The Lancet Commission on Reframing NCDs and Injuries for the Poorest Billion (Lancet NCDI Poverty Commission) is shifting the paradigm of NCDs and injuries in settings of extreme poverty. This landmark report draws attention to the burden of NCDs in rural, lower-resource settings – severe conditions such as type 1 diabetes, rheumatic heart disease, pediatric cancers, and sickle cell disease that disproportionately impact younger and more marginalized communities.
This report examines the burden of disease among the world’s poorest people and provides in-depth analysis and recommendations on how to prioritize services with an emphasis on equity to reach the most marginalized communities. Further, the report delves into global financing for NCDs and draws attention to the crucial gap in financing for these essential services – for instance, less than $100 Million of aid (0.3% of development funds for health) goes to non-communicable diseases and injuries in the countries where the poorest billion people live.
Finally, the report looks at the governance of how NCDs have been framed and included in global policy to date, and identifies opportunities and key advocacy steps to better advocate for the needed technical and financial resources to provide care. As the report highlights, 4.6 million lives could be saved by 2030 with affordable, cost-effective and equitable interventions for NCDs and Injuries among the world’s poorest people.
This Commission also oversaw the launch of 15 National NCDI Poverty Commissions that have completed similar analysis in their respective countries. Collectively, this group of national experts will form the NCDI Poverty Network – a working group of experts and partners that will continue the global and regional advocacy to close the gap in the provision of care for severe NCDs for the very poorest.
The report will launch on September 15, 2020 with regional launches planned for later in 2020.
The COVID-19 pandemic has created a double threat of adverse health and socioeconomic consequences for communities around the world. However, this threat is perhaps most immediate and tragic for people already living with severe and chronic non-communicable diseases (NCDs) in poor communities in low-income countries.
For young people living with chronic health conditions such as type 1 diabetes, rheumatic heart disease, sickle cell disease, or childhood cancer, there is an immediate and extreme danger of infection with COVID-19, which could rapidly lead to critical outcomes, as well as the interruption of vital health services and medications. A recent survey by the World Health Organization found that NCD services have already been disrupted in 3 out of 4 countries globally. Families and households in the world’s poorest communities are at immediate risk for further impoverishment, the majority of which are in South Asia and sub-Saharan Africa.
Partners In Health / The Zimbabwe NCDI Poverty Commission at a meeting in February 2020.
On July 1, 2020, teams in these six countries are initiating targeted programs to not only support the continuity of essential health services for young people living with these conditions, but develop innovative new approaches to bring those services to beneficiaries amidst the pandemic. These approaches include:
In-depth analyses of demand and supply-side barriers
Identification of vulnerable individuals
Decentralizing clinical services
Shifting point of care to home-based or virtual consultation
Facilitating supply chains for essential commodities
Developing peer support networks
In addition, these programs will target material needs in the form of protective personal equipment, essential medicines and supplies, nutritional support, and transportation to facilitate prevention against COVID-19 infection and optimize treatment outcomes.
Partners In Health / The Ethiopia NCDI Poverty Commission at the launch of their Report in Addis Ababa, November 2018.
NCD Synergies and the Program in Global NCDs and Social Change at Harvard Medical School is pleased to provide technical and financial support for the innovative efforts from each of these teams and will provide a routine webinar platform for learning and collaboration through the NCDI Poverty Knowledge Exchange. Experience and lessons learned from these innovative programs will be aggregated and actively disseminated to strengthen global efforts to allow for potential replication and scale-up of successful strategies to protect the world’s most vulnerable individuals during the COVID-19 pandemic.
The event focused on essential components of UHC delivery needed for the implementation of comprehensive care, many of which constitute some of the largest funding and delivery gaps currently in global health.
A full livestream of the event is available here:
We were fortunate to be joined by Dr. Gina Agiostradiou, Director of the Type 1 Diabetes Program at the Helmsley Charitable Trust and The Honorable Minister of State for Public Health and Primary Health Care of Rwanda Dr. Patrick Ndimubanzi. Both speakers called for decentralized and integrated delivery strategies that encompass the full extent of medical and surgical needs across the health system. The Honorable Minister shared formative lessons from Rwanda during the HIV/AIDS epidemic – in order to provide equitable care to everyone across all conditions, it is essential that the poorest and most vulnerable are prioritized.
Maia Olsen / Partners In Health Dr. Gina Agiostradiou, Dr. Gene Bukhman and Honorable Minister of State of Rwanda, Dr. Patrick Ndimubanzi provide welcoming and opening remarks during the co-hosted event at The Geneva Press Club.
The event then paused to share a video narrative of Dipesh Rai, a young man living in rural Nepal with rheumatic heart disease. Stories like Dipesh are the most instructive for our policy discussions on UHC, but he, and so many other patients, care providers and family members are not able to participate in global dialogues in Geneva due to structural and financial barriers. We need to make sure that those individuals from remote and lower-resource settings are included and heard in global advocacy discussions.
Next, Dr. Gene Bukhman, Director of the NCD Synergies Project and the Program in Global NCDs and Social Change at Harvard Medical School drew attention to gaps in prioritizing care for the poorest and most vulnerable in the NCD and UHC global agendas, leading into “Bridging the Gaps in UHC – Patient, Care Provider, and Health System Perspectives Discussion” moderated by Dr. Alishya Mayfield.
Mr. Joab Wako, TransplantEd (Kenya)
Dr. Maria Jose Pires Machai, FHI 360 (Mozambique)
Mr. William Osseus, Zanmi Lasante/Partners In Health Haiti
Ms. Marie Ketty Tout Puissant, Zamni Lasante/Partners In Health Haiti
Dr. Jones Masiye, Ministry of Health, Malawi
Dr. Teri Reynolds, World Health Organization
Maia Olsen / Partners In Health Mr. Joab Wako shares his experience living with Chronic Kidney Disease on a panel with other patient advocates, clinicians, national and global policy makers.
This panel deliberately highlighted a range of perspectives spanning the health care system, from patients, community health workers, clinicians, and national and global policy makers. Through rich discussion, panelists shared their experiences and presented their recommendations for achieving equitable care, especially regarding access to diagnostics, medicines, and treatment at a low-cost. Mr. Joab Wako, a patient advocate from Kenya living with chronic kidney disease, and Executive Director of TransplantEd Kenya, explained:
“Since my kidney transplant, it’s like day and night. Other patients who are stuck on dialysis deserve to feel like this. A transplant isn’t a cure, it’s a treatment – but everyone who needs it should have access to it. I wish everyone in the community had the same access to treatment that I had.”
Mr. William Osseus, a Community Health Worker supervisor and Ms. Marie Ketty Tout Puissant, a nurse leader joined us from Zanmi Lasante, PIH’s sister organization in Haiti boldly stating that delivery of care in possible and feasible. Mr. Osseus shared:
“Sometimes, I walk four hours each way to reach all of my patients. We work to bring healthcare to everyone no matter where they live.”
Maia Olsen / Partners In Health Mr. William Osseus, a Community Health Worker Supervisor at Zanmi Lasante, PIH’s sister organization in Haiti, shares his experience working with and supporting his community for the last 13 years.
Dr. Jones Masiye, Deputy Director of Clinical Services at the Ministry of Health in Malawi, closed the discussion by sharing his key ask for UN/WHO community in the lead up to the HLM on UHC:
“If I had just one recommendation, it would be to invest in human resources for health. We must build up this capacity to bring care closer to where people live.”
Dr. John Meara, Director of the Program in Global Surgery and Social Change, provided closing remarks, thanked the panelists for their courage in sharing their personal stories and reiterated the need for a “social reconstruction in health care delivery.”
In featuring the voices of those directly affected by what member states and the global community are striving to achieve when it comes to ambitions around UHC, the discussion on Wednesday was a stark reality check on what is truly needed to achieve equitable care from the community to the hospital.
Amy McLaughlin / Partners In Health The full group from numerous partners participating and supporting the side event in Geneva at WHA 72.
During the first week of April 2019, WHO and the larger global health community is celebrating the contributions that health workers make in their communities, and their fundamental role in achieving comprehensive Universal Health Coverage.
The NCD Synergies team is fortunate to work alongside incredible care teams at PIH-supported sites in Haiti, Liberia, Malawi and Rwanda, which include nurses, clinical officers, physicians and community health workers (CHWs). These teams of providers work tirelessly to deliver, integrated care for severe, chronic NCDs such as type 1 diabetes, sickle cell anemia, and rheumatic heart disease (RHD) in rural, resource-poor settings. This model of care includes a significant investment in training and task shifting to bring high-quality care closer to communities and the patients and families who need it.
Todd Ruderman / Partners In HealthDr. Brown Khongo, Clinical Officer Wellington Mazengera and Dr. Fred Ochieng conduct an echocardiogram at the Matope Health Care Center.
On March 20th, Abwenzi Pa Za Umoya (APZU), PIH’s sister site in Malawi tested its new strategy for active case-finding for heart failure in Neno District, a predominantly rural district that serves over 170,000 people. Active case finding is a critical strategy for finding patients with subtle illness early so they can get the treatment they need, before the disease progresses. The team trained over 100 community health workers to screen community members in their homes for symptoms of heart failure and referred them in for further evaluation. Accompanied by Dr. Fred Ochieng, a cardiologist and fellow in Cardiovascular Disease and Global Health Equity at Brigham and Women’s Hospital, the clinical team of clinical officers, nurses, and physicians evaluated 67 patients who were referred by the community health workers.
This included seven patients visited at home because they were unable to travel, conducting at-home echocardiograms to screen for heart failure and identifying at-risk patients to enroll in follow-up care. The team also worked closely with CHWs to identify symptoms and ask screening questions to diagnose suspected heart failure. Of the 67 patients visited, 28 needed further care and were enrolled in both APZU’s Integrated Chronic Care Clinic (IC3) or the Advanced NCD Clinic for follow-up. Of these 28 patients, 12 were diagnosed with heart failure, including seven with RHD.
In the coming months, the APZU NCD team will continue to work in both clinics and throughout the surrounding communities to strive toward universal access to high-quality care for patients living with RHD, type 1 diabetes and other severe, chronic NCDs.
Partners In Health / The APZU NCD team heading to communities in Neno to identify patients with heart failure and other severe, chronic conditions.
This work represents just one of many great
examples of efforts by health workers to support essential care for people
living with severe NCDs. On World Health Worker Week, and every week, we
celebrate our colleagues, collaborators and partners in rural settings like Neno
District, and recognize the key role they play in achieving and delivering
high-quality universal health care.
On December 5th, the Program in Global NCDs and Social Change at Harvard Medical School with support from the NCD Synergies program at Partners In Health hosted a four-day NCDI Poverty National Commission Initiator’s Workshop at the Harvard Medical School Center for Global Health Delivery in Dubai, UAE. The Workshop brought together Ministry of Health and implementer colleagues from across 16 low and lower-middle income countries.
Partners In Health 45 participants and faculty joined together in Dubai, UAE for a four-day NCDI Poverty National Commission Initiator’s Workshop.
The Workshop welcomed 45 participants and facilitators to delve into the work of the National NCDI Poverty Commissions that has been accomplished by the 10 established groups, and provided an exploratory platform for six new countries to begin the Commission process.
Participant-facilitators included representatives from Afghanistan, Haiti, Ethiopia, Kenya, Liberia, Malawi, Mozambique, Nepal, Rwanda and Tanzania from the existing National NCDI Poverty Commissions. In addition, we were joined by Ministry of Health colleagues and national NCDI implementers from Chhattisgarh State in India, Madagascar, Sierra Leone, Uganda, Zambia and Zimbabwe.
Day 1 – NCDI burden among the poorest billion
Drs. Gene Bukhman and Ana Mocumbi, co-chairs of the Global NCDI Poverty Commission, opened the first day by welcoming participants and introducing the key concepts addressed by this network of Commissions to date. Dr. Bukhman then introduced the focal point for the course – the global burden of disease that has shaped NCD policy is not a reflection of those living in extreme poverty. Dr. Mary Mayige, co-chair of the Tanzania NCDI Poverty Commission, moderated all discussions and presentations.
Amy McLaughlin / Partners In Health Workshop participants engage in a discussion on the first morning.
Amy McLaughlin / Partners In Health Drs. Ana Mocumbi and Gene Bukhman present on the Global Lancet Commission.
Amy McLaughlin / Partners In Health Participants complete global burden of disease (GBD) analysis workshops in groups.
Dr. Neil Gupta introduced the course, its objectives and approach, and Matt Coates gave two in-depth presentations on the measurement of poverty and global burden of disease (GBD). Finally, the group heard from Dr. Gladwell Gathecha and Noel Kasomekera who presented key findings on national data disaggregated by socioeconomic status from the Kenya and Malawi NCDI Poverty Commissions.
In the afternoon, the group of participants were divided into three groups, and led through a series of exercises to apply the methods presented earlier, to measure poverty and burden of disease using national-level data sources.
Day 2 – Priority setting for key interventions to address NCDIs of poverty
Amy McLaughlin / Partners In Health Dr. Solomon Memire presents on the methodology of prioritization of NCDs and injuries using national data sources.
The second day built on the analytical framework that was established on Day 1. Dr. Gladwell Gathecha was a moderator throughout the day and introduced Dr. Solomon Memire of Addis Ababa University and Dr. David Watkins from the University of Washington to introduce the principles of priority setting and how the Disease Control Priorities Group (DCP3) has defined health interventions.
Amy McLaughlin / Partners In Health Dr. David Watkins from the University of Washington presents on behalf of the Disease Control Priorities Group (DCP3).
The participants then heard from from Drs. Solomon and Emily Wroe, who presented on the priority setting experience of the Ethiopia and Malawi National NCDI Poverty Commissions. In this session, they discussed how each country approached priority setting, not just using cost-effectiveness as a factor, but including equity, severity and financial risk protection as fundamental reasoning.
Participants were then led through a series of two exercises in groups – the first looked at the prioritization of NCDs and injuries based on national disease burden, and then subsequent prioritization of interventions based on these chosen conditions. Finally, the group heard from SP Kaulanee from Possible Health and the Nepal NCDI Poverty Commission – he presented on how the Nepal Commission measured the impoverishing impact of NCDs in their recently published report.
In the evening, the group celebrated the rare occasion of all being together and spent the evening cruising sand dunes and watching performances in the desert!
Partners In Health All 45 Workshop participants ventured out of Dubai on the second evening, and went on an excursion to the desert.
Partners In Health The full group of participants gathered in the desert for sunset, before having a group dinner with camel rides and dance performances.
Day 3 – Planning and organizing health services for expanded NCDIs
Day 3, moderated by Noel Kasomekera of the Malawi NCDI Poverty Commission, took the analysis conducted on Days 1 and 2 and introduced service availability and readiness and the organization and clustering of services for NCDIs within the health system.
Matt Coates opened the day with a presentation on approaches to service availability and readiness and intervention coverage. Dr. Fred Amegashie of the Liberia NCDI Poverty Commission shared their team’s experience in measuring service availability. The groups then worked through a skill set using facility surveys to assess the availability of services using national data sources.
Amy McLaughlin / Partners In Health Colleagues from Kenya, Zambia, Zimbabwe, and Madagascar work together on Day 3.
Amy McLaughlin / Partners In Health A breakout group on Day 3 works through the care pathways needed to treated pediatric cancer in each of the countries represented.
The large group was then divided into groups to watch four Voices of NCDI Poverty videos, and then work together to develop a care delivery value chain for severe NCDIs such as type 1 diabetes, rheumatic heart disease, pediatric cancer and severe mental health disorders. Dr. Emily Wroe then led the group through a large brainstorm to identify opportunities for NCDI service integration and decentralization.
Amy McLaughlin / Partners In Health Colleagues from Haiti, Liberia, and Rwanda work with Matt Coates and Arielle Eagan on the service availability and readiness of health facilities based on national data.
Next, Dr. Gene Bukhman walked the group through health services prioritized on Day 2 can be integrated and decentralized across the national health system. Dr. Darius Fenelon, from PIH’s sister organization Zanmi Lasante and the Haiti National NCDI Poverty Commission, then demonstrated how this organization of health services had been conducted by their team.
Finally, Dr. Paul Park presented on clinical models of NCDI service delivery at first-level hospitals as seen across PIH sites in Rwanda and Malawi. Dr. Christian Rusangwa subsequently followed to present on the national scale-up of the “PEN-Plus” model in Rwanda.
Day 4 – Determining and mobilizing resources and stakeholders for action
SP Kaulanee moderated and guided the final day of the workshop. Dr. Neil Gupta opened the day with a presentation on the costing of prioritized NCDI interventions and Dr. Solomon Memire built on this presentation by highlighting the work that had been on fiscal space analysis by the Ethiopia NCDI Poverty Commission. The groups were then led through two concrete exercises to understand how to cost prioritized health interventions and analyze fiscal space in their own national context.
The conversation continued as Dr. Gene Bukhman presented on global donor funding and fiscal global space for NCDIs. Amy McLaughlin followed-up the presentation with an overview of global NCDI policy and opportunities for advocacy in 2019 for NCDs.
Amy McLaughlin / Partners In Health (left to right) Noel Kasomekera, SP Kalaunee, Dr. Solomon Memire, Dr. Fred Amegashie, Dr. Darius Fenelon, and Dr. Mary Mayige speak on a panel about their experience with their respective National NCDI Poverty Commissions and share guidance for new commissions on ways to engage other national stakeholders.
The day concluded with a panel discussion with all existing National NCDI Poverty Commissioners to offer insight into their Commission experience and share how their respective Commissions had acted as a catalyst for national change and impact, leading to a rich discussion between country teams.
After an incredibly full four days, Drs. Gene Bukhman and Neil Gupta closed the workshop with key highlights and lessons from each day. The incredible discussions that began in Dubai will continue as the work of the National NCDI Poverty Commissions strengthen, with many opportunities for collaboration in the coming year.
On Tuesday September 25th, 2018 our team, in partnership with the Program in Global NCDs and Social Change (PGNCDSC) at Harvard Medical School and the Leona M. & Harry B. Helmsley Charitable Trust, hosted a two-hour side-event during the week of the 73rd United Nations General Assembly. Over 130 people attended the event, including high-level participation from the Ministries of Health of Rwanda and Malawi, the World Health Organization, the World Bank, and a wide array of global health funding agencies, stakeholders, and peer institutions.
Dr. Julie Makani, Professor of Health and Allied Sciences at Muhimbili University and a global NCDI Poverty Commissioner, acted as Master of Ceremonies. She first welcomed David Panzirer, a Trustee with the Helmsley Charitable Trust, to welcome participants. In his address, David shared personal experience with type 1 diabetes in his family and emphasized that geography should not dictate access to quality care for severe NCDs like T1D.
Next, Dr. Sania Nishtar, co-chair of the WHO High-Level Commission on Noncommunicable Diseases and Founder and President of the NGO Heartfile, gave opening remarks. Dr. Nishtar challenged the traditional paradigm of “4×4” framing, and drew attention to congenital heart disease and other severe NCDs that disproportionately impact children, young adults, and people living in settings of extreme poverty.
Andrew Marx / Harvard Medical School Dr. Gene Bukhman presents on the need to broaden the NCDI agenda to include the diversity of conditions that affect the poorest during the PIH and HMS-hosted UNGA side event on Tuesday, September 25th.
Dr. Nishtar was then followed by NCD Synergies and PGNCDSC Director, Dr. Gene Bukhman, who represented the Global Lancet NCDI Poverty Commission and introduced efforts from the National NCDI Poverty Commissions and Voices of NCDI Poverty initiative. In his presentation, Dr. Bukhman shared the importance of reframing NCDs and injuries for the poorest billion, and the need to pursue a nationally-led priority-setting framework. This framework should reflect individual disease severity and better address the challenges faced by communities living in extreme poverty through approaches to integration science, such as clustered “PEN-Plus” services for severe, chronic NCDs at first level hospitals.
The event then transitioned to a moving panel discussion from people living with severe NCDs and care providers. We were privileged to first hear from Aldophmy Joseph via video, a young patient advocate living with type 1 diabetes in the Central Plateau of Haiti, as he was unfortunately unable to join us in New York due to visa challenges. We then moved onto a discussion with the following participants, moderated by Maia Olsen (NCD Synergies Program Manager):
Erneste Simpunga – patient advocate living with rheumatic heart disease, medical student from the University of Rwanda
Nancy Larco – Executive Director of Fondation Haïtienne de Diabète et de Maladies Cardio-Vasculaires (FHADIMAC)
Cory McMahon – Director of Nursing & Midwifery at Partners In Health
Andrew Marx / Harvard Medical School Cory McMahon, Dr. Nancy Larco and Erneste Simpunga participated in a discussion highlighting Voices of NCDI Poverty, moderated by NCD Synergies Program Manager, Maia Olsen.
The panel discussion was impactful in drawing attention to the need to put patients and care providers at the center of the global policy discussion of NCDs. Erneste shared his story of living with rheumatic heart disease and the challenges in accessing life-saving cardiac surgery in a country like Rwanda where those resources are not available yet. Both Dr. Larco and Cory then drew on the impact they had seen chronic diseases have on the patients and families they work with. As Dr. Larco said during the panel discussion: “I’ve watched families learn of a diagnosis and have to make impossible choices.”
Following this dialogue, we moved to a second panel discussion with representatives of five National NCDI Poverty Discussions, moderated by Dr. Neil Gupta (NCD Synergies Policy Director):
Bhagawan Koirala, Nepal NCDI Poverty Commission
Kibachio Joseph, Kenya NCDI Poverty Commission
Mary Mayige, Tanzania NCDI Poverty Commission
Wubaye Walelgne, Ethiopia NCDI Poverty Commission
Andrew Marx / Harvard Medical School Dr. Wubaye Walelgne (Ethiopia), Dr. Bhagawan Koirala (Nepal), Dr. Mary Mayige (Tanzania) and Dr. Kibachio Joseph (Kenya) discuss the work of their respective National NCDI Poverty Discussions. The panel was moderated by NCD Synergies Policy Director, Dr. Neil Gupta.
This rich dialogue delved into some of the key findings from the respective countries represented by the National NCDI Poverty Commissions regarding the disease burden faced by those living in extreme poverty, as well as recommendations for priority-setting and action to address barriers in these populations. As Dr. Bhagawan Koirala stated in the discussion, “The poorest populations are not just faced with the high morbidity and mortality due to NCDs – the economic burden, the catastrophic expenditure and lost economic prosperity, are insurmountable for them.” As Dr. Joseph Kibachio underscored as well: “NCDs are non-communicable but their impact, their burden, and their impoverishment is communicable”.
Andrew Marx / Harvard Medical School Dr. Gary Gottlieb, Dr. Nancy Larco and Prof. Agnes Binagwaho listen to closing remarks from Dr. Tim Evans at Tuesday’s side event.
The panel then turned to the audience, which included statements and questions from:
Honorable Minister of Health of Malawi, Atupele Muluzi
The Minister of State in charge of Public Health and Primary Health Care, Ministry of Health of Rwanda Patrick Ndimubanzi
Etienne Krug, Director of the WHO Department for Management of NCDs, Disability, Violence, and Injury Prevention
Florence Berteletti from the World Heart Federation
Professor Agnes Binagwaho, Vice Chancellor of the University of Global Health Equity at Partners In Health and a Global NCDI Poverty Commissioner
Next, Dr. Tim Evans, Senior Director for Health, Nutrition, and Population at the World Bank, and Dr. Svetlana Akselrod, Assistant Director General for NCDs and Mental Health at the World Health Organization, were both welcomed to provide closing remarks. Dr. Evans, commended the work of the National Commissions in using data to make informed decisions on NCDI prioritization and budgeting. In his remarks, he drew particular attention to the synergy between NCDs and Universal Health Coverage, and the need to include NCDs and injuries of poorest populations in UHC planning. Dr. Akselrod also addressed the importance of this work, stating: “We must be partners for the poorest in the fight against NCDs.”
Andrew Marx / Harvard Medical School Dr. Sania Nishtar, Dr. Tim Evans, and Dr. Svetlana Akselrod provided opening and closing remarks at the NCDI Poverty side event.
Finally, Dr. Gary Gottlieb, CEO of Partners In Health closed the meeting, and thanked the audience for their attendance and participation. He reminded those in attendance that, “NCDs are lifestyle diseases – lifestyle includes birth, existence and being, and impacts people at every stage of life.” Dr. Gottlieb called for the prioritization of those living in extreme poverty, and to address the conditions that disproportionately impact children and the most vulnerable.
We are so grateful to our speakers and partners for their support in this successful event and we look forward to reinvigorated dialogue continuing on these critical topics in months to come.
***
In addition to the Tuesday session, our team had the opportunity to engage in stakeholder meetings and a number of other events throughout the week of UNGA, including an event co-hosted by the American Heart Association on “Time to Disrupt the Health System: Novel Solutions for Quality Care in the NCD Era”. In this event, Erneste Simpunga told his moving story on a panel of people living with heart disease and other NCDs. Dr. Bhagawan Koirala participated in a second panel with health systems champions, emphasizing the importance of capacity-building efforts at secondary and tertiary level in countries like Nepal and underscoring why providing free tertiary services like cardiac surgery for children is an equitable and high-impact intervention for the very poorest.
Our team was also able to attend the Third High-Level Meeting on NCDs on Thursday, along with colleagues from Ministries of Health and national governments, civil society, and the private sector. In her remarks within the multistakeholder panels, Dr. Sania Nishtar used a portion of her statement to call on the UN and member states to address the needs of the poorest billion, as part of a Universal Health Coverage agenda grounded in principles of human rights and equity.
On Thursday during the High-Level Meeting, the political declaration was adopted by UN Member States. The declaration falls short of prioritizing the needs of the poorest and most vulnerable. Our team commits to continuing to push the boundaries of NCDI framing to ensure that the needs of those who endure the greatest amount of suffering are met and addressed.
From August 27th-31st 2018, Ministers of Health throughout the WHO African region (WHO AFRO) convened in Dakar, Senegal on health policy at this year’s WHO Regional Committee for Africa. At this meeting, Harvard Medical School – with support from the NCD Synergies team at Partners In Health – had the opportunity to co-organize an official side-event on the integrated management of severe NCDs such as type 1 diabetes and advanced rheumatic heart disease in collaboration with the NCD cluster at WHO AFRO.
This session was held on Tuesday evening August 28th, and was attended by numerous Ministers of Health, additional high-level representatives from member state delegations, and civil society advocates in attendance.
Noel Kasomekera / Partners In Health Honorable Minister Diane Gashumba from Rwanda, Joseph Waogoda Caboré, Dr. Gene Bukhman and Dr. Steven Shongwe speak on a panel at WHO African Regional Meeting on August 28, 2018 in Dakar, Senegal.
Speakers for the event included:
Joseph Waogodo Caboré, Director of Programme Management at WHO AFRO
Steven Shongwe, acting Director of the Noncommunicable Diseases cluster at WHO AFRO
Honorable Minister Diane Gashumba, Ministry of Health, Rwanda
Gene Bukhman, Director of the Program on Global NCDs and Social Change at Harvard Medical School and Director of the NCD Synergies program at Partners In Health
The session served as both a review of progress on the WHO package of essential NCD interventions for primary health care in low resource settings (PEN), as well as discussion on how to address a critical delivery gap in current resources regarding longitudinal outpatient services for severe and complex chronic NCDs that cannot generally be managed and treated at the primary care level.
In the side event, Dr. Bukhman, with support from the team leading the NCD cluster at WHO AFRO, proposed a strategy to address this gap by developing specialized outpatient NCD clinics at first level hospitals (PEN-Plus), which provides an essential first step to establishing the follow-up of patients with severe, chronic NCDs. In the session, Dr. Bukhman also mentioned the role that specialized outpatient clinics can play in supporting the expansion of WHO PEN implementation at health center level through task-sharing and mentorship, training, and supervision of integrated chronic care providers.
Noel Kasomekera / Partners In Health Meeting attendees engage in a discussion with session panelists on treatment and decentralized care for severe, chronic NCDs such as type 1 diabetes and rheumatic heart disease across the African Region.
In her remarks, Honorable Minister Diana Gashumba elaborated on the technical presentations from Dr. Shongwe and Dr. Bukhman on PEN and PEN-Plus by presenting on the experience of the government of Rwanda in addressing NCDs at national level. The Honorable Minister mentioned critical national efforts in prevention and at community level, as well as efforts that the Ministry of Health in Rwanda has prioritized in decentralizing and strengthening care for NCDs at district hospitals.
Given the recent adoption of Director General Dr. Tedros’ Thirteenth General Programme of Work for 2019-2023, which focuses heavily on targets to achieve universal health coverage, it was no surprise that UHC was a running theme for the side session. The content presented on management of severe NCDs transitioned into a lively discussion by Ministers of Health attending the session regarding how to accelerate progress in NCD care and treatment across all levels of the health system.
Maia Olsen / Partners In Health Dr. Gene Bukhman and Dr. Steven Shongwe of WHO AFRO during the opening gala at the WHO Regional Committee for Africa in Dakar.
Specifically with respect to the PEN-Plus portion of the dialogue, Ministers of Health and country delegations reiterated challenges around the unaddressed burden for conditions like rheumatic heart disease, severe mental illness, and kidney failure. Some comments, from Ministers representing countries like Central African Republic, also underscored that technical expertise on care delivery packages like PEN-Plus would potentially help support countries in more adequately responding to the kinds of conditions their colleagues see in clinics and 1st level hospitals throughout the African region.
Our teams at Harvard Medical School and Partners In Health hope that this discussion is merely a preview of regional dialogue and technical efforts that will continue across the African region to develop and define a package of interventions for severe, chronic NCDs at first-level hospitals (PEN-Plus). We look forward to future collaboration to come.
On July 2nd, the NCD Synergies program in partnership with the Program in Global NCDs and Social Change at Harvard Medical School and Brigham and Women’s Hospital, welcomed Dr. Fred Ochieng’, our team’s first Advanced Fellow in Cardiovascular Disease and Global Health Equity. Dr. Ochieng’ is a cardiologist who will be working across the NCD Synergies-supported PIH sites to provide decentralized cardiac care, and will oversee the training of nurses and other mid-level providers on skills and diagnostics, with a particular focus on echocardiography.
We are delighted to welcome Fred to our team!
Photo: Andrew Marx / Harvard Medical School Dr. Gene Kwan (left), NCD Synergies Associate Director of Cardiovascular Training & Research and Dr. Gene Bukhman (right), NCD Synergies Program Director, welcome Dr. Fred Ochieng (center) to our team as the inaugural fellow in Cardiovascular Disease and Global Health Equity.
Following Fred’s arrival, the Program in Global NCDs and Social Change at HMS directed a three-day Continuing Medical Education (CME) course from July 28th – 30th on Cardiovascular Disease and Global Health Equity at Harvard Medical School, directed by Dr. Gene Bukhman.
This three-day course in CVD and Global Health Equity aimed to equip participants with the knowledge, clinical skills, and assessment strategies needed to deepen their involvement in cardiovascular policy and service delivery in low- and middle-income countries. The course had an emphasis on rural communities with a high burden of conditions such as rheumatic and congenital heart disease.
Over 10 participants completed the course. Participants had a diverse range of backgrounds, including physicians-in-training, early and mid-career physicians, as well as nurse practitioners, and physician’s assistants. Participants also had a range of global health experience: some who were very interested and wanted to learn more, while others had long-term relationships in low-income country settings and were looking to gain more skills and knowledge. The course will be offered during the summer on an annual basis going forward.
The course brought together 18 faculty members including experts in cardiology, interventional cardiology, electrophysiology, cardiothoracic surgery, emergency medicine, nursing, neurology, epidemiology, clinical mentoring, and community-based care. The discussions spanned topics around costing of cardiology care, prioritizing equity in providing treatment in lower-resource settings, and the use of integrated care teams in delivering high-quality care.
Gene Bukhman / Harvard Medical School Participants in front of Harvard Medical School upon completion of the Continuing Medical Education Course on “Cardiovascular Disease and Global Health Equity”.
This course bridged the gap between interest in global policy and knowledge of treating these prevalent conditions in lower-resource settings. Upon conclusion of the course, participants will continue to build on their obtained knowledge by contributing to cardiovascular research and supporting clinical capacity building in lower- and middle-income countries.
Our teams at Partners In Health and HMS look forward to continuing to further expand training and mentorship for the treatment of cardiovascular disease in global health, and working to bring care and treatment of cardiovascular disease closer to patients and their families.
The goal of the meeting was to broaden the NCD and injuries dialogue beyond its conventional cardiometabolic focus, and to emphasize the need to prioritize interventions to address severe conditions affecting children and young adults.
This dialogue built on the findings of the Mozambique and Malawi National NCDI Poverty Commissions. These Commissions are part of a growing movement of countries coordinating National Commissions and Groups supported by the global Lancet Commission on Reframing NCDIs for the Poorest Billion. The two-day meeting featured an in-depth discussion on strengthening health systems to provide treatment to the most vulnerable populations throughout the region. In addition to representatives of the World Bank, WHO AFRO Regional Office, WHO Mozambique, participants included Ministry of Health leads, researchers, Partners In Health Colleagues from Lesotho, Malawi and Rwanda, and clinical implementers representing nine countries: Lesotho, Madagascar, Malawi, Mozambique, Rwanda, South Africa, eSwatini (formerly Swaziland), Zambia and Zimbabwe.
Amy McLaughlin / Partners In Health Over 40 participants from more than 10 countries gathered in Maputo for a two-day dialogue on severe, chronic NCDs and Injuries in the Southern Africa Region.
Day 1
Amy McLaughlin / Partners In Health Global NCDI Poverty Commissions, Dr. Gene Bukhman and Dr. Ana Mocumbi at the two-day discussion in Maputo.
Day 1 opened with introductory presentations from global NCDI Poverty Commission co-chairs Dr. Gene Bukhman and Dr. Ana Mocumbi, providing participants with important context for the burden of NCDs and poverty in Southern Africa and the global initiatives gaining momentum to address these critical issues. Next, the group heard in-depth presentations sharing key National NCDI Poverty Commission findings from Dr. Humberto Muquingue (Mozambique) and Dr. Jones Masiye (Malawi).
The Malawi and Mozambique NCDI Poverty Commissions shared some commonalities that question common assumptions and rhetoric around NCDs. For example, both groups found that a significant proportion of NCD disease is not attributable to known behavioral/metabolic or environmental risk factors (50% of the burden of disease in Malawi and 60% in Mozambique).
In order to gather additional data among the poor, the Malawi team also shared a productive partnership with WHO to conduct a national STEPs survey, which built in socioeconomic factors to collect critical representative data
Amy McLaughlin and Neil Gupta / Partners In Health Dr. Jones Masiye (Malawi) and Dr. Humberto Muquingue (Mozambique) present the key findings of the National NCDI Poverty Commissions.
At the end of Day 1, the group heard presentations from Ministry of Health NCD leads from Lesotho, Madagascar, Swaziland, Zambia, and Zimbabwe. Key similarities successes, and challenges across the region were discussed in a session moderated by Dr. Humberto Cossa and Dr. Gene Bukhman. Lack of data presents a fundamental challenge, as the real burden of NCDs and injuries, particularly in rural areas is not known. Specialized services are typically restricted to capital cities and can come at an extremely high cost. Finally, each Ministry representative emphasized the need for integration of NCD services, particularly within existing HIV platforms and other vertical programs.
Day 2
Day 2 discussions centered on the “how” of service provision. The morning session opened with a video of Sheila Chipenge, a 14-year old girl living with type 1 diabetes in rural Malawi and receiving care from Partners In Health. Throughout the day, many presenters referenced the experience of Sheila and others with severe chronic illness, emphasizing the need to reach those living in rural communities.
The group first heard from Dr. Paul Park, who presented on a model of outpatient clinics for severe, chronic NCDs, which has been successful in Rwanda. Following Dr. Park, a number of other innovative service delivery models were presented:
Swaziland, ICAP
Swaziland, National cancer registry program,
Malawi, Integrated Chronic Care Clinic (IC3) Partners In Health / Abwenzi Pa Za Umoyo (PIH/APZU),
Malawi, Dignitas International,
Zimbabwe, Medecins Sans Frontieres
Given the prevalence of HIV in this region, the following discussion moderated by Dr. Karen Sliwa and Dr. Park centered heavily on the integration of NCD services into HIV programs, including the potential challenges posed by overloading HIV funding. In this discussion, participants acknowledged that achieving UHC means providing curative services and treatment, not just prevention of NCDs. In addition, robust maternal and child health programs can also provide a platform for the integration of NCD services.
Following the discussion, the group heard from colleagues working on innovative service delivery models for complex NCDs. This featured:
Zambia, CIDRZ
Zambia, Rheumatic heart disease programs
South Africa, Chronic Disease Initiative
Lesotho, Partners In Health’s model of care for NCDs
Rwanda, Partners In Health / Inshuti Mu Buzima integrated NCD program that was nationally scaled in 2016
In this discussion moderated by Sir Magdi Yacoub and Dr. Simon Stewart, the group recognized the financial and geographical barriers that make accessing care for severe, chronic NCDs even more difficult, particularly for vulnerable and marginalized groups.
Amy McLaughlin / Partners In Health Dr. Ana Mocumbi with Dr. Emily Wroe and Dr. Neil Gupta of the NCD Synergies team during the two-day regional dialogue.
The following sessions on Human Resources moderated by Dr. Albertino Damasceno, Dr. Custodia Mandlhate and Dr. Sharon Kapambwe; and Monitoring & Evaluation, moderated by Dr. Fassil Shiferaw and Professor Fastone Goma enabled the group to discuss the relevant recommendations from the Mozambique and Malawi Commissions in more detail. For example, Dr. Emily Wroe and Dr. Jones Masiye of the Malawi NCDI Poverty Commission highlighted the need to have a standardized set of priority indicators across the health system – ones that are feasible to collect in paper-based systems – to better understand and track the national burden of disease and patient outcomes. This can be facilitated by the use of systems such as simple standard patient charts and other data collection tools to improve patient tracking and follow-up.
Finally, Dr. Ana Mocumbi and Dr. Simon Stewart presented on key findings from an in-depth analysis studying outcomes from Emergency Departments at Maputo Hospitals. Their findings highlight a breadth of NCDs and injuries being presented, that emphasize the need for health system readiness to provide sufficient care for this broad range of conditions.
Call to Action
Amy McLaughlin / Partners In Health Participants broke into group to discuss themes from the two-day dialogue, and identify key lessons and messages.
Day 2 closed with breakout sessions to discuss the following key themes in addressing NCDs and injuries across the region:
Priority setting
Human resources
Health Information Systems
Financing
Governance and Advocacy
Given such lively discussion throughout the two days, meeting participants are now working on a Call to Action for the southern African region. This outcome document will highlight the urgency and absolute need for actionable, practical steps to address severe and endemic chronic NCDs.
Mozambique NCDI Poverty Commission Launch
On Monday June 11th the Mozambique NCDI Poverty Commission launched their final report in Maputo. With over 100 people in attendance, Dr. Ana Mocumbi, Lancet NCDI Poverty Commission co-chair and lead of the Mozambique Commission presented key findings and highlights of the report. In addition to fellow commissioners and researchers, the audience included several stakeholders namely, health professionals, academics, researchers, civil society and patient groups.
Amy McLaughlin / Partners In Health Dr. Ana Mocumbi presents key findings of the Mozambique National Commission to a packed room in Maputo at the launch of the final report.
On Monday, March 26th 2018, the Nepal NCDI Poverty Commission, the Nepal Ministry of Health and Population, and various collaborators gathered in Kathmandu, Nepal for the launch of the Commission’s 2018 report. Nepal is one of eleven countries who have been working withThe Lancet Commission on Reframing NCDs and Injuries for the Poorest Billion (NCDI Poverty) to convene a National NCDI Poverty Commission to assess the local burden of NCDIs and baseline service availability to provide national priority-setting recommendations for equitable NCD strategies and interventions.
Over 80 people attended the launch of the Nepal NCDI Poverty Commission report to hear from Nepalese policymakers, researchers, and clinical implementers share key findings and national recommendations from the report.
Photo Credit / Nepal NCDI Poverty Commission Nepal Commission Co-Chair Dr. Bhagawan Koirala and Dr. Pushpa Chaudhary, Secretary of the Nepal Ministry of Health and Population, officially launch the report in Kathmandu.
Proceedings were moderated by Commission co-chair Dr. Bhagawan Koirala and Nepal Commission Coordinator Dr. Biraj Karmacharya. Throughout the day, presentations highlighted Commission findings evaluating national NCDI burden of disease and risk factor attribution and the impact NCDs have on financial hardship and impoverishment in Nepal, particularly among the poorest. The report also provided national recommendations for the prioritization of NCDI services from an equity-based lens, accounting for cost-effectiveness, priority to the worse off, and financial risk protection.
Photo Credit / Nepal NCDI Poverty Commission Over 80 people attended the launch in Kathmandu, to watch the Nepal Commission launch the report. The Nepal Ministry of Health and Population, as well as many other key national stakeholders, were well represented.
In addition to presenting the key findings of the Commission, the launch featured presentations by:
Pushpa Chaudhary – Secretary, Nepal Ministry of Health and Population
Jos Vandelaer – Nepal Country Representative, WHO
Gene Bukhman – Co-chair, global Lancet NCDI Poverty Commission
Indrani Gupta – Commissioner, global Lancet NCDI Poverty Commission
The Nepal NCDI Poverty Commission was established in November 2016, and has been led by Co-Chairs Dr. Bhagawan Koirala from Tribhuvan University and Dr. Senendra Raj Upreti, Secretary at the Nepal Ministry of Health. The Commission is comprised of 24 multisectoral experts who have overseen and guided the Commission’s work, efforts which have been supported by two research assistants and three advisors.
Since the Commission’s first meeting, Commissioners have conducted an in-depth cost analysis and impact assessment on two exceptional innovations that Nepal has led to provide healthcare to the poorest. These programs include:
A national program that guarantees cardiac surgery, free of charge for all children with congenital and rheumatic heart disease; and
A countrywide initiative providing all patients below the poverty line with government subsidized medical support for nine major NCDs.
In the coming months, the Nepal NCDI Poverty Commission will continue to disseminate its findings and extend its work into new areas of analysis. The group will also focus on implementation of the policy and service delivery recommendations laid out in the report in specific regions around the country.
