By Gene Bukhman, MD, Ana O Mocumbi, MD, Prof Rifat Atun, FRCP, Prof Anne E Becker, MD, Prof Zulfiqar Bhutta, PhD, Prof Agnes Binagwaho, PhD, et al.
The Lancet, September 14, 2020
We live in an era of unprecedented global wealth. Nevertheless, about one billion people in low-income and lower-middle-income countries (LLMICs) still experience levels of poverty that have long been described as “beneath any reasonable definition of human decency”, in the words of former World Bank president, Robert McNamara. This Commission was formed at the end of 2015 in the conviction that non-communicable diseases and injuries (NCDIs) are an important, yet an under-recognised and poorly-understood contributor to the death and suffering of this vulnerable population. The aims of the Commission were to rethink global policies, mend a great disparity in health, and broaden the global health agenda in the interest of equity.
Conclusion: global solidarity for NCDI Poverty and universal health coverage
Propelled by a 2001 UN General Assembly Special Session, the first decade of the 21st century saw dramatic growth in development assistance for HIV. In many cases HIV financing has had collateral benefits for those afflicted by other conditions, but it has not been sufficient. We have estimated that around 85% of the poorest billion live in countries with a per-capita GDP of less than US$1600 in 2015 exchange-rate US dollars. Simply put, these countries do not have the domestic resources to address even their most urgent health-care needs.
NCDIs have been understood by development agencies and multilateral institutions as an emerging problem associated with ageing, urbanisation, and economic growth, rather than a constituent part of the most extreme poverty. The 2011 UN High-Level Meeting on NCDs was greeted with hope for a new era of global solidarity despite the 2008 financial crisis. These hopes have not materialised. Our Commission has shown that little development assistance for NCDIs has been mobilised for NCDIs over the past decade, and that almost none has gone to the poorest countries.
The framing of NCDs that crystallised through the 2011 UN High-Level Meeting was, in part, a solution to the perceived weakness inherent in the heterogeneity of a large array of non-infectious conditions. This Commission proposes that this complexity should be recognised as an inescapable part of the NCDI burden in the poorest populations. More than that, this complexity should be leveraged to build global solidarity and to catalyse structural reforms for quality and innovations in integrated service delivery for the world’s poorest and most vulnerable people.
To begin to remedy the shocking neglect of NCDI Poverty by rich countries, this Commission is launching an NCDI Poverty Network. This Network is composed of a growing group of National NCDI Poverty Commissions and their allies. The Network will work over the next decade to catalyse financing and technical partnerships to support implementation of integrated delivery strategies for locally prioritised interventions. The Network will also work closely with The Lancet and the NCD Countdown 2030 Group to report on progress toward locally identified goals. In doing so, we hope that this Commission will elevate an emerging NCDI Poverty movement and accountability mechanism that will contribute to health and shared prosperity for all.
Addressing NCDI Poverty offers a chance for the poorest countries to build durable, high-quality health systems. It also presents an important occasion to act on the underlying social determinants of disease such as housing, household energy, food insecurity, education, and transportation. In order to be successful, these countries will require greater global commitments to health equity. Private philanthropic organisations have small resources at their disposal but can have an outsized effect on policy and research. We ask that, when funding disease-specific initiatives, these organisations consider the poorest billion and recognise the need to invest in integrated strategies that drive health system improvements.
Bilateral donors must increase their investments in health in the poorest countries. When funding NCDIs as part of UHC expansion pathways, bilateral donors and multilateral institutions must also begin with the poorest billion in mind. Prospects exist to build on existing investments and to crowd-in resources for NCDI Poverty in priority countries and populations. Financing to address treatment gaps in the poorest countries should not be neglected even as resources should also be increased to support common goods for health such as research, policy, and coordination.
We call on WHO to expand its UHC monitoring and NCD action plan after 2020 to address the diverse set of diseases and conditions recognised as NCDIs in its own Global Health Estimates; intervention priority setting at WHO to give due consideration to equity (including condition severity and distribution among the poorest) in addition to cost-effectiveness and feasibility; and WHO to strengthen its work on integrated service delivery for NCDIs, and particularly to invest in development of technical packages for first-level hospitals.
NCDI Poverty is one of the largest gaps and largest opportunities for UHC and global health equity in the SDG era. The Director General of WHO has called for one billion more people to benefit from UHC by 2023. The scope of UHC recognised by this commitment must be broadened to include NCDI Poverty. Consistent with the SDG pledge that, “no one will be left behind”, and the SDG commitment, “to reach the furthest behind first”, the next billion to benefit from this more inclusive conception of the UHC should be the poorest billion.
Comment:
By Don McCanne, M.D.
I have always been concerned about the inadequacies of health care programs in poor nations. Who hasn’t?
A few decades ago, as I was approaching retirement, I wanted to become part of a movement to ensure that the entire world has affordable access to all essential health care services. The need was so great. But first we needed to address the health care deficiencies in our own nation so that we could stand as an example to all other nations. We certainly had enough funds, but we needed to fine tune our system by improving Medicare and expanding it to cover everyone. That was the easy step that we could take immediately and then move on to addressing the rest of the world’s health care problems.
Easy step? Oh my!
The Director General of WHO has called for taking care of one billion more people by 2023, while reaching the furthest behind first. Considering the efforts of President Trump to reduce the efforts on improving health care in the United States, it is no wonder that he withdrew both funding and membership in the WHO as they embark on this international effort to provide care for the poorest one billion people in the world.
But the need is so great that we should start supporting the WHO effort now. As far as the comparatively minor effort required in the United States, we can do that simultaneously. PNHP would gladly provide guidance on Medicare for All. We should be able to complete that task in 2021, and then move on to help with the goal of expanding care to another one billion people by 2023. And they told us that Medicare for All was a tough haul. That’s the easy part.
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