Healthcare Getting It Right : Noncommunicable Disease (NCD)

The world is taking on noncommunicable disease (NCD), and we’re getting this right. Successful local, national and global attention to NCD should be valued.

Extended until 2030, the WHO Global Action Plan for NCD remains the primary document to steer course [1,2]. The plan is efficient, thorough and precise. WHO updates on each country’s adoption of the measures [3] and global NCD department focus [4] are complimentary.

· Opportunities to advance this plan forward should begin by examining the past decade. The NCD Global Action Plan has been available since 2013. Identification of a decade of epidemiological gaps could assist. Epidemiology should assure consistency, accuracy and timeliness of the indicator data for all 194 (or so) countries participating. Epidemiology should address survey bias, particularly with lifestyle issues like drugs and alcohol. A strategic movement that finances and trains epidemiological support for epidemiological integrity would be awesome. Streamlined data details could be incorporated into progress reports [5] or toolkits [6]. This could be supported by the CDC’s Division of Global Health Protection NCD group [7], the NIH or the HHS Office of Global Affairs.

· Opportunities to define NCD should be taken. Nonprofits, philanthropists, researchers, medicine and global health attention to NCD is collegial and sincere. Therefore, streamlined NCD definition and categories is very achievable. NCD categories and “other” categories do not align worldwide. Mental health and “other” NCDs are not included in the original 4 WHO categories yet could be incorporated moving forward. A literature review and nonprofit review could easily tell us common categories, as well as how and why researchers in medicine are frequently misaligned. Examination of epidemiological disorganization that has persisted is an opportunity to get the next decade right.

· Opportunities to clarify prioritization and methodology of the goals should be taken. There are many NCD indicators asking for improvement and often there isn’t enough resource to prioritize it all. What is the methodology to prioritize? NCD leadership is capable and can be tasked to response. Confidence should be handed to a global team to get the prioritization methodology straight.

· Opportunities to clarify disability within the NCD realm should begin. If four behaviors contribute most to NCDs, are these considered the four targets for the WHO NCD disability strategy? Or are other disability causes (trauma, injury) included? [4]. This clarification is achievable and necessary, particularly as disability remains a WHO 12 Signature Solution for NCD yet is less visible in the Plan.

· Opportunities to enhance the NCD policy recommendations are clear. The detailed policy options are a strength of the Global Action Plan. Methodology to weigh policy decisions, including pragmatic designs of research, were not included [8]. Methodology to evaluate policies, conduct research or compare a country’s portfolio of regulations and policies could be offered. This could be a responsibility of the technical advisory group [9]. National or regional changes after the 2013 plan call for policy evaluations, and evaluations should be conducted.

· Opportunities to align NCD paths in global health are present because of the incredible interest. Alignment between the Global Action Plan and the WHO’s 12 Signature Solutions for NCD should be clearer[4].

Global health public messaging around NCD is clear. National leadership support is strong. Investment advantages and direct statements on investing in noncommunicable disease (NCD) care are easy to understand [10]. With excellence, continued support is warranted. Here are some ways we could support:

· Messaging NCD work requires commitment to the structure of NCDs. Definition, analysis of NCDs across common medical divisions and differentiation between behavioral/lifestyle factors and the actual diseases are important. Messaging also requires commitment to the methodology used. What are the formulas that assist with directing actions? How are burden and cost estimated based on action or policy? There’s already been great work on this, and a focused answer is achievable.

· NCD prevention and treatment success requires public inclusion, so the public should be able to understand the goals and results. For example, access to care and reduction of tobacco use have been named as the primary reason for a 15% decrease in premature death due to NCD globally between 2000-2012[11]. Since the 2013 plan was adopted, what are the primary reasons for any decrease in premature death or increase in NCD incidence and prevalence? Which policies have countries adopted that have contributed?

· Methodology to accept public perception and public behavior must be factored into NCD work. How do the public’s individualities and preferences fit into healthcare leadership plans? How does the public view for-profit contributors (tobacco, saturated fats, alcohol) alongside health quality of life? There must be space for free choice and liberty. People are going to live lives with some satisfaction, and some unhealthy behavior, and healthcare’s acceptance of flexibility should start with NCD risk behavior work.

· Crossover actions between UN departments is messaged really, really well in the Global Action Plan. This is refreshing to see, and countries could model similar structure in individual gameplans. Shared interests and crossover work could be written out, as well. Expectations of wording and focus alignment should be set.

· Medical expertise should be aligned for countries without many health resources. Resource-strapped countries have been given a minimum standard for addressing NCD. The WHO manual is outstanding and clear [12]. It would be helpful to have leading expert societies acknowledge review of the content. It would also be helpful to spell out what the minimum labor, education and credentialing requirements should be for the tasks. Training and certification navigation could be part of the content, especially for countries needing assistance. Medical missions and charitable medical trips should be held to the basic minimums.

· NCD case studies and emergency assistance, highlighted through WHO [13], show the diversity of the work. Global health has gotten this detailed focus right.

· Publishers continue to focus on NCD innovation, and this commitment is commendable. The acronym NCD (as opposed to NCCD or other created ones) [14] could be standardized.

US national work on NCD is a focus of almost all major health organizations, and the work falls under many divisions. NCD work crosses acute care delivery, long term care, public health, industry, and government. Though NCD burden differs in the United States, NCD is a burden. Despite a Division of Global Health with a commitment to NCD, there remains no visible alignment between US national NCD work, PAHO/regional work [15] and the WHO Plan. Opportunities for the US to model NCD are only available because of the fantastic efforts already underway. These opportunities include:

· Separating NCD as a topic [16]

· Creating NCD as a CDC or public health topic site, or linking NCD sites, alongside a gameplan

· Commitment to the definitions of NCD or additions to WHO definition

· Visible alignment with WHO data asks online, including how the data was obtained

· Methodology and epidemiology clarity

· Policy and regulation crosswalks

· Labor, credentialing, education and training explanations

· Improved public health, outpatient and hospital data alignment

· Coordination between nonprofits, academia, hospital associations, public health, quality accreditation and pharmaceutical players. The coordination should center on actions and interventions to tackle US NCD goals

· Clearer rehabilitation and disability gameplans, as a collegial model to the WHO and UN efforts [4]

· Improved primary care delivery to address healthy nutrition and physical fitness.

· Improved accountability around healthy eating and physical fitness in adolescent populations.

· Improved accountability to vision and dental as components to medical care, not separated simply because some insurance company says so.

Military and VA NCD efforts mirror national efforts; efforts to improve patient health, address cost effectiveness and seek evidence basis are commendable. NCD work is multidisciplinary and separated by divisions (cardiovascular, respiratory, wellness, substance abuse, etc). Opportunities to improve NCD work for military and veteran populations are available because of the commendable work. These opportunities also mirror national efforts and include:

· Methodology consensus on NCD burden, costs associated with care, out of pocket expenses, costs associated to employers, rehabilitation and disability costs, and unpaid caregiver resource allocation estimates. Research and analyses on VA and military-related NCDs have been conducted for decades. It is time to make decisions on how we are estimating costs and allocating funding, and it’s beyond time to include non-VA user veteran populations in the methodology. Inclusion shouldn’t be an afterthought, it should be an expectation.

· Decisions on cost and funding assessment intervals. If weight-related NCDs cost the military over $1 billion in 2007 [17] how have the past two decades responded? How long should we anticipate validating or adopting methodology, and what are the NCD assessment intervals we should expect?

· Transparency around NCD budgets and expenditures between contracted civilian, MHS and VA healthcare.

· Transparency, beyond research publication, around NCD as it relates to international military alliances [18].

· Transparency with regulatory, accreditation and financial standardization across military and civilian health organizations.

· Streamlined definitions, alignment and data on NCDs.

· Consensus on application of NCD terminology. NCD may not even be terminology in NCD-related military research [19], and the question of relevance should be brought up. Importantly, reliance on divisions within departments does not always differentiate between infectious and non-infectious. For example, the research and services at the VA’s respiratory health division do not refer to NCD, and we are left without a clear picture of chronic respiratory NCD and infectious respiratory conditions [20]

· Incorporation of caregiver health and research into NCD work. NCD burdens and suboptimal care can be avoided or mitigated for caregivers and families. Many veterans and military members are caregivers beyond their work. Shouldering extra responsibilities, such as deployment, shouldn’t disrupt optimal NCD care.

· Emphasis on organizing evidence synthesis of the thousands of research studies that address NCDs, from biological research to behavioral interventions like medication adherence to rehabilitation. Veterans and the VA are a large part of these small studies, and efficiency to medical research respects their contribution.

· Emphasis on organizing the research portfolio, including continued support on interventions for health behaviors and a more coordinated research structure (as opposed to piecemeal, philanthropic or small study selections).

· Continued support with military and civilian comparison work [21].

· Methodology to assess what it would take to adopt expert recommendation on substance abuse interventions [22], and methodology that includes civilian healthcare responsibilities to this adoption. If alcohol and tobacco are two of the four major behavioral factors with NCDs, and mental health a component to NCD, why wouldn’t recommendation implementation be a priority?

The US healthcare system collaborates well with military and veteran partnerships for cancer research and treatment. Trial innovation, prevention efforts, access to care, caregiver support and all other efforts should set the bar for military-civilian healthcare and research coordination. The US healthcare system can and should do more to partner with military and VA work to lead NCD structure.

· Public health could examine gaps between base and non-base data aggregation and jurisdiction, for example. NCD risk behaviors and metabolic/physical changes [23] could be better understood across military and civilian populations. Fresh produce availability, healthy food choices, food deserts and access to physical fitness could be better measured for military and civilian populations.

· With the metrics already available, health leadership could be held accountable to interventions and policy improvements. Public health and other government agencies could seek military and veteran leadership to address the disability component of NCD [4].

· CDC support with military readiness [24] could also grow, with a focus on personalized prevention work related to NCD-related risk or a focus on population work related to nutrition and physical fitness before recruitment.

· Care coordination across civilian and military healthcare could target transition support, with NCD-related efforts a primary focus.

· Durable medical equipment, transportation, housing and other factors could see a national plan of inclusion. Adding these as indicators to health quality of life, or adding these as components to primary care or acute care assessments and treatment plans, could be targeted in relation to NCD-related work.

References

1. https://www.who.int/publications/i/item/9789241506236

2. https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases#cms

3. https://www.who.int/news/item/12-05-2022-new-report-shows-progress-and-missed-opportunities-in-the-control-of-ncds-at-the-national-level

4. https://www.who.int/teams/noncommunicable-diseases/about

5. https://www.who.int/publications/i/item/9789240047761

6. https://www.who.int/publications/i/item/9789240043596

7. https://www.cdc.gov/globalhealth/healthprotection/resources/fact-sheets/global-ncd-fact-sheet.html

8. https://www.who.int/initiatives/global-noncommunicable-diseases-compact-2020-2030/achievements

9. https://www.who.int/publications/i/item/9789240050082

10. https://www.who.int/initiatives/global-noncommunicable-diseases-compact-2020-2030

11. https://www.who.int/data/gho/publications/mdgs-sdgs