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Moderators of Non-Communicable Diseases and GHDonline staff

GHDonline Expert Panel: Funding Challenges for Non-Communicable Diseases in Resource-Limited Settings

By Sarah Arnquist | 16 Jun, 2011 Last edited by Sophie Beauvais on 29 Dec 2011

Funding for expanded chronic disease prevention and treatment cloud is a major concern as the global health community prepares for this fall's UN NCD Summit. From June 17 to June 24, experts and professionals working to find funding for non-communicable diseases in resource-limited settings will take up these questions around costs, funding, and priority shifting in a virtual panel discussion.

Panelists will start off the discussion by responding to the following initial questions

• What are some of the financial challenges for governments and international institutions in addressing NCDs?

• What are the donors’ roles regarding NCDs, what should different types of donors be contributing, and how can advocates raise awareness about NCDs funding?

• How might donors work with governments and health implementers to promote NCD prevention, care and treatment? What do we know and what should we know about how service integration and health system strengthening can be used to address NCDs?

• Can you share examples of integrated service delivery, health insurance schemes, or innovative partnerships that offer lessons for NCD program and funding development?

Panelists

• Rachel Nugent, PhD, senior research scientist in the Department of Global Health at University of Washington

• Miriam Rabkin, MD, MPH, Director for Health Systems Strengthening at ICAP Columbia and Associate Clinical Professor of Medicine & Epidemiology, Mailman School of Public Health, Columbia University

• Sumi Mehta, Senior Technical Manager, Global Alliance for Clean Cookstoves

• Brian Bilchik, MD, Director of ProCor

• Charlanne Burke, Senior Associate, and Robert Marten, Associate at the Rockefeller Foundation

• Kyle Peterson, Managing Director at FSG Social Impact Consultants

• Representatives from The Young Professionals Chronic Disease Network

Replies

 

Rachel Nugent Replied at 11:29 PM, 16 Jun 2011

Question 1: What are some of the financial challenges for governments and international institutions in addressing NCDs?
Developing countries rely on external funds to help them meet their health needs, with donors providing almost $1 in every $6 spent on health in low income countries in 2005. While most bilateral and multilateral global health donors have acknowledged that NCDs are becoming a large share of disease burden in even the poorest countries, they have done very little to help developing countries address the need. The paramount challenge is that the amount of funds available is nowhere near what is needed to address NCDs in developing countries. Research from the NHLBI Centers of Excellence led by Louis Niessen estimates that national health expenditures would need to rise by 5% to 76% to fully implement prevention of cardiovascular disease. A related challenge is that donor resource tracking systems are not at all geared toward NCDs, so it is very difficult to say with any precision how much donor funding exists for NCDs, and what is needed. According to our analysis at the Center for Global Development, less than 3% of donor funding for health is allocated to NCDs, even including external private sector and research funding. At this week's Global Health Council meeting, Professor David Bloom of Harvard presented an estimate of $31 trillion in economic losses from NCDs. Kind of stunning, isn't it? Available donor assistance for NCDs is in the Millions, and estimated economic losses from NCDs are in the Trillions! Measures of both NCD resources and needs need to be made systematically and regularly to help donors understand the role they need to play.


Question 2: What are the donors’ roles regarding NCDs, what should different types of donors be contributing, and how can advocates raise awareness about NCDs funding?

First, donors ought to use funds and expertise wisely. That implies at least some relationship between the burden of disease and donor expenditures. Our analysis showed that $31 per DALY (disability-adjusted life year) was spent by donors on HIV/AIDS, TB, and malaria in 2008, compared to $1.01 per DALY on NCDs. With projected increases in mortality and morbidity from NCDs in developing countries, and declines in infectious causes of death and illness, that imbalance between health need and donor spending will widen unless donors adopt a broader view of health.
Second, donors should work with developing country leaders to adapt and improve on existing technology, service delivery systems, and knowledge to reduce NCD risks and incidence. Collaboration can take many avenues, but should be truly developing country-led. The rich world has no monopoly on good ways to address NCDs and can, in fact, learn much from low- and middle-income countries that are able to avoid making the same mistakes. Feasible and sustainable solutions to NCDs in any country will require involvement of multiple ministries of government, from agriculture to education; knowledge of high-risk cultural and social behaviors and how to change them; willingness to rely on the private sector and work with it in partnership; and hard financial choices. These steps are only possible with the authority and involvement of the highest levels of government in a country, and will produce different solutions in each country that undertakes them. Public sector donors can help develop the governance and institutional arrangements needed, global professional associations can share knowledge and implementation experience, and private sector donors can bring expertise, experimentation, and technology. Each can play a supportive role.
Accomplishing what is described above will require donors and funders of all stripes. Bilateral donors working on MDGs 4 and 5 might find ways to improve maternal and child health outcomes by screening for hypertension and diabetes in pre-natal clinics, and incorporating developmental origins of health into early childhood nutrition programs. Multilateral financing and technical agencies can work in countries across sectors to align agricultural, food, transportation, urban planning, and other policies and programs toward a common set of health and development objectives. For instance, development banks can consider health impacts in their sectoral projects. Corporations and philanthropies can design and test small-scale pilot projects that can inform governments about what works, especially working with private sector health providers, and can use their communication and marketing know-how to encourage healthier behaviors in their workforces and in the public. Research agencies can fund and build scientific capacity to improve our understanding of basic biological and other mechanisms influencing NCD risks and disease transmission, with a heavy emphasis on operations research in developing countries.
There are many interesting avenues to be tried before we are can confidently say how to reduce NCDs around the world. Both because of limited financial capacity and because of the multitude of ways to address NCD problems, the results of these efforts will be a more decentralized array of interventions and actors than what we have witnessed in global health over the past decade. While at times the multi-actor, multi-target approach to NCDs may sound like a cacophony, it is both realistic in the current financial environment and desirable to spur innovation and adaptation.

Question 3: How might donors work with governments and health implementers to promote NCD prevention, care and treatment? What do we know and what should we know about how service integration and health system strengthening can be used to address NCDs?

A challenge for governments and advocates is to articulate a clear need and direction on NCDs in order to obtain resources from global donors. In addition to being an important source of funds and technical assistance, donors have great influence over health priorities and programs in developing countries. When donors say a health issue is not important enough for them to invest in, the country has a hard time prioritizing that need. That highlights another financial challenge for both donors and developing country governments: how to spend money wisely. Developing countries need to have access to global and domestic financing mechanisms that are geared toward disease prevention, long-term disease care and management, and affordable treatment. They also need information about cost-effectiveness and affordability of NCD interventions. Donors should be helping construct the evidence to guide country policy and expenditure choices on NCDs to ensure they get the most health improvement for their investments.

Donors can bring both funds and useful experience to address NCDs in developing countries, but they should also bring an open mind. We don’t know enough about many important questions, such as how to design combination interventions that address multiple risk factors and conditions, or what intermediate and final outcome measures capture effects of interventions across people’s lifetimes. Therefore donors should be prepared to bring expertise – such as the vast learning that arises from the years of building HIV/AIDS programs in developing countries – and funds with which to answer those and other questions. Because of the high hopes for integrating NCD response with existing programs, such as HIV/AIDs and maternal health, operations research on integration should be a high priority. We should start by finding out the potential for low- and no-cost enhancements to those programs to achieve better overall health outcomes for populations in developing countries.

Can you share examples of integrated service delivery, health insurance schemes, or innovative partnerships that offer lessons for NCD program and funding development?

I don’t have much direct contact with health service delivery so I look forward to examples from others contributors. However, I’ve been impressed with what I’ve heard about programs that recognize the multi-faceted health needs of people rather than separating and segregating services. An example is AMPATH in Kenya, a program run by Moi University and Indiana University. Over the years, the doctors and other staff at AMPATH have expanded their mandate to fit the needs of the population being served. For instance, responding to the nutrition needs of HIV/AIDS patients by helping them learn to grow food, addressing their economic fragility by helping them sell their surplus food, then as ARV treatment expanded, seeking private-sector financial support that allowed them to treat the NCDs they increasingly found among their AIDS patients. This seems like a promising example of integrated programming and partnering. Now it needs economic evaluation so that donors and developing country governments can consider the possibilities of scaling it up and adapting it to other settings.

Brian Bilchik Replied at 9:35 AM, 17 Jun 2011

Question 1: What are some of the financial challenges to addressing NCDs?
In the last several years the healthcare community has done an excellent job describing the enormity of NCDs, its contribution to premature death and disability, and the fact that it’s largely preventable. It is now well known that the burden does not solely affect affluent societies. Low- and middle-income countries are afflicted with the double burden. We have not done as good a job defining cost-effective strategies and policies to address NCDs.

In lower resource countries, funding for healthcare is, by necessity, rationed. Because NCD prevention requires long-term planning, and the benefits are only reaped years later, our efforts are often sabotaged by acute crises.

Funding for prevention strategies should incorporate population focused strategies (such as tobacco control) as well as personal risk focused strategies which would utilize cost-effective risk assessment tools (for example, a BMI measurement may be as good and more cost-efficient as a laboratory cholesterol).

Government allocation for healthcare per person per year in low-resource settings may exceed the cost of treating disease, however the costs generally don’t exceed the cost of effective prevention strategies. Our messaging needs to be clear.

ProCor was founded on the premise that information poverty is yet another risk factor to address NCDs. Cost effective, timely, responsible, and reliable information is required. We need to get the right information into the hands of the decision-makers. There needs to be trust that any allocation of resource will produce effective, measurable, and sustainable results.

Question 2: What are the donors’ roles regarding NCDs, what should different types of donors be contributing, and how can advocates raise awareness about NCDs funding?
One of the funding challenges is creating even greater awareness of the current and growing NCD in developing countries with decision-makers. Funding challenges should be overcome as new data emerges that clearly shows the impact and potential of low-cost, effective prevention strategies. However in this period of economic downturn, political turmoil, and multiple natural disasters, there continues to be a reactive response to funding allocation. The return on investment on NCD prevention is many years down the road and the metrics used to calculate successful outcomes are not always easily understood. Our messaging needs to be clear, succinct, and bold. These interventions need to be sustainable. There needs to be collaboration between public healthcare agencies and industry. We need to engage industry in a productive and positive manner. Educating the population in a way that creates demand for healthier products, lifestyles, and work environments are imperative.

Question 3: How might donors work with governments and health implementers to promote NCD prevention, care and treatment? What do we know and what should we know about how service integration and health system strengthening can be used to address NCDs?
In low-resource settings it is critical not to duplicate prevention efforts. There are many examples of cost-effective projects, programs, and policies - yet these are not often shared. Creating visibility, sharing information of these successful, low-cost, sustainable interventions are important.

Creating policies that address both population strategies and personal strategies are essential. Utilizing and developing preventive technologies and tools, rather than reaching for the most recent high tech treatment (often most expensive) strategies, will be important. We need to educate governments and policy-makers that following models of sick care systems like that in the US are not effective and we should instead create systems that are health focused.

One of the most valued resources of low- and middle-income countries is their intellectual assets. Brain drain has contributed to the impediment of improving healthcare. Funding is necessary to ensure that the public sector healthcare providers are sufficiently reimbursed to prevent movement to private sectors and emigration.

Funding is necessary for public health training, policy development and then implementation, information technology, and health communication.

It remains illogical that healthy behavior and healthier foods are more expensive and more difficult to obtain than the unhealthy alternatives.

In difficult economic times, donors are strapped, governments have fewer funds, and the personal out-of-pocket expense for the individual makes discussions and forums such as these essential and timely.

Miriam Rabkin Replied at 11:46 AM, 17 Jun 2011

My fellow panelists have done a terrific job initiating the conversation around questions 1-3, so perhaps I will focus my initial comments on question 4.

When we talk about integrated service delivery, I find it immensely helpful to be quite precise about definitions.
• Firstly, integration is rarely if ever a binary condition. As Rifat Atun and his colleagues have illustrated quite elegantly, disease-focused programs are often integrated within health systems at some levels and in some ways and not at others. I tend to think of “upstream” integration – integration of planning, financing, procurement, M&E, and other systems – and “downstream” integration, where services are integrated at the health facility and patient levels.
• Secondly, there is sometimes a bit of “fuzziness” about what is being integrated with what. Should we be attempting to integrate NCD services with primary care services? Or with each other? It probably goes without saying that not all NCD services can or should be integrated with primary care services. Providing integrated wellness counseling at the primary care level makes a lot of sense. Having non-specialists prescribe radiation treatment for cancer, or perform valve replacement surgery for mitral stenosis is obviously a less sensible approach. Similarly, providing integrated services for chronic conditions such as diabetes and hypertension is considerably more feasible than providing integrated services for, say, chronic lung disease and road traffic accidents.
• Finally, as we have learned from HIV programs, the way in which services are implemented makes an immense difference, both to clients and to the impact on health systems at large. Similarly, local context is key. I doubt there is a “one size fits all” approach that will work across countries and communities.

That said, I think there are some early but interesting examples in which programs have leveraged the lessons, platforms, partnerships and tools developed for HIV service delivery and used them to “jumpstart” NCD diagnosis, care, and treatment initiatives. From a programmatic perspective, the challenge of providing continuity care over a lifetime is quite similar, no matter which chronic disease you are treating. And in many countries, HIV scale-up has created the first large-scale chronic care program in history - something that can be adapted and built upon to provide services for other chronic diseases.

As Rachel notes, the AMPATH program in Kenya is doing home-based testing not only for HIV, but for some NCDs and risk factors. FHI has taken a similar approach in Kenya, using the VCT platform to test for hypertension, hyperlipidemia, and obesity as well as HIV. ICAP Columbia, where I work, has conducted a situational analysis of NCD programs in Swaziland, which has highlighted the multiple opportunities to build on existing HIV systems to support diabetes and HTN care. And we have taken this one step further in Ethiopia, adapting HIV systems, tools, and approaches for use in diabetes care and treatment. I can describe some of this work in more detail in later posts, if people are interested.

Sumi Mehta Replied at 12:07 PM, 17 Jun 2011

Building on what Brian Bilchik noted above, a major impediment has been the limited focus on identifying the major risk factors for NCDs among the poor in developing countries. The four major modifiable risk factors which currently share the spotlight, namely unhealthy diet, physical inactivity, tobacco use, and the harmful use of alcohol, are not necessarily the most relevant for the ‘bottom billion’. For more information on this important issues, see http://www.pih.org/pages/harvardncd.
For example, household air pollution from cooking and/or heating with solid fuels is arguably the most widespread risk factor among the poor in developing countries, and responsible for over a million NCD deaths each year. While cigarettes are the leading cause of COPD in developed countries, HAP is the leading cause of COPD among nonsmoking women in developing countries.
In addition, given the growing evidence base which is breaking down the perception that there is a distinct division between ‘infectious’ and ‘chronic’ disease, one can only speculate about other infectious risk factors for NCDs which have yet to be uncovered. As such, there could be other important links between access to clean water / sanitation and NCDs which need to be explored.

Shweta Khandelwal Replied at 1:31 AM, 18 Jun 2011

Hi All,
My name is Shweta Khandelwal and i work with Dr Srinath Reddy as a public health nutritionist at the PHFI, New Delhi (http://phfi.org/about/ffprogramme.html#19). I also am a faculty at the Foundation. I am here as one of the representatives of the YP-CDN.

Should global health donors alter their priorities and strategies to include NCDs, or are there ways to address the NCD needs in developing countries within existing priorities and strategies?

I can talk with India as an example of a developing country. We definitely need to realign country’s health priorities. While our economic growth rate is surging (~ 9 percent), it has not been translated to actual improvement in public health. The situation is particularly grave in rural areas, where more than 70 percent of the country's 1.2 billion people live. A long-term impact on our country’s growth is portended - especially as two-thirds of the population is under 35 and would constitute India's work force for several coming years. Yet expenditure on health care is paltry- a mere 1.1 % of GDP (WHO estimates).

The Lancet NCD Action Group and the NCD Alliance proposed five overarching priority actions for responding to the crisis—leadership, prevention, treatment, international cooperation, and monitoring and accountability—and the delivery of five priority interventions—tobacco control, salt reduction, improved diets and physical activity, reduction in hazardous alcohol intake, and essential drugs and technologies. To roll these out in India, one would expect a dedicated unit for each of these – all of which may jointly report to one nodal government agency/body/Ministry. Currently there is no department or Ministry for ensuring all these interventions categorically. The Ministry of health and Family Welfare (MOHFW) does pay attention to some amount but can we really blame them when there are competing and even more grave emergencies/priorities to tackle/respond to. I would like to recall Dr Reddy’s op-ed in the Hindu, where he urges shouldn’t all ministers be health ministers? (http://www.hindu.com/2009/06/03/stories/2009060353170800.htm) He writes that since matters of health are substantially influenced by policies and programmes followed in other sectors, all the Ministries of government must play an active role in advancing health goals. We must also build up a much more powerful partnership between the generators of the research and the generators of policy.

At present, there is no regular consultative mechanism. Dr Srinath Reddy had suggested in one of his interviews that the health ministry could have an informal committee of experts broadly for the area of public health which can meet once a month and take a view on critical challenges. And this committee come up with suggestions that could be considered by policy makers. One example is the formation of Planning Commission’s HLEG (high level expert group) assigning PHFI as their secretariat. This group represented by officials from ministry, private sector, academicians, medical professionals, etc, have discussed several issues on Universal health care as a part of coming up with the recommendations for the next 5 year plan for the Indian Government. This complimentary service would aid the policy making decisions, plays a role in the advisory capacity and can also shoulder responsibilities assigned by stakeholders for public health action. If we don’t have systems like that, I am afraid the health ministry will only be fire fighting.

One more example is from the field of higher education and research. We need to utilise our existing resources much more efficiently. For example, medical colleges in India are grossly underutilised. About five medical institutes in India contribute nearly 90% of all publications from India. We don’t even require a massive up-scaling of resources to do this – just some creative thinking, innovative solutions. We can initiate short term skill building courses or training programs– on NCD epidemiology, public health, community nutrition, etc for interested students or professionals. Forums of young professionals where dynamic youth bring fore the energy, passion and multiple disciplines together should be encouraged. These communities can act as think tanks and can help to give inputs or quick condensed (like preparing quick overview, identifying research gaps, documenting success stories and reasons for failure /scope of improvement in others)where required.





How much does it cost to address NCDs in resource-limited settings, and what is the right contribution for donors to contemplate?

I am not sure of the numeric costs and I am sure it will vary a lot depending on which country are we talking about..However, I think one comment which I can make is that both direct and indirect costs should be considered while computing these. Costs which donors should contemplate while contributing need to encompass:

1. Costs for providing treatment for the ones already inflicted with NCDs

2. Costs for putting prevention mechanisms in place including knowledge generation activities

3. Costs for preventing and treating Risk factors for NCDs







Are there good examples of integrated service delivery or innovative partnerships to address NCDs?

India needs both “knowledge translation” and “knowledge generation” research. For example, we don’t have information on disease incidence in various regions. We have no method of telling how many Indians suffer a heart attack each year. I see Surveillance at national and global levels to play a critical role in addressing or at least mapping out trends, vulnerable areas, incidence of disease, risk factors etc. This quality information is required urgently to tackle this huge burden of NCDs. There needs to be an integration of the common questions which can be asked at the global level (will give a broad picture like the GBD study etc) plus standardized questions specific to local levels (country and/or district wise) taking cultural considerations into account. India has an example of IDSP- integrated disease surveillance program (currently includes only 7 states and not whole of India) which has helped generate great data (http://idsp.nic.in/) on NCDs and its risk factors. We can definitely triangulate information from other national surveys like NFHS but a sustainable and quality surveillance mechanism in place can really act as a great health index for any country.

Another area I feel needs innovative partnerships and inter-sectoral participation is improving the health education curricula and delivery. A recent commission of global experts from various fields also recommended designing new instructional and institutional strategies to combat multiple looming health challenges (Lancet publication Frenk et al, 2010). The recommendations include aligning national efforts through joint planning, especially in the education and health sectors, engaging all stakeholders in the reform process and developing global collaborative networks for mutual strengthening. They also advocate developing competency-based curriculum of globally recognized high academic standards.Courses (and thereby professionals) on public health, NCD epidemiology, public health nutrition, physical activity and lifestyle management are virtually nonexistent in a country like India where they are needed the most.

Should external funding from the private sector be utilized to address NCDs in poor countries?

As Dr Nugent points out in her paper, donor funding to developing countries for NCDs grew by 618 % between 2001 and 2008, with the largest share of the increase coming from private, non-profit donors, and evidence of accelerating interest from public donors. We at PHFI are also a public-private partnership working towards nurturing and producing a pool of professionals who could contribute in bettering the public health current scenario in India. But if by private sector you mean industry- my personal view would be to refrain any technical involvement of industry especially the food industry.

We all recognize that unhealthy diet is one of most important risk factors for NCDs. Thus I feel that allowing industry to openly blur our objectivity is a waste of resources. There are several arguments put forward by Jeff Koplan, Kelly Brownell and others against food industry being allowed to influence decisions for public health. An option however could be accepting blind donations without any obligation to announce where the money came from. So if the industries genuinely feel like endorsing improved public health, they should give the money in a blinded fashion. Other ways to help tackle NCDs could be announcing public health scholarships for bright students from resource-constrained countries to pursue their passion in this field.

Robert Marten Replied at 10:54 AM, 18 Jun 2011

My name is Robert Marten, and I work at the Rockefeller Foundation in New York City. Thanks so much for the invitation to participate and to my fellow panelists for getting this discussion going. I’m honored to be part of such a great panel, and I am looking forward to learning from this discussion.



¨ What are some of the financial challenges for governments and international institutions in addressing NCDs?



It’s a time of financial austerity, and many assume we will see cuts in spending for development on health. While this seems possible, and perhaps likely, for some big-ticket diseases like HIV/AIDS (within overall development aid for health spending), I’m not yet convinced this will happen for health spending overall. And domestically, or within countries globally, it seems fairly certain that overall spending, both private and public, will increase. What does this mean for NCDs? I think it’s a mixed message: if NCDs want to be the next HIV/AIDS, I don’t think the necessary appetite or financing is there. Yet as the need grows within countries, I see financial spending on NCDs increasing. Regardless of donors and/or global institutions, domestic spending on NCDs globally will likely rise. Building off of some of the successes and experiences of HIV/AIDs and other vertical approaches, the new buzz word for NCDs is going to be(come) integration. The challenge is going to be figuring out what integration actually means, and ensuring that integration both leads to better health impacts and does not have negative implications for the poor and vulnerable.



More specifically, we all know the startling statistics from Rachel Nugent’s work at CGD. But these statistics are not going to change overnight. It will take time for the donors to shift. Yet, I’m not sure we should or need to wait for donors. There are some low-hanging fruits. There are some big and quick policy wins around tobacco, alcohol and food and nutrition that governments can begin to enact. For example, I think of South Africa’s experiences with tobacco, or Botswana’s experiences with alcohol are places to look to for lessons. New York City is also pioneering some of the more innovative policies around food. Finally, I think there are great opportunities to leverage the huge investments in NCD research invested in countries like the US and view this research as a global public good.





¨ What are the donors’ roles regarding NCDs, what should different types of donors be contributing, and how can advocates raise awareness about NCDs funding?



Answering this question representing a donor is somewhat fraught; however, I would stress that donors need to spend time to better understand the NCD challenge and should play to their strategic strengths where and when they can add value. Obviously this means different things for different donors.



At the Rockefeller Foundation, we are focusing our current efforts on supporting health systems as they are transformed by new technologies and improving economies with an aim for universal health coverage (UHC). The question for us is and will be how do NCDs fit into this?



¨ How might donors work with governments and health implementers to promote NCD prevention, care and treatment? What do we know and what should we know about how service integration and health system strengthening can be used to address NCDs? Can you share examples of integrated service delivery, health insurance schemes, or innovative partnerships that offer lessons for NCD program and funding development?



These are some great, and I think the right, questions. We probably need more research to illuminate proven interventions, and then sustained efforts to ensure that policymakers get this information. This research should help policymakers not only become aware of these interventions, but assist them in scoping possible pathways to overcome the challenges that become obstacles in the implementation of these interventions. Alongside researchers and think tanks, there is certainly a role and a need for civil society too. There seems to be a need to convene policymakers, researchers and activists.



I also have a feeling we might learn a lot from the experience of some of those delivering integrated health services like Partners in Health, Brazil, BRAC in Bangladesh or as already noted AMPATH in Kenya. But I’m sure there are others, and I’m looking to learn from my fellow panelists and the participants in this forum. Miriam, I would certainly be interested to hear more about your experience and work in Ethiopia and any other relevant examples.





All the best,

Robert







Robert Marten

The Rockefeller Foundation

420 Fifth Avenue

New York, NY 10018, USA

Andrea Feigl Replied at 1:44 PM, 18 Jun 2011

Hi all

Last but (hopefully not least), I wanted to contribute to the discussion on Financing on NCDs as well. I am currently a 1st/2nd year doctoral student at the Harvard School of Public Health, and I've had the wonderful opportunity to work with Rachel Nugent on the Analysis of Health Financing for NCDs.

I am currently part of a larger team, led by Dr. David Bloom at Harvard, that aims to estimate the global cost of illness of NCDs (see below for some teaser estimates), and am hoping that my thesis will build on this work regarding NCDs.

Without further due, here are my replies to the discussion questions:

*Should global health donors alter their priorities and strategies to include NCDs, or are there ways to address the NCD needs in developing countries within existing priorities and strategies?*

The answer to this question is not quite as simple and straightforward as one might hope.

By simply suggesting a shift of funding from infectious to non-communicable diseases, one remains stuck in the common trap of ‘disease-driven’, rather than health and health-systems-driven, health financing approaches.

Second, the answer to addressing NCDs meaningfully, comprehensively, and sustainably is not simply found in increased funding for NCDs based on big donors writing a check to countries. The answer to the question is much more complex than that.

As a starting point, my recommendation to donors would be to investigate how to fund the integration of NCD prevention and treatment components for existing (ID) projects, a solution that perhaps elegantly circumvents the notion of DAH as a zero-sum game.

Secondly, prioritizing NCDs does not necessarily mean increased funding. It could mean country-support to draft and implement tobacco, salt, and trans-fat policies, or it could mean advocacy support to negotiate affordable drug and technology prices.

While ideally, the DAH agenda should reflect the burden and greatest health needs of countries, any change in that direction will have to ensure that existing programs are sustained and improved along the way.

Lastly, as a side note, many official strategies, like that of USAID, already include language around NCDs in their reports to OECD/DAC. However, that does not always mean that there is actual NCD funding, despite a project description in reported funding that refers to NCDs.

*How much does it cost to address NCDs in resource-limited settings, and what is the right contribution for donors to contemplate?*

I am currently involved in a project, under the leadership of Dr. David Bloom at Harvard, and commissioned by the WEF, to estimate the global cost of illness for NCDs. While the results of this analysis will be released in
a report at the UN Summit in September, I can give you some ‘teaser’ numbers (not to be officially quoted): treating all people affected by COPD in a given year in addition to the indirect cost of COPD (loss of employment, sick days at work, burden on families), costs several hundred million dollars per year, and so does treating all incident cancer cases on a global level.

Over a thirty year time period, the cost-of-illness for all NCDs is in the double-digit trillions. [stay tuned for the exact estimates when released during the UN Summit]

These estimates do not take into account prevention programs or a rise in disease burden. Therefore, the cost of inaction, given the projected rise in disease burden, and factors such as the strong global tobacco lobby, could be as much as six times higher than these estimates.

• Are there good examples of integrated service delivery or innovative partnerships to address NCDs? **

Since others on this forum have already addressed this question, I will dedicate my last response to the following question:

*Should external funding from the private sector be utilized to address NCDs in poor countries?*

Again, the answer to this question, as well as the question itself, is more complex than it would seem at first.

As we all know, there are parts of the private sector that have been essential to treatment and care delivery on a global scale, ranging from the production of vaccinations, to cell phone companies for new technology
diagnosis networks, as well as simple private contractors that build hospitals.

Then again, there are sections of the private sector that have contributed, and perhaps substantially so, to the burden of chronic diseases: this is especially true for the tobacco industry, to a lesser extent, global mining
companies (and the poor working conditions that workers are subjected to), and to a lesser degree, global food companies, ranging from Nestle to Monsanto to several fast food companies.

In the middle of that spectrum are companies that employ large part of the global work force, which can both be a threat as well as an opportunity to tackle NCDs on a global level. A threat, since poor working conditions,
often a side effect of companies’ focus on the bottom line, can cause and exacerbate NCDs. An opportunity, since large global employers are awakening to the fact that absenteeism and large health insurance premiums can be averted by better working conditions and work wellness programs. This increased awareness about NCDs affecting the workforce among business leaders is evidenced by the results of the latest World Executive Opinion survey, which showed that the majority of global employers are deeply concerned about absenteeism due to NCDs in their workforce.

Given the private sector’s already involvement in the issue of NCDs, the question at hand is of how the private sector should be involved, and how the global health advocacy community can form partnerships that are based on shared values and that tap into the great communication and technology resources that the private sector has, to leverage limited resources to a maximum.

Further, the private sector is already funding several global health initiatives, with funding coming from both the for-profit as well as the non-profit private sector (think: MedTronic and PepsiCo vs. the BMGF).

While additional funding from private donors is of course an overall ‘good thing’ given that many developed country governments are cash-strapped in this historical moment of fiscal austerity, it still needs to insured that the funding serves the true sufferers of NCDs, and is not used to simply embellish a company’s CSR portfolio to hide business practices that are at odds with the development agenda.

Private funding as a form of DAH is still a relatively novel scenario, and looking into the future, the question will be how to ensure that private sector funding is best leveraged to reach those in need at the same time as
ensuring that upstream business and policy approaches are more closely aligned with the NCD and global health goals for a healthier society.

Miriam Rabkin Replied at 11:10 AM, 19 Jun 2011

For those who are interested, there is a related conversation taking place on Karen Grepin's Global Health Blog here: http://bit.ly/jDr8Pb NB an interesting exchange on the opportunity costs of scaling up NCD services.

Kyle Peterson Replied at 10:23 AM, 20 Jun 2011

Hello, I am Kyle Peterson, Managing Director at FSG and a co-panelist for this discussion. FSG is a nonprofit consulting firm that provides strategy and evaluation services to foundations, nonprofits, companies, and governments. We were founded in 2000 and, since that time, have worked with a number of organizations on program development for NCDs in resource-limited settings.

Thanks for the opportunity to provide some thoughts to this interesting set of questions.

Q1: What are some of the financial challenges for governments and international institutions in addressing NCDs?

My fellow panelists have already articulated the main financial challenges in addressing NCDs – overall strapped budgets due to the economic downturn, fatigue with funding of infectious diseases, difficulty in even understanding the size of the problem, and most importantly, nascent knowledge in knowing what to fund to provide the greatest bang for the buck. To this last point, the fact that we are at the “beginning of the scale up” of NCD solutions must be acknowledged as a significant barrier. The situation is reminiscent of the late 1990s for HIV/AIDS when funders were unsure of the efficacy of such novel approaches as Voluntary Counseling and Testing. Thankfully, however, we are beginning to see clearer lines of argument for what can and should be funded, thanks to the work of the NCD Alliance, WHO, and various preparatory discussions for the UNGASS meeting.

Q2: What are the donors’ roles regarding NCDs, what should different types of donors be contributing, and how can advocates raise awareness about NCDs funding?

Rachel Nugent lays out a nice list of considerations for the many types of organizations that are part of the NCD solution. Rather than reprise a similar list, I’d like to call out one of the groups that has not been considered a major “funder” to global health issues – the private sector.

Any discussion of NCDs in resource limited settings in 2011 must contemplate a significant role for the private sector. Certainly, corporations will contribute philanthropically through cash and donated medicines or other gifts in kind (medical equipment) as they have done in the past for infectious diseases. But even if those numbers are similar to what we presently see from the likes of Pfizer ($300 mm in cash and $2 billion in product donations in 2009), they are a drop in the bucket to what is needed or in comparison to the bilateral and multilateral contributions. More important, a view of the private sector as a “funder” is outdated.

Regardless of the NCD burden and debate, companies are slowly but surely reassessing their engagement with society. To date, social problems, such as NCDs, have been the domain of the corporate foundation/citizenship/CSR groups with little or no connection to the fundamental strategy of the company, the staff responsible for revenue generation, or the vast network of corporate suppliers and partners. In the last decade, however, we have seen a noticeable shift to Creating Shared Value where social problems are considered business opportunities or critical costs to the firm that must be addressed. Whether viewed as an opportunity in terms of a new customer in a new market or a cost (as larger percentages of employees suffer from diabetes and require chronic care), engagement on NCDs will become important for long-term, corporate competitive advantage.

In the next five years, we will see multinational and indigenous firms reconceiving their products (whether medicines, medical technologies, or foods) to meet the needs of growing populations in places like India, where diabetes is rampant. Companies will need to adapt all aspects of their products (price, packaging, promotion, delivery) to make them more appropriate in these settings. This is a good thing in itself as the life-saving and life-improving technologies are more available in resource-limited settings. But a greater benefit will be bestowed upon the infrastructure or ecosystems in which these companies work. The private sector will have to invest in the health care and agricultural infrastructure in order to be viable players in the long run. These investments will not be motivated by “doing good” or activist complaints but rather through an understanding of what is needed to sell their products in these settings. And the investments will move away from showcase, single-company projects to more collaborative initiatives in concert with governments and bilateral/multilaterals.

This is a new day for considering the role of the private sector in NCDs – diseases that require a great deal of individual behavior change and self-administered medicines or status checks. Considering that these diseases are chronic and patient populations are exploding, we need solutions that can be scaled quickly and affordably. The private sector is not the silver bullet here but must be considered in a new way and given a seat at the table, less as a “funder” and more as a partner with other key players.

Of course, the private sector contributes to the NCD burden in many counties in particular contexts. I am not a Pollyanna for the private sector when it does harm and thus recognize the role companies play in selling tobacco products and high-fat and sugar products to people in resource-limited settings. These companies will need to take a hard look at their products in line with Creating Shared Value to ensure that they are providing more nutritious products, thereby ensuring their own long-term competitive advantage/survival. The New Yorker featured a good article that shows some positive developments and new approaches by one food company.

Q3: How might donors work with governments and health implementers to promote NCD prevention, care and treatment? What do we know and what should we know about how service integration and health system strengthening can be used to address NCDs?

NCDs will be the final trumpet blast to the slowly-building orchestration to service integration in resource-limited settings. While there is coordination momentum in terms of infectious disease, some donors have not yet digested this new world fully. The penchant for clear battle fields to prove attribution for results is still a heavy cloud that hangs over uncoordinated health care in Africa and Southeast Asia.

Rachel’s example of AMPATH integrating NCD care in a rural health care setting in Western Kenya is one that all donors and implementers should heed. Another is Partners in Health’s hospital-based care approach in Rwanda. There, HIV served as the foundation for care to patients in southeastern Rwanda. Now, the tireless workers at Butaro Hospital are using the relationships in the community and its army of community health workers to increase awareness, diagnosis, and care for NCDs, including cancers, diabetes, and CVD.

Q4: Can you share examples of integrated service delivery, health insurance schemes, or innovative partnerships that offer lessons for NCD program and funding development?

There are emerging examples, similar to the AMPATH and PIH Butaro Hospital ones mentioned above. Eli Lilly and Company is currently developing programs in four countries that will pilot new treatment models for diabetes care – all of these models will be in partnership with government and integrated within existing public or nonprofit care settings. FHI is also exploring some interesting integration ideas, screening patients for CVD and diabetes in HIV clinics in Kenya and Nigeria. I also noted a very interesting FHI project integrating cervical cancer screening with PMTCT patients at a hospital in Nigeria.

Here’s a development that bodes well for integration, again, focusing on the private sector: about two weeks ago, the Global Business Coalition on HIV, TB, and Malaria expanded its remit to include NCDs. The newly named GBCHealth has a membership of hundreds of multinationals including the likes of Coca Cola, Abbott Labs, and Chevron and will advocate for Shared Value approaches that coordinate action on both infectious diseases and NCDs.

Miriam Rabkin Replied at 12:09 PM, 20 Jun 2011

The topic of integration and implementation seems to be of interest, so although it is not directly relevant to questions around funding, I will add a link to last week's GHD panel on leveraging HIV programs to support NCD services:
http://www.globalhealth.org/conference_2011/presentations/432

Brian Bilchik Replied at 4:18 PM, 22 Jun 2011

This has been an important discussion, with some great input. I am learning a lot. David Bloom and Rachel Nugent’s research on the disparities between NCD disease burden, economic impact, and funding brings up some important questions. With such strong data, it is “stunning” that decision-makers aren’t addressing it in large, meaningful ways. This begs the question: Is the data not believable? Or is the data not well known? Or are their hands tied with other economic/fiscal realities that they choose to ignore it?

Re: Integration; I think part of the issue is that the healthcare community has created strong silos separating NCDs and infectious disease. Are these not somewhat artificial and counter-productive? There is a mindset that there needs to be separate infrastructures to support both infectious diseases and NCDs.

Surely we need to look at better ways to collaborate with the existing infrastructure that infectious disease has created. The public and governments look at healthcare as one big bucket. Yet we are vying for more than the 3% of the dollars allocated for ID’s.How can you convince donors that more funding is needed for health issues when there’s internal conflict? Shweta Khandelwal’s recollection of Dr. Reddy’s opinion that “all ministers should be health ministers” is apt.

At ProCor, we’re idealistic health communicators. When we look at the big picture, we often wonder, “Why is there this inherent competitiveness between diseases that is detrimental to the overall health outcome?” When it comes to working together, the NCD community’s messaging needs to be consistent, clear, and bold, we are and will be at the table. As a community we cannot afford to be inconsistent with our data, messaging, and approach.

Sarah Arnquist Replied at 10:21 AM, 23 Jun 2011

Thanks to everyone who has contributed so far to this discussion. It would be great to have some wrap-up comments and also for anyone to contribute lingering questions.

In the meantime, here is a list of readings related to this question about how to finance prevention and treatment for NCDs.

Recommended Reading:

Rachel Nugent and Andrea B. Feigl. Where Have All the Donors Gone? Scarce Donor Funding for Non-Communicable Diseases Working Paper 228. November 2010 http://bit.ly/bnfFzJ

J. Stephen Morrison, Devi Sridhar, Peter Piot. Getting the Politics Right for the September 2011 UN High-Level Meeting on Noncommunicable Diseases. Center for Strategic & International Studies, Global Health Policy Center. February 2011 http://bit.ly/hdZHlw

Christopher JL Murray et al. Development assistance for health: trends and prospects. The Lancet, Early Online Publication, 11 April 2011. http://bit.ly/jKALs2

Prof Robert Beaglehole DSc et al. Priority actions for the non-communicable disease crisis. The Lancet, Volume 377, Issue 9775, Pages 1438 - 1447, 23 April 2011 http://bit.ly/fCFSnk

Dr Badara Samb MD et al. Prevention and management of chronic disease: a litmus test for health-systems strengthening in low-income and middle-income countries. The Lancet, Volume 376, Issue 9754, Pages 1785 - 1797, 20 November 2010 http://bit.ly/eAcfXm

Miriam Rabkin and Wafaa M. El-Sadr. Why re-invent the wheel? Leveraging the lessons of HIV scale-up to confront non-communicable diseases. Global Public Health. Vol. 6, No. 3, April 2011, 247 256. http://bit.ly/jmAW5i

World Health Organization. Global status report on noncommunicable diseases 2010. May 2011 http://bit.ly/kLCGoR

64th World Health Assembly Resolution on NCDs (Item 13.12) http://bit.ly/jgFt6x

Sarah Boseley's Global Health Blog. Heart disease and cancer - the global threat omitted from the MDGs. The Guardian. April 6, 2011 http://bit.ly/fjhqsn

Global Health Initiative, National Heart and Blood Institute, National Institutes if Health http://www.nhlbi.nih.gov/about/globalhealth/

Attached resource:
  • Reading Materials related to Financing NCD (download, 28.5 KB)

    Summary: Thanks to everyone who has contributed so far to this discussion. It would be great to have some wrap-up comments and also for anyone to contribute lingering questions.

    In the meantime, here is a list of readings related to this question about how to finance prevention and treatment for NCDs.

    Recommended Reading:

    Rachel Nugent and Andrea B. Feigl. Where Have All the Donors Gone? Scarce Donor Funding for Non-Communicable Diseases Working Paper 228. November 2010 http://bit.ly/bnfFzJ

    J. Stephen Morrison, Devi Sridhar, Peter Piot. Getting the Politics Right for the September 2011 UN High-Level Meeting on Noncommunicable Diseases. Center for Strategic & International Studies, Global Health Policy Center. February 2011 http://bit.ly/hdZHlw

    Christopher JL Murray et al. Development assistance for health: trends and prospects. The Lancet, Early Online Publication, 11 April 2011. http://bit.ly/jKALs2

    Prof Robert Beaglehole DSc et al. Priority actions for the non-communicable disease crisis. The Lancet, Volume 377, Issue 9775, Pages 1438 - 1447, 23 April 2011 http://bit.ly/fCFSnk

    Dr Badara Samb MD et al. Prevention and management of chronic disease: a litmus test for health-systems strengthening in low-income and middle-income countries. The Lancet, Volume 376, Issue 9754, Pages 1785 - 1797, 20 November 2010 http://bit.ly/eAcfXm

    Miriam Rabkin and Wafaa M. El-Sadr. Why re-invent the wheel? Leveraging the lessons of HIV scale-up to confront non-communicable diseases. Global Public Health. Vol. 6, No. 3, April 2011, 247 256. http://bit.ly/jmAW5i

    World Health Organization. Global status report on noncommunicable diseases 2010. May 2011 http://bit.ly/kLCGoR

    64th World Health Assembly Resolution on NCDs (Item 13.12) http://bit.ly/jgFt6x

    Sarah Boseley's Global Health Blog. Heart disease and cancer - the global threat omitted from the MDGs. The Guardian. April 6, 2011 http://bit.ly/fjhqsn

    Global Health Initiative, National Heart and Blood Institute, National Institutes if Health http://www.nhlbi.nih.gov/about/globalhealth/

    Source: Global Health Delivery Project

    Keywords: donors, financing, health system integration

Sarah Arnquist Replied at 4:12 PM, 9 Aug 2011

We've summarized this great discussion into a brief with key points and useful resources related to financing NCDs. Hopefully, you'll find this document helpful leading up to the UN NCD Summit next month.

The discussion brief is now listed alongside this discussion, but for convenience, here is the link. http://www.ghdonline.org/ncd/discussion/ghdonline-expert-panel-funding-challe...

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