Series www.thelancet.com Vol 376 November 20, 2010 1785 Lancet 2010 376: 1785���97 Published Online November 11, 2010 DOI:10.1016/S0140- 6736(10)61353-0 See Comment Lancet 2010 376: 1619���21 See Online/Comment DOI:10.1016/S0140- 6736(10)61856-9, and DOI:10.1016/S0140- 6736(10)61891-0 This is the fourth in a Series of fi ve papers about chronic diseases World Health Organization, Geneva, Switzerland (B Samb MD, S Mendis MD, F Celletti MD, T Evans MD, A Alwan MD, C Etienne MD) Consultant, Public Health, Chronic Diseases: Chronic Diseases and Development 4 Prevention and management of chronic disease: a litmus test for health-systems strengthening in low-income and middle-income countries Badara Samb, Nina Desai, Sania Nishtar, Shanti Mendis, Henk Bekedam, Anna Wright, Justine Hsu, Alexandra Martiniuk, Francesca Celletti, Kiran Patel, Fiona Adshead, Martin McKee, Tim Evans, Ala Alwan, Carissa Etienne National health systems need strengthening if they are to meet the growing challenge of chronic diseases in low- income and middle-income countries. By application of an accepted health-systems framework to the evidence, we report that the factors that limit countries��� capacity to implement proven strategies for chronic diseases relate to the way in which health systems are designed and function. Substantial constraints are apparent across each of the six key health-systems components of health fi nancing, governance, health workforce, health information, medical products and technologies, and health-service delivery. These constraints have become more evident as development partners have accelerated eff orts to respond to HIV, tuberculosis, malaria, and vaccine-preventable diseases. A new global agenda for health-systems strengthening is arising from the urgent need to scale up and sustain these priority interventions. Most chronic diseases are neglected in this dialogue about health systems, despite the fact that non- communicable diseases (most of which are chronic) will account for 69% of all global deaths by 2030 with 80% of these deaths in low-income and middle-income countries. At the same time, advocates for action against chronic diseases are not paying enough attention to health systems as part of an eff ective response. Eff orts to scale up interventions for management of common chronic diseases in these countries tend to focus on one disease and its causes, and are often fragmented and vertical. Evidence is emerging that chronic disease interventions could contribute to strengthening the capacity of health systems to deliver a comprehensive range of services���provided that such investments are planned to include these broad objectives. Because eff ective chronic disease programmes are highly dependent on well-functioning national health systems, chronic diseases should be a litmus test for health-systems strengthening. Introduction The burden of disease attributable to chronic disorders, such as cardiovascular disease, diabetes, cancers, and respiratory disease, is higher in low-income and middle- income countries than it is in high-income countries, and continues to rise.1 Non-communicable diseases (most of which are chronic) will account for 69% of all global deaths by 2030 with 80% of these deaths in these countries.2 This mirrors the globalisation of risk factors such as tobacco, the combination of increased calorie intake and reduced exercise, and the ageing of populations.3���5 The chronic characteristics of non-communicable diseases contrast with the predominantly acute nature of infectious diseases (although inevitably there are exceptions, such as HIV, tuberculosis, and leprosy). Chronic illness demands a complex health-systems response that needs to be sustained across a continuum of care. Evidence-based interventions should be delivered by health professionals with diverse skills. Appropriate technologies, dependable pharmaceutical supplies, and clean, accessible health facilities need to be brought together over a sustained period. These eff orts should also be complemented by eff ective public policies to tackle major risk factors. Such inter- ventions are possible only with a functioning health system, which can deliver disease prevention and Key messages ��� Many cost-eff ective interventions exist to address the growing burden of chronic diseases in low-income and middle-income countries however, weak national health systems often make it impossible to deliver and sustain interventions eff ectively and equitably. ��� Constraints on the capacity of countries to respond to the challenge of chronic diseases exist across each of the six key health-systems components of health fi nancing, governance, health workforce, health information, medical products and technologies, and health service delivery. ��� Eff orts to scale-up interventions for chronic diseases in low-income and middle-income countries tend to focus on one disease and its causes, and are often fragmented and vertical. These eff orts represent missed opportunities to leverage the health-system reforms that are needed. ��� Global dialogue about health-systems strengthening neglects most chronic diseases. ��� Advocates for action on chronic diseases are not paying enough attention to the interface between chronic disease responses and health systems. Increased focus and understanding on the dimensions of health systems is needed if countries are to address the challenge of chronic diseases. ��� Interventions for responding to chronic diseases can lead to overall improvements in health systems in low-income and middle-income countries, provided that such investments are planned to include these broad objectives from the outset. ��� Chronic disease interventions depend on well-functioning national health systems since long-term coordinated and intersectoral responses are needed across a continuum of care. Reduction of mortality and morbidity that is associated with chronic diseases will be an important measure for assessment of eff orts to strengthen health systems.

Series 1786 www.thelancet.com Vol 376 November 20, 2010 London, UK (A Wright BA) George Institute for Global Health, London, UK (N Desai MD) Heartfi le, Islamabad, Pakistan (S Nishtar MD) World Health Organization, Manila, Philippines (H Bekedam MD) London School of Hygiene and Tropical Medicine, London, UK (J Hsu MSc, Prof M McKee MD) George Institute for Global Health, Sydney, Australia (A Martiniuk PhD) National Health Service, West Midlands Strategic Health Authority, Birmingham, UK (K Patel FRCP) and UK Department of Health, London, UK (F Adshead MD) Correspondence to: Dr Badara Samb, World Health Organization, Health Systems and Services, 20 Avenue Appia, Geneva, 1201 Switzerland sambb@who.int education services alongside integrated care and intersectoral collaboration that extends beyond the health sector.6 However, most low-income and middle-income countries have fragile health systems that are under- resourced and in need of structural and policy reform.7 The rapid transition in disease burden to chronic diseases is an enormous challenge for these weak systems. Cost- eff ective interventions to address chronic diseases exist, although progress is being stalled by shortfalls in the ability of health systems to ensure the eff ective and equitable delivery of these interventions. We aim to assess the challenges involved in the delivery of services for chronic diseases in low-income and middle-income countries from a health-systems perspective explore whether interventions to address chronic conditions can contribute to improving the capacity of health systems to deliver comprehensive health services and assess whether the rapid emergence of a global agenda for health-systems strengthening, focused mainly on specifi c infectious diseases, is taking account of the growing need for services that can meet the challenge of chronic diseases in these countries. Methods We undertook an extensive review of published work from the past 10 years (1999 to present) in the Cochrane and PubMed databases. The search was done to identify health-systems aspects of prevention, diagnosis, treatment, monitoring, and management of chronic diseases in low-income and middle-income countries. Key search terms were: ���chronic disease���, ���developing country���, ���low-income���, ���health system���, ���monitoring���, ���prevention���, ���screening���, ���risk assess*���, ���diagnosis��� ���medical test���, ���diagnostic���, ���treatment���, ���drug therapy���, ���behavioral therapy���, ���management���, ���lifestyle modifi cations���, and ���developing world���. We also searched for reports that addressed staff and physician training, technology development, patient education and counselling, patient records management, surveillance and monitoring systems, and access to care. We included prevention, diagnosis, treatment, monitoring, and management of chronic diseases in low-income and middle-income countries as related terms to health systems. We excluded evidence-based strategies from high-income countries that could be extended to low- income and middle-income countries (eg, blood pressure management guidelines). We assessed evidence by applying a conceptual framework, adapted from that developed by the WHO, which identifi es distinct components of health systems.8 This health-systems framework enabled an analysis of performance demands and related challenges in the areas of health fi nancing, governance, health workforce, health information, medical products and technologies, and health-service delivery. We did an extensive search of recent government and non-government resolutions and statements about chronic diseases, and of those about health-systems strengthening. The list was built up by the authors who verifi ed that most global resolutions or statements were identifi ed. Initially, the search terms ���chronic disease���, ���non-communicable disease���, and ���health systems��� were used, and subsequently each resolution or statement was explored in detail to achieve a two-fold objective: fi rst, to identify how much the burden of chronic diseases is recognised and addressed within high-level political discourse related to health- systems strengthening and second, to establish whether the need for strengthening is su��� ciently emphasised by global advocacy for chronic diseases. We adopted WHO���s defi nition of health systems as all organisations, people, and actions whose main intent is to promote, restore, or maintain health. This defi nition includes eff orts to address the determinants of health and direct activities to improve health. A health system is therefore ���more than a pyramid of publicly owned facilities that deliver personal health services��� (fi gure).8 A well functioning health system is one that allows any person wherever they live and whatever their social and economic circumstances to access appropriate, good quality primary-care services, with referral to secondary and tertiary care when needed, without the risk of fi nancial hardship. We focus on chronic diseases���ie, those that cause chronic ill health. Not all chronic diseases are non- communicable and not all non-communicable diseases are necessarily chronic. Health systems constraints to delivery of chronic disease services Background The prevention, treatment, and management of chronic diseases, whether in low-income, middle-income, or high-income countries, entails a core range of interventions���ie, primary prevention, proactive case fi nding (eg, assessment of risk factors and screening), education of both the public and health-care workers, e��� cient referrals, pharmacological and psychosocial interventions, long-term surveillance, and monitoring and assessment of quality of care.6 Although such interventions might be the same, substantial diff erences exist between low-income and middle-income countries and high-income countries in the type and scale of the barriers to implementation���most notably, strategies are conditioned by resource availability. Constraints also arise in relation to the ways in which national health systems are designed and function. These systemic constraints are the focus of our analysis. Health systems of many low-income and middle- income countries share many features such that they can be discussed as one group for the purposes of this analysis. Importantly, health systems are complex and context specifi c with some substantial variations between countries and regions. The overall approach