An analysis of policy and funding priorities of global actors regarding noncommunicable disease in low- and middle-income countries

Mapping the Common Barriers to Optimal COPD Care in High and Middle-Income Countries: Qualitative Perspectives from Clinicians

Purpose

Chronic obstructive pulmonary disease (COPD) poses a significant global health burden despite being largely preventable and treatable. Despite the availability of guidelines, COPD care remains suboptimal in many settings, including high-income countries (HICs) and upper-middle-income countries (UMICs), with varied approaches to diagnosis and management. This study aimed to identify common and unique barriers to COPD care across six countries (Australia, Spain, Taiwan, Argentina, Mexico, and Russia) to inform global policy initiatives for improved care.

Methods

COPD care pathways were mapped for each country and supplemented with epidemiological, health-economic, and clinical data from a targeted literature review. Semi-structured interviews with 17 respiratory care clinicians were used to further validate the pathways and identify key barriers. Thematic content analysis was used to generate the themes.

Results

Six themes were common in most HICs and UMICs: "Challenges in COPD diagnosis", "Strengthening the role of primary care", "Fragmented healthcare systems and coordination challenges", "Inadequate management of COPD exacerbations", "Limited access to specialized care" and, "Impact of underfinanced and overloaded healthcare systems". One theme, "Insurance coverage and reimbursement challenges", was more relevant for UMICs. HICs and UMICs differ in patient and healthcare provider awareness, primary care involvement, spirometry access, and availability of specialized care. Both face issues with healthcare fragmentation, guideline adherence, and COPD exacerbation management. In addition, UMICs also grapple with resource limitations and healthcare infrastructure challenges.

Conclusion

Many challenges to COPD care are the same in both HICs and UMICs, underscoring the pervasive nature of these issues. While country-specific issues require customized solutions, there are untapped possibilities for implementing global respiratory strategies that support countries to manage COPD effectively. In addition to healthcare system-level initiatives, there is a crucial need for political prioritization of COPD to allocate the essential resources it requires.

Knowledge of gendered needs among the planners and policy makers for prevention of NCDs in Bangladesh: a qualitative exploration

BACKGROUND

Globally, non-communicable diseases (NCDs) are increasingly the primary cause of mortality and morbidity among women. Like many developing countries, Bangladesh also faces a growing burden of NCDs. The "Multisectoral Action Plan for Prevention and Control of Non-communicable Diseases, 2018-2025" signifies Bangladesh's commitment to comprehensively combating the rising burden of NCDs. This study investigates the perceptions of those involved in developing the action plan and if/how a gender lens was incorporated into its implementation.

METHODS

In-depth interviews were conducted with 25 key individuals involved in a high-level committee to develop and implement Bangladesh's multisectoral action plan to address the burden of NCDs. Data were collected between July and November 2021, and thematic analysis was conducted.

RESULTS

The findings revealed that interviewees believed the multisectoral action plan adopted a population-wide approach without considering gender-specific needs. This study presents the explanations for this inattention under five themes: (1) A population-level approach to NCD prevention; (2) Understanding women's health beyond reproductive health; (3) Absence of gender-specific programs; (4) Lack of consideration of gender constraints on physical activity; and (5) Lack of collaborative efforts to address NCDs beyond the health ministry.

CONCLUSION

In conclusion, governments in countries like Bangladesh can develop more effective strategies to reduce the disease burden of NCDs among women by recognizing and addressing the gendered nature of preventive health. This can be achieved by promoting gender-responsive research, programs, and policy initiatives that consider women's specific health concerns, ultimately leading to better health outcomes for all.

Public expenditure on health care and the incidence of non-communicable diseases (NCDs) in China from 2008 to 2018

OBJECTIVES

This study investigates whether differences in individual-level and provincial-level health funding could explain or mitigate health inequalities among older people in terms of non-communicable diseases within a population served by fragmented health insurance schemes.

STUDY DESIGN

A national repeated cross-sectional analysis was done of the 2008, 2011, 2014, and 2018 Chinese Longitudinal Healthy Longevity Surveys. These provided a total of 44,623 persons aged 60 and over.

MAIN OUTCOME MEASURES

Respondents were asked whether they had been diagnosed with any types of non-communicable diseases by doctors. A dichotomous outcome variable was constructed to indicate whether older people had any diagnosed non-communicable diseases.

RESULTS

Compared with uninsured older persons, those who were enrolled in social health insurance schemes designed for civil servants as cadres, urban employees and urban residents were more likely to report a higher incidence of non-communicable diseases. There were no significant differences in the prevalence of non-communicable diseases between uninsured older people and those in the New Rural Cooperative Medical Scheme. Although the incidence of non-communicable diseases among older persons increased over the study period, greater health expenditure was significantly associated with a lower risk of non-communicable diseases. The interaction results between individual social health insurance schemes and public health expenditure indicate that disparities in the incidence of non-communicable diseases among different health insurance schemes diminish as public health expenditure increases. Older individuals with Public Free Medical Services benefited the most in provinces with higher public health expenditure compared with other health insurance schemes.

CONCLUSIONS

Given the evidence of the beneficial effects of universal health coverage on non-communicable diseases among older persons, these results should encourage policy makers to increase public health funding and to raise the overall benefit packages for social health insurance schemes.

Health seeking behaviours and private sector delivery of care for non-communicable diseases in low- and middle-income countries: a systematic review

BACKGROUND

Globally, non-communicable diseases (NCDs) are the leading cause of mortality and morbidity placing a huge burden on individuals, families and health systems, especially in low- and middle-income countries (LMICs). This rising disease burden calls for policy responses that engage the entire health care system. This study aims to synthesize evidence on how people with NCDs choose their healthcare providers in LMICs, and the outcomes of these choices, with a focus on private sector delivery.

METHODS

A systematic search for literature following PRISMA guidelines was conducted. We extracted and synthesised data on the determinants and outcomes of private health care utilisation for NCDs in LMICs. A quality and risk of bias assessment was performed using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

We identified 115 studies for inclusion. Findings on determinants and outcomes were heterogenous, often based on a particular country context, disease, and provider. The most reported determinants of seeking private NCD care were patients having a higher socioeconomic status; greater availability of services, staff and medicines; convenience including proximity and opening hours; shorter waiting times and perceived quality. Transitioning between public and private facilities is common. Costs to patients were usually far higher in the private sector for both inpatient and outpatient settings. The quality of NCD care seems mixed depending on the disease, facility size and location, as well as the aspect of quality assessed.

CONCLUSION

Given the limited, mixed and context specific evidence currently available, adapting health service delivery models to respond to NCDs remains a challenge in LMICs. More robust research on health seeking behaviours and outcomes, especially through large multi-country surveys, is needed to inform the effective design of mixed health care systems that effectively engage both public and private providers.

TRIAL REGISTRATION

PROSPERO registration number CRD42022340059 .

[Evolution and Application of Disease Control Priorities]

Disease control priority (DCP) is an important public health intervention strategy. Diseases that should be prioritized for prevention and control are first screened with a series of criteria, including the severity of the disease burden, the effectiveness of disease control technologies, the prevention and control capacity of the existing health system, etc. Then, the prevention and control technologies for these diseases undergo qualitative evaluation (eg, face-to-face interviews, expert consultation, workshops, etc) and quantitative evaluation (eg, cost-benefit analysis, multi-criteria decision analysis, etc). Finally, the public health initiatives that should be prioritized are identified. From the conception of the idea, to the formal proposition of the concept, to guidance for practice, DCP has gone through more than 70 years of development. Through DCP, significant contributions has been made to improving the efficiency of health care service systems and promoting the health of populations in developing countries. Herein, we systematically reviewed the background, development history, realization method, and practical applications of DCP, focusing on exploring the application potential of DCP in health governance and providing technical support and decision-making reference for the comprehensive promotion of the Healthy China Initiative.

Cancer incidence, mortality, and survivorship in African women: a comparative analysis (2016-2020)

Objectives

This research aims to provide concrete insight into cancer incidence, mortality, and survivorship dynamics among African women between 2016 and 2020.

Methods

The study computes the Mortality-to-Incidence Ratio (MIR) for 53 countries in Africa with available mortality and incidence data. It uses relevant Life Tables to obtain the 5-year Relative Survival rate for women in different age cohorts based on General Survival Rate and 5-year Cancer Prevalence data from the World Health Organization (WHO). The study performs an analysis of variance tests.

Results

The results of the initial data analysis show that women in the top economies in Africa have the highest cancer incidence and mortality. The study also finds that women in Northern and Southern African countries have higher relative survival rates and lower MIR than other African regions. ANOVA results confirm statistically significant differences in 5-year relative survival across the African regions. The relative survival at 5 years was an average of 45% across all age groups within the continent although relative survival is highest among females aged 5-19 and 80-84. The lowest relative survival rates are seen for infants (0-4), adolescents and young adults (25-29), and the very elderly (85+).

Conclusion

The study concludes that while cancer incidence in Africa is linked to affluence, survival is very challenging, especially for the least developed economies in Western, Eastern, and Central Africa. The results indicate the need for crucial intervention in the continent concerning awareness, research, and data collection methodology.

Convergence of HIV and non-communicable disease epidemics: geospatial mapping of the unmet health needs in an HIV hyperendemic community in South Africa

INTRODUCTION

As people living with HIV (PLHIV) are experiencing longer survival, the co-occurrence of HIV and non-communicable diseases has become a public health priority. In response to this emerging challenge, we aimed to characterise the spatial structure of convergence of chronic health conditions in an HIV hyperendemic community in KwaZulu-Natal, South Africa.

METHODS

In this cross-sectional study, we used data from a comprehensive population-based disease survey conducted in KwaZulu-Natal, South Africa, which collected data on HIV, diabetes and hypertension. We implemented a novel health needs scale to categorise participants as: diagnosed and well-controlled (Needs Score 1), diagnosed and suboptimally controlled (Score 2), diagnosed but not engaged in care (Score 3) or undiagnosed and uncontrolled (Score 4). Scores 2-4 were indicative of unmet health needs. We explored the geospatial structure of unmet health needs using different spatial clustering methods.

RESULTS

The analytical sample comprised 18 041 individuals. We observed a similar spatial structure for HIV among those with combined needs Score 2-3 (diagnosed but uncontrolled) and Score 4 (undiagnosed and uncontrolled), with most PLHIV with unmet needs clustered in the southern urban and peri-urban areas. Conversely, a high prevalence of need Scores 2 and 3 for diabetes and hypertension was mostly distributed in the more rural central and northern part of the surveillance area. A high prevalence of need Score 4 for diabetes and hypertension was mostly distributed in the rural southern part of the surveillance area. Multivariate clustering analysis revealed a significant overlap of all three diseases in individuals with undiagnosed and uncontrolled diseases (unmet needs Score 4) in the southern part of the catchment area.

CONCLUSIONS

In an HIV hyperendemic community in South Africa, areas with the highest needs for PLHIV with undiagnosed and uncontrolled disease are also areas with the highest burden of unmet needs for other chronic health conditions, such as diabetes and hypertension. Our study has revealed remarkable differences in the distribution of health needs across the rural to urban continuum even within this relatively small study site. The identification and prioritisation of geographically clustered vulnerable communities with unmet health needs for both HIV and non-communicable diseases provide a basis for policy and implementation strategies to target communities with the highest health needs.

An evidence gap map of interventions for noncommunicable diseases and risk factors among children and adolescents

Substance misuse, obesity, mental health conditions, type 1 diabetes, cancers, and cardiovascular and chronic respiratory diseases together account for 41% of disability-adjusted life years linked to noncommunicable diseases (NCDs) among children and adolescents worldwide. However, the evidence on risk factors and interventions for this age group is scarce. Here we searched four databases to generate an evidence gap map of existing interventions and research gaps for these risk factors and NCDs. We mapped 159 reviews with 2,611 primary studies; most (96.2%) were conducted in high-income countries, and only 100 studies (3.8%) were from low- and middle-income countries (LMICs). The efficacy of therapeutic interventions on biomarkers and adverse events for NCDs appears to be well evidenced. Interventions for mental health conditions appear to be moderately evidenced, while interventions for obesity and substance misuse appear to be moderate to very low evidenced. Priority areas for future research include evaluating digital health platforms to support primary NCD prevention and management, and evaluating the impact of policy changes on the prevalence of obesity and substance misuse. Our findings highlight the wide disparity of evidence between high-income countries and LMICs. There is an urgent need for increased, targeted financing to address the research gaps in LMICs.

Pharmacological and Therapeutic Potential of Cucumis callosus: a Novel Nutritional Powerhouse for the Management of Non-communicable Diseases

Cucumis callosus (Kachri) is an under-exploited fruit of the Cucurbitaceae family, distributed majorly in the arid regions of India in the states of Haryana, Rajasthan, and Gujarat. The fruit is traditionally used by the native people at a small scale by home-level processing. It is a perennial herb that has been shown to possess therapeutic potential in certain disorders. In several studies, the antioxidant, anti-hyperlipidaemic, anti-diabetic, anti-cancerous, anti-microbial, and cardioprotective properties of Kachri have been reported. The fruit has a good nutritional value in terms of high percentages of protein, carbohydrates, essential fatty acids, phenols, and various phytochemicals. Also, gamma radiation treatment has been used on this crop to reduce total bacterial counts (TBC), ensuring safety from pathogens during the storage period of the fruit and its products. These facts lay down a foundation for the development of functional food formulations and nutraceuticals of medicinal value from this functionally rich crop. Processing of traditionally valuable arid region foods into functional foods and products can potentially increase the livelihood and nutritional security of people globally. Therefore, this review focuses on the therapeutic and pharmacological potentials of the Kachri fruit in the management of non-communicable diseases (NCDs) namely, diabetes, cancer, and hyperlipidemia. Graphical abstract of the review.

Diabetes Care in Humanitarian Settings

Despite the increasing prevalence of diabetes in populations experiencing humanitarian crisis, along with evidence that people living with diabetes are at higher risk for poor outcomes in a crisis, diabetes care is not routinely included in humanitarian health interventions. We here describe 4 factors that have contributed to the inequities and lack of diabetes inclusion in humanitarian programmes: (1) evolving paradigms in humanitarian health care, (2) complexities of diabetes service provision in humanitarian settings, (3) social and cultural challenges, and (4) lack of financing. We also outline opportunities and possible interventions to address these challenges and improve diabetes care among crisis-affected populations.

Does structural form matter? A comparative analysis of pooled procurement mechanisms for health commodities

INTRODUCTION

Pooled procurement can be seen as a collaboration initiative of buyers. Such mechanisms have received increased attention during the Covid-19 pandemic to improve access to affordable and quality-assured health commodities. The structural form of pooled procurement mechanisms ranges from a third-party organization that procures on behalf of its buyers to a buyer's owned mechanism in which buyers operate more collaboratively. However, little is known about how these types of pooled procurement mechanisms differ in terms of characteristics, implementation and developmental process. To fill this gap, we compared four pooled procurement mechanisms. Two buyer's owned mechanisms: the Organisation of the Eastern Caribbean States (OECS) and the Pacific Island Countries (PIC). And two third-party mechanisms: the Global Drug Facility (GDF) and the Asthma Drug Facility (ADF).

METHODS

For this qualitative study, we used a multiple case-study design. The cases were purposefully selected, based on a most-similar case study design. We used the Pooled Procurement Guidance to collect data on individual cases and compared our findings between the case studies. For our analysis, we drew upon peer-reviewed academic articles, grey literature documents and 9 semi-structured interviews with procurement experts.

RESULTS

Buyers within a buyer's owned mechanisms differ in procurement systems, financing structures, product needs and regulatory and legal frameworks. Therefore, buyers within such mechanisms require relative alignment on motivations, goals and operations of the mechanism. Our study showed that buyers' relative homogeneity of characteristics and their perceived urgency of the problems was particularly relevant for achieving that alignment. Third-party organization mechanisms require less alignment and consensus-building between buyers. To participate, buyers need to align with the operations of the third-party organization, instead of other buyers. Elements that were essential for the successful implementation and operation of such mechanisms included the procurement secretariat's ability to create local and global awareness around the problem, to induce political will to act upon the problem, to mobilize sufficient funding and to attract qualified staff.

CONCLUSION

To successfully sustain pooled procurement mechanisms over time, key actors should drive the mechanism through continuous and reflexive work on stakeholder engagement, mobilization of funding and alignment of interests and needs.

The impact of UN high-level meetings on non-communicable disease funding and policy implementation

Since the original UN General Assembly 'special session' for HIV/AIDS, there has been a proliferation of health-related high-level meetings (HLMs), including three for non-communicable diseases (NCDs) and a 2019 HLM on universal health coverage that was closely aligned to the NCD framework. This paper attempts to assess the impact of these meetings in terms of funding allocations, domestic NCD policy implementation, as well as the level of international engagement with the HLMs by reviewing attendance data and records of statements ('interventions') made by country delegations. In contrast to HIV/AIDS, whilst NCDs have enjoyed a marked rise in international political exposure and high-level political commitments, these have not always translated into national policy implementation or greater funding allocations. This is true even for countries that have engaged most deeply with HLMs. These findings should give pause to NCD advocacy groups that expend substantial energy in calling for further high-level political commitments and highlight the need to focus support on the translation of commitments into sustainably funded action.

Exploring health promotion efforts for non-communicable disease prevention and control in Ghana

Noncommunicable diseases (NCDs) are a growing public health challenge in Ghana. Health promotion can provide useful avenues to reduce the incidence of NCDs in the country. We used the Ottawa Framework to assess health promotion efforts for the prevention and control of NCDs in Ghana. Data were collected using key informant interviews and documentary sources. A content analysis approach was adopted for data analysis using Nvivo 11 Software. We found a strong policy framework for NCD prevention in Ghana with the ratification of several international protocols and resolutions and the development of national and specific NCD-related policies. Implementation of these policies, however, remains achallenge due to limited resources and the overconcentration on communicable diseases. Attempts have been made to create a supportive environment through increased access to NCD services but there are serious challenges. Respondents believe the current environment does not support healthy eating and promotes unhealthy use of alcohol. The Community-based Health Planning and Services (CHPS) program engenders community participation in health but has been affected by inadequate resources. Personal skills and education programs on NCDs are erratic and confined to a few municipalities. We also found that NCD services in Ghana continue to be clinical and less preventative. These findings have far-reaching implications for practice and require health planners in Ghana to pay equal attention in terms of budgetary allocations and other resources to both NCDs and communicable diseases.

Developing a social mobilisation intervention for salt reduction: participatory action research in Bombali district, Sierra Leone

BACKGROUND

High salt intake is a major risk factor for hypertension, which in turn contributes to cardiovascular diseases, the major cause of death from non communicable diseases (NCDs). Research is limited on social mobilisation interventions to tackle NCDs, including in fragile health settings such as Sierra Leone.

METHODS

Participatory action research methods were used to develop a social mobilisation intervention for salt reduction in Bombali District, Sierra Leone. A team of 20 local stakeholders were recruited to develop and deliver the intervention. Stakeholder workshop reports and interviews were used to record outcomes, enablers, and barriers to the intervention. Focus group discussions were used to observe knowledge, attitudes, and behaviours of community members pre- and post- the intervention.

RESULTS

Stakeholders showed enthusiasm and were well engaged in the social mobilisation process around salt reduction. They developed radio jingles, radio show talks, organised community awareness raising meetings, school sensitisation outreaches, and door to door engagements. Stakeholders reported benefiting personally through developing their own skills and confidence in communication and felt positive about their role in educating their community. The interventions led to reported increased awareness of risks of high salt intake and NCDs, resulting in a reduction of salt use in the community, leading to perceived health gains. However, salt reduction was also met with some resistance due to social factors. Local community structures were also reactivated to work on the interventions and connect the community to the local health facility, which saw an increase in patients having their blood pressure checked. The comparison villages also experienced an increase in awareness and perceived reductions in salt intake behaviours. This was as messages had cascaded via the radio and initial focus group discussions. The social mobilisation stakeholders also agreed on future activities that could continue at no or low cost.

CONCLUSION

Social mobilisation interventions can provide low-cost strategies to tackle NCDs in fragile settings such as Sierra Leone through the utilisation of community structures. However, more research is required to ascertain the key enablers for replicability and if such successes can be sustained over a longer follow up period.

Experiences of communities with Lebanon's model of care for non-communicable diseases: a cross-sectional household survey from Greater Beirut

OBJECTIVES

Assess community perceptions of the Lebanese care model for non-communicable diseases (NCDs) and trust in the health system among others, and test association between them.

DESIGN

Cross-sectional study using multistage random sampling and targeting adult community members living with NCDs.

SETTING

Households in Greater Beirut-Lebanon.

PARTICIPANTS

941 respondents including 574 Lebanese community members and 367 Syrian refugees.

PRIMARY AND SECONDARY OUTCOMES

Three main outcomes (barriers to care seeking, perceptions of the care model and trust in healthcare) were assessed including by multiple linear regressions.

RESULTS

Reported NCDs were hypertension (51.3%) and diabetes (34.5%), followed by chronic respiratory conditions (21.9%) and other cardiovascular diseases (20.0%). Communities reported seeking care from different sources. While 78% of Lebanese participants had visited private clinics at least once within the 6 months preceding the survey, 56% of Syrian refugees had done so. Determinants of access to care were health coverage, gender, and employment among Lebanese, and socioeconomic status among Syrian refugees. Lebanese community members had more positive perceptions of the care model compared with Syrian refugees and determinants included sociodemographic characteristics and the type of providers. Trust in the health system was higher among Syrian compared with Lebanese participants and was significantly influenced by the care model score and barriers to care seeking.

CONCLUSION

Our study generated evidence about the experience of people living with NCDs with Lebanon's care model and can inform service delivery interventions towards a more inclusive person-centred approach.

Bridging the "Know-Do" Gaps in Five Non-Communicable Diseases Using a Common Framework Driven by Implementation Science

According to the United Nations High-Level Meeting 2018, five non-communicable diseases (NCDs) including cardiovascular diseases, chronic respiratory diseases, diabetes mellitus, cancer, and mental health conditions accounted for two-thirds of global deaths. These five NCDs share five common risk factors including tobacco use, unhealthy diets, physical inactivity, alcohol use, and air pollution. Low- and middle-income countries (LMICs) face larger burden of NCDs than high-income countries (HICs), due to differences in ecological, technological, socioeconomic and health system development. Based on high-level evidence albeit mainly from HICs, the burden caused by NCDs can be reduced by affordable medicines and best practices. However, "know-do" gaps, ie, gaps between what we know in science and what we do in practice, has limited the impact of these strategies, especially in LMICs. Implementation science advocates the use of robust methodologies to evaluate sustainable solutions in health, education and social care aimed at informing practice and policies. In this article, physician researchers with expertise in NCDs reviewed the common challenges shared by these five NCDs with different clinical courses. They explained the principles of implementation science and advocated the use of an evidence-based framework to implement solutions focusing on early detection, prevention and empowerment, supplemented by best practices in HICs and LMICs. These successful stories can be used to motivate policymakers, payors, providers, patients and public to co-design frameworks and implement context-relevant, multi-component, evidence-based practices. In pursuit of this goal, we propose partnership, leadership, and access to continuing care as the three pillars in developing roadmaps for addressing the multiple needs during the journey of a person with or at risk of these five NCDs. By transforming the ecosystem, raising awareness and aligning context-relevant practices and policies with ongoing evaluation, it is possible to make healthcare accessible, affordable and sustainable to reduce the burden of these five NCDs.

Vestibular migraine in low- and lower-middle-income countries: A scoping review

Background

Vestibular migraine (VM) is a common cause of dizziness that is underrecognized, underdiagnosed, and challenging to effectively treat. The prevalence, appropriate diagnostic workup, and therapies for VM in low- and lower-middle-income countries (LLMICs) remain understudied. The objective of this scoping review is to evaluate the current state of VM research in LLMICs.

Methods

PubMed, Embase, and Web of Science databases were searched to execute a scoping review of VM. Keywords "vestibular diseases" and "vertigo" were used in combination with terms referring to LLMICs as defined by the World Bank. Title and abstract screening, full-text review, and data collection were conducted by two authors independently.

Results

Twenty-six studies were included in the scoping review. Most studies were cross-sectional (57.7%) or case studies/series (23.1%) and were conducted in urban settings only (92.3%). Geographic distribution of studies was skewed, with 65.4% of articles originating from India. The prevalence of VM among clinic patients ranged from 0.3% to 33.3%. VM most frequently presented as headache, nausea and vomiting, and photophobia. Radiographic imaging, audiometry, and electronystagmography/videonystagmography were the three most commonly utilized diagnostic modalities in the dizziness workup. The most studied pharmacotherapies included calcium channel blockers, followed by beta-blockers and antiepileptics. Case studies and series discussed less common VM pharmacotherapies, such as ayurvedic medicine.

Conclusions

There is a need for more VM research in LLMICs, including innovative diagnostic approaches and therapies that can improve VM care globally. Equitable partnerships between LLMIC and high-income country researchers must expand vestibular research capacity and productivity in LLMICs.

The challenges in protecting public health interests in multisectoral governance in the context of small island developing states: the case of tobacco control in Fiji and Vanuatu

BACKGROUND

The commercial determinants of health (CDoH) drive the rise of NCDs globally, and their regulation requires multisectoral governance. Despite existing recommendations to strengthen institutional structures, protecting public health interests can be challenging amidst industry interference and conflicting policy priorities, particularly in low and middle-income countries (LMICs) where the need for rapid economic development is pronounced. Small island developing states (SIDS) face even more challenges in regulating CDoH because their unique socioeconomic, political, and geographic vulnerabilities may weaken institutional conditions that could aid health sector actors in protecting health interests. This study aims to explore the institutional conditions that shape health sector actors' capability to protect public health interests in tobacco governance in Fiji and Vanuatu.

METHODS

We employed a qualitative, exploratory case study design. We applied the administrative process theory to inform data collection and analysis. Seventy interviews were completed in Fiji and Vanuatu from 2018 to 2019.

RESULTS

The findings show that the protection of health interests in tobacco governance were not supported by the institutional conditions in Fiji and Vanuatu. While the policy processes formally ensured a level playing field between actors, policies were often developed through informal mechanisms, and the safeguards to protect public interests from vested private interests were not implemented adequately. SIDS vulnerabilities and weak regulation of political parties contributed to the politicisation of government in both states, resulting in high-level government officials' questionable commitment to protect public health interests. The system of checks and balances usually embedded into democratic governments appeared to be muted, and policymakers had limited bureaucratic autonomy to elevate health interests in multisectoral policymaking amidst high-level government officials' frequent rotation. Finally, capacity constraints aggravated by SIDS vulnerabilities negatively impacted health sector actors' capability to analyse policy alternatives.

CONCLUSIONS

Health sector actors in Fiji and Vanuatu were not supported by institutional conditions that could help them protect public health interests in multisectoral governance to regulate CDoH originating from the tobacco industry. Institutional conditions in these states were shaped by SIDS vulnerabilities but could be improved by targeted capacity building, governance and political system strengthening.

Effectiveness and implementation of psychological interventions for depression in people with non-communicable diseases in South Asia: Systematic review and meta-analysis

We evaluate the effectiveness of psychological interventions for depression in people with NCDs in South Asia and explore the individual, organizational, and policy-level barriers and facilitators for the implementation and scaling up of these interventions. Eight databases (and local web pages) were searched in May 2022. We conducted random effects models to evaluate the pooled effect of psychological interventions on depression in people with NCDs. We extracted the individual, organizational, and policy level barriers and facilitators. We found five randomized control trials, nine qualitative studies, and 35 policy documents that fitted the inclusion criteria. The pooled standardized mean difference in depression comparing psychological interventions with usual care was -2.31 (95% CI, -4.16 to -0.45; p = .015, I2 = 96.0%). We found barriers and facilitators to intervention delivery, mental health appears in the policy agenda in Bangladesh and Pakistan. However, there is a lack of policies relating to training in mental health for NCD health providers and a lack of integration of mental health care with NCD care. All of the psychological interventions reported to be effective in treating depression in this population. There are important delivery and policy barriers to the implementation and scaling up of psychological interventions for people with NCDs.

Primary health care system responses to non-communicable disease prevention and control: a scoping review of national policies in Mainland China since the 2009 health reform

This study aims to review China's national policies related to non-communicable disease (NCD) prevention and control at the primary health care (PHC) level since China's 2009 health system reform. Policy documents from official websites of China's State Council and 20 affiliated ministries were screened, where 151 out of 1,799 were included. Thematic content analysis was performed, and fourteen 'major policy initiatives' were identified, including the basic health insurance schemes and essential public health services. Several areas showed to have strong policy support, including service delivery, health financing, and leadership/governance. Compared with WHO recommendations, several gaps remain, including lack of emphasis on multi-sectoral collaboration, underuse of non-health-professionals, and lack of quality-oriented PHC services evaluations. Over the past decade, China continues to demonstrate its policy commitment to strengthen the PHC system for NCD prevention and control. We recommend future policies to facilitate multi-sectoral collaboration, enhance community engagement, and improve performance evaluation mechanisms.

Geospatial assessment of the convergence of communicable and non-communicable diseases in South Africa

Introduction

Several low-and middle-income countries are undergoing rapid epidemiological transition with a rising burden of non-communicable diseases (NCDs). South Africa (SA) is a country with one of the largest HIV epidemics worldwide and a growing burden of NCDs where the collision of these epidemics poses a major public health challenge.

Methods

Using data from a large nationally representative survey, the South Africa Demographic and Health Survey (SADHS 2016), we conducted a geospatial analysis of several diseases including HIV, tuberculosis (TB), cardiovascular, respiratory, and metabolic diseases to identify areas with a high burden of co-morbidity within the country. We explored the spatial structure of each disease and associations between diseases using different spatial and visual data methodologies. We also assessed the individual level co-occurrence of HIV and the other diseases included in the analysis.

Results

The spatial distribution for HIV prevalence showed that this epidemic is most intense in the eastern region of the country, mostly within the Gauteng, Mpumalanga, and Kwazulu-Natal provinces. In contrast, chronic diseases had their highest prevalence rates the southern region of the country, particularly in the Eastern and Western Cape provinces. Individual-level analyses were consistent with the spatial correlations and found no statistically significant associations between HIV infection and the presence of any NCDs.

Conclusions

We found no evidence of geospatial overlap between the HIV epidemic and NCDs in SA. These results evidence the complex epidemiological landscape of the country, characterized by geographically distinct areas exhibiting different health burdens. The detailed description of the heterogenous prevalence of HIV and NCDs in SA reported in this study could be a useful tool to inform and direct policies to enhance targeted health service delivery according to the local health needs of each community.

Concomitant illnesses in pregnancy in Indonesia: A health systems analysis at a District level

BACKGROUND

In LMICs, including Indonesia, there is a rising burden of non-communicable diseases (NCDs) with a prevailing burden of infectious diseases, including among pregnant women. The Indonesian health system faces significant challenges to provide effective care for infectious diseases, and even more so, NCDs. This is concerning due to the greater vulnerability of pregnant women to complications caused by concomitant illnesses (NCDs and infectious diseases), and the need for complex, integrated healthcare between maternal care and other health services.

METHODS

The objective of this study was to understand supporting factors and challenges of the health system to providing care for concomitant illnesses in pregnancy and how it may be improved. Semi-structured interviews were conducted with sixteen key stakeholders, including health providers and health service managers, involved in maternal healthcare for concomitant illnesses at a District level in Indonesia. The study was conducted in Kutai Kartanegara District of East Kalimantan. Analysis was conducted using framework analysis to identify themes from transcripts.

RESULTS

Supporting factors of the health system to provide care for concomitant illness in pregnancy included collaboration between health providers and health services, availability of screening and diagnostic tools, and access to universal healthcare coverage and financial subsidies. Common challenges included knowledge and awareness of concomitant illnesses among health providers, competency to diagnose and/or manage concomitant illnesses, and inappropriate referrals. Suggested improvements identified to address these gaps included increasing education and refresher training for healthcare providers and strengthening referrals between primary and hospital care.

CONCLUSIONS

The findings identified gaps in the health system to provide care for concomitant illnesses in pregnancy in Indonesia that need to be strengthened. More evidence-based research is needed to guide the implementation of policy and practice interventions for the health system to deal with a broader range of concomitant illnesses in pregnancy, particularly NCDs.

A Culturally Sensitive and Theory-Based Intervention on Prevention and Management of Diabetes: A Cluster Randomized Control Trial

Type 2 diabetes is an emerging concern in Kenya. This clustered-randomized trial of peri-urban communities included a theory-based and culturally sensitive intervention to improve diabetes knowledge, health beliefs, dietary intake, physical activity, and weight status among Kenyan adults. Those in the intervention group (IG) received a culturally sensitive diabetes education intervention which applied the Health Belief Model in changing knowledge, health beliefs and behavior. Participants attended daily education sessions for 5 days, each lasting 3 h and received mobile phone messages for an additional 4 weeks. The control group (CG) received standard education on COVID-19. Data was collected at baseline, post-intervention (1 week), and follow-up assessment (5 weeks). Linear mixed effect analysis was performed to assess within and across group differences. Compared to the control, IG significantly increased diabetes knowledge (p < 0.001), health beliefs including perceived susceptibility (p = 0.05), perceived benefits (p = 0.04) and self-efficacy (p = 0.02). IG decreased consumption of oils (p = 0.03), refined grains (p = 0.01), and increased intake of fruits (p = 0.01). Perceived barriers, physical activity, and weight status were not significantly different between both groups. The findings demonstrate the potential of diabetes education in improving diabetes knowledge, health beliefs, and in changing dietary intake of among adults in Kenya.

Temporal trends in the burden of non-communicable diseases in countries with the highest malaria burden, 1990–2019: Evaluating the double burden of non-communicable and communicable diseases in epidemiological transition

Background

Non-communicable diseases (NCDs) are rapidly increasing in sub-Saharan African countries, where 96% of global malaria deaths occur. This study aimed to investigate the disease burden of NCDs in countries with the current highest malaria mortality.

Methods

Data for this study were obtained from the Global Burden of Disease 2019 study (1990–2019). We selected the ten countries with malaria’s highest age-standardised mortality rate (ASMR) and identified and ranked the five NCDs with the highest ASMR in each country. Measures of the NCDs disease burden included ASMR, age-standardised disability-adjusted life-years (DALY), years of life lost (YLL) and years lost due to a disability (YLD). The Estimated annual percentage change (EAPC) was used to examine the trends of the NCDs disease burden from 1990 to 2019.

Results

As of 2019, the ASMR of chronic liver disease, kidney disease, diabetes mellitus, Alzheimer’s disease and other dementias, hypertensive heart disease and stroke were higher than the global average. From 1990 to 2019, the ASMR for Alzheimer’s disease and other dementias, type II diabetes mellitus, and chronic kidney disease increased by 3.0%, 10.8%, 13.3%, and the age-standardised DALY rate increased by 3.7%, 27.6%, 6.3%, and the increases tended to be in younger populations.

Conclusion

The double burden of non-communicable and communicable diseases is crippling the health systems of many sub-Saharan African countries and is often neglected. The prevention, surveillance, and control of diseases require an integrated strategy, with governments and non-government organisations aligned and supported by the global initiative.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-022-00882-w.

The Correlates of Government Expenditure on Mental Health Services: An Analysis of Data From 78 Countries and Regions

Background

Governmental investment in mental health is of vital importance for the implementation and maintenance of educational, preventive, and therapeutic services related to mental illness, particularly in low- and middle-income countries (LMICs). However, mental health expenditures represent only a small portion of total health spending in many countries. Little is known about the economic, social, or health-related factors that may influence variations in governmental spending in this sector.

Methods

Data on government expenditure on mental health as a percentage of total healthcare expenditure, collected by the WHO from 78 countries and regions in the period 2013-2014, was available for study. These data were analyzed in relation to key economic, social, and health-related indicators. The selection of these indicators was based on prior national and regional research and expert opinion as reported in the existing literature.

Results

Government spending on mental health was below 1% of health expenditure in 24.4% of the countries studied. A number of economic, social, and health-related indicators were significantly associated with variations in spending on mental health. Based on the partial correlation, sub-group, and multivariate linear regression analyses, the variables most significantly associated with low government spending on mental health were the burden of communicable diseases (β = −.47, p = .001) and cultural collectivism (β = −.37, p = .008).

Conclusions

These results suggest that low government investment in mental health may be associated not only with economic or political factors but also with variations in disease burden and in cultural attitudes across countries. Though no direct assumption regarding causation can be made, such findings may be of value when advocating for greater public investment in mental health, particularly in non-Western cultures with a high competing burden of infectious diseases.

Strengthening Diabetes Care in Humanitarian Crises in Low- and Middle-income Settings

Amid the growing global diabetes epidemic, the scale of forced displacement resulting from armed conflict and humanitarian crises is at record-high levels. More than 80% of the displaced population lives in lower- and middle-income countries, which also host 81% of the global population living with diabetes. Most crises are protracted, often lasting decades, and humanitarian aid organizations are providing long-term primary care to both the local and displaced populations. Humanitarian crises are extremely varied in nature and occur in contexts that are diverse and dynamic. The scope of providing diabetes care varies depending on the phase of the crisis. This paper describes key challenges and possible solutions to improving diabetes care in crisis settings. It focuses on (1) ensuring a reliable supply of life preserving medications and diagnostics, (2) restoring and maintaining access to health care, and (3) adapting service design to the context. These challenges are illustrated through case studies in Ukraine, Mali, the Central African Republic, and Jordan.

Estimating the burden of cancer in South Africa

Background: The incidence of cancer is on the rise in South Africa and globally. However, literature on the current and expected future burden of cancer in the country is lacking.Aim: To develop a model that forecasts the incidence of five of the most commonly diagnosed cancers in South Africa. The model aims to estimate the true underlying burden of cancer, as opposed to diagnosed cases only.Setting: South Africa.Methods: Age-specific incidence rates for each cancer are forecasted for the period 2019–2030, based on a combination of public and private sector cohort data. It is assumed that historical trends in changes in the incidence rate of cancer will continue over the forecasting period. Forecasted incidence rates are applied to population forecasts to find the total number of incident cancer cases for the relevant year.Results: The incidence of all cancers included in this research is increasing over time, with the total number of cases just less than doubling between 2019 and 2030 (from approximately 62 000 to 121 000 incident cases). This is a result of increases in the age-specific incidence rate of cancer, as well as the growth and ageing of the South African population.Conclusion: Results confirm that cancer is a major and growing public health problem in South Africa. This highlights the need for increases in resources available for cancer services, as well as rapid implementation of cancer prevention strategies, to reduce the number of future cancer cases, and thereby reduce the burden on the health system.

Context and priorities for health systems strengthening for pain and disability in low- and middle-income countries: a secondary qualitative study and content analysis of health policies

Musculoskeletal (MSK) health impairments contribute substantially to the pain and disability burden in low- and middle-income countries (LMICs), yet health systems strengthening (HSS) responses are nascent in these settings. We aimed to explore the contemporary context, framed as challenges and opportunities, for improving population-level prevention and management of MSK health in LMICs using secondary qualitative data from a previous study exploring HSS priorities for MSK health globally and (2) to contextualize these findings through a primary analysis of health policies for integrated management of non-communicable diseases (NCDs) in select LMICs. Part 1: 12 transcripts of interviews with LMIC-based key informants (KIs) were inductively analysed. Part 2: systematic content analysis of health policies for integrated care of NCDs where KIs were resident (Argentina, Bangladesh, Brazil, Ethiopia, India, Kenya, Malaysia, Philippines and South Africa). A thematic framework of LMIC-relevant challenges and opportunities was empirically derived and organized around five meta-themes: (1) MSK health is a low priority; (2) social determinants adversely affect MSK health; (3) healthcare system issues de-prioritize MSK health; (4) economic constraints restrict system capacity to direct and mobilize resources to MSK health; and (5) build research capacity. Twelve policy documents were included, describing explicit foci on cardiovascular disease (100%), diabetes (100%), respiratory conditions (100%) and cancer (89%); none explicitly focused on MSK health. Policy strategies were coded into three categories: (1) general principles for people-centred NCD care, (2) service delivery and (3) system strengthening. Four policies described strategies to address MSK health in some way, mostly related to injury care. Priorities and opportunities for HSS for MSK health identified by KIs aligned with broader strategies targeting NCDs identified in the policies. MSK health is not currently prioritized in NCD health policies among selected LMICs. However, opportunities to address the MSK-attributed disability burden exist through integrating MSK-specific HSS initiatives with initiatives targeting NCDs generally and injury and trauma care.

Implementation research on noncommunicable disease prevention and control interventions in low- and middle-income countries: A systematic review

BACKGROUND

While the evidence for the clinical effectiveness of most noncommunicable disease (NCD) prevention and treatment interventions is well established, care delivery models and means of scaling these up in a variety of resource-constrained health systems are not. The objective of this review was to synthesize evidence on the current state of implementation research on priority NCD prevention and control interventions provided by health systems in low- and middle-income countries (LMICs).

METHODS AND FINDINGS

On January 20, 2021, we searched MEDLINE and EMBASE databases from 1990 through 2020 to identify implementation research studies that focused on the World Health Organization (WHO) priority NCD prevention and control interventions targeting cardiovascular disease, cancer, diabetes, and chronic respiratory disease and provided within health systems in LMICs. Any empirical and peer-reviewed studies that focused on these interventions and reported implementation outcomes were eligible for inclusion. Given the focus on this review and the heterogeneity in aims and methodologies of included studies, risk of bias assessment to understand how effect size may have been compromised by bias is not applicable. We instead commented on the distribution of research designs and discussed about stronger/weaker designs. We synthesized extracted data using descriptive statistics and following the review protocol registered in PROSPERO (CRD42021252969). Of 9,683 potential studies and 7,419 unique records screened for inclusion, 222 eligible studies evaluated 265 priority NCD prevention and control interventions implemented in 62 countries (6% in low-income countries and 90% in middle-income countries). The number of studies published has been increasing over time. Nearly 40% of all the studies were on cervical cancer. With regards to intervention type, screening accounted for 49%, treatment for 39%, while prevention for 12% (with 80% of the latter focusing on prevention of the NCD behavior risk factors). Feasibility (38%) was the most studied implementation outcome followed by adoption (23%); few studies addressed sustainability. The implementation strategies were not specified well enough. Most studies used quantitative methods (86%). The weakest study design, preexperimental, and the strongest study design, experimental, were respectively employed in 25% and 24% of included studies. Approximately 72% of studies reported funding, with international funding being the predominant source. The majority of studies were proof of concept or pilot (88%) and targeted the micro level of health system (79%). Less than 5% of studies report using implementation research framework.

CONCLUSIONS

Despite growth in implementation research on NCDs in LMICs, we found major gaps in the science. Future studies should prioritize implementation at scale, target higher levels health systems (meso and macro levels), and test sustainability of NCD programs. They should employ designs with stronger internal validity, be more conceptually driven, and use mixed methods to understand mechanisms. To maximize impact of the research under limited resources, adding implementation science outcomes to effectiveness research and regional collaborations are promising.

"A Promise Unfulfilled": Stakeholder Influence and the 2018 UN High-Level Meeting on NCDs Comment on "Competing Frames in Global Health Governance: An Analysis of Stakeholder Influence on the Political Declaration on Non-communicable Diseases"

In recognition of the global burden of non-communicable diseases (NCDs), the past decade has seen three United Nations High-Level Meetings (UN HLMs) on NCDs. Yet progress in terms of political or financial commitments has been very slow. At the 2018 meeting, a political declaration was approved but featured language that had been watered down in terms of commitments. In "Competing Frames of Global Health Governance: An Analysis of Stakeholder Influence on the Political Declaration on Non-communicable Diseases," Suzuki et al analyze the documents that were submitted by Member States, non-governmental organizations and the private sector during the consultation period and conclude that the private sector and several high-income countries (HICs) appeared to oppose regulatory frameworks for products associated with NCDs, that wealthier countries resisted financing commitments, and that general power asymmetries affected the final document. This comment supports their findings and provides additional considerations for why the NCD response has yet to produce significant commitments.

Exploring ways to respond to rising obesity and diabetes in the Caribbean using a system dynamics model

Diabetes and obesity present a high and increasing burden of disease in the Caribbean that have failed to respond to prevention policies and interventions. These conditions are the result of a complex system of drivers and determinants that can make it difficult to predict the impact of interventions. In partnership with stakeholders, we developed a system dynamics simulation model to map the system driving diabetes and obesity prevalence in the Caribbean using Jamaica as a test case. The study aims to use the model to assess the magnitude changes necessary in physical activity and dietary intake to achieve global targets set by the WHO Global Action plan and to test scenarios for interventions to reduce the burden of diabetes and obesity. Continuing current trends in diet, physical activity, and demographics, the model predicts diabetes in Jamaican adults (20+ years) to rise from 12% in 2018 to 15.4% in 2030 and 20.9% by 2050. For obesity, it predicts prevalence to rise from 28.6% in 2018 to 32.1% by 2030 and 39.2% by 2050. The magnitude change necessary to achieve the global targets set by the World Health Organization is so great as to be unachievable. However, a combination of measures both upstream (including reducing the consumption of sugar sweetened beverages and ultra processed foods, increasing fruit and vegetable intake, and increasing moderate-to-vigorous activity) at the population level, and downstream (targeting people at high risk and with diabetes) can significantly reduce the future burden of diabetes and obesity in the region. No single intervention reduces the prevalence of these conditions as much as a combination of interventions. Thus, the findings of this model strongly support adopting a sustained and coordinated approach across various sectors to synergistically maximise the benefits of interventions.

NCD Countdown 2030: efficient pathways and strategic investments to accelerate progress towards the Sustainable Development Goal target 3.4 in low-income and middle-income countries

Most countries have made little progress in achieving the Sustainable Development Goal (SDG) target 3.4, which calls for a reduction in premature mortality from non-communicable diseases (NCDs) by a third from 2015 to 2030. In this Health Policy paper, we synthesise the evidence related to interventions that can reduce premature mortality from the major NCDs over the next decade and that are feasible to implement in countries at all levels of income. Our recommendations are intended as generic guidance to help 123 low-income and middle-income countries meet SDG target 3.4; country-level applications require additional analyses and consideration of the local implementation and utilisation context. Protecting current investments and scaling up these interventions is especially crucial in the context of COVID-19-related health system disruptions. We show how cost-effectiveness data and other information can be used to define locally tailored packages of interventions to accelerate rates of decline in NCD mortality. Under realistic implementation constraints, most countries could achieve (or almost achieve) the NCD target using a combination of these interventions; the greatest gains would be for cardiovascular disease mortality. Implementing the most efficient package of interventions in each world region would require, on average, an additional US$18 billion annually over 2023-30; this investment could avert 39 million deaths and generate an average net economic benefit of $2·7 trillion, or $390 per capita. Although specific clinical intervention pathways would vary across countries and regions, policies to reduce behavioural risks, such as tobacco smoking, harmful use of alcohol, and excess sodium intake, would be relevant in nearly every country, accounting for nearly two-thirds of the health gains of any locally tailored NCD package. By 2030, ministries of health would need to contribute about 20% of their budgets to high-priority NCD interventions. Our report concludes with a discussion of financing and health system implementation considerations and reflections on the NCD agenda beyond the SDG target 3.4 and beyond the SDG period.

Cervical cancer prevention and control in women living with human immunodeficiency virus

Despite being highly preventable, cervical cancer is the fourth most common cancer and cause of cancer death in women globally. In low-income countries, cervical cancer is often the leading cause of cancer-related morbidity and mortality. Women living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome are at a particularly high risk of cervical cancer because of an impaired immune response to human papillomavirus, the obligate cause of virtually all cervical cancers. Globally, approximately 1 in 20 cervical cancers is attributable to HIV; in sub-Saharan Africa, approximately 1 in 5 cervical cancers is due to HIV. Here, the authors provide a critical appraisal of the evidence to date on the impact of HIV disease on cervical cancer risk, describe key methodologic issues, and frame the key outstanding research questions, especially as they apply to ongoing global efforts for prevention and control of cervical cancer. Expanded efforts to integrate HIV care with cervical cancer prevention and control, and vice versa, could assist the global effort to eliminate cervical cancer as a public health problem.