The views expressed are those of the author and do not necessarily reflect the position of FORESIGHT Global Health.
Healthcare systems need to be prepared for a broad array of population requirements. Resource-rich High-Income Countries (HICs) generally have the spectrum of expertise needed. However, the COVID-19 pandemic showed that even rich countries need to divert resources for an infectious disease, depleting resources from routine care and worsening outcomes for non-communicable diseases (NCDs). The situation is far more dire in low- and middle-income countries (LMICs).
While the pandemic has highlighted the dangers of infectious diseases (IDs), a slow-motion catastrophe is taking place in LMICs as the burden of NCDs – cardiovascular, respiratory, oncologic and metabolic diseases – comes to equal or eventually surpass that of IDs. According to the World Health Organization (WHO), disability-adjusted life-years for NCDs represented twice the global burden of disease of “communicable, maternal, perinatal and nutritional conditions” in 2016. Yet, the Institute for Health Metrics and Evaluation in 2017 indicated that NCDs receive only a single-digit percentage of health-related development assistance.
Because of their slow and noncommunicable spread, NCDs may evoke a lower sense of urgency. Yet they place a large burden on healthcare systems struggling with providing other care, including preparing for and responding to pandemics, large-scale natural disasters (hurricanes and earthquakes) and industrial/intentional threat agents that can cause very large “no-notice” casualties (terrorist attacks or events such as the Beirut ammonium nitrate blast, the Fukushima Daiichi nuclear disaster or the Bhopal gas tragedy). Globalization of trade and travel can also produce an international crisis in which access to healthcare is no longer a local or national issue. Moreover, as seen with the COVID-19 outbreak, healthcare strongly depends on international global supply chains that can be broken in crises.
MAKING HEALTH SYSTEMS MORE ROBUST
The International Cancer Expert Corps (ICEC) was established to address cancer and the lack of cancer care in LMICs and geographically isolated regions in HICs. While prevention is certainly an important approach to cancer, appropriately addressing cancers in LMICs requires the complete spectrum of cancer care from prevention to proper diagnosis to treatment to supportive and palliative care. Radiation therapy is particularly important given its critical role in both curative and palliative cancer care, even more so given that many LMICs lack opioids and other painkillers available in richer countries. Access to such radiation therapy can be sparse to none; for example, while in the United Kingdom there is one linear accelerator treatment machine for about 200,000 people, in Uganda 48 million people must share one machine—nearly 200 times the number of people per machine. That far exceeds the 250,000 people per machine that is recommended by the International Atomic Energy Agency (IAEA). Even worse, nearly half the countries in Africa lack a single machine.
From our experience in healthcare systems, provision of care in urban and rural settings in HICs, work with partners in LMICs, and disaster preparedness and response, we have proposed an approach called flex-competence. Its essence is the construction of a multi-purpose healthcare system from the outset, with the organizational capacity and expertise to adapt to the predictable needs such as essential maternal, child, general healthcare and disease prevention. Such an approach would also permit the more complex management of IDs and NCDs, while building in flexibility to rapidly address a surge from a pandemic, natural disaster, industrial or terrorist incident. The ability to rapidly rebalance is built in from the ground up within a center or region, such that as the system matures it has the breadth it needs to serve all the illnesses encountered and has the systems and supply chains in place for a sudden and large surge.
BUILDING A MORE INTEGRATED HEALTH SYSTEM
The convergence of managing IDs and NCDs would recognise the fact that the two types of diseases can share similar causes. For example, infectious diseases are linked to some cancers; e.g., viral hepatitis is linked with liver cancer, and human papilloma virus with cervical and head and neck cancers. Environmental factors such as pollution can cause both respiratory diseases and lung cancer, while poor diets can lead to obesity, diabetes, heart disease, and liver cancer; and inflammation serves as a common mechanism for cardiovascular disease and cancer progression. Given these limits, it is logical to develop a healthcare system to simultaneously address IDs and NCDs, as illustrated in Figure 1 below, which we call An Integrated Healthcare System with Flex-Competence.. Notably both cancer and IDs, require a rapid response, use many of the same assessment services, and can be treated in the same clinical settings, creating a more effective approach to improving health outcomes.
There are four essential steps for developing a flex-competence system: First, countries need to build capacity for an integrated healthcare system by closely linking phased-in specialty expertise with program development for prevention, screening, treatment and acute and chronic disease management. Multi-level planning and management are also necessary, and should include policy, payment, clinical programs and personnel, regional services, input from patients and their families, and coordination between public and private sectors. Developing skills in change management and cross-training will enable rapid deployment that focuses on the variety of illnesses to be encountered to address diagnosis, treatment, epidemiology, and public health. Finally, development of a flex-competence system must entail coordination with the public sector and health ministries for accessing external financial and human resources and supply chain networks.
A SYSTEM BASED ON PRIMARY CARE
Our flex-competence approach to integrating care for IDs and NCDs recognizes that primary care is the cornerstone of care delivery, but benefits substantially from early investment in what is minimally needed for effective cancer care—essential diagnostics, imaging, radiation therapy and expertise accessible locally and through network partners. While public support and buy-in across national governments is necessary to accommodate the cost and scope of services needed for such a highly coordinated global system, improved global public health and economic development can be strong incentives. The private sector can bring its supply chains and global networks to plan for and ensure surge capacity, while nongovernmental organizations can focus on specific expertise needs and mentorship that can enhance the capability of the local staff.
One example of a sustainable mentorship program among expert- and resource-limited centers in LMICs is the ICEC model. Mentors, including retirees with a lifetime of experience, provide expertise and critical sustainable commitment to assist on-site champions in LMICs to develop the local capacity and capability and, over time, become regional expert centers. The LMIC centers in turn become expert hubs for their region, thereby enabling the exponential growth needed to address the current lack of cancer and NCD care.
Incorporating cancer care capability in the earliest steps of establishing a healthcare system creates a strong foundation, as the comprehensive services needed for cancer care serve as a base for most healthcare needs. Furthermore, common and terrifying diseases, such as cancer, have no geographic boundaries and do not distinguish among individuals. The human need for care and compassion provides a foundation for regional and global collaboration and an incentive and template for immediate and effective action with the creation of an integrated healthcare system with flex-competence. •
TEXT – Norman Coleman, MD, is the Associate Director, Radiation Research Program, DCTD, NCI and serves as a Senior Scientific Advisor to the International Cancer Expert Corps.
Eugenia (Nina) Wendling is the Chief Operating Officer of the International Cancer Expert Corps, Washington, DC.
Donna O’Brien is the President of Strategic Visions in Healthcare with extensive management experience with health systems, academic medical centers and hospitals, cancer programs, and with healthcare organization partnerships. Ms. O’Brien serves as a member of the ICEC Board of Directors.