The views expressed are those of the author and do not necessarily reflect the position of FORESIGHT Global Health.
The prevention, detection and treatment of non-communicable diseases (NCDs), such as diabetes, heart and lung diseases, and cancer, are among the biggest global health challenges today. You could be forgiven for thinking these are diseases of high-income countries (HICs) and elderly patients, as indeed this used to be the case. However, in the 21st century, 41 million deaths a year are attributable to NCDs, making them the leading cause of death worldwide. They are widely prevalent in low- and middle- income countries (LMICs) and can cause premature death in working age adults. In fact, the burden of these diseases is disproportionately high in LMICs, with over three-quarters of all NCD deaths occurring in these countries.
Winning the fight against NCDs requires reorienting how healthcare is delivered, namely, making it people-centred. The World Health Organisation endorses this approach, stating: “As health is influenced by a complex interplay of physical, social, economic, cultural and environmental factors, it must be seen in a broader context, with all stakeholders involved. We need to re-establish the core value of health care, which is health and well-being of all people as a central goal. This entails a more holistic and people-centred approach to health care.”
RESHAPING HEALTHCARE DELIVERY
In order to make healthcare more people-centred we need to move away from traditional, disease-focused, doctor-driven care and instead ask what matters to our patients, their families and communities in order for them to engage effectively with healthcare.
Imagine, for example, a patient has to travel for several hours to be seen at a clinic. When she arrives, the doctor looks at her blood test results and explains that she has type 2 diabetes and prescribes a medication to manage this. She is surprised, as she feels well and has no obvious symptoms. She goes away with a bill for medication she can’t afford, no real understanding of what lifestyle changes she could make, no support or empowerment to make these changes and no incentive to do so because she hasn’t been educated on the implications of poorly controlled diabetes. She makes the journey home again. The whole trip has taken more than half a day, time she can ill afford to be away from her work and family. The tablets give her side effects — loose stools and an upset stomach — and so she stops taking them. Unsurprisingly, she is lost to follow up and her next presentation, years later, is for a much more serious complication of uncontrolled type 2 diabetes that has devastating consequences for her, her family and their financial situation.
This is a hypothetical scenario, but it highlights some of common issues with treating NCDs. One particular hallmark of NCD treatment is the need for repeated and long-term engagement from the patient with the health system. This can be difficult to achieve if the system does not seek to put people at the centre. Primary Care International (PCI) has worked on numerous projects with partners in LMICs to create people-centred improvements in health systems; it is at the core of what we do. We are involved in a wide range of work from capacity building projects to enhancing the knowledge and skills of healthcare workers to related policy and advocacy work. Here we touch on three ways in which people-centred care can be improved based on our project experiences in this area.
COMMUNITY FOCUSED CARE
The first example addresses the access and reach of NCD care by bringing it closer to the community. Within a team-based care approach we have found that community health workers are ideally placed to provide education on NCDs and healthy lifestyle messages that are adapted for their local communities. Evidence shows that when people understand their health better and the impact of lifestyle choices, they are more likely to engage early and actively with the health system. Consequently, they are more likely to experience good health for longer and at less cost. For countries with limited resources, this approach represents the best opportunity for improved NCD-related health outcomes. Community health workers can also be empowered to screen patients for NCDs, monitor them for NCDs and refer patients who are unwell.
STRENGHTENING HEALTH SYSTEM ENGAGEMENT
The second area focuses on improving the quality of people’s experience of the health system. As you would expect, healthcare workers are key to the patient’s experience. If healthcare workers can adopt a holistic approach to their patient and engage them in shared decision making, this is often the best way to manage NCDs. PCI’s training, therefore, focuses not only on developing good clinical knowledge of NCDs but also on the specific consultation skills required to promote a productive relationship between patients and their health providers. Moreover, by co-creating the courses with local healthcare workers, the training and guidance is relevant, pragmatic and contextualised to their environment. Improvements in the quality of people’s experience of the health system is also achieved by the systems that support it, so those establishing programs must pay attention to how the system operates to deliver people-centred care with emphasis on access, affordability, availability and equity.
Finally, sustainability should be a core feature of any people-centred project so that benefits can be maintained beyond the initial intervention. One of the ways to do this is to adopt a cascade training approach. PCI provides NCD knowledge and skills to one group of healthcare workers who then become “NCD champions” and can pass on their knowledge and skills to other groups of healthcare workers with the support of mentors. In this way, we can build local capacity for long-term delivery of NCD care, reaching more healthcare staff and therefore more patients.
The ultimate goal for any healthcare system is to put people at the heart of its services. This is especially important for the prevention and care of NCDs that pose significant challenges for patients, their families and their communities. Organisations or individuals involved in contributing to healthcare development should pay close attention to patient-centred care, for it is vital to ensuring that interventions are meaningful and sustainable. •
TEXT – Dr. Mamsallah Faal Omisore is a General Practitioner and Clinical Director for Primary Care International.
Tineke de Groot is a nurse, international public health professional and educational trainer.
Dr. Anna Fraser is a General Practitioner with a special interest in palliative care and education.
PHOTO – Primary Care International