Elsevier

The Lancet

Volume 372, Issue 9642, 13–19 September 2008, Pages 940-949
The Lancet

Series
Improving the prevention and management of chronic disease in low-income and middle-income countries: a priority for primary health care

https://doi.org/10.1016/S0140-6736(08)61404-XGet rights and content

Summary

The burden of chronic diseases, such as heart disease, cancer, diabetes, and mental disorders is high in low-income and middle-income countries and is predicted to increase with the ageing of populations, urbanisation, and globalisation of risk factors. Furthermore, HIV/AIDS is increasingly becoming a chronic disorder. An integrated approach to the management of chronic diseases, irrespective of cause, is needed in primary health care. Management of chronic diseases is fundamentally different from acute care, relying on several features: opportunistic case finding for assessment of risk factors, detection of early disease, and identification of high risk status; a combination of pharmacological and psychosocial interventions, often in a stepped-care fashion; and long-term follow-up with regular monitoring and promotion of adherence to treatment. To meet the challenge of chronic diseases, primary health care will have to be strengthened substantially. In the many countries with shortages of primary-care doctors, non-physician clinicians will have a leading role in preventing and managing chronic diseases, and these personnel need appropriate training and continuous quality assurance mechanisms. More evidence is needed about the cost-effectiveness of prevention and treatment strategies in primary health care. Research on scaling-up should be embedded in large-scale delivery programmes for chronic diseases with a strong emphasis on assessment.

Introduction

The health transition to chronic, non-communicable diseases becoming the leading causes of death and disability worldwide is well underway. However, many low-income and middle-income countries are still facing large burdens of infectious diseases and serious maternal, newborn, and child health challenges. In these countries, an estimated 28 million people die annually from chronic, non-communicable disorders, such as cardiovascular disease (mainly heart disease and stroke), cancer, chronic respiratory disease, and diabetes.1 Another 2·1 million are estimated to have died from HIV/AIDS in 2007.2 The challenge to the health system in low-income and middle-income countries in terms of people living with chronic diseases is huge: around 33 million with HIV/AIDS; 246 million with diabetes;3 and around 1 billion with hypertension.4 Hundreds of millions suffer from mental disorders including depression, alcohol misuse disorders, and schizophrenia.5

Key messages

  • The burden of chronic diseases, which require care for extended periods or even throughout life, is increasing in low-income and middle-income countries

  • An integrated approach to the prevention and management of common chronic diseases, irrespective of cause, is needed in primary health care

  • Chronic disease management is distinct from health care for acute problems, and a refocusing and strengthening of primary health care is urgently required

  • Chronic diseases need opportunistic case finding for assessment of risk factors, detection of early disease, and identification of high risk status; a combination of pharmacological and psychosocial interventions, often in a stepped-care fashion; long-term follow-up with regular monitoring and promotion of adherence to treatment

  • Improved strategies in primary health care should be accompanied by public policies to prevent chronic diseases, particularly through tobacco control and reduced salt intake

  • Research on scaling-up should be embedded in large-scale programmes; this will require collaboration between policy makers, practitioners, consumers, public-health researchers, development agencies, and funding organisations

Though these disorders all have different causes, the demands (including financial costs) they place on patients, families, health-care systems, and governments are remarkably similar and substantial. From a health-care perspective, all are chronic diseases: they persist over time and require continuing care. Primary health care (see accompanying paper for discussion of the definition and taxonomy of different approaches6) is, in theory, best positioned to address the challenges of chronic disease prevention and management. The delivery of care in primary health-care settings is compromised in most low-income and middle-income countries by underfunding and an orientation towards acute problems. Health systems must evolve rapidly to manage common chronic diseases, irrespective of cause.

Generic disease-management strategies, including system-level changes in primary health care, hold promise for improving quality of care across a range of chronic diseases. In this article, we make the case that primary health-care strategies need to be developed, assessed, and implemented in low-income and middle-income settings to address the increasing burden of chronic disease and outline the requirements for such strategies.

Section snippets

Chronic diseases as a public-health priority

To help the worldwide community and national authorities to focus on prevention and control of chronic diseases, WHO proposed a goal, in addition to the Millennium Development Goals, that aims to reduce chronic-disease death rates by 2% per year over current trends.7 The goal is ambitious but achievable on the basis of current knowledge as summarised in the recent series on chronic diseases in The Lancet (panel 1);8, 9 nonetheless strengthened and reoriented primary health-care systems are

Interventions for chronic diseases in primary health care

Interventions selected for use in primary health care must lead to favourable changes in risk status and outcomes, be cost effective, and be financially and logistically feasible. Cost-effective interventions for chronic diseases are available for implementation across a range of resource settings.18 Several of these interventions are financially feasible for scaling-up and have the potential to substantially reduce the burden of chronic disease in low-income and middle-income countries. The

Organisation and delivery of chronic-disease management in primary health care

The challenge now is to ensure that primary health-care systems in low-income and middle-income countries are capable of delivering these interventions. Primary health care for chronic diseases is inherently different from care for acute problems and requires a greater level of organisation that must be sustained, commonly over a patient's lifetime. In addition, because patients are in many ways their own primary carers, their needs and preferences must be taken into account in the development

Improving the quality of chronic-disease management

Controlled studies and reviews from high-income countries have shown that, across a wide range of chronic diseases, the implementation of primary-care-led management models can produce improved health outcomes.34, 82, 83, 84, 85, 86, 87 Complex interventions that incorporated clinician education, an increased role of the nurse (nurse case management), and a greater degree of integration between primary and secondary care (consultation-liaison) were more likely to be beneficial in depression.86

Improvement of adherence to treatments

A systematic review of interventions to improve adherence in chronic disease showed that adherence increased most consistently with behavioural interventions that reduced dosing demands (all of three studies) and those involving monitoring and feedback (three of four studies).89 Adherence also improved in six multisession informational trials and eight combined interventions. 11 studies (four informational, three behavioural, and four combined) showed improvement in at least one clinical

Addressing the challenges of scaling-up

Scaling-up of efficacious interventions in primary care faces several challenges,90 notably that health workers are already overburdened with many responsibilities, lack supervision and specialist support after training, and often do not have a guaranteed continuous supply of drugs. The shortage of health workers around the world has attracted much attention in recent years.91, 92, 93, 94 In response, global strategies have been developed to scale up the workforce in low-income and

Conclusions

Many research questions still need to be addressed, but this is no excuse for inaction. Research on scaling-up should be embedded in large-scale programmes needing collaboration between national policy makers, practitioners, public-health researchers, development agencies, and funding organisations. Many of these questions are within the scope of public health and health policy and systems research (panel 5). There are important unresolved questions about cost-effective treatments for specific

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