This is a guest post from Wendy Johnson, a physician at the University of Washington with extensive experience working health issues in low-resource communities in Africa.
The UN High-level Meeting on Non-communicable Diseases (NCDs) couldn’t come at a worse time.
While the delegates, disease experts and functionaries gather in New York to discuss how to create a more comprehensive global health agenda, political leaders in a smaller city to the south with much more power to set that agenda will likely be dismantling the infrastructure and funding needed to support the fundamental change needed – health systems improvement.
As this story from Reuter’s notes, all foreign aid, and especially the USAID budget, is under serious threat, both from the so-called “super-committee” on debt and the deliberations over current spending bills taking place in Washington D.C. According to the article, House Foreign Affairs Committee Chairwoman Kay Granger is a proponent of deep cuts in aid who believes in limited programs that demonstrate quick impact and further U.S. national security.
This does not bode well for those at the UN meeting who will be arguing that the U.S. and other rich countries should make the long-term commitments necessary to address the disparities in NCDs such as diabetes, heart disease and cancer treatment in poor and middle-income countries. Representative Granger is unlikely to be convinced that diabetics in Bolivia or Indonesia without access to reliable health care pose a threat to our national security.
As calls for austerity and slashing public sector budgets become the norm across the globe, it is indeed hard to imagine how the any statement emerging from this UN meeting aimed at incorporating NCDs into the global health agenda will have any influence, no matter how strongly it is worded. In light of the huge budget-cutting sword of Damocles hanging over all of global health, it is hard to understand the UN’s apparent reluctance to set targets and convey a sense of urgency.
The draft Political Declaration on NCDs avoids setting meaningful targets and also side-steps the issue of access to vital new technologies and medicines. That vague statement has prompted this letter by the NCD Alliance, signed by many in the global health community and other political leaders, urging the UN to take a bolder stand.
If this controversy over target-setting seems like a fight over the configuration of deck chairs on the Titanic, a recent Lancet article calls into question the entire approach to the “NCD crisis”. The authors write:
“The worldwide attention on NCDs is timely, but the NCD Alliance seems to offer a conflicted strategy. On the one hand, a vertical and disease-oriented approach is recommended. . . . On the other hand, [calling]for strengthening of health systems, particularly primary health care. Yet their vision of primary care is limited and ambiguous. Primary care is seen as an opportunity for “case finding” (for the disease-oriented programmes), but is overlooked as the source of comprehensive care that integrates and coordinates care for all health problems and engages individuals, families, and the community. It is here that the real added value lies for health care and the health of people.
NCDs are by and large chronic diseases that require a completely different kind of health care system to adequately manage, one which facilitates continuity of care and provision of preventive services. In short, proper and effective management of NCDs require effective health systems built on a foundation of good primary care.
In my work scaling up HIV treatment in central Mozambique, we encountered a fragile health system completely organized around episodic care, too severely under-staffed to even perform those functions well. This is the norm in most poor countries. The scale-up of HIV treatment required some changes to those systems, but by and large they were made at the fringes, or in specialized clinics. Shoddy record-keeping systems, unreliable drug supplies and one-off consults at numerous clinics or hospitals remain the norm for other health problems.
In order to truly address NCDs, we need to address inequities in care and treatment for chronic diseases by revamping whole health systems (including in our own country, where good primary care is rare and continuity of care is a privilege of the well-insured.)
These are not the “short term, measurable goals” of which Representative Granger and others at USAID are so enamored of late. They require long term investments and a strong public sector to ensure equal access for all. The current austerity fad is a threat to global health that will have long-term implications for both rich and poor countries; and, as a recent UN report notes, it is unlikely to solve our economic problems, but will almost definitely worsen global health inequities and other social disparities.