIs among the poorest billion, which we term NCDI Poverty. To date, none of these schemes have fully recognised the burden of NCDI Poverty or offered strategies to adequately mitigate its effect (figure 1). For instance, the Millennium Development Goals (MDGs) focused attention on the health of the poorest billion and went a long way toward addressing many of the underlying infectious and poverty-related causes of disease.7Annan KA We the Peoples. The Role of the United Nations in the 21st Century. United Nations, New York2000Google Scholar However, these goals did not respond to the specific epidemiology of NCDIs, nor to the complexity of prevention and treatment of these conditions. Likewise, the WHO Global Action Plans for non-communicable diseases (NCDs) focused initially on four major disease categories (cardiovascular disease, diabetes, chronic respiratory disease, and cancer) and four groups of associated risk factors (unhealthy diets, physical inactivity, tobacco use, and harmful use of alcohol), known as the 4 × 4 conditions. These are undoubtedly global concerns, but leave out key NCDI priorities for the poorest billion.8WHOGlobal action plan for the prevention and control of NCDS 2013–2020. World Health Organization, Geneva2013Google Scholar The 2030 Sustainable Development Goal (SDG) targets, adopted in 2017, have remained consistent with these global NCD plans while expanding the focus to include mental health, substance use, and road traffic injuries.9UN Economic and Social CouncilReport of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators. E/CN.3/2016/2/Rev.1. UN Economic and Social Council, New York, NY2016Google Scholar Although the Sept 27, 2018, UN High-Level Meeting on NCDs extended the NCD agenda to include mental health and air pollution (thereby extending 4 × 4 to 5 × 5), it is necessary to go further if we are to address the full scope of diseases that constitute NCDI Poverty.10UN General AssemblyPolitical declaration of the 3rd High-Level Meeting of the General Assembly on the prevention and control of non-communicable diseases. A/RES/73/2. United Nations General Assembly, New York, NY2018Google Scholar UHC holds great promise, but it will fulfil the promise of universality only if its structure and implementation recognise and respond to NCDI Poverty.11UN General AssemblyA/RES/67/81. Global health and foreign policy. United Nations, Geneva2013Google Scholar, 12WHOSustainable health financing, universal coverage and social health insurance. World Health Assembly 58.33. World Health Organization, Geneva2005Google Scholar Key messages•For the poorest of our world, non-communicable diseases and injuries (NCDIs) account for more than a third of their burden of disease; this burden includes almost 800 000 deaths annually among those aged younger than 40 years, more than HIV, tuberculosis, and maternal deaths combined•Despite already living in abject poverty, between 19 million and 50 million of the poorest billion spend a catastrophic amount of money each year in direct out-of-pocket costs on health care as a result of NCDIs•Progressive implementation of affordable, cost-effective, and equitable NCDI interventions between 2020 and 2030 could save the lives of more than 4·6 million of the world's poorest, including 1·3 million who would otherwise die before the age of 40 years•To avoid needless death and suffering, and to reduce the risk of catastrophic health spending, essential NCDI services must be financed through pooled, public resources, either from increased domestic funding or external funds•National governments should set and adjust priorities based on the best available local data on NCDIs and the specific needs of the worst off•International development assistance for health should be augmented and targeted to ensure that the poorest families affected by NCDIs are included in progress towards universal health care •For the poorest of our world, non-communicable diseases and injuries (NCDIs) account for more than a third of their burden of disease; this burden includes almost 800 000 deaths annually among those aged younger than 40 years, more than HIV, tuberculosis, and maternal deaths combined•Despite already living in abject poverty, between 19 million and 50 million of the poorest billion spend a catastrophic amount of money each year in direct out-of-pocket costs on health care as a result of NCDIs•Progressive implementation of affordable, cost-effective, and equitable NCDI interventions between 2020 and 2030 could save the lives of more than 4·6 million of the world's poorest, including 1·3 million who would otherwise die before the age of 40 years•To avoid needless death and suffering, and to reduce the risk of catastrophic health spending, essential NCDI services must be financed through pooled, public resources, either from increased domestic funding or external funds•National governments should set and adjust priorities based on the best available local data on NCDIs and the specific needs of the worst off•International development assistance for health should be augmented and targeted to ensure that the poorest families affected by NCDIs are included in progress towards universal health care Beginning in 2016, this Commission organised a team of 23 clinicians, researchers, and policy practitioners into four working groups with these objectives: to learn about the scale and pattern of the NCDI burden among the poorest; to identify priority interventions and delivery strategies to address this burden; to consider gaps and opportunities for NCDI financing in the countries where the poorest billion live; and to better understand the history and current state of NCDI framing and governance within key global institutions and at national levels. Since its inception, the Commission has convened five global meetings. It has helped to establish National NCDI Poverty Commissions and Groups in 16 LLMICs, involving more than 247 NCDI leaders, representing countries that are home to approximately half of the world's poorest billion people. The Commission has co-hosted five Knowledge Exchanges, bringing these National NCDI Poverty collaborators together both virtually and at World Bank offices of four continents.13The Lancet NCDI Poverty CommissionNational NCDI Poverty Commissions and Groups.https://www.ncdipoverty.org/overview1Date accessed: May 20, 2020Google Scholar Using videography, the Commission has documented the experience of over 40 patients with a diverse set of NCDIs from sub-Saharan Africa, the Caribbean, and South Asia. The Commission has also participated in developments that have substantially expanded the NCDI and UHC agendas over the past 3 years to include a broader range of conditions, risks, interventions, and people.14Countdown NCD NCD Countdown 2030: worldwide trends in non-communicable disease mortality and progress towards Sustainable Development Goal target 3.4.Lancet. 2018; 392: 1072-1088Summary Full Text Full Text PDF PubMed Scopus (102) Google Scholar, 15WHOReport of the WHO independent high-level commission on noncommunicable diseases. World Health Organization, Geneva2018Google Scholar, 16Jamison DT Alwan A Mock CN et al.Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edn.Lancet. 2018; 391: 1108-1120Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 17Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (552) Google Scholar, 18Knaul FM Farmer PE Krakauer EL et al.Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report.Lancet. 2018; 391: 1391-1454Summary Full Text Full Text PDF PubMed Scopus (231) Google Scholar, 19Jain Y Desiraju K It is not enough to grieve; we must learn from Gorakhpur.Indian J Med Ethics. 2017; 2: 221-223Crossref PubMed Scopus (1) Google Scholar, 20WHORheumatic fever and rheumatic heart disease. World Health Organization, Geneva2017Google Scholar, 21Consunji R Ameratunga S Hyder AA Trauma care in the developing world: introduction to special issue.Surgery. 2017; 162: S2-S3Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 22Agyepong IA Sewankambo N Binagwaho A et al.The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa.Lancet. 2018; 390: 2803-2859Summary Full Text Full Text PDF PubMed Scopus (62) Google Scholar, 23Tluway F Makani J Sickle cell disease in Africa: an overview of the integrated approach to health, research, education and advocacy in Tanzania, 2004–2016.Br J Haematol. 2017; 177: 919-929Crossref PubMed Scopus (18) Google Scholar, 24Mould-Millman N-K Dixon JM Sefa N et al.The state of Emergency Medical Services (EMS) systems in Africa.Prehosp Disaster Med. 2017; 32: 273-283Crossref PubMed Scopus (43) Google Scholar, 25Mendoza W Miranda JJ Global shifts in cardiovascular disease, the epidemiologic transition, and other contributing factors: toward a new practice of global health cardiology.Cardiol Clin. 2017; 35: 1-12Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 26Bhutta ZA Lassi ZS Bergeron G et al.Delivering an action agenda for nutrition interventions addressing adolescent girls and young women: priorities for implementation and research.Ann N Y Acad Sci. 2017; 1393: 61-71Crossref PubMed Scopus (0) Google Scholar, 27Atun R Davies JI Gale EAM et al.Diabetes in sub-Saharan Africa: from clinical care to health policy.Lancet Diabetes Endocrinol. 2017; 5: 622-667Summary Full Text Full Text PDF PubMed Scopus (113) Google Scholar The Commission's working groups have developed six key messages based on original analyses of epidemiology, organisation of health interventions, financing, history, and governance (appendix p 3). The methodology behind the estimates used to support these messages and other findings and recommendations of the Commission is described throughout the report and in its appendices (panel 1).Panel 1Key recommendationsLocal action•Ministries of health in high-poverty countries should partner with academic and civil society groups to assess their national non-communicable disease and injury (NCDI) poverty burden, identify priority conditions and interventions using multiple criteria (including equity and cost-effectiveness), estimate the cost and impact of action, to develop delivery strategies, and advocate for expanded domestic and external financial resources; these NCDI interventions include intersectoral policies, as well as surgical, medical, psychosocial, and rehabilitative services•National health statistics and surveillance should include information about socioeconomic status and a more diverse set of priority NCDIs•Governments should establish multi-sectoral mechanisms to coordinate the efforts of ministries responsible for energy, transportation, and social protection so that they consider the special vulnerability of those with severe NCDIs•National NCDI civil society organisations should make special efforts to channel the voices and priorities of the poor•National research institutions in high-poverty countries should stimulate investigation to fill knowledge gaps regarding the cost-effectiveness and equity of NCDI interventions and delivery model design•National professional societies should elaborate a scope of practice and develop career pathways for mid-level providers in priority NCDI service areas•Ministries of finance should increase fiscal space for health care through taxation of unhealthy products and progressive revenue collection mechanisms.Making NCDI Poverty a global priority in the sustainable development goal (SDG) era•Broaden the interpretation of the SDG NCDI targets to encompass reducing NCDI mortality at all ages and from all causes, with particular attention to reducing mortality under the age of 40 years•Disaggregate existing targets for reducing maternal and under-5 mortality by cause of death to highlight and address the role of NCDIs•Expand universal health coverage and monitoring to include interventions for less common and more severe conditions and those that cause the most lifetime loss of health•Disaggregate the existing SDG target for social protection to target poor and vulnerable people living with severe NCDIs•High-income countries should fully implement their development assistance commitments and renew their focus on the comprehensive health and social needs of the poorest people in the poorest countries, inclusive of NCDIs Local action •Ministries of health in high-poverty countries should partner with academic and civil society groups to assess their national non-communicable disease and injury (NCDI) poverty burden, identify priority conditions and interventions using multiple criteria (including equity and cost-effectiveness), estimate the cost and impact of action, to develop delivery strategies, and advocate for expanded domestic and external financial resources; these NCDI interventions include intersectoral policies, as well as surgical, medical, psychosocial, and rehabilitative services•National health statistics and surveillance should include information about socioeconomic status and a more diverse set of priority NCDIs•Governments should establish multi-sectoral mechanisms to coordinate the efforts of ministries responsible for energy, transportation, and social protection so that they consider the special vulnerability of those with severe NCDIs•National NCDI civil society organisations should make special efforts to channel the voices and priorities of the poor•National research institutions in high-poverty countries should stimulate investigation to fill knowledge gaps regarding the cost-effectiveness and equity of NCDI interventions and delivery model design•National professional societies should elaborate a scope of practice and develop career pathways for mid-level providers in priority NCDI service areas•Ministries of finance should increase fiscal space for health care through taxation of unhealthy products and progressive revenue collection mechanisms. Making NCDI Poverty a global priority in the sustainable development goal (SDG) era •Broaden the interpretation of the SDG NCDI targets to encompass reducing NCDI mortality at all ages and from all causes, with particular attention to reducing mortality under the age of 40 years•Disaggregate existing targets for reducing maternal and under-5 mortality by cause of death to highlight and address the role of NCDIs•Expand universal health coverage and monitoring to include interventions for less common and more severe conditions and those that cause the most lifetime loss of health•Disaggregate the existing SDG target for social protection to target poor and vulnerable people living with severe NCDIs•High-income countries should fully implement their development assistance commitments and renew their focus on the comprehensive health and social needs of the poorest people in the poorest countries, inclusive of NCDIs We have found that NCDIs constitute more than a third of the disease burden among the poorest billion, and that around half of this burden is due to causes afflicting children and young adults. Section 1 of this report—the burden of NCDI Poverty—describes the geographical and demographic distribution of the world's poorest people and characterises the magnitude and pattern of their NCDI burden. More than 90% of the poorest billion live in rural areas of LLMICs in sub-Saharan Africa and South Asia. More than half a billion people will probably still be living in extreme poverty until 2030. Some projections range as high as 1 billion, taking account of the adverse impact of climate change and inequalities in the distribution of economic growth. The COVID-19 pandemic is now pushing projections of extreme poverty even higher. The World Bank estimates that the pandemic will drive between 71 million and 100 million people into extreme poverty, 81% of them in sub-Saharan Africa and South Asia—the regions that are already home to more than 90% of the world's poorest billion people.28World Bank BlogsUpdated estimates of the impact of Covid-19 on global poverty.https://blogs.worldbank.org/opendata/updated-estimates-impact-covid-19-global-povertyDate: 2020Date accessed: August 27, 2020Google Scholar Around 80% of the poorest billion are aged younger than 40 years, and around 90% are younger than 55 years. Our analysis shows that NCDIs in these populations are due to a diverse set of conditions and risks. Notably, these conditions are heterogeneous in their effect on the lifetime health of those affected. Those NCDIs associated with the greatest health loss among the poorest billion result in the loss of 20 more years of healthy life per person than the same conditions in high-income populations. Much of this is because NCDIs among the poorest are acquired at younger ages (partly due to population age structure) and because NCDIs are more lethal when they occur among those living in extreme poverty with low access to quality health services. This Commission has identified a set of cost-effective and equitable interventions to address NCDI Poverty. Although global initiatives have largely focused on health behaviours, the interventions we have identified also have to be delivered through the health sector, including at secondary facilities (such as, district hospitals) to treat established disease. In section 2—integrating NCDI Poverty in UHC—we describe these interventions and show how they can be implemented at scale. Intersectoral strategies can prevent drowning, road traffic injuries, heart attacks, strokes, type 2 diabetes, chronic lung disease, and some cancers. Better housing, sanitation, transportation and energy infrastructure, and nutritious foods can relieve other social determinants of NCDI Poverty. We find that health-sector interventions to address NCDI Poverty are diverse and require integration both within and across levels of the health system. We introduce the concept that delivery of these interventions through integrated care teams can help drive transformative change to improve the quality of services in health systems. The resources being allocated to address NCDI Poverty are grossly insufficient. International development agencies have been the most neglectful. Section 3 of this report—financing to address NCDI Poverty—assesses the current state of both domestic and external NCDI financing in the LLMICs where the poorest billion live. Information from national health accounts suggests that government expenditure on NCDIs is low in these countries. Global development assistance for NCDIs has remained minimal, and little of this funding has been directed toward the poorest countries. The largest organisational channel for development assistance for NCDIs in 2017 was the WHO (US$164 million). The dismal projected financing capacity in many LLMICs will be inadequate to address NCDI Poverty by 2030 at current levels of development assistance for health. Because NCDIs are the largest unmet need in LLMIC health financing, expanding development assistance will be essential to achieving UHC in the poorest countries. There are no existing institutions focused on addressing NCDI Poverty at either global or national levels. Section 4 of this report—global and national policy, governance, and agenda-setting for NCDI Poverty—identifies opportunities to strengthen current health governance arrangements both globally and at the country level. We find that efforts to improve the health of the world's poorest people and to control NCDIs have largely run on parallel tracks over the past 40 years. Poverty-focused global and national health initiatives have concentrated on infectious diseases, and maternal and child health. Meanwhile, the influential NCD priorities at WHO, largely adopted by the World Bank and other global institutions, have focused on a narrow set of conditions and risks (4 × 4, then 5 × 5). In the SDG era, these two perspectives have continued to shape UHC monitoring, as well as investments from global multilaterals, development agencies, philanthropists, and national governments. The thinking behind these arrangements seems obvious if unacknowledged: poor countries must use their own meagre resources to deal with their health problems. We hope that the new evidence from this Commission offers an opportunity for the expansion of these frameworks so that NCDI Poverty can be honestly acknowledged and addressed. To tackle the current failure of reason and compassion, we offer seven recommendations for local action, based on our experience with National NCDI Poverty Commissions. We recommend the following: ministries of health in high-poverty countries should partner with academic and civil society groups to assess their National NCDI Poverty burden, identify priority conditions and interventions using multiple criteria (including equity and cost-effectiveness), estimate the cost and impact of action, develop delivery strategies, and advocate for expanded domestic and external financial resources; national health statistics and surveillance should include information about socioeconomic status and a more diverse set of priority NCDIs; governments should establish multi-sectoral mechanisms to coordinate the efforts of ministries responsible for energy, transportation, and social protection so that they consider the special vulnerability of those with severe NCDIs; national NCDI civil society organisations should make special efforts to channel the voices and priorities of the poor; national research institutions in high-poverty countries should stimulate investigation to fill knowledge gaps regarding the cost-effectiveness and equity of NCDI interventions and delivery model design; national professional societies should elaborate a scope of practice and develop career pathways for mid-level providers in priority NCDI service areas; and ministries of finance should increase fiscal space for health care through taxation of unhealthy products and progressive revenue collection mechanisms. A commitment to the treatment and prevention of NCDIs is enshrined in the SDGs. To ensure that this commitment does not bypass the poorest people in the world, a global NCDI Poverty Network is being established to support the implementation of this Commission's recommendations. Composed of a growing group of National NCDI Poverty Commissions, this Network will strive to catalyse financial and technical partnerships to implement pro-poor NCDI interventions in the countries where the poorest billion live. This Network, working closely with The Lancet and the NCD Countdown 2030, will also monitor and report on implementation progress, strengthening both national and global accountability mechanisms. In 2018, the Director General of WHO set an ambitious goal that would have an additional one billion people benefiting from UHC by 2023.29WHOThirteenth general programme of work 2019–2023. World Health Organization, Geneva2018Google Scholar To fulfil the SDG promise –"to reach the furthest behind first"–29WHOThirteenth general programme of work 2019–2023. World Health Organization, Geneva2018Google Scholar this billion should be the poorest billion. And, one of the greatest gaps in UHC for this population is NCDI Poverty. Some will question whether this Commission is urging leaders in LLMICs to place NCDI Poverty above other pressing health and social concerns, such as infectious epidemics. We are not. Instead, we are calling to expand the pro-poor agenda and mend a deep historical injustice. There is a need for greater resources for health (both domestic and external) to adequately address the obscene lack of care for NCDIs (and other conditions) among the poorest billion. The authors of this Commission are aware that an extraordinary global commitment will be required to realise our recommendations for redress and coverage. Based on our analyses, we believe it is crucial to articulate, defend, and advance these aspirations for global health equity.