Series www.thelancet.com Vol 376 November 20, 2010 1785 Lancet 2010; 376: 1785–97 Published Online November 11, 2010 DOI:10.1016/S0140- 6736(10)61353-0 See Comment Lancet 2010; 376: 1619–21 See Online/Comment DOI:10.1016/S0140- 6736(10)61856-9, and DOI:10.1016/S0140- 6736(10)61891-0 This is the fourth in a Series of five papers about chronic diseases World Health Organization, Geneva, Switzerland (B Samb MD, S Mendis MD, F Celletti MD, T Evans MD, A Alwan MD, C Etienne MD); Consultant, Public Health, Chronic Diseases: Chronic Diseases and Development 4 Prevention and management of chronic disease: a litmus test for health-systems strengthening in low-income and middle-income countries Badara Samb, Nina Desai, Sania Nishtar, Shanti Mendis, Henk Bekedam, Anna Wright, Justine Hsu, Alexandra Martiniuk, Francesca Celletti, Kiran Patel, Fiona Adshead, Martin McKee, Tim Evans, Ala Alwan, Carissa Etienne National health systems need strengthening if they are to meet the growing challenge of chronic diseases in low- income and middle-income countries. By application of an accepted health-systems framework to the evidence, we report that the factors that limit countries’ capacity to implement proven strategies for chronic diseases relate to the way in which health systems are designed and function. Substantial constraints are apparent across each of the six key health-systems components of health financing, governance, health workforce, health information, medical products and technologies, and health-service delivery. These constraints have become more evident as development partners have accelerated efforts to respond to HIV, tuberculosis, malaria, and vaccine-preventable diseases. A new global agenda for health-systems strengthening is arising from the urgent need to scale up and sustain these priority interventions. Most chronic diseases are neglected in this dialogue about health systems, despite the fact that non- communicable diseases (most of which are chronic) will account for 69% of all global deaths by 2030 with 80% of these deaths in low-income and middle-income countries. At the same time, advocates for action against chronic diseases are not paying enough attention to health systems as part of an effective response. Efforts to scale up interventions for management of common chronic diseases in these countries tend to focus on one disease and its causes, and are often fragmented and vertical. Evidence is emerging that chronic disease interventions could contribute to strengthening the capacity of health systems to deliver a comprehensive range of services—provided that such investments are planned to include these broad objectives. Because effective chronic disease programmes are highly dependent on well-functioning national health systems, chronic diseases should be a litmus test for health-systems strengthening. Introduction The burden of disease attributable to chronic disorders, such as cardiovascular disease, diabetes, cancers, and respiratory disease, is higher in low-income and middle- income countries than it is in high-income countries, and continues to rise. 1 Non-communicable diseases (most of which are chronic) will account for 69% of all global deaths by 2030 with 80% of these deaths in these countries. 2 This mirrors the globalisation of risk factors such as tobacco, the combination of increased calorie intake and reduced exercise, and the ageing of populations. 3–5 The chronic characteristics of non-communicable diseases contrast with the predominantly acute nature of infectious diseases (although inevitably there are exceptions, such as HIV, tuberculosis, and leprosy). Chronic illness demands a complex health-systems response that needs to be sustained across a continuum of care. Evidence-based interventions should be delivered by health professionals with diverse skills. Appropriate technologies, dependable pharmaceutical supplies, and clean, accessible health facilities need to be brought together over a sustained period. These efforts should also be complemented by effective public policies to tackle major risk factors. Such inter- ventions are possible only with a functioning health system, which can deliver disease prevention and Key messages • Many cost-effective interventions exist to address the growing burden of chronic diseases in low-income and middle-income countries; however, weak national health systems often make it impossible to deliver and sustain interventions effectively and equitably. • Constraints on the capacity of countries to respond to the challenge of chronic diseases exist across each of the six key health-systems components of health financing, governance, health workforce, health information, medical products and technologies, and health service delivery. • Efforts to scale-up interventions for chronic diseases in low-income and middle-income countries tend to focus on one disease and its causes, and are often fragmented and vertical. These efforts represent missed opportunities to leverage the health-system reforms that are needed. • Global dialogue about health-systems strengthening neglects most chronic diseases. • Advocates for action on chronic diseases are not paying enough attention to the interface between chronic disease responses and health systems. Increased focus and understanding on the dimensions of health systems is needed if countries are to address the challenge of chronic diseases. • Interventions for responding to chronic diseases can lead to overall improvements in health systems in low-income and middle-income countries, provided that such investments are planned to include these broad objectives from the outset. • Chronic disease interventions depend on well-functioning national health systems since long-term coordinated and intersectoral responses are needed across a continuum of care. Reduction of mortality and morbidity that is associated with chronic diseases will be an important measure for assessment of efforts to strengthen health systems.