In The Lancet, David Watkins and colleagues explore how countries can get back on track to reach the Sustainable Development Goal (SDG) 3.4 target of reducing premature mortality from cancers, cardiovascular diseases, chronic respiratory diseases, and diabetes by a third by 2030. Drawing on the Disease Control Priorities Project and what WHO considers the “best buys”, they synthesise the evidence for 21 interventions that can rapidly reduce non-communicable disease (NCD) death rates and be implemented in countries at any income level. Under realistic conditions, Watkins and colleagues conclude that the world could achieve the SDG 3.4 target by spending an additional US$18 billion per year. The economic benefits of this investment would outweigh the costs 19:1. In the process, 39 million premature deaths from NCDs could be prevented—a huge health and economic dividend for a small outlay. Some countries are going beyond these recommendations and implementing extensive suites of interventions. Many others might not have robust enough health systems or resources for ambitious, comprehensive NCD action plans, but the Health Policy by Watkins and colleagues provides a framework to begin making further gains on NCDs. And a practical way to emerge from the impact of COVID-19.
For the impact has been enormous. An assessment by WHO early in the pandemic found that 94% of countries reported that all or some of the staff working on NCDs in health ministries had been reassigned to COVID-19. As intermittent lockdowns and high infection rates compounded the pressure on health-care systems, there were huge declines in the screening and treatment of NCDs. Cancer registration and screening fell rapidly in most countries, even in those with low rates of COVID-19, such as New Zealand, where cancer registrations decreased by around 40%. The result has been a screening deficit of millions of people. A prospective cohort study across 61 countries, which enrolled more than 20 000 patients, showed that one in seven patients who were in regions with full lockdowns had delays to their curative cancer surgery. NCDs are difficult and complex conditions to manage at the best of times. Now, with millions of people around the world on waiting lists for diagnosis and treatment, the scale of the problem is daunting indeed. Following the same course as before the pandemic and expecting a different result would be foolish. So: what now for NCDs?
To date, too much of the narrative around NCDs has focused on mortality. But morbidity—the lived burden on billions of people—can be a powerful lever for action. The Lancet NCDI Poverty Commission declared that not enough attention is paid to “addressing the inadequate resources available for the poor to be properly nourished, live safely, and to access health care”. NCDs remain a neglected development issue. Organisations should attempt to break down structural barriers that inhibit meaningful patient engagement, expand the advocacy community, fight against the inequitable focus of money, expertise, and attention on high-income countries, and push for conversations and decisions on NCDs to be driven by those populations that suffer the most from them (ie, people in low-income and middle-income countries). Attending to the commercial determinants of health and the proper regulation of industry to create health-promoting environments must be a priority.
More importantly, resilient health systems must be created with sufficient capacity for NCD care in a pandemic and post-pandemic world. Information should be the backbone of this reimagination—in particular, expanded diagnostic capacity. The Lancet Commission on diagnostics found that 47% of the global population has little to no access to diagnostics. Accurate information on prevalence of disease—as well as on the availability of resources such as treatments and access to care—will provide the basis for countries to make strategic changes to health systems. Successfully reducing the burden of NCDs is tied closely to the quality of universal health coverage and primary health care. To make population-level changes, whole health systems must be reoriented, and cross-cutting care models employed. On April 12, an International Strategic Dialogue on NCDs and the SDGs will be hosted by the president of Ghana, the prime minister of Norway, and the director-general of WHO. It must recognise that now is the time for the radical reform of health systems positioned around NCDs.
For more on the economic case for investing in NCDs see https://www.who.int/publications-detail-redirect/9789240041059
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