What Wind Blew those NCDs Hither?
On September 19, the Center for Global Development (CGD) asked: One Year Later, What Happened to Noncommunicable Diseases (NCDs)? It cited the UN General Assembly Resolution of 2011 adopting a 13-page “political declaration” to address the prevention and control of non-communicable diseases worldwide. Yet, no measurable goals to reduce NCDs, such as targets to reduce global mortality, or increased access to medicines, were agreed upon until a year later at the 2012 World Health Assembly (WHA).
Earlier, it seemed NCDs were gaining traction. In the Center for Strategic & International Studies (CSIS) report, they positioned this emerging issue on the global health agenda in February 2011 by stating the need to focus and leverage existing assets. In April 2011, the First Global Ministerial on Healthy Lifestyles and Noncommunicable Diseases convened in Moscow to galvanize support and provide policy guidance for the forthcoming UN High-Level Meeting on NCDs in September 2011. Subsequently, WHO drafted the ‘Moscow Declaration’ placing itself at the global epicenter of NCD prevention and control.
More than a year has passed and the upward trajectory of action hasn’t been perceptible. The CGD looked at this stagnation and asked if was caused by the bad economic climate or lack of political attention? The answer is, neither. Rather, those advocating NCDs can be said to have based their assessments on the Columbus Effect: the donor community’s “discovery” of NCDs. Donors are giving attention to them as if NCDs are akin to a newly discovered continent. However, reliable sources identified their emergence decades ago, and developing countries themselves invest heavily in building and operating hospital systems to address them.
Since 1984, the World Bank has reported that developing countries were expending the majority of their national resources in hospital-based services, largely for patients above the age of 15 years with chronic conditions. Many of these facilities have earned the highly reputable Joint Commission International (JCI) which has accredited organizations in 39 countries and in over 300 public and private health care facilities. Most are in aid-assisted countries, e.g., 45 are in Turkey; 25 in Brazil; 17 in India. Others with more than 2 facilities are located in Bangladesh, China, Costa Rica, Ecuador, Egypt, Ethiopia, Indonesia, Jordan, South Korea, Lebanon, Malaysia, Mexico, Pakistan, the Philippines, Thailand, Viet Nam and Yemen.
Developing countries have also become health care attractions for citizens of donor countries. Medical tourism is a major multi-billion dollar industry in Malaysia, India,
Thailand—each one an aid-assisted country. The largest, the Apollo Hospitals, is based in India and it frequently collaborates with Johns Hopkins International. Medical tourism is the largest service sector with estimated revenue of $35 billion, constituting 5.2% of India’s GNP, and employing 4 million people. By the end of 2012, it is expected to grow at 15% per annum, with revenues of $78.6 billion, reaching 6.1% of GDP, and employing 9 million people.
While donors were pouring more resources into communicable diseases, they failed to notice that recipient countries were expending large portions of national health allocations in hospitals for chronic care. In 1984, the World Bank records that Malawi was spending 81% of its total public recurrent health expenditures on hospital care; it was 75% in Jordan; 74% in Lesotho; 73% in Kenya; 72% in Jamaica; 71% in the Philippines; 71% in Sri Lanka; 70% in Somalia; 68% in Brazil; 67% in Colombia; 54% in Zimbabwe. Of the hospital expenditures listed above for these countries, “all use at least 70% of their national health resources on adult and elderly patients”.
While developing countries have long been stepping up to the plate in combating these diseases, in contrast the WHO has recommended that the donor response to NCDs be limited to only four diseases: CVDs, cancer, diabetes, and upper respiratory diseases.
These limitations are contrary to the extant clinical standards of most developing countries which have Constitutional guarantees to open and free access on healthcare. Most importantly, they reflect donor priorities, attempting to force-fit them into those already taking place by the countries themselves. They represent the values of ‘discoverers’ ring-fencing their newly found possessions around indigenous institutions.
In the end hospitals will continue to absorb the largest share of national health expenditures, independently of anything the donor health community will do with its recent ‘discovery’ of these diseases. If WHO is successful in guiding donor support for NCDs, then it will have to post this notice in public hospitals:
If you have a CVD, cancer, diabetes, or an upper respiratory infection, with one of the four designated risk factors, welcome! Otherwise, please move on to one of our nation’s local hospitals which offer comprehensive NCD prevention, care and treatment.
Such a policy outcome from the WHO recommendations has no clear or fair rationale. It is unlikely to resonate with the professional medical societies in the developing world which, in most countries, are under the purview of ministries of higher education and provide clinical staffing for NCDs to their major hospitals. Perhaps NCDs would not have blown away, had collaborative strategies been discussed at first ‘discovery’ by donors.