Health Affairs
September 2015; Volume 34, Issue 9
http://content.healthaffairs.org/content/current

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Issue Theme: Noncommunicable Diseases: The Growing Burden
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Achieving Effective Universal Health Coverage And Diagonal Approaches To Care For Chronic Illnesses
Felicia Marie Knaul1,*, Afsan Bhadelia2, Rifat Atun3 and Julio Frenk4
Author Affiliations
1Felicia Marie Knaul (fknaul@gmail.com) is director of the Miami Institute for the Americas and professor at the Miller School of Medicine, University of Miami, in Florida. At the time this research was conducted, she was director of the Harvard Global Equity Initiative, in Boston, Massachusetts.
2Afsan Bhadelia is a research associate at the Harvard Global Equity Initiative.
3Rifat Atun is a professor of global health systems in the Department of Global Health and Population at the Harvard School of Public Health.
4Julio Frenk is president of the University of Miami, in Florida. At the time this research was conducted, he was dean of the Harvard School of Public Health.
*Corresponding author
Abstract
Health systems in low- and middle-income countries were designed to provide episodic care for acute conditions. However, the burden of disease has shifted to be overwhelmingly dominated by chronic conditions and illnesses that require health systems to function in an integrated manner across a spectrum of disease stages from prevention to palliation. Low- and middle-income countries are also aiming to ensure health care access for all through universal health coverage. This article proposes a framework of effective universal health coverage intended to meet the challenge of chronic illnesses. It outlines strategies to strengthen health systems through a “diagonal approach.” We argue that the core challenge to health systems is chronicity of illness that requires ongoing and long-term health care. The example of breast cancer within the broader context of health system reform in Mexico is presented to illustrate effective universal health coverage along the chronic disease continuum and across health systems functions. The article concludes with recommendations to strengthen health systems in order to achieve effective universal health coverage.

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Cardiovascular Disease Screening By Community Health Workers Can Be Cost-Effective In Low-Resource Countries
Thomas Gaziano1,*, Shafika Abrahams-Gessel2, Sam Surka3, Stephen Sy4, Ankur Pandya5,
Catalina A. Denman6, Carlos Mendoza7, Thandi Puoane8 and Naomi S. Levitt9
Author Affiliations
1Thomas Gaziano (tgaziano@partners.org) is an assistant professor in the Cardiovascular Division of Brigham and Women’s Hospital, in Boston, Massachusetts.
2Shafika Abrahams-Gessel is a research manager at the Center for Health Decision Science in the Harvard T. H. Chan School of Public Health, in Boston.
3Sam Surka is a researcher in the Chronic Diseases Initiative for Africa at Old Groote Schuur Hospital, in Cape Town, South Africa.
4Stephen Sy is a programmer at the Center for Health Decision Science in the Harvard T. H. Chan School of Public Health.
5Ankur Pandya is an assistant professor of health policy and management at the Harvard T. H. Chan School of Public Health.
6Catalina A. Denman is a professor in the Centro de Estudios en Salud y Sociedad at El Colegio de Sonora, in Hermosillo, Mexico.
7Carlos Mendoza is a coinvestigator at the Instituto de Nutricion de Centro America y Panama, in Guatemala City, Guatemala.
8Thandi Puoane is a professor in the School of Public Health at the University of the Western Cape, in Bellville, South Africa.
9Naomi S. Levitt is director of the Division of Diabetes and the Chronic Diseases Initiative for Africa, both at Old Groote Schuur Hospital.
*Corresponding author
Abstract
In low-resource settings, a physician is not always available. We recently demonstrated that community health workers—instead of physicians or nurses—can efficiently screen adults for cardiovascular disease in South Africa, Mexico, and Guatemala. In this analysis we sought to determine the health and economic impacts of shifting this screening to community health workers equipped with either a paper-based or a mobile phone–based screening tool. We found that screening by community health workers was very cost-effective or even cost-saving in all three countries, compared to the usual clinic-based screening. The mobile application emerged as the most cost-effective strategy because it could save more lives than the paper tool at minimal extra cost. Our modeling indicated that screening by community health workers, combined with improved treatment rates, would increase the number of deaths averted from 15,000 to 110,000, compared to standard care. Policy makers should promote greater acceptance of community health workers by both national populations and health professionals and should increase their commitment to treating cardiovascular disease and making medications available.

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Overcoming Obstacles To Enable Access To Medicines For Noncommunicable Diseases In Poor Countries
Sandeep P. Kishore1,*, Kavitha Kolappa2, Jordan D. Jarvis3, Paul H. Park4, Rachel Belt5,
Thirukumaran Balasubramaniam6 and Rachel Kiddell-Monroe7
Author Affiliations
1Sandeep P. Kishore (sunny.kishore@gmail.com) is a fellow at Yale University, in New Haven, Connecticut, and president of the Young Professionals Chronic Disease Network, in Boston, Massachusetts.
2Kavitha Kolappa is a resident in psychiatry at Massachusetts General Hospital, in Boston, a and board member for the Young Professionals Chronic Disease Network.
3Jordan D. Jarvis is executive director of the Young Professionals Chronic Disease Network and a former postgraduate research fellow at the Harvard Global Equity Initiative, in Boston.
4Paul H. Park is director of noncommunicable diseases for Partners in Health—Rwanda and a member of Universities Allied for Essential Medicines, in Washington, D.C.
5Rachel Belt is a member of Universities Allied for Essential Medicines.
6Thirukumaran Balasubramaniam is a Geneva representative at Knowledge Ecology International, in Switzerland.
7Rachel Kiddell-Monroe is a special adviser for the Universities Allied for Essential Medicines, a board member for the Young Professionals Chronic Disease Network, and a member of the International Board for Médecins sans Frontières, in Geneva.
*Corresponding author
Abstract
The modern access-to-medicines movement grew largely out of the civil-society reaction to the HIV/AIDS pandemic three decades ago. While the movement was successful with regard to HIV/AIDS medications, the increasingly urgent challenge to address access to medicines for noncommunicable diseases has lagged behind—and, in some cases, has been forgotten. In this article we first ask what causes the access gap with respect to lifesaving essential noncommunicable disease medicines and then what can be done to close the gap. Using the example of the push for access to antiretrovirals for HIV/AIDS patients for comparison, we highlight the problems of inadequate global financing and procurement for noncommunicable disease medications, intellectual property barriers and concerns raised by the pharmaceutical industry, and challenges to building stronger civil-society organizations and a patient and humanitarian response from the bottom up to demand treatment. We provide targeted policy recommendations, specific to the public sector, the private sector, and civil society, with the goal of improving access to noncommunicable disease medications globally.