In the lead up to the UN High-Level Summit on Non-Communicable Diseases (NCDs), there is been much discourse – and the rightfully so – on the need for greater public awareness of the threat NCDs, the framing of NCDs as a human rights issue, the importance of new funding mechanisms, and the urgency of collaborative action. However, missing has been the call to fundamentally redesign health care delivery systems to meet a fundamentally different set of medical diseases.
A fork is a great utensil but not for eating soup. Similarly, the current model of health care delivery is effective for managing acute illnesses such as infections or trauma. But for NCDs such as cardiovascular diseases and diabetes, which increasingly overwhelm health care systems around the globe, our current delivery model is largely ineffective.
Why Are NCDs Different?
In acute illnesses, a patient feels unwell, seeks care by a health care professional, and then receives a short course of treatment at home or in the hospital. The focus is on accurate and rapid diagnosis, which is usually done in a health care setting, and treatment is brief and often curative. In contrast, non-communicable diseases are best diagnosed through screening and early detection and are managed over months to years through by both patients and health care professionals through a combination of behavior change, medical therapy, and specialized care.
A special case is behavior-related chronic diseases such as hypertension, as opposed to non-behavior-related diseases such as cancer. These NCDs are not treated in a single clinic visit or hospitalization but rather are managed at home for years by patients themselves. A doctor may see a diabetes patient in clinic 15 minutes 4 times a year, while the patient self-administers her medications, monitors her sugars, and modifies her lifestyle the other 8,759 hours of the year. It is little wonder then that from diabetes and hypertension to chronic obstructive lung disease, behavior-related NCDs are poorly controlled and among the leading causes of preventable disability and death even among developed health care systems.
New Care Delivery Models for NCDs
Our current conception of health care delivery systems for cardiovascular disease was born in an era when heart attacks were viewed as little more than random strikes of lightning. There was little that could be done to prevent them and even less to treat them. Older age and male sex were risk factors but were not modifiable. Patients who suffered from heart attacks were prescribed bed rest and monitored for complications. Now heart attacks are considered to be a late complication of atherosclerosis. The vast majority of heart attacks are preventable through lifestyle modifications and preventive medications. Treatment has also advanced considerably through medical as well as interventional and surgical therapies.
These advances in medicine and public health require a fundamentally different approach to health care. Our health care delivery systems need to support lifestyle modifications to prevent the onset of cardiovascular disease, screening and early detection of risk factors, evaluation and treatment of chronic disease, and the triage and treatment acute complications. Such a system cannot merely be confined to the clinic and hospital setting, but must also be community-based. This system would include but not be limited to:
- population health measures to monitor and modify risk factors
- community-based screening and referral programs
- community-based disease management, remote monitoring
- clinic-based diagnosis and treatment
- referral to higher levels of care
- care coordination
Community-based care is not only important for prevention and early detection but also for those with advanced disease. While clinics and hospitals provide highly specialized care to these patients, care often continues at home, most visibly through chronic medications. Community-based care is essential to support ongoing disease management including medication adherence, behavior change, and monitoring. And yet today our care delivery system is still largely built around clinics and hospitals, rather than around patients and communities.
The appropriate care delivery model follows from the science of medical care. Delivery of effective cardiovascular disease care requires attention to the full spectrum of care, with an emphasis on prevention. In contrast, few measures are known as of yet to prevent breast cancer. Rather screening and early detection as well as specialized treatment of those with advanced disease are critical. As result, care delivery systems for breast cancer would focus on public awareness, access to screening, and referral to specialized centers for treatment.
Fork In The Road
To be effective, efficient, and equitable, our health care delivery systems must provide the right care, at the right time, and in the right place. Fundamental questions include:
- What is the optimal structure of a health care delivery system designed to address prevention, detection and treatment NCDs?
- What is the role of a primary health care in improving population health?
- How can innovation in health care delivery be fostered, sustained, and scaled?
Though health care delivery may seem like a “micro” issue less pertinent to national and international policymakers, it isn’t. Here are some steps we can take:
- Foster global shared learning. The issues of access, cost, and quality in the face NCDs are faced by health systems around the globe, whether developed countries or developing. In fact, a recent report from the World Economic Forum suggests that the majority of innovation in health care delivery is coming from developing world health systems, where the necessity for innovation is the greatest and barriers to change the lowest. Thus, health care delivery system redesign will not result from developed health systems providing expert guidance to emerging health systems and instead will require a multilateral global effort and shared learning.
- Create regulatory framework that supports innovation. Many countries including the U.S. have large public health systems that finance and provide health care. For example, moving from fee-per-service payment to risk-adjusted capitation models would allow provides to innovate.
- Training and collaboration. Interventions at the national, regional and local level impact the health of populations both by preventing disease and treating existing disease. At the same time, individuals with NCDs are also patients and often require evaluation, diagnosis and treatment under the supervision of trained health care professionals. As a result, addressing NCDs will require leaders with training in clinical medicine and public health and increased collaboration.
The primary attention to health care delivery has been the call for health systems strengthening. We need more effective health care workforce, last mile supply chains, and global health technologies; but we also need to fundamentally restructure and innovate upon our models for care delivery. At this pivotal moment for NCDs let us rally around a cry for transforming the way we deliver health care so that we may leverage our collective actions into better health for all.
- Shantanu Nundy, M.D.