Integration

NCD prevention and control need not be a standalone programme. In fact, there are many health programmes where NCD interventions can fit in well. An integrated approach can also provide an opportunity to learn from other health programmes (e.g. HIV, TB) through case studies on community engagement mechanisms.

Palliative care is a crucial part of integrated, people-centred health services. National health systems are responsible for including palliative care in the continuum of care for people with chronic and life-threatening conditions, linking it to prevention, early detection, and treatment programmes. Palliative care needs to be provided in accordance with the principles of universal health coverage.

A phased approach is needed for integration and must be relevant to the context. Interventions can also be seen as relevant to the life course, as presented in the WHO menu of cost-effective interventions for mental health (45), and the WHO global air quality guidelines (46) can be considered, along with other NCD interventions, as appropriate to the local context.

The need to establish, strengthen and facilitate referral mechanisms with objective thresholds for referral up and down the system are an important aspect for consideration. Good referral systems can help maximize the use of expertise and health care infrastructure in line with the complexity of the disease being managed. A “hub and spoke model” can arrange service delivery assets into a network consisting of an anchor establishment (hub), which offers a full array of services, complemented by secondary establishments (spokes), which offer more limited-service arrays, routing patients needing more intensive services to the hub for treatment.

Integration of NCD services with existing programmes

NCD control programmes can no longer be viewed as standalone. There is undoubtedly a co-existence of NCDs with other conditions; for example, comorbidity with TB and HIV is well established, and in many countries bi-directional screening under TB or HIV control programmes has already been implemented. HPV vaccination for cervical cancer prevention can be integrated with the country’s national immunization programme. Gestational diabetes is an important condition to be addressed, which can be integrated with maternal care services. Cross-cutting areas, such as nutrition, are essential not only for the control of childhood obesity but for other disease conditions as well. All these can be integrated in the existing nutrition programmes. This holistic approach will also help to promote efficient disease control systems.

Life-course approach to addressing NCDs

Many of the NCDs experienced in adulthood stem from exposures early in life. Though major NCDs are often associated with older age groups, evidence suggests that they affect people of all ages. NCD prevention begins with the antenatal period, and proper nutrition that starts from infancy through childhood will have a long-lasting effect. Similarly, physical activity is required through all phases of life. Air pollution has detrimental effects on all stages of life, though manifestation of its effect may be seen later in adulthood. Other risk behaviours, such as tobacco use, alcohol consumption and certain sexual behaviours, need to be addressed in all stages of life. A life-course approach that considers the needs of all age groups and addresses NCD prevention and control in its earliest stages is therefore essential for prevention-control of NCDs.

Implementation research

Implementation research investigates the various factors that affect how a new policy or intervention may be used (or implemented) in reallife settings. The focus of an evaluation of the implementation process is on the type and quantity of policies and interventions delivered, the beneficiaries of those policies and interventions, the resources used to deliver the policies and interventions, the practical problems encountered, and the ways in which such problems were resolved. Implementation research should be embedded in all stages involving the selection, adaptation and evaluation of policies or interventions for the prevention and control of NCDs.

It is also important for the knowledge created to be shared among policy-makers, implementers and researchers through cross-country and cross-sectoral platforms and collaborations. The WHO publication A guide to implementation research in the prevention and control of noncommunicable diseases provides more operational details (47).

Universal health coverage

Progressive realization of universal health coverage can contribute to the achievement of the right to health. Consideration of the positive value of financial risk protection is particularly relevant for NCD priority-setting, given the long-term cost implications for the patient and their household. The 2019 global monitoring report indicates that there has been no pronounced progress for the NCD component since 2000 and this situation will have to be addressed in all countries (48).

Those seeking to improve NCD service delivery through essential health benefit packages should consider the following principles. Essential benefit package design should be:

• impartial, aiming for universality;
• democratic and inclusive, with public involvement, including from disadvantaged populations;
• based on national values and clearly defined criteria;
• data driven and evidence-based, and should include revisions in light of new evidence;
• respect the difference between data analysis, deliberative dialogue and decision;  
• linked to robust financing mechanisms;
• include robust service delivery mechanisms that can promote quality care; and
• open and transparent in all steps of the process, and decisions should be clearly communicated (49).

Sustainable financing is required for countries to support populationlevel interventions and reduce the unmet need for services and financial hardship arising from out-of-pocket payments. Countries should incrementally increase the allocation for health and, within that, for NCDs. This also involves improving the effectiveness of catalytic funding support. Out-of-pocket expenditure can be reduced only when NCDs are well covered under financial protection schemes in countries.

Meaningful involvement of the private sector, quality of care and outcome-based information collection are important elements that need to be addressed. Public–private partnership is one option, but approaches such as engaging private care to replicate the primary care centres as per national guidance and other such options can be considered.

Shifting public sector spending towards primary health care interventions, which form the backbone of universal health coverage, requires not only financial resources but strong political and logistical commitments. Achieving universal health coverage is not merely a financial, technical or rhetorical issue; successful national initiatives to provide genuine universal health coverage will require strong social movements and political leadership, among other factors (50).