A Research Blog

This week, we hear directly from the Health Services and Systems Research (HSSR) Programme at Duke-NUS about their pick for the biggest research story in 2016 to influence health services research. Director of the programme, Professor David Matchar, and Deputy Director, Amina Mahmood Islam, tell us more about non-communicable diseases (NCDs) and how NCDs impact future health services research.

The HSSR Programme considers the increase in chronic, NCDs globally, regionally and in Singapore, the key health services challenge we currently face.

NCDs: the growing challengeHSSR 2016

The most recent survey of the Global Burden of Disease Study focused on trends over the past decade, from 2005 to 2015: people are living longer in nearly every region; there has been a sustained decrease in infectious diseases and a corresponding decrease in infant mortality. All this good news is counter balanced by the increase in NCDs. Globally, ischaemic heart disease and stroke were the two leading causes of premature death in 2015. The prolonged periods of treatment for people with chronic conditions leads to significant increases in healthcare costs as well as a loss of work productivity.

The main risk factors contributing to the rising number of mortality and morbidity from chronic diseases are the trio of unhealthy diets, physical inactivity and tobacco use. This set of common modifiable risk factors could potentially be mitigated. An estimated 80% of premature heart disease, stroke, and type 2 diabetes, and 40% of cancer, could be avoided through healthy diet, regular physical activity, and avoidance of tobacco use. However, coordinated and systematic efforts spanning a wide spectrum of activities will be required.

NCDs in developing countries

The shift in life expectancy and causes of death are particularly problematic in low and middle income countries (LMICs) as they continue to tackle communicable diseases – thus facing the ‘double burden’ of disease.

The challenge of the increasing burden of chronic disease is well-recognised and widely acknowledged as an important issue facing the health and wellbeing of citizens in these countries. However, this awareness has not been matched with corresponding resources or strategies for intervention. Discussions around how best to tackle this burden have been characterised by vigorous debate between practitioners and policy makers with competing priorities. Within some groups, resources needed to effectively manage chronic diseases are seen as diverting resources from communicable, maternal, neonatal, and nutritional diseases that are still prevalent in many LMICs.

While the treatment of chronic diseases might differ substantially from dealing with infectious diseases, the structures developed to manage communicable disease like HIV and TB could potentially be utilised to develop healthcare systems for all patients with long-term care needs.  In particular, the systems developed to care for, monitor and follow up with HIV patients on anti-retroviral treatment can be duplicated for the treatment and management of chronic diseases. The sustainability of such programmes might be enhanced when they are utilised for multiple diseases. In low resource settings, such considerations take on a greater urgency.

The ability to prevent, control and treat chronic diseases is constrained as much by the lack of resources as by the structures and networks required to effectively and holistically address the associated complex set of issues. Tackling these challenges requires innovative strategies based on country specific research, relevant data and an accepted framework for analysis. This framework must represent the interests of disparate groups – including consumers of health services across the urban and rural landscape and across socioeconomic groups, healthcare providers and key stakeholders. Special attention should be paid to the marked variation in wealth and disparity in access to relevant health services for the treatment and management of chronic diseases. With the rich elite concentrated in urban areas there is a trend towards high-tech curative services available through a fragmented private sector at the expense of a coordinated public health response.

The best way to try and balance competing priorities is to develop robust and evidence-based health policies that direct resources to the most effective strategies for combating both infectious diseases and chronic conditions.

NCDs in Singapore

The challenges of managing chronic diseases are not limited to low resource settings. Despite its robust health infrastructure, Singapore is also grappling with the complexity of responses required to effectively address the health needs of its ageing population. Currently 11% of the population is aged 65 and over, and this proportion will increase to 19% in 2030.  Over two-thirds of older Singaporeans suffer from at least one chronic condition. The current health system emphasises disease-based acute services and tends to treat chronic conditions episodically. Although various initiatives have been introduced to respond to the growing need to manage chronic diseases, much remains to be known about the potential consequences of different ways of organising care in Singapore.

Experiments with a variety of models of care aimed at optimising healthcare delivery for chronic diseases can be found internationally, and variants of these are being considered or actively tested in Singapore. These include changes in the role and incentives of the private sector and general practitioners, changes in subsidies to patients and the use of empanelment to assign individual patients to individual chronic providers and care teams. In this context, enhanced primary care, in which well-trained, equipped and supported teams of primary care providers managing the needs of patients with multiple chronic conditions, may be a potential solution. 

The path to efficient management of chronic diseases in a way that optimises health outcomes, maximises patient satisfaction and is cost conscious is still being paved.

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