The Community Health System InnovatiON (COHESION) project
No business as usual, the need of a holistic approach in addressing NCDs
Von Olivia Heller & Claire Somerville
The Community Health System InnovatiON (COHESION) project is a Swiss funded multi-country study, with the aim of improving health systems for noncommunicable disease (NCDs) and neglected tropical diseases (NTDs) in Mozambique, Nepal and Peru. NCDs have received increased prioritization at the global level, but how do these translate into action at national and local levels? Although, NCDs are the leading cause of morbidity and mortality worldwide, alone such disease burdens do not always result in proportional political support. A two-pronged holistic approach is needed to address NCDs. 1) linking NCDs to the SDG agenda; showing relationships between the causes and impacts of NCDs across the SDG goals 2) management of chronic diseases at Primary Health Care (PHC) level.
Nepal – Household Survey (Photo: © COHESION-Project)
The Community Health System InnovatiON (COHESION) project is a Swiss funded multi-country study, which addresses the double burden of disease, with the aim of improving health systems for noncommunicable diseases (NCDs) and neglected tropical diseases (NTDs) in Mozambique, Nepal and Peru. The COHESION Project has examined policies at global and national levels along with health system assessment and community health perceptions study in all three countries in order to develop targeted interventions with local stakeholders. Here we reflect on some of the factors that have led to increase prioritization of NCDs on the global health agenda.
NCDs on the global agenda
The process of prioritizing health issues at the global level is complex and deeply political. Health issues that transcend national boundaries and pose a threat in terms of health security often receive rapid prioritization, global attention and funds, e.g. HIV/AIDS and Ebola. Despite being the leading cause of morbidity and mortality worldwide NCDs were late in gaining prominence on the global agenda. However, by 2011 NCDs were the second related health issue to be addressed at the United Nations General Assembly (UNGA) after the 2001 UNGA on HIV/AIDS. The UNGA on NCDs resulted in a political declaration that led the World Health Organization (WHO) to respond with a renewed Global Action Plan, the latest running from 2013-2020. This includes a set of interventions to support countries in tackling the burden of NCDs. Furthermore, and possibly most importantly, NCDs are now incorporated into the Sustainable Development Goals (SDG) and therefore have global political commitment. NCDs are now linked to wider development issues such as poverty, inequality and social justice.
Awareness yes, but what about action?
While NCD awareness has increased in the political realm, they remain complex to prevent, cannot be cured, require a whole of society approach and well-functioning and financed health systems. The complexity is summed up by a global key opinion leader interviewed for the global policy analysis: "What is the equivalent of a condom in diabetes? It is not there. HIV, we can go to an assembly and have a condom in our hand and say: this is it, use this, make this available, you control the disease. Can we do that with diabetes?...No.”
There are multiple barriers to the development and implementation of effective NCD interventions. The absence of funding is a major issue resulting in a limited response compared to the HIV/AIDS response; the NCD civil society movement, although highly effective, were latecomers. The role of the private sector is highly complex and sensitive; some sectors are contributors to the NCD burden in what has become termed as the “commercial determinants of health”. This has also lead to conflicts of interest with the private sector funding civil society and NCD related initiatives. The presentation on the soda tax in Mexico during the MMS symposium clearly highlights the challenge of tackling big industry in the fight against NCDs. However, if we take NTDs as an example, it is plausible to view the many different private sectors as a part of the solution and not only a problem.
The challenge is complex. The lack of a silver bullet for NCDs as a collective group means that despite the plethora of strategies, actions plans, and reports since the 2011 Political Declaration that have emphasized the importance of NCDs as a cause of premature mortality, progress and action has been inadequate, uneven and only sometimes effective, as noted by the WHO 2017 progress monitor report. This is not only true for LMICs, but also shockingly in our own country Switzerland.
Mozambique – Diabetes consultation (Photo: © COHESION-Project)
A holistic approach is needed
The COHESION project believes that a two-pronged holistic approach is needed to address NCDs. Firstly, linking NCDs to the SDGs and showing the far-reaching impact and relationships between the causes and impacts of NCDs to sustainable global development. For example, articulating poverty (SDG Goal 1) in relation to NCDs whereby NCDs are both a disease of poverty and also a cause. Addressing health and well-being, and the barriers to Universal Health Coverage (UHC) (SDG Goal 3) are key elements in tackling many health-related issues. By looking at gender roles in care, barriers to care and also having gender appropriate interventions developed as part of COHESION project (SDG Goal 5). By working in three LMICs, it will highlight inequalities within and between countries and link these issues back to Primary Health Care (PHC) in developing interventions at policy, health system and community levels (SDG Goal 10). As NCDs have their determinants in the environments where people live, some of the COHESION’s interventions at policy, health system and community levels may address elements included in the proposed SDG Goal 11. Finally, as COHESION is a global partnership between 4 countries (Mozambique, Nepal, Peru and Switzerland) and 7 institutions, it will help develop North-South and South-South collaboration and capacity building (SDG Goal 17).
Secondly, through this partnership, the second prong will be using a holistic approach in addressing chronic diseases at PHC. HIV/AIDS, NTDs and NCDs are all chronic diseases and their management is a challenge for health systems established for acute care management. All chronic diseases, whether communicable or noncommunicable require a focus on the individual and in strengthening of PHC.
There may be no condom for NCDs and most likely as a global health community we will not see funding equivalent to what was available for HIV/AIDS. That said through partnerships, collaborations and innovation as actors in the global health arena we can bring together different strengths to address this challenge, as was seen during the different presentations at the MMS Symposium. The diversity of projects and programs that emanate from Switzerland to address NCDs was impressive. To facilitate this, funding is needed and the Swiss National Science Foundation and Swiss Agency for Development and Cooperation through their support for the r4d program, and projects such as COHESION, have enabled this process for a variety of global issues including health to be addressed. More support will be needed to identify solutions to address NCDs and implement the lofty goals and targets developed at a global level to truly impact health and well-being for those in most need.
Olivia Heller .
Dr Claire Somerville is a medical anthropologist and currently executive director of the Gender Centre at the Graduate Institute Geneva. She is co-applicant to the COHESION-project.