|REVIEW ARTICLE- PLENARY SESSION
|Year : 2017 | Volume
| Issue : 4 | Page : 94-101
Health system strengthening for the control of noncommunicable diseases and risk factors
Rahul Pandey Rapporteur
Department of Community Medicine, School of Public Health, PGIMER, Chandigarh, India
|Date of Web Publication||22-Feb-2018|
School of Public Health, PGIMER, Chandigarh
Source of Support: None, Conflict of Interest: None
The United Nation's (UN) high-level meeting on noncommunicable diseases (NCDs) in September 2011 created much-needed thrust for a global movement against preventable mortality, morbidity, and disability from NCDs. For the success of NCD prevention and control strategies, health system strengthening is crucial. Through this review, the health system was examined thoroughly to summarize the existing work done, identify shortcomings, and underpin way forward for NCD prevention and control. An in-depth review of literature was done using major search engines and various related journals. A search strategy was developed and employed to review published literature available through different search engines. Success stories from different domains of health system research were presented as case studies. The concept of universal health coverage was also discussed along with the strategies for its measurement. It was concluded that NCDs pose a major challenge and health system strengthening is critical to ensure the vision of UN sustainable development goals 2030.
Keywords: Finance, governance, health system, information, medicine, noncommunicable diseases, service delivery, universal health coverage, workforce
|How to cite this article:|
Pandey R. Health system strengthening for the control of noncommunicable diseases and risk factors. Int J Non-Commun Dis 2017;2:94-101
|How to cite this URL:|
Pandey R. Health system strengthening for the control of noncommunicable diseases and risk factors. Int J Non-Commun Dis [serial online] 2017 [cited 2018 Dec 14];2:94-101. Available from: http://www.ijncd.org/text.asp?2017/2/4/94/225980
| Introduction|| |
The World Health Organization (WHO) defines health system as all organizations and institutions whose primary purpose is to promote, restore, or maintain health. The prime objective for any health system is to provide sufficient and satisfactory health-care services to the population without imposing financial hardships on individuals or families. Noncommunicable diseases (NCDs) which were not the part of the millennium development goals (MDGs) are in focus of the sustainable development goals (SDGs). Fifteen million people who die from NCDs every year lie between the productive age group of 30–69 years and 80% of these premature deaths occur in low- and middle-income countries (LMICs). Sturdy national health system is a prerequisite to meet the challenges imposed by NCDs. Constraints are prominent across all the six pillars of health system.
A global urgency toward health system strengthening for the prevention and control of NCDs started during the Moscow declaration  which was then followed by the United Nations (UN) political declaration on NCDs (2011). The UN General Assembly (UNGA) was called in 2014 to monitor progress on NCDs prevention and control  which was again refreshed during the WHO Conference on NCDs at Montevideo, Uruguay, and World NCD Congress 2017 at Chandigarh, India. The next high-level meeting of the UNGA on NCDs will be scheduled in 2018. All these high-ended meetings have or will emphasis health system strengthening as one of the deliverables for the prevention and control of NCDs. Every pillar of the health system needs to be examined thoroughly for work done, prevailing shortcomings, and way forward.
| Methodology|| |
An in-depth review of literature was done using major search engines and various related journals. Post-MDG period was taken as the timeline for search. A background paper was prepared on “Health system strengthening for the control of noncommunicable diseases and risk factors” and shared with all resource persons. in advance and before the session.
The topic was also discussed in a plenary session at the World NCD Congress on November 4, 2017, at Chandigarh, India. With a comprehensive background review of the work done on the health system domains for the prevention and control of NCDs, experts discussed the topic at the World NCD Congress. The conference recorded the session and outcome was verified with those records also.
| Results|| |
Review of existing work emphasized on promoting the primary health care, improving financial allocation, minimizing information gap, and availability of drugs, health cadre, and equitable services delivery. These all points refine themselves as the building blocks of health system. Existing work also shows that expert globally has emphasized on all most the same strategies to counter NCDs. The prevailing shortcoming in the health system is almost the same with difference in the intensity accordingly. The way forward discussed during the session has been supported by the recommendations from the reviewed literature. The comprehensive review of the topic complimented by the expert session in World NCD Congress 2017 compiled the apt guidance about the work done, prevailing shortcoming, and suggestions for the improvement in health system for control of NCDs. This review presents the deliberation in context of building blocks of health system.
| Governance|| |
Nations have constitutional legislature for right to health, so country's health profile is the parameter for governance and leadership. Cost-effective and evidence-based interventions needed for NCD prevention and control were enlisted in the WHO Action Plan for the Prevention and Control of NCDs 2013–2020 called WHO Best Buys which included focus on tobacco cessation, depleting alcohol consumption, improving diet, and promoting physical activity. They were adopted by the member nations in line of World Health Assembly 2012 resolution for achieving global target of a 25% reduction in NCD mortality by 2025. Governments need to increase their spending for these strategies (Best Buy). Every nation should a have specific NCD prevention and control program.
Moreover, experts in the session also agreed that multi-sectored governance approach is needed for NCDs prevention as already documented globally.,, This should be complemented with national leadership involvement from the highest levels which can be through president or prime minister , as emphasized by Dr. Bekedam in the session too. For instance, in Mexico's National Council for NCDs prevention  and USA National Prevention Council are appropriate example. The judicial system can also play a key role; for instance, the apex court of India directed the central and state governments to ban smoking at public places. Therefore, apt governance model for prevention and control of NCDs should include the following domains [Figure 1].
Case study 1: India's first smoke-free city
In May 2003, India's anti-tobacco law COTPA received presidential consent. Advocacy meetings for smoke-free Chandigarh were organized by civil societies, action groups, and Chandigarh Healthy Heart project. They also approached the court for speedy implementation of the law. Once the law was implemented by the Chandigarh administration, it directed the police and food and drug inspectors (Department of Health) to take action against those who violate the law. The administration also involved the representatives of trade associations, nongovernmental organizations, hotels, restaurants, and slum areas for promoting awareness among the masses. With these collaborative efforts and instrumental display of governance, Chandigarh was the first smoke-free city in India on July 15, 2007.
NCDs put heavy pressure on nation's financial and economic prosperity. Despite increase in burden, health financing for NCDs is low (1%–2%). Comprehensive NCD treatment process takes prolonged time which leads to high out-of-pocket expenditure in the developing nations. The political declaration of the UNGA on the Prevention and Control of NCDs (2011) states to explore the provision of adequate and sustained financing resources. The expert panel in the session also concluded the governments should device specific model for financing NCD prevention and control strategies accordingly to priorities and burden.
Financial sources can be national, foreign, and innovative allocations. In national context, prepayments in the form of insurance, government's health budget, and taxation provisioning should be the main source of assistance. Increasing sin tax, improving the system of revenue collection, and increasing the tax compliance are some of ways to generate substantial revenue for NCD prevention and control. Foreign assistance from institutions such as development banks, supporting partners (WHO, UNICEF), and World Bank is important. Innovative financing mechanisms for NCD prevention and control include levies on commodities such as airplane tickets, amusement activities, and credit card rounding plans. For example, the “Pink Ribbon” campaign for breast cancer. Many private sector firms are involved in the NCD prevention agenda such as those selling fruits, running fitness centers, and many pharmaceutical industries  which need to be utilized for public good. Prioritization of strategy with a mix of all above methods for generating funds will be most sustained to finance NCDs prevention and control interventions [Figure 2].
Case study 2: Fat tax on junk food by Indian state
The Southern Indian state of Kerala stood second in India for childhood obesity in 2015. Hence, with a vision of healthy life for its people, Kerala implemented an innovative finance strategy by imposing 14.5% fat tax on selling of junk food, which is a common NCD risk factor globally. It is similar to the sin tax imposed on items such as alcohol or tobacco to discourage their consumption. This innovating tax system also ensured an annual profit to the state treasury. This strategy ensures a substantial and sustainable inflow of funds for NCD prevention and control interventions.
Medicines and medical technologies
According to WHO, three out of ten hardships faced in health system globally is attributed to medicines and medical technologies. In the developing world, more than 20% of the health spending is on medicines and medical technologies. Out-of-pocket expenditure is a common practice for patient care in LMICs; therefore, WHO in its global action plan included a voluntary target for 80% availability of affordable basic medicines and technologies., WHO recommends that every nation should have a national drug policy for NCDs. There are 95 essential medicines for NCD prevention and control introduced in May 2015. The panel recommended that low-cost generic medicines should be promoted in the healthcare sector for NCDs.
Existing work from the developing nations showed that availability of generic medicine is low in the public sector.,, Every nation needs situational analysis for the assessment of medicine pool in health system according to the disease burden and priorities for NCD prevention and control. The strategies for sustained availability of generic medicines in health system have been discussed in the WHO discussion paper. Recently, Government of India launched “Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJK)” with prime objective to make quality medicines available to common Indians  to lower high out-of-pocket expenses. WHO methods for measuring prices and availability and affordability for medicines should be used uniformly. Hence, the way forward for sustained medicine and medical technologies in health care for NCD prevention and control is mentioned below [Figure 3].
NCD prevention and control strategy demands a diverse workforce. Scale-up efforts have been made globally, but nations still have less than WHO-recommended ratio of 23 skilled health workers per 10,000 people. Shortage of workforce is a major constraint in the NCD prevention and control strategies.
As specifically trained health worker for NCD prevention and control strategy is limited, community health workers (CHWs) may fill in the gap. CHWs constitute a diverse workforce which work in the society, mainly equipped with elementary training for delivering specific health services. Already proven, CHW have been very efficient in programs requiring health behavior remodeling as a major endeavor, for instance, HIV prevention and control. This approach is cost-effective and develops an ownership pattern in the concerned society too for its sustenance. Furthermore, sociodemographic issues such as low literacy in a community, diverse terrains, and cultural and ethical practices halt the NCD prevention and control efforts; therefore, CHWs can be very instrumental in such issues. Few works from the developing countries have already concluded effectiveness of CHWs for NCD preventive strategies. It is also thought that for health system strengthening in the developing nations, task shifting can be an affordable and effective strategy, especially for NCD prevention at primary health-care level which can be facilitated by CHWs. For instance, in India ASHA, a cadre of health workers from the community has been instrumental in mother and child health-care domain. Now, their expertise is planned to be utilized for NCD prevention and control under National Programme for Prevention and Control of Diabetes, Cardiovascular Disease and Stroke.
Hence, optimal health workforce for NCD prevention and control should include following strategies [Figure 4].
The success of NCD prevention and control interventions is dependent on a consistently working and well-structured health information system. Experts in the session also agreed that nations have developed robust health information sources for diseases such as HIV and TB, but they lack any such infrastructure to measure NCDs and risk factor burden which blemishes the prospects of evidence-based policies and intervention.
An important progress was made in 2013 when the World Health Assembly adopted “Comprehensive Global Monitoring Framework” (GMF) having indicators and targets for the prevention and control of NCDs. The foremost activity for its uniform inception globally is that countries should device method to capture reliable and relevant data. Countries can also consider their priorities from the WHO Best Buys and the GMF can be aligned accordingly. For example, India has introduced a multi-sector action plan in the line of GMF and an additional tenth target of indoor air pollution has been incorporated. Similarly, priority changes have been done by Caribbean countries and Pacific region countries., Reliable, relevant, and good-quality data with key indicators are more useful rather than large sheets of unrealistic data. For NCDs, it could be from vital registries for specific mortality, population surveys for major risk factors, and periodic reports or documents on key NCD interventions. The WHO STEPwise surveillance of NCD risk factors (STEPS) is a relevant example for what is needed. Therefore, reliable data are the key for enhancing health system and tracking public health challenges from NCDs [Figure 5].
Case study 3: National Institute for Health and Care Excellence Guidelines 
The National Institute for Health and Care Excellence (NICE) in the UK documents guidelines on healthcare. NICE was been given the status of statutory body in 2013. It provides guidelines to improve public health practices for better health outcome. For NCDs, NICE has drafted appropriate and evidence-based guidelines with the engagement of local and national government. NICE guidelines provide range of information. People can access to the best suitable services and make priorities accordingly. NICE empowers the common citizen in treatment-related decision-making and improves the quality and reliability of the health system.
Health service delivery
Population-based and individual-based approaches should be the key strategies of health service deliveries for NCD prevention and control. Population-based approaches mainly comprise promotive and preventive services complemented with legislatures such as increased taxation on risk factors services (such as sin taxes). Individual-based approach covers nonclinical as well as clinical services such as health education, counseling, early detection through opportunities screening, functional referral system, acute clinical care, and rehabilitative care.
Experts in the session mentioned that hammering on the risk factors is among the most cost-effective, suitable, and sufficient way to prevent the NCDs at individual as well as population level. As in HIV programs gender sensitivity was considered crucial, similar approach shall be applied for NCDs service delivery strategies. For instance, the diet chart could be poor for female compared to male counterparts. In resource-scare settings, NCD prevention and control efforts can be integrated in operational programs (HIV, tuberculosis, vector-borne disease control, and maternal and child health) with a caution that the existing program is not disturbed.,, For instance, gestational diabetes case detection in MCH programs can be very helpful. Similarly, HIV programs can go hand in hand with NCD mitigation efforts.
In 2010, WHO launched an innovative approach “Package of Essential NCD Interventions” or WHO package of essential noncommunicable (PEN) for better health service delivery for NCDs prevention and control. From Southeast Asia regions, Sri Lanka and Bhutan were selected. The PEN approach utilizes primary healthcare domain for NCD prevention and control. It was an important step for integration of NCD into primary health care and strengthening health system.,
So far, efficient and effective health delivery prospect following range of activities are needed [Figure 6].
Universal health coverage for noncommunicable disease prevention and control (measurement and priority settings)
The passage of the UNGA resolution in December 2012 has given thrust to universal health coverage (UHC) as a major development agenda. The resolution has urged the member nations to strengthen health systems so as to decrease hardships (accessibility, coverage, and financial) in healthcare. SDGs prelude to achieve UHC through greater financial coverage, increased accessibility to services in the population with maximum population coverage.
In India, the 12th Five-Year Plan stated developing strategies to achieve UHC which was adopted by NITI Aayog with special emphasis for the coverage of NCDs in National Health Policy 2017., Following the national discourse, several state governments such as Kerala, Karnataka, and Tamil Nadu have developed plans and implemented for UHC in their one or two districts.
Health and related ministries have made progress toward the UHC by establishing departments and units for NCDs prevention and control, especially after WHO high-level meeting on NCD prevention and control. Already New Delhi Call for Actions to address NCDs and many other regional action plans have focused primarily for strengthening the health system for NCDs prevention and control efforts vis-a-vis UHC.
The World Health Report of 2013 recognizes UHC progress assessment as a major research priority. World Bank and the WHO produced a framework for measuring progress of UHC. It names coverage of services, population, and financial aspect as its domains for measurement. Previously, most of the work for measuring UHC was directed only on financial aspect or on health services. For comprehensive measurement of UHC, composite indicators are needed. Attempts have been made but are limited to MCH only. For UHC measurements pertaining to NCDs, composite measurement indicators are must.
Case study 4: Thailand's achievement in universal health coverage and health system strengthening 
Government of Thailand introduced the National Health Security Act in 2001. This leads the foundation for Universal Coverage Scheme (UCS) financed by general taxation. The Thai health system promotes multidimensional ways to improve health-care services and outcomes. The financial pool is funded by sin taxes from alcohol and tobacco product. This fund is also utilized for prompting campaign against unhealthy lifestyle. The UCS beneficiaries can get medical support from any public or private health-care institute of their choice. The bureaucracy and government also support spending in primary prevention methods. Even experimental and innovative approaches in health practices are supported through Health Intervention and Technology Assessment Programme (HITAP). Being a developing economy, Thailand has shown way forward to all nations for UHC.
| Discussion|| |
To ascertain the pledge of health for all sinew healthy system is needed to sustain over a period of time through evidence-based planning. Appropriate public health policies should also come up globally to stand aside with these inputs. For prevention and control of NCDs, integrated health approach involving multisector coordination and inclusive involvement of everyone is the need of the hour. The rapid transition in disease burden from acute to chronic diseases has put on enormous pressure on the health systems and cost-effective, yet quality-assured interventions such as WHOs Best Buys, STEPS, and PEN are needed. With this work, we aimed to examine existing approaches and challenges in health system regarding NCD prevention and control. We tried to have a global snapshot with special emphasis on LMICs. Few good practices in every domain of health system improvement proved that if proper commitment and involvement of every stakeholder is assured, then success has been achieved even in resource-scare settings. If we dream of UHC, then health system strengthening is one strategy to attain the same.
| Conclusion|| |
The plenary session outcome and comprehensive review of literature concluded that health system strengthening is crucial for NCD prevention and control. Multisector involvement, primary health care approach, evidence-based policy, and cost-effective intervention are among the key deliverables needed at the earliest.
Dr. Henk Bekedam: WHO Country Representative, India; Dr. Palitha Mahipala: Director General of Health Service, Sri Lanka; Dr. Fikru Tullu: WHO, India; Dr. Sadhana Bhagwat: WHO, India; Dr. Laura Downey: Imperial College, London; Dr. Shankar Prinja: School of Public Health, PGIMER, Chandigarh, India; and Mr. Bundit Sornpaisarn: Thai Health Promotion Foundation, Thailand.
Financial support and sponsorship
The session was supported by the WHO.
Conflicts of interest
There are no conflicts of interest.
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