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
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The burden of chronic diseases, which require care for extended periods or even throughout life, is increasing in low-income and middle-income countries
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An integrated approach to the prevention and management of common chronic diseases, irrespective of cause, is needed in primary health care
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Chronic disease management is distinct from health care for acute problems, and a refocusing and strengthening of primary health care is urgently required
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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
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Improved strategies in primary health care should be accompanied by public policies to prevent chronic diseases, particularly through tobacco control and reduced salt intake
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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.