Viewpoint

Improving responsiveness of health systems to non-communicable diseases

Health expenditures are a major financial burden for many people in low and middle-income countries. Cardiovascular diseases (CVDs) caused almost a third of the total deaths globally in 2016. The financial burden of CVD s globally was around US$ 863 billion in 2010 and is estimated to rise by 22% (which means around US$ 1044 billion) by 2030. Hence, there is an urgent need to know the burden of CVDs and the financing strategies for CVDs in India. The data for this study was obtained from the 75th round of the National Sample Survey (NSS) on the theme ‘Social consumption: Health’ (2017–18). The present study uses data of 6144 people who sought the treatments from hospitalization care in the last 365 days and 8401 people who sought the treatments from Outpatients (OPD) care in the last 15 days preceding the survey. Almost, 50.3 percent and 43.2 percent of the households faced catastrophic health expenditure due to hospitalization care and OPD care respectively and 19.0 percent and 8.9 percent of the households were forced to below poverty line from above poverty line due to hospitalization care and OPD care respectively due to CVD treatment. Based on our analysis certain important conclusions and recommendations can be proposed. These include increasing the screening for CVDs for timely diagnosis and treatment, improving the healthcare services for the management of CVDs in the public sector, improving awareness amongst the masses for identifying the early signs of CVDs and a multi-stakeholder approach consisting of improvement in areas particularly healthcare, literacy, employment, and women upliftment to limit and manage the burden of CVDs in India.

Non-communicable diseases (NCDs) disproportionately affect people living in fragile contexts marked by poor governance and health systems struggling to deliver quality services for the benefit of all. This combination can lead to the erosion of trust in the health system, affecting health-seeking behaviours and the ability of individuals to sustain their health. In this cross-country multiple-case study, we analyse the role of trust in health-seeking for NCD services in fragile contexts. Our analysis triangulates multiple data sources, including semi-structured interviews (n = 102) and Group Model Building workshops (n = 8) with individuals affected by NCDs and health providers delivering NCD services. Data were collected in Freetown and Makeni (Sierra Leone), Beirut and Beqaa (Lebanon), and Morazán, Chalatenango and Bajo Lempa (El Salvador) between April 2018 and April 2019. We present a conceptual model depicting key dynamics and feedback loops between contextual factors, institutional, interpersonal and social trust and health-seeking pathways. Our findings signal that firstly, the way health services are delivered and experienced shapes institutional trust in health systems, interpersonal trust in health providers and future health-seeking pathways. Secondly, historical narratives about public institutions and state authorities’ responses to contextual fragility drivers impact institutional trust and utilisation of services from public health institutions. Thirdly, social trust mediates health-seeking behaviour through social bonds and links between health systems and individuals affected by NCDs. Given the repeated and sustained utilisation of health services required with these chronic diseases, (re)building and maintaining trust in public health institutions and providers is a crucial task in fragile contexts. This requires interventions at community, district and national levels, with a key focus on promoting links and mutual accountability between health systems and communities affected by NCDs.