The Case for Integrating Health Systems to Manage Noncommunicable and Infectious Diseases in Low- and Middle-Income Countries: Lessons Learned From Zambia

Addressing the Common Features of Noncommunicable and Infectious Diseases

An economically sound approach to incorporating NCDs into routine healthcare services in LMICs that is feasible for implementation in the short and medium term requires improved alignment of institutions that support prevention and control of both NCDs and infectious diseases (IDs). This approach would ultimately reduce the economic burden of disease management by addressing the convergence of NCDs and IDs such as direct interactions between both disease types, common risk factors, or overlapping at-risk populations. Direct interactions between NCDs and IDs—a notion that includes an elevated risk for key IDs among patients with underlying NCDs—have been extensively discussed in the literature. For instance, patients with diabetes mellitus have a 2 to 3 times higher risk of developing active tuberculosis (TB), having a TB relapse, or developing a multidrug-resistant TB infection, compared with patients without diabetes mellitus.^15,16-23 Consequently, investing in prevention and control of NCDs is a forward-looking strategy that will ultimately help reduce the medical costs associated with related IDs as well.

Addressing common risk factors of NCDs and IDs is an important strategy for decreasing the economic burden of disease management and improving health outcomes. As evident from previous studies, NCDs and IDs share common risk factors for the acquisition and accelerated progression of a variety of IDs that remain common in LMICs, including influenza, TB, pneumonia, sexually transmitted diseases, and hospital-acquired infections. ² Therefore, including evidence-based, cost-effective interventions, especially those proven to be feasible for implementing in low-resource settings,^24,25 has the potential to reduce the incidence and intensity of both disease types and, hence, decrease the associated costs.

Another opportunity to address common features of NCDs and IDs occurs when a country is prone to climate- or conflict-driven population movement. These scenarios can lead to added pressure on the health components of social institutions.^26-28 From a societal and national perspective, adoption of integrated approaches to ensure delivery of essential services, including vaccine delivery, may yield improvements in efforts to prevent and control NCDs and IDs in the medium and long term by supporting the country's capacity to prevent, detect, and respond to public health threats.

Enhancing Optimal Resource Use and Reducing the Economic Burden of Diseases

Integrated approaches to disease management contribute to reducing the economic burden of NCDs and IDs by promoting efficient use of scarce resources. When health professionals receive training in comanaging both disease types, they can contribute to scaling up interventions focused on common risk factors and interventions.^29,30 Furthermore, these same personnel may provide longer-term follow-up, treatment, and care for chronic IDs and NCDs.^29,30 Integrated care approaches can also reduce the per-patient cost of medical care by using the same facilities and equipment to provide ID and NCD care.^2,26,31 This “economies of scope” approach enables the fixed costs of maintaining facilities and equipment to be distributed between a larger pool of patients.^2,26,31 Finally, synergistic care for IDs and NCDs has the potential for reducing future costs within the healthcare system by promoting prevention, testing, and early detection of IDs and NCDs in ways that improve outcomes for individuals and strengthen core public health system components.^4,30

Vertical and Horizontal Modalities of Health Services Integration

The synergistic approach to managing NCDs and IDs may include 2 pathways: vertical and horizontal service delivery. The vertical approach, in which resources are allocated for specific diseases, has been traditionally considered a feasible approach in resource-constrained settings, as it focuses on a specific problem and applies additional resources to scale up existing interventions to alleviate newly emerged acute health needs.^30,32-34 A vertical approach to some health financing mechanisms, such as foreign health aid, has proven to be effective in reducing morbidity and mortality for leading NCDs. ³³ For example, an additional US dollar in per capita NCD-targeted vertical assistance to LMICs has been estimated to avert, on average, 7,459 disability-adjusted life years per 281 deaths after 1 year and 8,957 disability-adjusted life years per 346 deaths after 3 years. ³³ However, while vertical programs might be helpful for filling health sector gaps in LMICs over the short run, they might not represent a long-term solution, particularly in the context of the 2030 Sustainable Development Goals. ³² A recent analysis by the NCD Countdown 2030 collaborators revealed that no country could achieve Sustainable Development Goal Target 3.4 by focusing on a single disease; in addition, in half the countries, achieving the target would require improvements in at least 5 causes of NCD-related deaths.^30,32,33 In the horizontal approach, where resources are allocated across the health system to strengthen its overall ability to deliver services, the primary care infrastructure becomes particularly important in low-resource settings as a key element of accessible health systems. In this context, integrating NCDs as a part of primary healthcare can help deliver high-impact services to strengthen early detection and timely treatment of diseases.^25,30 Early assessment of national efforts to integrate NCDs as a part of primary healthcare demonstrated promising reductions in NCD mortality if the interventions were implemented at a large scale. For instance, after Mexico integrated NCD services into its primary healthcare system for half of the country's population, mortality rates, expressed per 100,000 persons, declined for a wide variety of NCDs, with notable declines of 43 for ischemic heart disease and 49 for diabetes mellitus. ³⁵

Feasible Planning, Implementation, and Assessment Steps

A national plan for integrating NCD services into a health system revolves around 3 key steps: planning, implementation, and assessment. ³⁶ Planning entails mobilization of a multisector response through a government-led process to ensure the highest commitment and ownership at the various administrative levels with strong coordination across sectors, including private entities^36-38 (Table 1). In this context, effective multisector responses engage various government sectors within and outside of the health system to address the social determinants of health and to prevent exposure to risk factors that are common to NCDs and IDs.^36,37,42 Another facet of multisector response entails collaboration between government agencies and other sectors of the society to ensure commitment and secure resources in a way that is more effective and sustainable than might be achieved by any sector acting alone.^36-38 Multisector processes to advance a coordinated response may take several forms, depending on their specific purpose and national context, and can include cross-country partnerships, cross-ministerial executive committees, task forces, and action teams.^36,38

Implementation efforts need to center around cost-effective or cost-saving interventions that involve few additional financial resources to achieve substantial reductions in NCD mortality. ³⁶ A set of “best buys” and other recommended interventions developed by WHO provide the guideposts to develop powerful economic tools that include 88 interventions and recommendations, with an emphasis on synergy between disease prevention and control—a strategy that offers higher return on investment than disease control alone in countries at all income levels.^{3,24,32,33,37,42}

A wide range of WHO-recommended interventions can pave the way for synergistic care for IDs and NCDs.^24,37 For example, WHO developed a package of essential NCD interventions specifically for primary healthcare in low-resource settings. This package prioritizes a set of cost-effective tools adaptable to local settings that are able to deliver high-quality care in countries at all income levels. ²⁵ Of note, besides outlining possible avenues for NCD and ID prevention and care, some of the WHO-recommended interventions can help to mobilize funds to support national disease management programs. ³⁸

Review of a country's progress toward the integration of NCDs into the health system relies on timely data and on tools designed to monitor advancements in achieving national goals and targets. ³⁶ The WHO STEPwise Approach to NCD Risk Factor Surveillance ⁴⁰ promotes the collection of small amounts of information on a regular basis and, thus, involves few financial resources at each data collection round. ³⁶ A plethora of tools to monitor trends and to assess progress in the implementation of national strategies and plans on NCDs are available (Table 1).^{32,37,38,40-42} These routinely updated tools include a set of universal indicators capable of application across regional and country settings. While these tools do not offer country-specific recommendations on how to facilitate the transition toward the integration of NCD prevention and care into the healthcare system, they can be used to identify gaps in health systems, services, surveillance, and policies, to target when revising and modifying national NCD integration strategies.

Between 1990 and 2017, there was a 67% increase in the all-age disability-adjusted life years attributable to NCDs in sub-Saharan Africa. ⁴³ Zambia is one of many LMICs undergoing this epidemiological transition of increased burden of NCDs relative to IDs. ⁴⁴ The history of and experience with health systems integration in Zambia provides lessons learned for LMICs interested in implementing a wide range of health system integration initiatives to mitigate the impact of NCDs on population health. The following section summarizes Zambia's experience in this regard, with the objective of synthesizing lessons learned and informing potential pathways for integration in other countries.

Increasing Attention to Noncommunicable Diseases in Zambia

Zambia's progress in tackling NCDs is particularly noteworthy when considering the baseline conditions in the country. In the early 2000s, Zambia experienced a high burden from IDs (eg, malaria, HIV and AIDS, sexually transmitted infections, TB), and maternal, neonatal, and child morbidities and mortalities. The country also faced a rapidly rising burden of NCDs, including mental health disorders, diabetes, cardiovascular diseases, and violence. ⁴⁵ The country's ability to respond to the emerging challenges was particularly hampered by 2 factors: the limited availability of funding to tackle NCDs and the lack of community awareness of the issue. In many LMICs, including Zambia, the external funding to support public health programs and interventions is traditionally allocated for IDs, with less than 2% of all funds allocated for NCDs. ³³ According to the National Health Strategic Plan of Zambia for 2017 to 2021, ⁴ continuous underinvestment in NCD-related initiatives manifested in a noticeable lack of NCD-specific drugs, lab reagents, and diagnostic facilities and in inadequate medical expertise instrumental for providing high-quality prevention and care for NCDs. ⁴³ Community awareness of NCDs and associated risk factors was also lacking. According to a needs assessment conducted by the Zambia Ministry of Health (MOH) in the mid-2000s, nearly 80% of Zambians were unaware of prevention, screening, and treatment options for diabetes and hypertension and for cervix, breast, and prostate cancers. ⁴⁵

Heeding the 2009 NCD symposium recommendations, Zambia embarked on a number of multisector interventions to develop and support a national NCD action plan (Table 2). ⁴⁵ According to a local health official and subject matter expert from Zambia who described the process of integrating health systems to manage NCDs and IDs in Zambia, the global NCD movement and the information campaigns launched in the country—especially those conducted via TV, internet, and social media—changed the perception of high-risk behaviors. Public support corroborated by multisector partnership engagements created multiple opportunities to address the NCD epidemic. NCDs were included as one of the national health priorities in the Seventh National Development Plan and the National Health Strategic Plan for 2017-2021.^4,46 These documents, which guide discussions with development partners in support of the health sector, ensured that development partners aligned their funding priorities to include NCD prevention and control. In addition, Zambia conducted several surveys to collect data on population lifestyles, risk factors, and the burden of NCDs—components needed to inform the NCD integration efforts. Close collaboration between government agencies, public health experts, and academia resulted in a position paper that specified the key steps in transforming the health system, the costs of the changes and the stakeholders involved. ⁴⁷

Zambia's Approach to Health Systems Integration

Zambia's approach to integrating NCDs into the healthcare system evolved over time from an exclusively vertical approach to a combination of vertical and horizontal integration. Traditionally, healthcare in Zambia was centered around vertically integrated programs aimed to reduce the burden of IDs. Since 2004, Zambia received substantial annual support from the US President's Emergency Fund for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria to develop and coordinate response to the HIV epidemic.^48,49 Advancements in Zambia's HIV and AIDS program, enhanced by continued PEPFAR funding, made antiretroviral therapy available to nearly 90% of those in need of treatment.^48-50

The rapid increase in HIV treatment coverage in Zambia shifted priorities of the country toward providing long-term care services for antiretroviral therapy patients, including monitoring, retention in care, and treatment of patients with NCD-related metabolic side effects of antiretroviral therapy medications. ⁵¹ Because of an increasing number of people living with HIV, Zambia reoriented care delivered at its tertiary, general, and district hospitals to include NCD diagnosis, treatment, and monitoring^4,49 (Table 3). In addition to modernizing its hospital system, the country is working to reorient infrastructure and support systems built to provide the HIV care cascade to also provide care for patients with NCDs. ⁴⁹

Starting in 2010, Zambia embarked on a blending of vertical and horizontal integration components to include NCD care services. The vertical approach was still appropriate at the central level to plan, coordinate, mobilize, and facilitate countrywide action on NCDs (eg, developing clinical nutrition/dietary guidelines or treatment protocols for NCDs).^45,49 At the local level, Zambia focused on the decentralized health system and community-based models. ⁴ As part of this approach, the MOH launched the Community Health Assistant (CHA) Program to address a critical shortage of trained workforce at the local level.^4,49,52 CHAs focused on primary care and provided interventions for common diseases that can be identified and addressed at an early stage, including for NCDs. ⁵² Another example of a vertical program transitioning to population-level service delivery when integrated into the routine healthcare system was the cervical cancer screening program led by the MOH. Between 2006 and 2013, nurse-provided cervical cancer screening scaled up from solely women infected with HIV to include all women served by 33 health facilities across Zambia's 10 provinces. ⁵³

Current State of Systems Integration in Zambia

Zambia has actively engaged every level of its society to advance the integration of NCD management into its healthcare system. At the national level, collaboration between government agencies and academia helped develop the national plan for NCD integration and to collect the first round of data on population lifestyles, risk factors, and the burden of NCDs (Table 2). At the central government level, the MOH aligned a multitude of health, community development, and social welfare agencies to address social determinants of health that shape NCD-related health outcomes. Furthermore, the MOH teams at central, provincial, and district levels were strengthened with NCD specialists responsible for coordinating efforts across the country. At the service delivery level, Zambia opened the Cancer Diseases Hospital with a 240-bed capacity inpatient unit^4,49 and worked to establish and staff an NCD clinic in every provincial hospital (Table 3). ⁴⁹ In addition, Zambia has embarked on scaling up health posts and rolling out the CHA program to strengthen provision of primary care services, freeing up nurses and midwives for more complex NCD and ID care. Finally, at the societal level, Zambia has successfully implemented a set of interventions to increase community awareness of NCDs that, in turn, increased pressure on the Zambian government to accelerate the changes to its health system (Table 2).

Although Zambia has achieved substantial progress in developing the national plan for NCD integration, more time is needed to implement every module of the plan. Currently, the country's hospital system is only partly prepared to manage NCDs, as secondary-level hospitals have limited means to address obesity and cholesterol-related illnesses, ⁴⁹ and only 10% to 15% of all hospitals meet the minimum threshold for managing NCDs in line with WHO recommendations. ⁵¹ In addition, shortages in NCD essential medications remains a key service delivery challenge, as only a limited number of essential diabetes and antihypertensive medications are available in all provinces of the country. Furthermore, for those widely available medications, median prices remain higher than international reference prices, with no medicines that are affordable as measured in the context of Zambia's poverty line. ⁵⁴ At the local level, NCD integration efforts have been slowed by a shortage of skilled healthcare workforce—a persistent issue within the healthcare system in Zambia.^4,50 Financial and in-kind support mechanisms introduced to attract and retain medical providers, especially those in remote facilities (eg, improved opportunities for career development or in-service education, staff housing, or transportation reimbursements),^55,56 have not applied to CHAs. ⁵² In terms of the sustainability of ongoing integration efforts, Zambia made limited progress in repositioning funding opportunities to support the national disease prevention and control programs. The recent efforts to levy a 3% tax on nonalcoholic beverages, aimed at tackling NCDs, was demonstrated to be too low to either affect consumption or to raise revenues that could be reinvested in the health sector. ⁵⁷ Finally, being able to demonstrate and measure the efficacy of systems-level change hinges on redirecting additional human and financial resources to boost the assessment of NCD integration efforts.

Development of Policy and Guidelines

Lessons learned from Zambia can serve as helpful guideposts for other LMICs, particularly for countries that started moving through NCD integration relatively recently. A review of the Zambia MOH policy response to NCDs raises important considerations. ⁶¹ Long policy development timelines affect consistency in the composition of stakeholders and endangers policy development momentum. Local population- or facility-level data are needed to determine reasonable and measurable indicators and targets. Guidelines should be based on local or regional disease priorities and risk factors. In addition, incorporating health education measures can improve health-seeking behavior by the public. ⁶¹ Due to the characteristics of NCDs (eg, multiple risk factors, long-term health effects, long-term treatment, and frequent comorbid conditions with other NCDs or IDs) progress should be assessed through population- and facility-level surveillance of programmatic (process) and disease and risk factor-related (outcome) indicators and capacity measures such as sustainable funding.

Evidence of Progress and Improved Efficiency

As Zambia continues with integration of NCDs and IDs, future assessments of the consequences of NCD integration will continue. Although the probability of dying from NCDs remained fairly stable during the past decade at 27% to 29% of all deaths, Zambia made substantial progress in reducing the risk of premature death from NCDs.^62,63 In 2010, premature deaths under age the age of 60 years were estimated at 49.5% for men and 43.9% for women. ⁶² By 2016, the percentage of NCD-related deaths that occurred prematurely—including deaths between ages 60 and 70 years—exhibited more than a 2.5-fold decline and dropped to 18% for male and 17% for female individuals. ⁶³

Early evidence from pilot facilities demonstrates that integration of NCD and ID services boosts efficiency by improving the availability of drugs through shared clinic resources, promoting knowledge and skills among medical personnel, providing equitable access to grants and infrastructure for all patients and staff, and reducing service duplication. ⁵⁰ High-cost NCD drugs and diagnostic materials can also be addressed through negotiated pricing or pooled procurement, which might be especially useful for drugs that enable long-term planning such as NCD drugs. ⁶⁴ Other studies have reported the feasibility of integrated multimonth dispensing for both hypertension and HIV treatment in LMICs, achieving improved hypertension control and sustained optimal HIV viral suppression and retention for people living with HIV. ⁶⁵

NCD Prevention and Control as a National Priority

Zambia included NCD prevention and control as one of its strategic national priorities, thereby safeguarding support of the health sector and strengthening support from development partners who include NCD prevention and control in their funding priorities. Zambia committed itself to modernizing its healthcare system to include NCDs by creating agencies and teams responsible for coordination of NCD integration at national, provincial, and community levels; developing relevant policies, regulations, strategic plans, and treatment guidelines; and establishing and strengthening multisector plans and partnerships. Academia was instrumental in providing technical support to develop the national plan for NCD integration. Some of the civil society and nongovernmental organization stakeholders that participated in the process went on to form the Zambia NCD Alliance in 2017 to coordinate efforts to address NCD goals. ⁶⁶ The public, inspired by the global NCD movement and equipped with knowledge from the countrywide information campaigns on high-risk behaviors and NCD management, created social pressure needed to accelerate changes to the health system.

Integrated Interventions

At the service delivery level, Zambia implemented a variety of economically sound interventions that enabled the country to rapidly incorporate NCD care into routine healthcare services. First and foremost, to promote efficient use of scarce resources and to reduce the per patient cost of care, Zambia reoriented existing facilities, equipment, and personnel to provide NCD care, to scale up interventions on the major risk factors, and promote prevention, testing, and early detection of NCDs in patients diagnosed with IDs. Second, the country recognized the importance of the social and physiological interactions between NCDs and IDs and worked to apply extensive expertise in treating patients with “chronic” IDs and leverage PEPFAR funding to address both disease types and their synergistic impacts. With these interventions, Zambia had time to accumulate sufficient resources that enabled them to gradually introduce other changes, such as staffing lower-tier hospitals and primary health centers with NCD specialists, adding necessary equipment, and strengthening community health centers with CHAs trained in NCD care.

Challenges

Since the onset of change to its health system, Zambia has encountered numerous challenges. Some of them, such as a profound shortage of skilled medical personnel, are specific to a subset of LMICs and could be mitigated by interventions unrelated to NCD integration.^50,56,67,68 Other challenges—such as the need for timely surveillance and research to help monitor and evaluate national progress in NCD management—would likely resonate with a broad group of LMICs. Launching a universal electronic system, which covers all service delivery levels and enables monitoring NCDs and IDs in real time requires substantial coordination and investments, particularly at the community level. Experience from other countries demonstrates that an array of lower-cost alternatives are feasible for implementation in the medium term including (1) conducting routine national STEPwise Approach to Surveillance surveys to monitor the trends in NCDs and risk factors, ⁶³ (2) adopting mobile-enabled health services and information systems to facilitate access to NCD diagnostic services and to improve NCD reporting in remote areas, ⁶⁹ and (3) using tools developed by international, regional, and research organizations to identify gaps in health systems, services, and policies that hinder national NCD integration efforts.^32,37,38,40

Notably, Zambia's ability to implement change and ensure program sustainability is hampered by a persistent lack of resources and aggravated by long-term dependence on vertical program funding. By contrast, other countries (eg, Argentina, Bolivia, Mexico, Nicaragua, Peru) further ahead in the NCD transition have involved microfinance institutions to make the basic package of NCD services—including blood pressure, blood glucose, and body mass index measurements, breast exam, Pap smear, and health education—available to all patients. ⁷⁰ In line with WHO recommendations, ²⁴ Mexico also adopted a wide range of taxes on tobacco, alcohol, sugar-sweetened beverages, and ultra-processed food,^38,71 with taxes in some instances accounting for as much as 75% of the final sales price. ²³ In addition to tax revenues, these fiscal interventions produced cost savings by discouraging consumption of taxed goods that may trigger NCDs. Of note, the effects of taxation tended to be larger for households in lower socioeconomic tiers^38,71 who were disproportionally affected by NCDs. ¹⁴