Cover Story | Charting a Healthier Future: Navigating the Path Forward For NCDs
– Political Declaration from the United Nations High-level Political Forum on Sustainable Development
It's been more than a decade since the United Nations General Assembly adopted the first Political Declaration on the Prevention and Control of Noncommunicable Diseases (NCDs) which recognized the social and economic impacts of NCDs to be among the top global challenges for sustainable development this century.
According to the World Health Organization, NCDs are responsible for the deaths of 41 million people each year, or nearly 75% of all deaths globally. Of these deaths, nearly two-thirds are in low- and middle-income countries with cardiovascular diseases ranking number one, followed closely by cancers, chronic respiratory diseases, and diabetes.
The formal report from the UN Secretary General in May 2011 noted that "[NCDs] could be significantly reduced and prevented, with millions of lives saved and untold suffering avoided, through proven and affordable measures, many of which are complementary to global health efforts already underway." It went on to state that the "knowledge and technology to fight the onset and effects of noncommunicable diseases already exist" and called for action "to save future generations from the health and socio-economic harm of such diseases."
A Call to Global Action
Early efforts focused on four preventable risk factors – tobacco use, unhealthy diet, physical inactivity and use of alcohol – and looked to governments, the private sector, civil society, the UN and international organizations to adopt cost-effective, population-wide health-care interventions. "The greatest reductions in [NCDs] will come from a complete government approach to adopting population-wide interventions that address risk factors. Those interventions can be achieved through modest and cost-effective investment," according to the report.
The global community rallied around the call to action. In 2012, the Global Cardiovascular Disease Taskforce, a group of experts representing the ACC, World Heart Federation, American Heart Association, European Heart Network and European Society of Cardiology jointly released a health policy outlining specific targets that included a 10% relative reduction in prevalence of insufficient physical activity in adults aged 18+ years; a 30% relative reduction in prevalence of current tobacco smoking; a 30% relative reduction in mean adult population intake of salt; and a 25% relative reduction in prevalence of hypertension.
"We now have the opportunity to make meaningful changes in our countries by adopting evidence-based targets and implementing tactics that will guide health policy, chronic disease plans and, ultimately, resources for national public health interventions," said the statement authors, which included then-ACC President William A. Zoghbi, MD, MACC.
Making Progress, But is it Enough?
In the years following the first political declaration and the development of specific recommendations, subsequent reports from the UN recognized that progress on NCDs was being made with certain countries implementing policies that taxed items like tobacco or sugary beverages. Others were launching community-wide initiatives targeting salt intake or hypertension. A 2013 UN General Assembly report noted a "growing international awareness that the promises and commitments made at the high-level meeting offer a paradigm shift in thinking about [NCDs] as an issue that requires Governments to assume a primary role and responsibility which goes beyond the health sector alone."
Putting Pressure on Hypertension
As part of efforts leading up to the UN General Assembly Summit, the WHO released its first-ever report on the devastating global impact of hypertension, along with recommendations for reversing this trend.
According to the report, the number of people living with hypertension doubled between 1990 and 2019, from 650 million to 1.3 billion. Of these, 75% live in low- and middle-income countries. It goes on to note that an increase in the number of patients effectively treated for hypertension to levels observed in high-performing countries, could prevent 76 million deaths, 120 million strokes, 79 million heart attacks and 17 million cases of heart failure between now and 2050.
The report recommends the following five components for improving hypertension treatment:
- Development of practical dose- and drug-specific treatment protocols with specific action steps for managing uncontrolled blood pressure that can streamline care and improve adherence.
- Regular, uninterrupted access to affordable medication. (Currently, prices for essential antihypertensive medicines vary by more than tenfold between countries.)
- Leveraging of team-based care to adjust and intensify blood pressure medication regimens per doctor orders and protocols.
- Use of patient-centered services to reduce barriers to care, such as free medications, close-to-home follow-up visits and ready access to blood pressure monitoring.
- Implementation of user-centered, simple information systems that can aid rapid recording of essential patient-level data, reduce data entry burden, and support rapid scale-up while maintaining or improving the quality of care.
"Hypertension control programs remain neglected, under-prioritized and vastly underfunded," said WHO Director-General Tedros Adhanom Ghebreyesus, MD. "Strengthening hypertension control must be part of every country's journey towards universal health coverage, based on well-functioning, equitable and resilient health systems, built on a foundation of primary health care." Click here to access the full report.
However, the report also highlighted "insufficient and highly uneven" implementation efforts. This sentiment was echoed in a 2017 UN report that said, "initiatives to improve access to good-quality essential health-care services and to safe, effective, good-quality and affordable essential medicines and vaccines for the prevention and control of non-communicable diseases have not been scaled up in the majority of developing countries." It went on to add that "political commitments have often not been translated into concrete action" and "serious constraints driven by economic and trade promotion interests are impeding the implementation by many Governments" of some of the recommendations.
"The world is reaching an inflection point," the report stated. "Without significant investment now, premature mortality from non-communicable diseases in developing countries will continue to increase and the world will not be able to reach target 3.4 of the Sustainable Development Goals on [NCDs] by 2030."
To add to the challenges of scalability, escalating environmental factors like air pollution and climate change, as well as the growing number of political conflicts and war, have only made it harder for people – especially those in low- to middle-income countries – to access basic health care, let alone longer-term prevention and treatment options. As of 2019, these growing factors were among the major reasons why more than 50% of countries were not on track to reach the goal of reducing premature deaths from NCDs by 2030, according to data from the NCD Alliance.
The impact of the COVID-19 pandemic also can't be ignored. Governments and health care professionals were forced to pivot to address the global crisis, redirecting resources to fighting the fast-moving virus. A WHO political declaration from January 2021 found that "more than 80 countries reported complete or partial disruptions to management services for people with hypertension or diabetes and diabetic complications" as a result of the "deadly interplay" with the COVID pandemic. Additionally, the declaration highlighted significant declines in screenings, referrals and/or hospitalizations for cancer and cardiovascular disease. The pandemic also underscored the need to address mental health, health equity, and workforce as part of large-scale NCD efforts.
The Road Ahead
Fast forward to today and the quest to solve for the NCD crisis – and broader Sustainable Development Goals – by the 2030 deadline continues. Most recently the heads of state and government met in New York in September for the UN Sustainable Development Summit aimed at measuring progress towards achieving the goals. Leaders expressed "alarm" that the progress on most of the goals either continues to move too slowly or has regressed. They voiced concerns about the "persistent and long-term impacts from the COVID-19 pandemic, continued poverty and widening inequalities, and the multiple interlinked crises that are pushing our world to the brink, particularly in developing countries and for the poorest and most vulnerable" and urged a recommitment to a vision where no one is left behind.
"The [Sustainable Development Goals] aren't just a list of goals. They carry the hopes, dreams, rights and expectations of people everywhere," said UN Secretary-General António Guterres. "Yet today, only 15 percent of the targets are on track."
In the official Political Declaration coming out of the Summit, the leaders called for "continuous, fundamental, transformative and urgent actions at all levels and by all stakeholders to overcome the crises and obstacles facing our world." They added: "We recognize that the integrated nature of the Sustainable Development Goals requires a global response. We renew our commitment to multilateralism, to find new ways of working together and to ensure that multilateral institutions keep pace with the rapid changes taking place."
– António Guterres
New ways of working together include finding opportunities to leverage new technologies and innovations, including artificial intelligence (AI), to expand data collection, research and the dissemination of new science that can inform government policies and, in the case of NCDs, aid communities and health care providers in ensuring universal access to health care.
"The ACC has a long legacy of international collaboration and engagement with the goal of improving the quality of cardiovascular care worldwide," said ACC Past President John Gordon Harold, MD, MACC, who has been involved in the ACC's NDC work from the very beginning. "Our Vision specifically recognizes the role of science, knowledge and innovation in optimizing patient care and outcomes and we are uniquely positioned to work with governments, industry and other societies around the world to identify and implement on-the-ground solutions that improve heart health for all."
Examples of the ACC's work, include the NCD Academy, the Global Heart Attack Treatment Initiative (GHATI), and Global Quality Solutions. The NCD Academy, which is a partnership between the ACC, World Heart Federation, NCD Alliance and Viatris, offers free online education focused on all four major NCDs, as well as mental health and health equity, and is designed with primary care and community health care clinicians in mind. To date, 20,000 clinicians across 145 countries have taken part in the program. Meanwhile, GHATI takes lessons learned and best practices from improving STEMI care in the U.S. and works with hospitals and health systems in low- and middle-income countries to apply these lessons in their respective institutions. With lots of discussions taking place about how best to gather data, Global Quality Solutions leverages the ACC's NCDR Registry platforms to help countries capture data and identify areas for improvement.
Visit ACC.org/ncdacademy for all the free, online courses, including Cardiovascular Disease and Stroke Prevention, Health Equity and more.
On the data front, the College is also exploring opportunities with governments, Ministries of Health, and public health programs around registry adoption and use. The ACC has convened in-person meetings with Ministry of Health officials in Saudi Arabia, Mexico, India, Singapore, and most recently Germany, highlighting opportunities to work together to align data collection and use the NCDR registries as a blueprint for understanding how cardiac care services compare to global standards.
According to ACC President B. Hadley Wilson, MD, FACC, the College's work can't and won't end here. Other critical steps include engaging in global health advocacy in support of people living with heart disease. Supporting clinicians and health care professionals at all levels of training is another priority and includes putting tools in the hands of primary care and front-line health care workers to better manage NCDs. Focusing on specific geographies and providing targeted local support must also occur, Wilson says. He cites the College's work to provide echocardiography training in Kenya as a means of addressing the shortage of trained and certified diagnosticians as an example of direct, hands-on programs that address a clear need and deliver results.
"One of the silver linings from the COVID pandemic is that we clearly saw that it's possible for the global community to unite around a shared mission," says Wilson. "I have no doubt that we have it in us to deliver on the Sustainable Development Goals and help turn the tide on NCDs. I'm hopeful that we will see demonstrated progress when the UN General Assembly convenes its fourth high meeting on this topic in 2025."
Sustainable Workforce Critical to Sustaining Universal Health Coverage
Ensuring an adequate and sustained health care workforce is a critical component of global efforts in support of Universal Health Coverage (UHC), which refers to a "system in which all people have access to quality health services they need, when and where they need them, without financial hardship."
To date, many countries lack the necessary minimum number of health care workers to meet primary care needs, let alone that of specialties like cardiology. "Health workers are the backbone of every health system, and yet 55 countries with some of the world's most fragile health systems do not have enough and many are losing their health workers to international migration," said WHO Director-General Tedros Adhanom Ghebreyesus. High-income countries like the U.S. are also not immune to workforce challenges that include aging populations with more comorbidities, clinician burnout accelerated by the COVID pandemic, and a smaller pipeline of future clinicians.
Heading into the 2023 UN Summit, the ACC, NCD Alliance and WHF, with support from Viatris, brought together leaders in global health and technology for a special forum dedicated to discussions on opportunities to leverage innovation to enhance the health workforce. The event provided an opportunity to share examples of how technology is supporting global health workforce training; highlight case studies of how successful implementation of technology at the front lines of care delivery can support better management of NCDs in communities; and identify concrete ideas of how workforce issues can be addressed through task shifting, training and supportive technology.
Speaking at the Forum, Tom Frieden, MD, MPH, president and CEO of Resolve to Save Lives, stressed that technology has often overpromised and under-delivered. Effective models will need to empower patients and align financing, governance and technology in ways that emphasize health vs. financial profits. Technology should also make the most of the care team. "Team-based care – with doctors, nurses, pharmacists, social workers, and community health workers collaborating to support patients – is the most effective way to improve care and save lives," Frieden said. "Digital tools that are created to support health care workers through user-centered design can accelerate progress."
Rebecca Bunnell, PhD, MEd, acting principal deputy U.S. Global AIDS Coordinator for PEPFAR, highlighted opportunities to learn from successful HIV efforts, especially when it comes to partnering on education and working directly with communities on implementation programs. She stressed the need to be creative and intentional to successfully sustain gains and develop a long-term, durable infrastructure. She also noted the importance of integrating technologies and innovations into health systems to ensure long-term stability. This need for integration was echoed by David Rhew, MD, global chief medical officer and vice president of health care at Microsoft, who said "a sustainable data infrastructure needs to connect public health, community organizations and hospital electronic health records."
"Health care is the one sector that has not adequately adopted the technology to increase access to care and allow patient empowerment often from within their own homes," said Tom A. Gaziano, MD, MSc, FACC, chair of WHF's Science Committee. "However, the tools are there for the taking, we just need to mobilize to adopt the technology and free ourselves from the model that solely revolves around the clinic and the hospital." "All of this is very hard, but it's very doable provided you have commitment and a common purpose," said Tracey McNeill, RN, director of primary health care for the Bill and Melinda Gates Foundation.
Clinical Topics: Cardiovascular Care Team
Keywords: ACC Publications, Cardiology Magazine, Noncommunicable Diseases, Cardiovascular Diseases, Health Policy
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