Achieving effective health care with a new approach to caring for chronic illnesses

Their report is published in the September issue of the journal Health Affairs.

The authors shared their findings on Wednesday, September 9, at the educational forum "Ensuring Patient Access in Latin America: Governance, Assessment Methodologies, and Evidence-Informed Decision Making in Health Policy," held in Santiago, Chile, and at the Health Affairs briefing titled "Noncommunicable Diseases: The Growing Burden," in Washington, D.C.

First author of the study, Felicia Marie Knaul, a breast cancer survivor, director of the College of Arts & Sciences' Miami Institute for the Americas, and professor at the Miller School of Medicine at the University of Miami, says her personal experience has taught her the importance of accessing care at all stages of the disease, including survivorship.

"Health systems around the world can and must be transformed to meet the challenge of chronic illness and respond to the needs of patients from prevention to palliation to achieve effective universal health coverage," said Dr. Knaul, who was the director of the Harvard Global Equity Initiative at the time this research was conducted.

Chronic diseases are conditions where ongoing treatment is needed for months or years before the occurrence of death or before being considered no longer at risk of dying from that ailment. They are costly to treat. Proper management involves consideration of each stage of the chronic disease continuum -- prevention, early detection, treatment, survivorship, rehabilitation, palliative, and end-of-life care.

Advances in medicine have transformed many terminal diseases into chronic conditions. Moreover, rapidly aging populations impose an increasing burden on already weak systems of health care in low- and middle-income countries.

Typically, health care systems in low- and middle-income countries are designed to treat acute episodes of illnesses and injuries. They are ill prepared to meet the challenge of the rise in chronic diseases. Hence, the paper suggests a need to focus on effective universal health care coverage, to holistically redesign health care systems for care across the life span of a person.

According to the report, there are three basic requirements for achieving universal health coverage: legislation and affiliation to ensure coverage of all people, provision of access to cost-effective health services, and creation of a means of financial protection. Effective universal health coverage adds another additional component -- integration of services at each stage of the care continuum and health systems function.

Traditional approaches for health care systems in low- and middle-income countries are inadequate to deal with the shifts in the burden of disease toward noncommunicable and chronic illnesses. The approach has been either vertical strategy--targeting particular diseases, or horizontal strategy--targeting health care systems, hence investing in one disease or stage of care at the cost of neglecting another, the report says.

The diagonal strategy proposed by the authors aims to form synergies between elements of vertical and horizontal approaches, giving precedence to programs that respond to multiple diseases, explained Julio Frenk, president of the University of Miami and co-author of the study. Dr. Frenk was dean of the Harvard T.H. Chan School of Public Health at the time this research was conducted.

"A diagonal approach to health care is an efficient strategy for achieving better results with limited resources," said Dr. Frenk. "It changes the fragmented view of health systems, which focuses on its constituent elements -- like human resources, financing, facilities, and technologies -- individually, in a sort of 'laundry list' conception, to a new system based on the interrelations among the various components. This concept can help move forward universal health coverage in all countries."

In the report, the researchers present a case study on the management and treatment of breast cancer, as a tracer illness for assessing effective universal health coverage within the context of the 2003 health care reform in Mexico. The case study outlines the shortcomings of the reform in considering stages of the care continuum beyond treatment, such as early detection and palliative care. It then presents diagonal strategies implemented to address these gaps.

The report concludes with a set of recommendations to implement diagonal strategies in the health care systems of low- and middle-income countries, by integrating services and strengthening existing platforms to provide care to individuals, which takes into consideration the needs and potential of the person, throughout her lifetime and across the different stages of disease.

In the future, the researchers would like to develop a more detailed analysis of effective universal health coverage for each stage of breast cancer, beyond early detection and palliation, within the context of health reform in Mexico and in other low- and middle-income countries, in hopes of utilizing this type of health systems analysis as a model for other chronic conditions.

"Along with my co-authors, I plan to continue research around health systems strengthening and chronic disease management, particularly to promote means for improved priority-setting around chronic diseases and to reduce health inequities," said Afsan Bhadelia, visiting scientist at the Harvard T.H. Chan School of Public Health and co-author of the study, who was a research associate at the Harvard Global Equity Initiative at the time this research was conducted.

The findings are published in an article titled "Achieving Effective Universal Health Coverage And Diagonal Approaches To Care For Chronic Illnesses." Rifat Atun, professor of global health systems at the Harvard T.H. Chan School of Public Health is also a co-author of the study. The original research was conducted at Harvard University. The work will continue in collaboration with the Miller School of Medicine, Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine, and the Miami Institute for the Americas.