Reframing the NCD agenda: a matter of justice and equity

The international development community has never taken non-communicable diseases (NCDs) seriously. Seen largely as a challenge for high-income nations, NCDs and their community of advocates have met with, at best, warm words and, more commonly, indifference. There have been moments for optimism. The landmark 2005 WHO report, Preventing Chronic Diseases: a Vital Investment;¹ the 2011 Political Declaration on NCDs;² and the inclusion of NCDs in the Sustainable Development Goals (SDG) in 2016 (SDG 3.4: by 2030, reduce premature mortality from NCDs by a third and promote mental health and wellbeing). But, despite an increasingly well organised civil society response, NCDs have not broken through into the mainstream of development and global health.

One reason could lie in the framing of NCDs. A biomedical model, for example, emphasises genetic and other biological risk factors and processes. When viewed through the lens of epidemiological transitions, changes in NCD prevalence are associated with industrialisation, growing economic prosperity, and rises in life expectancy. And when NCDs are viewed as lifestyle conditions, attention is paid to individual behaviours rather than to wider social and commercial determinants of health.³

The current 5 × 5 approach to NCDs, favoured by WHO, focuses on five diseases (cardiovascular disease, cancer, diabetes, chronic respiratory diseases, and mental ill-health) and five risk factors (tobacco use, unhealthy diets, physical inactivity, harmful use of alcohol, and air pollution).⁴ But, as the NCD Countdown 2030 showed, “Although premature mortality from NCDs is declining in most countries, for most the pace of change is too slow to achieve SDG target 3.4”.⁵ The global NCD community needs to consider a different approach to the framing of chronic diseases.

The central argument of The Lancet NCDs and Injuries (NCDI)⁶ Poverty Commission is that although the existing concept of NCDs has achieved much, it has come at a cost to the world's poorest and most marginalised populations. Commission co-chairs Gene Bukhman and Ana Mocumbi led an international team of 23 researchers, clinicians, and policy makers to define the NCDI burden among the world's poorest billion, propose a set of cost-effective and equitable NCDI interventions tailored to the needs of this population, and issue a call for global solidarity to address this burden.

The Commission found that NCDIs account for more than a third of the burden of disease among the world's poorest people, including almost 800 000 deaths annually among those younger than 40 years. Compared with higher-income populations where the burden of NCDs strongly correlates with advancing age, the poorest billion suffer higher morbidity and mortality from NCDIs at every age. And although diabetes, cardiovascular disease, cancer, chronic respiratory diseases, road traffic injuries, substance use, and mental disorders account for a large proportion of the avoidable disease burden among the poorest billion, about half of this avoidable burden is due to less-recognised NCDIs, including haemoglobinopathies, acute abdominal disorders, musculoskeletal conditions, sense organ diseases, congenital disorders, and neurological conditions. The epidemiological picture of NCDIs that emerges from this Commission is thus one of a more diverse set of conditions and risk factors across a broader age range compared with the dominant global NCD framework. Crucially, NCDIs must be viewed not only as diseases of affluence but also as diseases of poverty.

Despite the importance of NCDIs to the health and wellbeing of the world's poorest billion, the Commission's economic analyses reveal that funding to address this burden is grossly inadequate and that the share of development assistance for NCDIs directed at countries where most of the world's poorest reside is declining. The case for investment is nonetheless strong. The Commission shows that addressing NCDIs is key to achieving progress towards universal health coverage (UHC), with NCDIs accounting for 60–70% of the UHC financing needs in the low-income and lower-middle-income countries where the poorest billion live.

© 2020 Tommy Trenchard/Sightsavers/Panos Pictures

Importantly, given the low capacity for domestic spending on health by these countries, progress towards closing the NCDI poverty gap and realising UHC requires an expansion of development assistance. But as the world grapples with the economic consequences of the COVID-19 pandemic, health financing at national and global levels risks being squeezed, alongside projected increases in global poverty and economic inequality. Before COVID-19, the pace of reductions in global poverty was already slow.⁷ Now, although forecasts vary, it is estimated that between 71 million and 100 million people could be pushed into extreme poverty by the pandemic⁸ and an impending debt crisis looms for low-income economies.⁹

Advocates for expanding the global NCD agenda to encompass the needs, perspectives, and rights of the world's poorest face an enormous challenge. This is a task in which partnerships and coalition building will be key not only within the NCD community but also in alliances forged with the UHC and anti-poverty movements through recognition of shared values and cross-cutting interventions and programmes. The Commission has begun this journey through the establishment of an NCDI Poverty Network that is already active in 16 countries. This Commission's report will arm them with the evidence they need to strive for a more just and equitable future for the world's poor.