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Review
. 2020 Oct 3;396(10256):991-1044.
doi: 10.1016/S0140-6736(20)31907-3. Epub 2020 Sep 14.

The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion

Gene Bukhman  1 , Ana O Mocumbi  2 , Rifat Atun  3 , Anne E Becker  4 , Zulfiqar Bhutta  5 , Agnes Binagwaho  6 , Chelsea Clinton  7 , Matthew M Coates  8 , Katie Dain  9 , Majid Ezzati  10 , Gary Gottlieb  11 , Indrani Gupta  12 , Neil Gupta  13 , Adnan A Hyder  14 , Yogesh Jain  15 , Margaret E Kruk  3 , Julie Makani  16 , Andrew Marx  17 , J Jaime Miranda  18 , Ole F Norheim  19 , Rachel Nugent  20 , Nobhojit Roy  21 , Cristina Stefan  22 , Lee Wallis  23 , Bongani Mayosi  24 ; Lancet NCDI Poverty Commission Study Group
Collaborators, Affiliations
Review

The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion

Gene Bukhman et al. Lancet. .
No abstract available

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Figures

Figure 1
Figure 1
Visualising NCDI Poverty The circle areas are drawn precisely to be proportional to the number of DALYs associated with each group of conditions globally. NCDI Poverty includes DALYs among the world's poorest billion people due to all causes of NCDIs. The area where the circles overlap represents the NCDI burden among the poorest billion that is due to the 4 × 4 NCD conditions, mental and substance use disorders, and road traffic injuries. The circle areas within the dotted line represent the total number of DALYs among the poorest billion. Original analysis using data from the Global Burden of Disease 2017. SDG=Sustainable Development Goal. NCD=non-communicable disease. NCDI=non-communicable disease and injury. MDG=Millenium Development Goal. DALY=disability-adjusted life year. *WHO 4 × 4 Global NCD Action Plan agenda includes cardiovascular disease, neoplasms, diabetes, and chronic respiratory disease.
Figure 2
Figure 2
Geographical distribution of the poorest billion in 2017 Country size drawn in proportion to the number of people living with five or more of eight non-health indicators of deprivation. Original analysis using data from the most recent household surveys up to 2017.
Figure 3
Figure 3
Importance of NCDI disease burden for the poorest billion versus higher-income populations NCD=non-communicable disease. DALY=disability-adjusted life-year. YLD=years of life with disability. YLL=years of life lost. HIC=high-income countries. UMIC=upper-middle-income countries. LMIC=lower-middle-income countries. LIC=low-income countries. PB=poorest billion. NCDI=non-communicable disease and injury.
Figure 4
Figure 4
Causes of mortality by SES deprivation groups at selected INDEPTH health and demographic surveillance system sites Groups are defined by the number of deprivations as per the eight indicators of living standards and education: 0–2=fewest deprivations and 5–8=poorest billion globally. Age and sex were standardised using the INDEPTH network 2013 population standards for sub-Saharan Africa. Education indicators were unavailable for Manhiça, and deprivations from this site were reported out of six total indicators. Original analysis using data up to 2016 from sites in the INDEPTH network., SES=socioeconomic status.
Figure 5
Figure 5
Age-specific pattern of NCDI disease burden among the poorest billion Original analysis using data from Global Burden of Disease 2017. (A) NCDI YLL and YLD rates among the poorest billion. (B) NCDI YLLs and YLDs among the poorest billion. (C) NCDI DALYs in those aged younger and older than 40 years among the poorest billion; 49·5% of DALYs occur before the age of 40 years. NCD=non-communicable disease. YLD=years lived with disability. YLL=years of life lost. DALYs=disability-adjusted life-years. NCDIs=non-communicable disease and injuries. *Other congenital birth defects include neural tube defects, orofacial clefts, Down syndrome, congenital musculoskeletal and limb anomalies, digestive congenital anomalies, and other birth defects. †Other NCDs include cirrhosis and other liver diseases, chronic kidney disease, other abdominal and digestive disorders, other urogenital, blood and endocrine diseases, skin and subcutaneous diseases, and oral disorders. ‡Other injuries include unintentional injuries self-harm and interpersonal violence, other transport injuries, and forces of nature, conflict and terrorism, and executions and police conflict.
Figure 6
Figure 6
Avoidable NCDI disease burden among the poorest billion Original analysis using data from Global Burden of Disease 2017. (A) Age-specific avoidable NCDI DALY rates among the poorest billion. (B) Age-specific avoidable NCDI DALYs among the poorest billion. (C) Avoidable NCDI DALYs in those younger and older than 40 years among the poorest billion; 52% of avoidable DALYs occur before the age of 40 years. NCD=non-communicable disease. DALYs=disease-adjusted life-years. NCDI=non-communicable disease and injury. *Other congenital birth defects include neural tube defects, orofacial clefts, Down syndrome, congenital musculoskeletal and limb anomalies, digestive congenital anomalies, and other birth defects. †Other NCDs include cirrhosis and other liver diseases, chronic kidney disease, other abdominal and digestive disorders, other urogenital, blood and endocrine diseases, skin and subcutaneous diseases, and oral disorders. ‡Other injuries include unintentional injuries self-harm and interpersonal violence, other transport injuries, and forces of nature, conflict and terrorism, and executions and police conflict.
Figure 7
Figure 7
Avoidable NCDI burden among the poorest billion, DALYs attributable or unattributable to GMF risk factors* or air pollution, by age Original analysis using data from Global Burden of Disease 2017. (A) Age-specific avoidable NCDI DALY rates among the poorest billion. (B) Age-specific avoidable DALYs among the poorest billion. (C) Avoidable NCDI DALYs in those aged younger and older than 40 years among the poorest billion; 90% of attributable avoidable DALYs occur after the age of 40 years and 68% of unattributable avoidable DALYs occur before the age of 40 years. GMF=global monitoring framework. NCD=non-communicable disease. DALYs=disease-adjusted life-years. NCDI=non-communicable disease and injury. *GMF risk factors include alcohol consumption, physical inactivity, sodium consumption, tobacco use, raised blood pressure, high blood glucose, overweight and obesity, diets high in trans fats, high cholesterol, and diets low in fruits and vegetables. †Other congenital birth defects include neural tube defects, orofacial clefts, Down syndrome, congenital musculoskeletal and limb anomalies, digestive congenital anomalies, and other birth defects. ‡Other NCDs include cirrhosis and other liver diseases, chronic kidney disease, other abdominal and digestive disorders, other urogenital, blood and endocrine diseases, skin and subcutaneous diseases, and oral disorders. §Other injuries include unintentional injuries self-harm and interpersonal violence, other transport injuries, and forces of nature, conflict and terrorism, and executions and police conflict.
Figure 8
Figure 8
NCDI health loss and incidence among the poorest billion: years of healthy life lost versus incidence by condition Original analysis using data from Global Burden of Disease 2017. The blue rectangle encompasses less common conditions (<1000 per 100 000 incidence) resulting in greater health loss (≥15 years of healthy life lost). NCDI=non-communicable disease and injury.
Figure 9
Figure 9
Health sector NCDI interventions scored for cost-effectiveness and equity Cost-effectiveness data from the Disease Control Priorities 3rd edition (volume 9) with additional equity analysis by this Commission. All interventions are identified and described in more detail in the appendix (pp 64–88). NCD=non-communicable disease. ACEi=angiotensin-converting enzyme inhibitors. RHD=rheumatic heart disease.
Figure 10
Figure 10
Number of equitable and cost-effective interventions by level of health system health centres Calculations based on data from Disease Control Priorities 3rd edition. Includes conditions ranked 4 on equity and either 4 or 3 on cost effectiveness. NCDI=non-communicable disease and injury.
Figure 11
Figure 11
Illustrative integrated care teams for NCDIs within existing service delivery platforms ICT=integrated care team. NCDs=non-communicable diseases. NCDIs=non-communicable diseases and injuries.
Figure 12
Figure 12
National NCDI Poverty Commission health-sector intervention priorities converge on a smaller set of integrated care teams NCDI=non-communicable disease and injury. ICT=integrated care team. COPD=chronic obstructive pulmonary disease. VIA= visual inspection with acetic acid. NCD=non-communicable disease. RHD=rheumatic heart disease. *Includes interventions that were prioritised by at least 5 of the 6 national NCDI Poverty Commissions that had completed the priority-setting phase of their analyses as of Sept 10, 2019. †Includes interventions that were graded as 3 or 4 (on a 4-point scale) for both equity and cost-effectiveness as well as those that were graded 3 or 4 for equity for which cost effectiveness was not applicable (eg, palliative care).
Figure 13
Figure 13
Sources for health financing in the poorest billion countries: government health expenditures, development assistance for health, and out-of-pocket expenditures Countries are ordered from left to right within the income groups by ascending national per capita gross domestic product. Data are from the WHO Global Health Expenditure Database. UHC=universal health coverage. NCDs=non-communicable diseases. *Estimates for 52 poorest billion countries (27 low-income countries and 25 lower-middle-income countries) for which data are available; poorest billion countries are characterised by having at least one sub-national region where over 25% of the population are deprived of five or more of the eight non-health, multi-dimensional poverty indicators. †Essential UHC consists of interventions included in a model benefits package defined by the Disease Control Priorities Network as essential for achieving UHC and appropriate to the health needs and constraints of lower-middle-income countries. ‡US$ currency based on the 2017 exchange rate.
Figure 14
Figure 14
Domestic government spending on NCDIs in low-income and middle-income countries. USD$ per capita and percentage of general government expenditure on health*. The countries in red are the poorest billion counties. Data are from the WHO Global Health Expenditure Database. LIC=low-income country. LMIC=lower-middle income country. UMIC=upper-middle-income country. NCDI=non-communicable disease and injury. NCD=non-communicable disease. *36 low-income and middle-income countries for which National Health Account data at WHO Global Health Expenditure Database include spending on NCDIs.
Figure 15
Figure 15
DAH going to poorest billion countries versus other countries by condition, 1990–2016 Data are from Institute for Health Metrics and Evaluation. (A) DAH to the poorest billion and other countries by condition (1990–2016). (B) Share of DAH going to the poorest billion countries by condition (2000–16). DAH=Development Assistance for Health. NCDs=non-communicable diseases. *US$ currency based on the 2017 exchange rate.
Figure 16
Figure 16
Projected health financing capacity* versus essential EUHC† costs in the poorest billion countries, 2017–30 Data are from Global Health Expenditure Database, Overseas Development Institute, and World Bank. GDP=gross domestic product. EUHC=essential universal health coverage. UHC=universal health coverage. *Baseline includes government health financing plus external health financing. Projection includes constant external health financing. Government health financing increases as a function of GDP growth and linear increases up to potential additional revenue generation and to government expenditure on health of 15% of revenue. All estimates are based on 2017 GDP and current US dollars. †EUHC consists of interventions included in a model benefits package defined by the Disease Control Priorities Network as essential for achieving UHC and appropriate to the health needs and constraints of low-income and lower-middle-income countries. ‡Estimates for 52 poorest billion countries (27 lower-income countries and 25 lower-middle-income countries) for which data are available. The poorest billion countries are characterised by having at least one sub- national region where over 25% of the population are deprived of five or more of eight non-health, multi-dimensional poverty indicators.
Figure 17
Figure 17
NCDs and the poorest billion on two separate tracks (1948–2015) UHC=universal health coverage. SDGs=sustainable development goals. WHO EURO=WHO Regional Office for Europe. HICs=high-income countries. LMICs=low and middle income countries. NCDs=non-communicable diseases.
Figure 18
Figure 18
NCDI framing and population focus of global institutions Each circle represents one of the 35 organisations included in the policy review. Representative quotations from selected organisations are presented in this figure. A full list of organisations included, and documents reviewed is presented in the appendix (pp 110–16). LMICs=low and middle income countries. NCD=non-communicable disease. NCDIs=non-communicable disease and injury. SEARO=WHO Regional Office for South East Asia. AFRO=WHO Regional Office for Africa. GIZ=German Development Agency; Deutsche Gesellschaft für Internationale Zusammenarbeit.
Figure 19
Figure 19
National NCD Poverty Commission process This diagram depicts the conceptual and analytic framework for the work of National NCDI Poverty Commissions and Groups. The blue boxes represent processes while all the other boxes represent inputs and outputs. The dotted boxes indicate inputs that are being developed and tested. The dashed boxes indicate processes that are being developed and tested. Each Commission and Group adapts and implements the process to align with local conditions, needs, and available resources. As of August, 2020, 11 commissions have completed phase 1A of the process, nine have completed both phases 1A and 1B, and seven have published and launched reports presenting their phase 1 findings and recommendations. Three Commissions have initiated phase 2 activities. NCDI=non-communicable disease and injury. UHC=universal health coverage. HRH=human resources for health. GDP=gross domestic product. DAH=Development Assistance for Health. HR=human resources.
Figure 20
Figure 20
Global Action Plan best buys and prioritised interventions of National NCDI Poverty Commissions: a complementary agenda HPV=human papillomavirus. COPD=chronic obstructive pulmonary disease ACEi=angiotensin converting enzyme inhibitors.
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References

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