Managing chronic diseases in less developed countries

Throughout the world, chronic diseases—including non-communicable diseases, long term mental disorders, and persistent communicable diseases such as tuberculosis and HIV/AIDS—present a huge challenge to health. As part of the response to this challenge, the World Health Organization has conducted a two year review of healthcare models and best practices from around the world and has recently reported on this work. The report, Innovative Care for Chronic Conditions: Building Blocks for Action, provides a comprehensive conceptual framework for the prevention and management of long term illnesses in poorly resourced settings.¹ The most fundamental issue highlighted by the report is the pressing need to shift away from an acute, reactive, and episodic model of care.

Instead, health care should facilitate an ongoing relationship between provider and patient and help patients to make full use of their own and their community's resources for health.² The focus has to be on the person in his or her own context, not simply on the disorder. Partnership between patient and provider is not just a resource for understanding health problems; it is the basis for prevention and intervention.³ Inattention to the interpersonal aspects of care has serious potential consequences. Patients accustomed to inadequate care may become resentful or respond with passive acceptance of the situation—often seeing it simply as a further burden of poverty and social alienation. Both responses will hamper active participation in an ongoing programme of health care.

How can we translate these important concepts into practice in health care, particularly in developing countries? At the heart of the challenge for policy makers is the reality that healthcare systems will never have enough resources to meet all legitimate needs. Few providers, even in the best resourced settings, can say comfortably that they have done everything they conceivably could for all their patients. A paper in this week's BMJ by Rundall and others (p 958) bears this out by showing that even the leading healthcare providers in the United States find it hard to deliver really comprehensive care for people with chronic diseases.⁴

The term “resources” does not simply mean money: just as importantly, it also refers to the people who provide care and, in turn, the people who support and manage them. Providers who are overwhelmed by demand commonly defend themselves; getting into a vicious cycle in which they retreat from patients, patient demand increases, and providers have to withdraw further. All too often we hear criticisms such as, “If only they'd attend and listen to patients in the first place, patients wouldn't need to keep coming back and filling up the waiting rooms.” It is easy to attribute such withdrawal to lack of expertise or even to moral failings, but, if health care in poorly resourced contexts is to succeed, the human need to reduce the anxiety associated with overload needs to be taken seriously, with staff receiving the right support.⁵

This dynamic presents important challenges to healthcare teams, particularly in developing countries. Where resources are scarce and epidemics such as tuberculosis and HIV infection are rife, managers may see providers only as pairs of hands. This gives those providers little scope to view patients as actors in their own lives or to build ongoing partnerships with them. Managers may, understandably, focus far more on the technical aspects of controlling epidemics than on supporting or caring for staff. The paradox is, of course, that continuing care delivered by a well functioning team is the very basis on which control of both epidemics and chronic disease must rest.⁶

The people who make policies and the international organisations that support them comprise the higher tiers of healthcare funding. Health policymakers in the areas where needs are great and resources are scarce often have progressive attitudes towards political and social policy. But many still have an outmoded view of care for disease and disability, based on their own experiences, and see service delivery problems only as a series of isolated technical challenges. This report from the WHO should help them to change those views.

The WHO believes that good management ideas can travel and, if suitably modified, can reproduce success in different settings. The next phase of the process, then, needs to be the diffusion of these concepts. We hope that a network of interested participants will develop, to share ideas and experiences across countries and cultures, thereby providing the peer support needed to sustain change. Such collaboration is essential to implementing this new framework for chronic disease care.

Education and debate p 958