Catalysing the response to NCDI Poverty at a time of COVID-19

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Abstract

Nelson Mandela wrote ”Overcoming poverty is not a gesture of charity. It is an act of justice. It is the protection of a fundamental human right to dignity and decent life.” 1 In a world where there are increasing numbers of super-wealthy individuals, some with a personal wealth larger than the gross domestic product of entire countries, a catastrophic level of poverty affects the lives of about a billion people. 2 Over 90% of the poorest billion live in low-income and lower-middle-income countries (LLMICs) in sub-Saharan Africa and south Asia, and about 80% of them are younger than 40 years. 3 What can be done about this injustice? The Lancet NCDI Poverty Commission 4 presents a novel approach, with a strong equity framing, to non-communicable diseases and injuries (NCDIs) of the global poor. The findings and recommendations of this Commission advance our knowledge and framing of these multifactorial conditions. This comprehensive report makes us listen to the voices of our poorest patients and brings into context data on what has been achieved and where the global health community and governments have failed in the past decade. The Commission's new analyses highlight the importance of moving from individual responsibility to multisectoral responsibility to address NCDI Poverty. Led by Gene Bukhman and Ana Mocumbi, the Commissioners' report proposes a fundamental shift from the prevailing global framing of NCDs, which focuses on five diseases and five risk factors, 5 to a broader set of conditions and risk factors among younger populations. The Commission challenges the current narrow framing of NCDs based on an outdated concept of epidemiological transition, 6 whereby these diseases only emerge with advancing age, increasing affluence, and urbanisation. As the global poor are mainly younger than age 40 years, many NCDs, such as rheumatic heart disease, congenital heart disease, and peripartum and other cardiomyopathies, lead to heart failure and premature death in young populations. 7 The authors call for Sustainable Developmental Goal (SDG) targets 3.1 on maternal mortality and 3.2 on under-5 mortality to be separated by causes of death to identify the role of specific underlying NCDs. Furthermore, SDG 3.4, which tracks deaths from cardiovascular disease, cancer, diabetes, mental ill-health, and chronic respiratory diseases only in individuals aged 30–70 years, needs to be expanded to encompass all ages, and other NCD causes. The Commission highlights inadequate development assistance for NCDIs. An important role has been assumed by the UN system, with WHO alone responsible for 20% ($164 million) of NCDI development financing in 2017, showing technical leadership in this field. 8 A key message of the report is that “international development assistance for health should be augmented and targeted to ensure that the poorest families affected by NCDIs are included in progress towards universal health care”. 4 The Commission's recommendations are addressed to national governments, ministries of finance, national civil societies, and research institutions, among others. Some of the key recommendations are aimed at making NCDI Poverty a global priority in the SDG area through national governments adjusting priorities-based approaches to best available local data on NCDIs, and the specific needs of the poor. Structural reforms for quality and innovations in integrated service delivery, including prevention, medical management, surgery, and palliative care at primary, secondary, and tertiary levels, are identified as one of the key priority areas for cost-effective intervention. Efforts to tackle NCDI Poverty also need to address the social determinants of health, such as improved housing, household energy, food security, education, and transportation. To facilitate these key recommendations, international development assistance for health should be substantially augmented with a focus on poor populations. The Commission highlights some progress made in the past few years in delineating NCDI burden, catalysing financing, and developing partnerships, such as the Disease Control Priorities Project 3rd edition 9 and the Commission launching an NCDI Poverty Network to focus on integrated delivery strategies for locally prioritised interventions. © 2020 Tommy Trenchard/Panos Pictures 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. Crucially, the Commissioners call for global solidarity to tackle NCDI Poverty and bridge a gap in universal health coverage, including access to surgery. There is increased awareness of the lack of access to cardiothoracic surgery in LLMICs. The formation of the Cardiac Surgery Intersociety Alliance, supported by global cardiothoracic societies, with the goal of consolidation of cardiac surgical efforts within LLMICs, is a promising move.10, 11 Multisectoral action against NCDIs will be crucial, involving ministries of health, finance, energy, transportation, and social protection, as well as civil society groups, research institutions, and professional organisations. An example of the part that professional groups can play is the 2020 joint statement of the World Heart Federation and the World Stroke Organization that called on governments to deliver radical shifts in public health policy to deliver progress on cardiovascular disease and stroke prevention. 12 The two organisations urged governments to move away from the approach of individual clinical risk factor screening towards investment in primary prevention at the population level. By placing all our bets on identifying and treating diseases of the circulatory system, we are missing the opportunity to intervene on their shared causes much earlier in the prevention timeline where the costs are lowest. In 2020, the global response to the COVID-19 pandemic could hold some lessons for tackling NCDIs. Many LLMICs responded swiftly to the pandemic and implemented measures, such as lockdowns, physical distancing, and use of face masks, much faster than some high-income countries. 13 The importance of community-appropriate advocacy to communicate public health measures became clear. 14 One example of swift government action is how South Africa implemented novel approaches, including a ban on the sale of tobacco and alcohol for some months followed by restricted access. 15 Although these measures led to reductions in road traffic crashes and crime, allowing the reprogramming of hospital beds to accommodate COVID-19 patients, they impacted negatively on the economy and the broader COVID-19 response disrupted some routine health services. 15 Importantly, the pandemic has exposed deep inequalities in our societies and the world's poorest are among those most severely impacted. As the Commission describes, projections of extreme poverty have increased because of the pandemic and about 71–100 million people, most in sub-Saharan Africa and Asia, are likely to be pushed into extreme poverty because of the COVID-19 pandemic. Action to address economic inequalities and improve the lives and wellbeing of the poorest billion must be at the heart of efforts to rebuild our societies. It is in all our interests to improve the world we share in terms of the prevention of disease and access to health care. The Commission's report provides a much-needed, comprehensive analysis of NCDI Poverty and the achievable key interventions to make a substantial change. It calls on all of us to build global solidarity. Overcoming NCDIs linked to poverty is not a gesture of charity. It is an act of justice.

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Global Burden of Cardiovascular Diseases: Part II: Variations in Cardiovascular Disease by Specific Ethnic Groups and Geographic Regions and Prevention Strategies

Salim Yusuf, Srinath Reddy, Stephanie Ôunpuu … (2001)

This two-part article provides an overview of the global burden of atherothrombotic cardiovascular disease. Part I initially discusses the epidemiological transition which has resulted in a decrease in deaths in childhood due to infections, with a concomitant increase in cardiovascular and other chronic diseases; and then provides estimates of the burden of cardiovascular (CV) diseases with specific focus on the developing countries. Next, we summarize key information on risk factors for cardiovascular disease (CVD) and indicate that their importance may have been underestimated. Then, we describe overarching factors influencing variations in CVD by ethnicity and region and the influence of urbanization. Part II of this article describes the burden of CV disease by specific region or ethnic group, the risk factors of importance, and possible strategies for prevention.

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The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion

Gene Bukhman, Ana O Mocumbi, Rifat Atun … (2020)

Executive summary “As we embark on this great collective journey, we pledge that no one will be left behind. Recognizing that the dignity of the human person is fundamental, we wish to see the goals and targets met for all nations and peoples and for all segments of society. And we will endeavour to reach the furthest behind first.” Transforming our world: the 2030 agenda for sustainable development 1 We live in an era of unprecedented global wealth. 2 Nevertheless, about one billion people in low-income and lower-middle-income countries (LLMICs) still experience levels of poverty that have long been described as “beneath any reasonable definition of human decency”, in the words of former World Bank president, Robert McNamara.3, 4, 5 This Commission was formed at the end of 2015 in the conviction that non-communicable diseases and injuries (NCDIs) are an important, yet an under-recognised and poorly-understood contributor to the death and suffering of this vulnerable population. 6 The aims of the Commission were to rethink global policies, mend a great disparity in health, and broaden the global health agenda in the interest of equity. There are ways, with demonstrated effectiveness in real-world conditions, to address the constellation of afflictions known as NCDIs. We have found, however, that the world's poorest billion are being systematically deprived of those life-saving and life-changing interventions. This unfair exclusion stems both from a lack of global solidarity with the poorest of the poor, and from inadequate descriptions and comprehension of the problem. NCDIs are commonly represented as complications of ageing and development. In fact, they also constitute a large and diverse burden of illness among children and young adults, who make up the largest proportion of people living in extreme poverty around the world. Public health discourse and global solutions have generally focused on preventing NCDIs through changes in human behaviours, and not on addressing the inadequate resources available for the poor to be properly nourished, live safely, and to access health care. Meanwhile, treatments for NCDIs account for the largest gap in health financing for LLMICs, making a mockery of international commitments to universal health coverage (UHC). Many of the established global initiatives and frameworks for health equity are relevant for the heterogeneous set of conditions that comprise NCDIs among the poorest billion, which we term NCDI Poverty. To date, none of these schemes have fully recognised the burden of NCDI Poverty or offered strategies to adequately mitigate its effect (figure 1 ). For instance, the Millennium Development Goals (MDGs) focused attention on the health of the poorest billion and went a long way toward addressing many of the underlying infectious and poverty-related causes of disease. 7 However, these goals did not respond to the specific epidemiology of NCDIs, nor to the complexity of prevention and treatment of these conditions. Likewise, the WHO Global Action Plans for non-communicable diseases (NCDs) focused initially on four major disease categories (cardiovascular disease, diabetes, chronic respiratory disease, and cancer) and four groups of associated risk factors (unhealthy diets, physical inactivity, tobacco use, and harmful use of alcohol), known as the 4 × 4 conditions. These are undoubtedly global concerns, but leave out key NCDI priorities for the poorest billion. 8 The 2030 Sustainable Development Goal (SDG) targets, adopted in 2017, have remained consistent with these global NCD plans while expanding the focus to include mental health, substance use, and road traffic injuries. 9 Although the Sept 27, 2018, UN High-Level Meeting on NCDs extended the NCD agenda to include mental health and air pollution (thereby extending 4 × 4 to 5 × 5), it is necessary to go further if we are to address the full scope of diseases that constitute NCDI Poverty. 10 UHC holds great promise, but it will fulfil the promise of universality only if its structure and implementation recognise and respond to NCDI Poverty.11, 12 Figure 1 Visualising NCDI Poverty The circle areas are drawn precisely to be proportional to the number of DALYs associated with each group of conditions globally. NCDI Poverty includes DALYs among the world's poorest billion people due to all causes of NCDIs. The area where the circles overlap represents the NCDI burden among the poorest billion that is due to the 4 × 4 NCD conditions, mental and substance use disorders, and road traffic injuries. The circle areas within the dotted line represent the total number of DALYs among the poorest billion. Original analysis using data from the Global Burden of Disease 2017. SDG=Sustainable Development Goal. NCD=non-communicable disease. NCDI=non-communicable disease and injury. MDG=Millenium Development Goal. DALY=disability-adjusted life year. *WHO 4 × 4 Global NCD Action Plan agenda includes cardiovascular disease, neoplasms, diabetes, and chronic respiratory disease. Key messages • For the poorest of our world, non-communicable diseases and injuries (NCDIs) account for more than a third of their burden of disease; this burden includes almost 800 000 deaths annually among those aged younger than 40 years, more than HIV, tuberculosis, and maternal deaths combined • Despite already living in abject poverty, between 19 million and 50 million of the poorest billion spend a catastrophic amount of money each year in direct out-of-pocket costs on health care as a result of NCDIs • Progressive implementation of affordable, cost-effective, and equitable NCDI interventions between 2020 and 2030 could save the lives of more than 4·6 million of the world's poorest, including 1·3 million who would otherwise die before the age of 40 years • To avoid needless death and suffering, and to reduce the risk of catastrophic health spending, essential NCDI services must be financed through pooled, public resources, either from increased domestic funding or external funds • National governments should set and adjust priorities based on the best available local data on NCDIs and the specific needs of the worst off • International development assistance for health should be augmented and targeted to ensure that the poorest families affected by NCDIs are included in progress towards universal health care Beginning in 2016, this Commission organised a team of 23 clinicians, researchers, and policy practitioners into four working groups with these objectives: to learn about the scale and pattern of the NCDI burden among the poorest; to identify priority interventions and delivery strategies to address this burden; to consider gaps and opportunities for NCDI financing in the countries where the poorest billion live; and to better understand the history and current state of NCDI framing and governance within key global institutions and at national levels. Since its inception, the Commission has convened five global meetings. It has helped to establish National NCDI Poverty Commissions and Groups in 16 LLMICs, involving more than 247 NCDI leaders, representing countries that are home to approximately half of the world's poorest billion people. The Commission has co-hosted five Knowledge Exchanges, bringing these National NCDI Poverty collaborators together both virtually and at World Bank offices of four continents. 13 Using videography, the Commission has documented the experience of over 40 patients with a diverse set of NCDIs from sub-Saharan Africa, the Caribbean, and South Asia. The Commission has also participated in developments that have substantially expanded the NCDI and UHC agendas over the past 3 years to include a broader range of conditions, risks, interventions, and people.14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 The Commission's working groups have developed six key messages based on original analyses of epidemiology, organisation of health interventions, financing, history, and governance (appendix p 3). The methodology behind the estimates used to support these messages and other findings and recommendations of the Commission is described throughout the report and in its appendices (panel 1 ). Panel 1 Key recommendations Local action • Ministries of health in high-poverty countries should partner with academic and civil society groups to assess their national non-communicable disease and injury (NCDI) poverty burden, identify priority conditions and interventions using multiple criteria (including equity and cost-effectiveness), estimate the cost and impact of action, to develop delivery strategies, and advocate for expanded domestic and external financial resources; these NCDI interventions include intersectoral policies, as well as surgical, medical, psychosocial, and rehabilitative services • National health statistics and surveillance should include information about socioeconomic status and a more diverse set of priority NCDIs • Governments should establish multi-sectoral mechanisms to coordinate the efforts of ministries responsible for energy, transportation, and social protection so that they consider the special vulnerability of those with severe NCDIs • National NCDI civil society organisations should make special efforts to channel the voices and priorities of the poor • National research institutions in high-poverty countries should stimulate investigation to fill knowledge gaps regarding the cost-effectiveness and equity of NCDI interventions and delivery model design • National professional societies should elaborate a scope of practice and develop career pathways for mid-level providers in priority NCDI service areas • Ministries of finance should increase fiscal space for health care through taxation of unhealthy products and progressive revenue collection mechanisms. Making NCDI Poverty a global priority in the sustainable development goal (SDG) era • Broaden the interpretation of the SDG NCDI targets to encompass reducing NCDI mortality at all ages and from all causes, with particular attention to reducing mortality under the age of 40 years • Disaggregate existing targets for reducing maternal and under-5 mortality by cause of death to highlight and address the role of NCDIs • Expand universal health coverage and monitoring to include interventions for less common and more severe conditions and those that cause the most lifetime loss of health • Disaggregate the existing SDG target for social protection to target poor and vulnerable people living with severe NCDIs • High-income countries should fully implement their development assistance commitments and renew their focus on the comprehensive health and social needs of the poorest people in the poorest countries, inclusive of NCDIs We have found that NCDIs constitute more than a third of the disease burden among the poorest billion, and that around half of this burden is due to causes afflicting children and young adults. Section 1 of this report—the burden of NCDI Poverty—describes the geographical and demographic distribution of the world's poorest people and characterises the magnitude and pattern of their NCDI burden. More than 90% of the poorest billion live in rural areas of LLMICs in sub-Saharan Africa and South Asia. More than half a billion people will probably still be living in extreme poverty until 2030. Some projections range as high as 1 billion, taking account of the adverse impact of climate change and inequalities in the distribution of economic growth. The COVID-19 pandemic is now pushing projections of extreme poverty even higher. The World Bank estimates that the pandemic will drive between 71 million and 100 million people into extreme poverty, 81% of them in sub-Saharan Africa and South Asia—the regions that are already home to more than 90% of the world's poorest billion people. 28 Around 80% of the poorest billion are aged younger than 40 years, and around 90% are younger than 55 years. Our analysis shows that NCDIs in these populations are due to a diverse set of conditions and risks. Notably, these conditions are heterogeneous in their effect on the lifetime health of those affected. Those NCDIs associated with the greatest health loss among the poorest billion result in the loss of 20 more years of healthy life per person than the same conditions in high-income populations. Much of this is because NCDIs among the poorest are acquired at younger ages (partly due to population age structure) and because NCDIs are more lethal when they occur among those living in extreme poverty with low access to quality health services. This Commission has identified a set of cost-effective and equitable interventions to address NCDI Poverty. Although global initiatives have largely focused on health behaviours, the interventions we have identified also have to be delivered through the health sector, including at secondary facilities (such as, district hospitals) to treat established disease. In section 2—integrating NCDI Poverty in UHC—we describe these interventions and show how they can be implemented at scale. Intersectoral strategies can prevent drowning, road traffic injuries, heart attacks, strokes, type 2 diabetes, chronic lung disease, and some cancers. Better housing, sanitation, transportation and energy infrastructure, and nutritious foods can relieve other social determinants of NCDI Poverty. We find that health-sector interventions to address NCDI Poverty are diverse and require integration both within and across levels of the health system. We introduce the concept that delivery of these interventions through integrated care teams can help drive transformative change to improve the quality of services in health systems. The resources being allocated to address NCDI Poverty are grossly insufficient. International development agencies have been the most neglectful. Section 3 of this report—financing to address NCDI Poverty—assesses the current state of both domestic and external NCDI financing in the LLMICs where the poorest billion live. Information from national health accounts suggests that government expenditure on NCDIs is low in these countries. Global development assistance for NCDIs has remained minimal, and little of this funding has been directed toward the poorest countries. The largest organisational channel for development assistance for NCDIs in 2017 was the WHO (US$164 million). The dismal projected financing capacity in many LLMICs will be inadequate to address NCDI Poverty by 2030 at current levels of development assistance for health. Because NCDIs are the largest unmet need in LLMIC health financing, expanding development assistance will be essential to achieving UHC in the poorest countries. There are no existing institutions focused on addressing NCDI Poverty at either global or national levels. Section 4 of this report—global and national policy, governance, and agenda-setting for NCDI Poverty—identifies opportunities to strengthen current health governance arrangements both globally and at the country level. We find that efforts to improve the health of the world's poorest people and to control NCDIs have largely run on parallel tracks over the past 40 years. Poverty-focused global and national health initiatives have concentrated on infectious diseases, and maternal and child health. Meanwhile, the influential NCD priorities at WHO, largely adopted by the World Bank and other global institutions, have focused on a narrow set of conditions and risks (4 × 4, then 5 × 5). In the SDG era, these two perspectives have continued to shape UHC monitoring, as well as investments from global multilaterals, development agencies, philanthropists, and national governments. The thinking behind these arrangements seems obvious if unacknowledged: poor countries must use their own meagre resources to deal with their health problems. We hope that the new evidence from this Commission offers an opportunity for the expansion of these frameworks so that NCDI Poverty can be honestly acknowledged and addressed. To tackle the current failure of reason and compassion, we offer seven recommendations for local action, based on our experience with National NCDI Poverty Commissions. We recommend the following: ministries of health in high-poverty countries should partner with academic and civil society groups to assess their National NCDI Poverty burden, identify priority conditions and interventions using multiple criteria (including equity and cost-effectiveness), estimate the cost and impact of action, develop delivery strategies, and advocate for expanded domestic and external financial resources; national health statistics and surveillance should include information about socioeconomic status and a more diverse set of priority NCDIs; governments should establish multi-sectoral mechanisms to coordinate the efforts of ministries responsible for energy, transportation, and social protection so that they consider the special vulnerability of those with severe NCDIs; national NCDI civil society organisations should make special efforts to channel the voices and priorities of the poor; national research institutions in high-poverty countries should stimulate investigation to fill knowledge gaps regarding the cost-effectiveness and equity of NCDI interventions and delivery model design; national professional societies should elaborate a scope of practice and develop career pathways for mid-level providers in priority NCDI service areas; and ministries of finance should increase fiscal space for health care through taxation of unhealthy products and progressive revenue collection mechanisms. A commitment to the treatment and prevention of NCDIs is enshrined in the SDGs. To ensure that this commitment does not bypass the poorest people in the world, a global NCDI Poverty Network is being established to support the implementation of this Commission's recommendations. Composed of a growing group of National NCDI Poverty Commissions, this Network will strive to catalyse financial and technical partnerships to implement pro-poor NCDI interventions in the countries where the poorest billion live. This Network, working closely with The Lancet and the NCD Countdown 2030, will also monitor and report on implementation progress, strengthening both national and global accountability mechanisms. In 2018, the Director General of WHO set an ambitious goal that would have an additional one billion people benefiting from UHC by 2023. 29 To fulfil the SDG promise –“to reach the furthest behind first”– 29 this billion should be the poorest billion. And, one of the greatest gaps in UHC for this population is NCDI Poverty. Some will question whether this Commission is urging leaders in LLMICs to place NCDI Poverty above other pressing health and social concerns, such as infectious epidemics. We are not. Instead, we are calling to expand the pro-poor agenda and mend a deep historical injustice. There is a need for greater resources for health (both domestic and external) to adequately address the obscene lack of care for NCDIs (and other conditions) among the poorest billion. The authors of this Commission are aware that an extraordinary global commitment will be required to realise our recommendations for redress and coverage. Based on our analyses, we believe it is crucial to articulate, defend, and advance these aspirations for global health equity. An introduction to NCDI Poverty On March 2–3, 2011—ahead of the first UN High-Level Meeting on NCDs—a conference hosted in Boston (MA, USA) focused on the NCDs of the world's poorest billion, whose poverty was embodied in young average age, low energy intake, and subsistence through physical labour. 30 Participants at the Boston event argued that global thinking about NCDs had been too focused on a theory of epidemiological transition, which projected epidemics of chronic disease associated with development. 31 This theory created a blind spot regarding the existence and pattern of non-infectious conditions before declines in infectious mortality (pre-transitional NCDIs). The poorest populations were still experiencing NCDIs as part of a nexus of hunger, toxic environments, infectious diseases, and lack of health care. The NCDIs that emerged under these circumstances were both more severe and more varied than could be captured by frameworks developed for other populations. In April, 2011, the WHO African Regional Office held a consultation of health ministers in Congo (Brazzaville). 32 The Brazzaville Declaration on NCDs called for an expanded NCDI agenda addressing haemoglobinopathies (sickle cell disease), mental disorders, and violence and injury. 32 Other prominent African health experts called for a 5 × 5 strategy inclusive of neuropsychiatric disorders and infectious risks.33, 34 In July, 2013, at a meeting in Rwanda, a group of NCD unit leaders from ten African ministries of health called for a complementary strategy for NCDIs. 35 This NCDI equity agenda focused on policies and integrated health-sector interventions to eliminate deaths among the poorest children and young adults (aged 30% of total household income). Furthermore, the odds of becoming impoverished due to out-of-pocket expenditures were over 30% higher for households affected by NCDs as compared with households affected by communicable diseases. The Nepal NCDI Poverty Commission used data from the 2010–11 Nepal Living Standards Survey to estimate the disease-specific impoverishing effects of NCDIs.205, 206 The Nepal Commission found that every case of cancer, high blood pressure, injuries, and heart, kidney, and liver disease could cause between 0·3 and 1·5 cases of poverty. At the population level, injuries, gastrointestinal diseases, and heart disease had the highest effect on impoverishment due to their prevalence. To reduce the risk of CHEs, essential NCDI services must be financed through pooled resources, either from increased domestic funding or external funds. High out-of-pocket expenditures for essential NCDI services create financial stress and are inefficient and inequitable. 207 Domestic charitable spending on NCDIs Domestic non-governmental sources of funding, such as local charitable organisations and local disease-specific foundations, provide diverse services in the countries where the poorest billion live, but documentation and independent evaluation are rare. Thus, it is not possible to access in a systematic manner the part that charities play in addressing NCDI Poverty, but examples suggest that they provide tertiary services that would otherwise be completely unavailable or unaffordable to poor populations. The Heartfile Health Financing programme in Pakistan, for example, has been able to channel individual philanthropic contributions towards patients in need of specialised surgical and medical care for NCDIs. 208 External financing for NCDIs and NCDI Poverty We examined trends in external financing for NCDIs in general, and more specifically for the share targeted to the 55 LLMICs where the vast majority of the poorest billion lives (figure 15 ). Drawing on data from the Institute for Health Metrics and Evaluation, we found that between 1% and 2% of total Development Assistance for Health (DAH) has been targeted to NCDIs since 2001. 209 Our analysis also shows that the poorest countries have received a small and shrinking fraction of the limited DAH that goes to NCDIs. In 2011, the year of the first UN High-Level Meeting on NCDs, only US$74 million in external financing for NCDIs was directed to the poorest countries. 209 This represented 14% of all global development assistance for NCDIs in 2011. Between 2011 and 2016, even as NCDs were adopted as priorities within the UHC and SDG agendas, the amount of external financing targeted for NCDIs in the poorest countries had increased to just US$83 million This represented only 10% of global development assistance for NCDIs, and approximately 0·3% of the US$24·6 billion in all country-allocable DAH in 2016. Figure 15 DAH going to poorest billion countries versus other countries by condition, 1990–2016 Data are from Institute for Health Metrics and Evaluation. (A) DAH to the poorest billion and other countries by condition (1990–2016). (B) Share of DAH going to the poorest billion countries by condition (2000–16). DAH=Development Assistance for Health. NCDs=non-communicable diseases. *US$ currency based on the 2017 exchange rate. To better understand how external financing has addressed the NCDIs of the poorest, we reviewed databases of donor funding for health to extract the amounts, sources, and destinations of NCDI funding from DAH for 2010–14 (appendix pp 103–105). There is little evidence that NCDI donors are targeting the poor in the poorest countries. Of the total DAH for NCDIs in 2014, 70% was not allocated to any specific country. Of the NCDI DAH that was targeted to specific countries in that year, US$68 million (6%) was allocated to one of the poorest 55 countries. 434 NCDI projects were identified in these countries, with a total budget of US$10 million that were explicitly targeting the poor. Projected financing capacity for NCDI Poverty in LLMICs Currently, there is a large gap between the cost of implementing the package of EUHC interventions (as defined by the DCP project) and available health financing capacity in the poorest countries (figure 16 ). Including both government and out-of-pocket expenditures and external financing, the poorest countries (except for a few, such as Rwanda) are not spending enough on health to fully finance the EUHC interventions to address infectious diseases and RMNCH issues. NCDI interventions are an additional opportunity that is currently out of reach for all but a handful. Figure 16 Projected health financing capacity* versus essential EUHC† costs in the poorest billion countries, 2017–30 Data are from Global Health Expenditure Database, 169 Overseas Development Institute, 210 and World Bank. 4 GDP=gross domestic product. EUHC=essential universal health coverage. UHC=universal health coverage. *Baseline includes government health financing plus external health financing. Projection includes constant external health financing. Government health financing increases as a function of GDP growth and linear increases up to potential additional revenue generation and to government expenditure on health of 15% of revenue. All estimates are based on 2017 GDP and current US dollars. †EUHC consists of interventions included in a model benefits package defined by the Disease Control Priorities Network as essential for achieving UHC and appropriate to the health needs and constraints of low-income and lower-middle-income countries. ‡Estimates for 52 poorest billion countries (27 lower-income countries and 25 lower-middle-income countries) for which data are available. The poorest billion countries are characterised by having at least one sub- national region where over 25% of the population are deprived of five or more of eight non-health, multi-dimensional poverty indicators. We have made projections until 2030 to understand the potential health financing capacity that could be available to countries as a result of economic growth and renewed domestic commitments even if external financing remains constant (figure 16 and appendix pp 106–108 [where we also provide country-specific estimates]). A range of plausible rates of per capita GDP growth during this period were considered.4, 211 We linearly scaled the rates of revenue generation from domestic taxation for each country based on estimates of taxation potential from the Overseas Development Institute. 210 Additionally, we scaled the proportion of government expenditure devoted to health up to 15% for all countries. 212 We found that, on average, both low-income and the poorest lower-middle-income countries have an opportunity to finance the US$32 to US$36 per capita estimated cost of essential interventions for infectious disease and RMNCH from domestic sources by 2030 even if external assistance remains constant. 210 Additionally, the poorest lower-middle-income countries might have an opportunity to finance essential NCDI interventions from additional domestic sources by 2030. However, these countries will struggle unless economic growth is strong, they are able to increase taxation, and they allocate a greater fraction of government expenditures to health. Even under highly optimistic scenarios, low-income countries and the poorest lower-middle-income countries will have a large gap in health financing capacity for NCDIs without additional development assistance (appendix pp 106–108). Section 4: Global and national policy, governance, and agenda-setting for NCDI Poverty In previous sections of this report, evidence about the importance of a diverse collection of NCDIs among the world's poorest billion people (NCDI Poverty) has been presented. Much of this burden has been shown to be among children and young adults and is avoidable through cost-effective interventions both within and outside the health sector. Additionally, the cost of these interventions collectively exceeds available resources in the countries where the poorest billion live. Without global solidarity, there will continue to be much unnecessary death, suffering, and impoverishment. This Commission may lead to a greater insight into the nature of NCDI Poverty. However, the Commission will only be successful if it convinces global actors and national governments to contribute to the health of the poorest on a greater scale, consistent with country priorities. Theories of political priority for movements in global health have focused on the importance of ideas and issue characteristics in addition to the strength of actors and the political contexts in which they operate.213, 214 In this section of our report, we seek to understand how NCDI Poverty has been addressed in global and national health and development policies, plans, targets and frameworks. We also seek to explore how issue framing might have contributed to the neglect of NCDI Poverty in global and national health and development agendas and resourcing. The UN system has been singularly important for global NCDI policy and governance. In 2017, WHO alone commanded 20% (US$164 million) of all NCDI development financing globally, more than any other single entity. 169 The World Bank had the second largest share (US$93·7 million in 2017), but most (78%) of this financing is provided at nearly commercial terms. In the context of otherwise extremely low amounts of development assistance for NCDIs (as discussed in section 3), WHO's resources enable it to play crucial normative, standard-setting, and convening functions. The dialogues, consultations, conventions, regulations, guidelines, and recommendations for public health policy that WHO produces–which are adopted and adapted by its 194 member states–are the means through which it fulfils its technical leadership role in health. We have reviewed the history of NCDIs within WHO and the World Bank have been reviewed using archival documents and interviews. To track the evolution of NCDI framing and policies at WHO, we examined approximately 500 documents from the WHO archives, as well as more than 450 published WHO documents, including official histories and technical report series. We conducted semi-structured interviews with four living former directors of the NCD units at WHO. Policy documents and assessments of the World Bank's engagement with global health over the same period were reviewed. The influence of NCDI framing at these two entities within the UN system on the discourse of other global actors were analysed through document reviews and key informant interviews (appendix pp 109–115). The influence of global NCDI frameworks on national policy in countries where the poorest billion live was evaluated. We find that, over the past 40 years, NCDI efforts in the UN system have been on a parallel track, separate and disconnected from the agenda to address the health of the poorest billion (figure 17 ). The agenda for the poorest billion, embodied by the MDGs, has been largely concerned with priority infectious diseases, maternal, and child health. Meanwhile, an agenda for NCD prevention and control was developed in WHO's European regional office in the late 1970s, and was later applied in low and middle income countries, based on a shared, common risk factor framework and consistent with increasingly popular theories of epidemiological transition. These NCD frameworks grew out of efforts to control cardiovascular disease and stroke in high-income countries, and increasingly replaced the broader understandings of NCDIs prevalent at WHO headquarters in earlier decades. This approach to NCDs was crystallised during the first UN High-Level Meeting on NCDs in 2011 in the 4 × 4 (four diseases and four risk factors) concept and its associated monitoring framework and best buys. Figure 17 NCDs and the poorest billion on two separate tracks (1948–2015) UHC=universal health coverage. SDGs=sustainable development goals. WHO EURO=WHO Regional Office for Europe. HICs=high-income countries. LMICs=low and middle income countries. NCDs=non-communicable diseases. In the SDG era, this legacy NCD framework continues to shape how NCDIs are understood by global multilaterals, development agencies, and philanthropists. At the same time, institutions designed to support the MDG agenda (such as the US President's Emergency Plan for AIDS Relief and the Global Fund to Fight AIDs, Tuberculosis, and Malaria) continue to channel the flow of most DAH. We found some modest indications from key informant interviews that reframing NCDI Poverty in terms of a broader range of severe conditions affecting children and young adults might shift the global financing landscape (appendix pp 104, 105). We find that NCDI Poverty Commissions are prioritising a broader range of interventions addressing a larger set of conditions than those identified among the global best buys. These interventions include treatment to manage (and in some cases cure) existing NCDIs using platforms at primary, secondary, and tertiary levels of the health system. Our analysis suggests that the SDG era has sustained a compromise wherein development assistance continues to provide catalytic funding for the MDG agenda for the poorest (although inadequately), while even low-income countries are expected to finance NCDI prevention from domestic resources. At the moment, external financing to treat NCDIs among the poorest children and young adults isn't even on the table. In part, global actors can claim that they are responding to country priorities.32, 195, 196, 197 At the same time, the countries in which the poorest billion live have not had the resources to define their NCDI priorities based on country-level data and ethical principles. As a result, there has been a vicious cycle in which neither national planning nor global strategies are fully addressing NCDI Poverty. The NCDI Poverty gap at global institutions On the eve of the UN SDG summit, a group of prominent health economists suggested that NCDIs should not yet be considered a priority for a “pro-poor pathway to UHC as an essential pillar of development”.215, 216 Writing in The Lancet, the economists declared that, “Our generation has a historic opportunity to achieve a grand convergence in global health, reducing preventable maternal, child, and infectious disease deaths to universally low levels by 2035”; reductions in preventable NCDI deaths were notably absent from the envisioned grand convergence. The tracks for the poorest billion and the NCDI agenda appeared to be distinct and parallel going into the SDG era. The 2011 UN High Level Meeting had assured that NCDs would be included in early 21st century global health priorities. But by importing 20th century chronic disease frameworks, the meeting also reinforced a prevailing NCDI Poverty gap. This Commission has worked to understand how the NCDI framing that developed within the UN system over the past 40 years has influenced the prioritisation and agendas of global institutions during the SDG era. We focused on those institutions that have an out-sized role in DAH as a proxy for their influence regarding policies for health, poverty reduction, and economic development. Institutions reviewed in our analysis included: multilateral health and development organisations, bilateral funders, and corporate and family foundations (appendix pp 110–116). In total, we examined 35 entities, and extracted textual mentions of NCDIs and risk factors, as well as text that discussed health equity, prioritisation of poor populations, and financial and social risk protection (figure 18 ). To the extent that they have addressed NCDs at all, we found that all of the global multilaterals and bilateral institutions, without exception, have adopted the 4 × 4 framing and the emphasis on health promotion and prevention of WHO's Global NCD Action Plan as the foundation of their approach to NCDIs. Although most of these institutions focus on poverty reduction as a priority, none of them identify NCDIs as either a cause or a consequence of extreme poverty to be addressed as a priority within the poverty eradication agenda. Figure 18 NCDI framing and population focus of global institutions Each circle represents one of the 35 organisations included in the policy review. Representative quotations from selected organisations are presented in this figure. A full list of organisations included, and documents reviewed is presented in the appendix (pp 110–16). LMICs=low and middle income countries. NCD=non-communicable disease. NCDIs=non-communicable disease and injury. SEARO=WHO Regional Office for South East Asia. AFRO=WHO Regional Office for Africa. GIZ=German Development Agency; Deutsche Gesellschaft für Internationale Zusammenarbeit. Regional institutions located in parts of the world with large concentrations of people living in extreme poverty have built and expanded on the 4 × 4 foundation to address other conditions and risk factors that disproportionately affect the poor. WHO regional offices in Africa and South East Asia, for example, discuss the four main diseases and risk factors with a focus on preventive health services, but also address other conditions and risk factors that are important in their regions. The Brazzaville Declaration, adopted by the WHO African Regional Office in advance of the 2011 UN High Level Meeting, emphasised the importance of “haemoglobinopathies (in particular sickle cell disease), mental disorders, violence and injuries, oral and eye diseases in the WHO African Region”. 32 Similarly, the WHO South East Asia Regional Office noted that “in addition to the four main NCDs, many other chronic conditions and diseases contribute significantly to the NCD burden in the Region” and highlighted the importance of infectious and environmental risks such as indoor air pollution. 96 Most of the corporate and family foundations that are influential in global health and development do not address NCDIs broadly as a category in their strategies and policies. With one notable exception, the large corporate or family foundations that do fund NCD programmes typically target specific conditions or risk factors, such as mental health, injuries, vision disorders, tobacco control, or road safety, without mentioning NCDIs as a group. The exception is Bloomberg Philanthropies. In its 2018 annual report, Bloomberg Philanthropies introduces its health programme by stating, “The Public Health program combats noncommunicable diseases and injuries by spreading solutions that are proven to save lives”. 217 The Bloomberg Philanthropies public health programme strategy aligns closely with the 4 × 4 framing and health promotion and prevention best buys of the Global Action Plan. The strategy features programmes to control tobacco use, prevent obesity, and improve road safety, as well as a leading role in the Resolve to Save Lives initiative to combat cardiovascular disease through treatment of high blood pressure and promotion of healthy diets. 218 Our analysis suggests that even global institutions with a focus on extreme poverty have tended to adopt an approach to NCD framing (4 × 4) that was historically developed by and for high-income regions. The lack of global resource mobilization for NCDI Poverty might be due, in part, to the way the full scope of this issue has been made invisible in current framing of the NCD agenda and its propagation through development and philanthropic institutions. NCDIs in national planning in the poorest countries As we had done with the global institutions, we sought to understand whether and how NCDI framing within the UN system has shaped health sector and poverty reduction planning in the countries where the poorest billion live. Since 2003, four high-level forums on aid effectiveness have emphasised the importance of alignment of development assistance around country-owned priorities.195, 196, 197, 219 National strategic planning should be guiding international cooperation and aid on NCDIs. Instead, our analysis suggests that the opposite is happening in practice: international frameworks are being replicated in the poorest countries even when these frameworks were not developed in response to local disease patterns and concerns. Additionally, at a national level, NCDI planning and anti-poverty strategy continue on the parallel tracks laid globally: NCDI Poverty in not being addressed in poverty eradication and sustainable development plans. Both National NCD Strategic Plans (NCDSPs) and Poverty Reduction Strategy Papers (PRSPs) were examined from LLMICs with at least one major sub-national region with more than a 25% prevalence of extreme poverty by multidimensional measures. NCDSPs are the country-owned planning documents that set out national priorities and resource needs for NCDI control–typically for a 5-year period–consistent with broader health-sector strategic plans. 220 Countries committed to developing NCDSPs during the first UN High-Level Meeting on NCDs in 2011, and again during the second High-Level Meeting on NCDs in 2014. 221 In advance of the third UN High-Level Meeting on NCDs in 2018, the Secretary General reported that 48% of UN member states had developed these plans. 222 PRSPs are country-owned planning documents that identify operational strategies and resource requirements for poverty reduction. Between 1999 and 2015, PRSPs were prepared by the poorest countries every 3 years to qualify for concessional lending from the World Bank and the International Monetary Fund.223, 224 PRSPs have since been replaced by sector-specific lending frameworks, but remain a valuable record of how health-sector interventions have been positioned as part of poverty eradication. We were able to identify the most recent publicly available NCDSPs from 27 of the poorest LLMICs that collectively were home to 47% of the world's poorest billion population (appendix pp 117–124). We also identified publicly available PRSPs prepared by 29 of these countries since 2000 (appendix pp 125–127). We analysed what NCDI conditions, risk factors, and interventions were discussed in these documents. What we found suggests that health sector policymakers in most countries recognise the importance of conditions and risk factors not targeted in GMFs. However, these countries have also largely adopted the voluntary targets and best buys of the 2013 Global NCD Action Plan (GAP) and GMF as the foundation of their NCD strategies.8, 95 Adherence to the 4 × 4 framework, GAP targets, and best buys was all but universal in the PRSPs. An expanded NCDI situation with a 4 × 4 monitoring framework in national NCD planning Our review of NCDSPs suggests that most countries' national NCD strategies have been strongly influenced by and oriented toward the NCD agenda advanced in WHO's Global NCD Action Plans and adopted in the SDGs. Most of the plans explicitly reference the 2011 High-Level Meeting on NCDs and WHO's 2013 GAP and GMF.8, 95 With a single exception, all of them discuss all four of the main disease categories that are included in the 4 × 4 framework and highlighted in the mortality reduction targets of the GPA and the SDGs. More than half discuss specific conditions within each of the categories, but only one other NCD condition–sickle cell disease–is mentioned by as many as half of the countries. Adherence to the framing and targets of global monitoring frameworks is even more pronounced in the NCD risk factors that are discussed in these NCD Strategic Plans. More than 80% of the plans reviewed explicitly discuss all four of the behavioural risk factors that define the 4 × 4 framework and are featured in the GMF's nine voluntary targets. The only other risk factors mentioned in more than half the plans are the four metabolic risk factors that are also included in the GMF's nine voluntary targets and 25 indicators. Most of the NCDSPs do recognise other conditions and risk factors that are important to the NCDI burden of their populations. More than three-quarters discuss injuries, and two-thirds include mental health and substance use disorders, anticipating the expanded 5 × 5 definition of NCDs adopted at the UN High-Level Meeting in 2018· 10 Most of the plans reviewed also address other NCDs that do not fall within the four main disease categories. More than 40% of these poorest billion countries discuss sickle cell disease and epilepsy. In addition, many of the specific conditions within the four main disease categories that are mentioned are not associated with the shared behavioural risk factors of the 4 × 4 model, including cervical cancer, rheumatic heart disease, and asthma, all of which are mentioned in more than 40% of the plans. Notably, these same conditions were also highlighted by our analysis of the severe NCDs that disproportionately affect the poorest billion and were prioritised by national NCDI Poverty Commissions that have completed their analyses. We did a deeper analysis of the 21 NCDSPs that included both situation analyses and frameworks for monitoring implementation and progress (appendix pp 117–124). Conditions and risk factors mentioned in background narratives were compared with those included in implementation monitoring frameworks. Our analysis found that although these countries discuss a broad range of conditions and risk factors in narrative situation analyses of their NCDI burden, the only conditions and risks included in 50% or more of the monitoring frameworks are the four main disease categories, plus six behavioural and metabolic risk factors that are included in the voluntary targets and indicators of WHO's Global Monitoring Framework. NCDIs and poverty eradication on separate tracks in national poverty reduction planning To understand how NCDIs are being framed as part of poverty eradication in the countries where the poorest billion live, we analysed PRSPs publicly available through the International Monetary Fund. As was the case with the NCDSPs, our analysis strongly suggests that the 2011 UN High-Level Meeting prompted these countries to include some mention of NCDs. This suggests that global political processes can have an effect on national agendas. At the same time, our analysis of the PSRPs suggests that in the SDG era, countries are continuing to view NCDIs as part of a health agenda that is separate and distinct from the health priorities of the poorest and from strategies for poverty eradication. Very few (only 3 of 14) of the PRSPs prepared before 2011 and the UN High-Level Meeting mention NCDs. Almost all (11 of 15) of those published after 2011 do mention NCDs. Those that do include a discussion of NCDs generally used the term generically, often referring to the category as an emerging problem, or specifically mentioned some or all of the four main disease categories and risk factors of the 4 × 4 framework. Many of the PRSPs included a discussion of mental health disorders. Consistent with the Brazzaville Declaration, several of the African countries also addressed sickle cell disease. Of the 29 PRSPs reviewed, none propose to undertake and monitor interventions specifically to address NCDIs among the poor (appendix pp 125–127). NCDI Poverty Commissions: expanding NCDI frameworks with a focus on the poorest To enable the countries where the poorest billion live to end the neglect of NCDIs, this Commission has supported National NCDI Poverty Commissions in LLMICs with a high prevalence of extreme poverty. As of August, 2020, 16 National NCDI Poverty Commissions have been established in the following countries: Afghanistan, Ethiopia, Haiti, India (Chhattisgarh State), Kenya, Liberia, Madagascar, Malawi, Mozambique, Nepal, Rwanda, Sierra Leone, Tanzania, Uganda, Zambia, and Zimbabwe (appendix pp 128, 129). Ten other countries in sub-Saharan Africa, Asia, and Latin America responded in July, 2020, to a Request for Applications for technical and financial support in establishing new National Commissions. Collectively, these Commissions already represent around half the world's poorest billion people. We hope that these National Commissions will break the cycle in which neither national planning nor global agendas are fully addressing NCDI Poverty. The composition of these National Commissions has mirrored The Lancet NCDI Poverty Commission, with around 10–20 members and co-chairs typically representing an academic institution and the Ministry of Health. In addition to regular meetings within country to develop and review analyses and recommendations, leadership from these Commissions participated in teleconference Knowledge Exchange meetings, co-hosted by the World Bank. 225 The initial work of these National Commissions has been focused on situation analysis and priority setting. Seven of the National Commissions have completed this work, and three have moved on to a second phase, focused on: the strategic dissemination of key findings and recommendations to elevate NCDI Poverty as a priority for national policies and financing; and the design of integrated delivery strategies for prioritised interventions. We hope that these National Commissions will move on to pilot the implementation of these delivery models and ultimately to national scale-up with the support of financial and technical partnerships (figure 19 ). Figure 19 National NCD Poverty Commission process This diagram depicts the conceptual and analytic framework for the work of National NCDI Poverty Commissions and Groups. The blue boxes represent processes while all the other boxes represent inputs and outputs. The dotted boxes indicate inputs that are being developed and tested. The dashed boxes indicate processes that are being developed and tested. Each Commission and Group adapts and implements the process to align with local conditions, needs, and available resources. As of August, 2020, 11 commissions have completed phase 1A of the process, nine have completed both phases 1A and 1B, and seven have published and launched reports presenting their phase 1 findings and recommendations. Three Commissions have initiated phase 2 activities. NCDI=non-communicable disease and injury. UHC=universal health coverage. HRH=human resources for health. GDP=gross domestic product. DAH=Development Assistance for Health. HR=human resources. The goals of the first phase of the National Commissions have also mirrored this Commission: analyse and highlight the national NCDI burden of disease, particularly in relation to poverty; understand the availability and coverage of NCDI services in the health sector; prioritise among conditions and interventions to address the NCDI burden, taking into account, at a minimum, both cost-effectiveness and equity (by giving some priority to the worst off in terms of both material poverty and disease severity); estimate the cost and potential impact of prioritised interventions; and forecast potential fiscal space to afford these interventions. Eight of the National Commissions (Afghanistan, Ethiopia, Haiti, Kenya, Liberia, Malawi, Mozambique, and Nepal) have already completed some or all this first phase of the Commission process and have published their initial reports. The Ethiopia Commission offers a good example of National Commission development in Africa (panel 11 ) and the Nepal Commission offers a good example from South Asia (panel 12 ). Panel 11 The Ethiopia NCDI Poverty Commission In August, 2016, Ethiopia established a National NCDI Poverty Commission with 18 members drawn from government, academia, and civil society, and a mandate to build the country's NCDI evidence base, and to create a forum for applying fair priority-setting principles through an accountable process. The Commission held five additional meetings before publishing its final report in November, 2018. 226 The Ethiopia Commission pursued a three-step priority-setting process based on WHO recommendations to consider cost-effectiveness, priority to the worse off (equity), and financial risk protection. 115 Step 1 was to identify relevant services and evidence. The Ethiopia Commission began with a list of NCDI services judged to be essential by the Disease Control Priorities 3rd edition (DCP3) project 227 and adapted it for the Ethiopian context. Each intervention was graded for cost effectiveness (based on evidence from DCP3 and available country-specific estimates), equity (based on estimates of lifetime loss of health due to specific causes), and financial risk protection.228, 229 Step 2 was to select the highest priority set of NCDI services. To determine which interventions to include, the Commission first ranked the list based on incremental cost-effectiveness and then adjusted it according to expected impact on equity and financial risk protection. Step 3 was to estimate costs and fiscal space. Costs were estimated using the OneHealth Tool (version 4.5) with most services scaled by 25% over the period from 2019 to 2023. Considerations of fiscal space suggested that incremental costs for NCDIs could not exceed around US$5 per capita (about 17% of total government health expenditure). By 2022, the incremental cost of the prioritised set of NCDI services would be around US$550 million, corresponding to US$4·7 per capita. The final list of prioritised NCDI services included 90 health-sector interventions, including palliative care, human papillomavirus vaccination, treatment of acute pharyngitis, chronic management of rheumatic fever, depression, those at high cardiovascular risk in the community; general surgery and chronic management of type 1 diabetes, heart failure, and psychosis at first-level hospitals; and surgery for congenital conditions, as well as chemotherapy for selected cancers at referral hospitals. Panel 12 The Nepal NCDI Poverty Commission Nepal established a National NCDI Poverty Commission in 2016 with a mandate to analyse the state of non-communicable diseases and infections (NCDIs) in Nepal and to recommend a package of cost-effective health sector interventions addressing the NCDI burden, with an emphasis on conditions affecting the poor in Nepal. The Commission convened its first meeting in November, 2016, and completed phase 1 of the National Commission Process—situation analysis and priority setting—over the next 18 months (figure 19). In March, 2018, the Commission published a report presenting its findings and recommendations. 230 The Commission found that NCDIs account for nearly two-thirds (65%) of the burden of disease in Nepal and that more than half of the NCDI conditions with the highest burden of disability-adjusted life-years (DALYs) in Nepal are not related to the 4 × 4 risk factors that have been emphasised by global monitoring frameworks and action plans. Their analysis also determined that, with the notable exceptions of diabetes and high blood pressure, the prevalence of many NCD categories was highest among the poorest quintiles of the population. To establish priorities for conditions and interventions, the Commission first ranked all NCDI conditions based on their overall health impact (total DALYs) and prevalence in Nepal. They then evaluated each condition for severity, inequity in outcomes between those who are poor and not poor, and impoverishing impact, to arrive at a list of 25 conditions requiring priority attention. To identify interventions to address this burden, the Commission worked from the Disease Control Priorities 3rd edition package of cost-effective interventions to achieve universal health coverage (UHC) in low-income countries. 23 of these interventions were selected for further evaluation based on their alignment with the disease conditions prioritised by the Commission, feasibility in the Nepali context, cost-effectiveness, financial risk protection, and equity. If these interventions are introduced and incrementally intensified to establish UHC, the Commission estimated that nearly 10 000 premature deaths per year could be averted by 2030, with an increase in costs of approximately US$8·76 per capita. In June, 2018, the Commission initiated work on phase 2 of the National Commission Process. The Commission's key objectives for this second phase include: disseminating the findings in the Commission report, determining the readiness of the Nepal Government to incorporate the recommendations of the report, critically analysing NCDI poverty issues among children and young adults, and developing and piloting models for integrated delivery of prioritised NCDI services. These Commissions prioritised a wide range of interventions, spanning prevention, medical management, surgery, and palliative care at primary, secondary, and tertiary levels (panel 13 ). The National NCDI Poverty Commissions have been focused primarily on interventions that can be delivered through the health sector. Many of these Commissions also recommended health promotion through intersectoral interventions. In this way, the National NCDI Poverty Commissions have offered a complementary agenda to the one identified in the WHO Global Action Plan for NCDs and its best buys, which have been primarily focused on policies to address behavioural risk factors for NCDs (figure 20 ).8, 196 Panel 13 Voices of NCDI Poverty Estifanos Balcha, type 1 diabetes, 20 years old (Ethiopia) * “I have type 1 diabetes, the kind you need insulin for. I used to be a street kid, though my parents are alive. My father is with someone else and my mother is with someone else. And they both see me as a bastard child. From the age of 6 to 13, I lived on the street. Getting food was difficult at times. When my sugar used to drop, I used to steal soda to get it up. While I was taking insulin, I used to sniff glue, smoke hash, hookah, cigarettes. I drank different kinds of alcohol. All this to forget my problems. On top of that, I didn't have anywhere to put my medicine. So I used the refrigerator in various stores. I didn't always take my medicine appropriately. I used to mess up the time, and sometimes I just didn't care.” At the age of 6 years, Estifanos Balcha was forced to fend for himself on the streets of Addis Ababa, Ethiopia. His parents had separated and neither of them wanted to take responsibility for a child with type 1 diabetes—a disease that is costly to treat and usually fatal for children in low-resource settings. “When I turned 16, I started to work. I looked for odd jobs so that I could earn money to pay for transportation to the doctor. But it was tough, so I tried to leave and go to Kenya. That didn't work, so I tried to leave for Sudan. I wasn't able to leave the country. But that's OK. Those experiences got me here.” The “here” Estifanos refers to is the Ethiopian Diabetes Association, where Misrak Tarekegn serves as the Project Director. The Association provides treatment and education for Estifanos and over 200 other children with type 1 diabetes. As Misrak explains: “The fact that diabetes and other non-communicable diseases have not gotten the same prioritization [as HIV, TB, and malaria] will always be an obstacle for our work. So what we want to tell the government is, even if their numbers are only 10 or 5 percent, each life has value.” Estifanos has his own message for the government and for the world: “The government must get involved with this issue. Let them get involved. Let them say, ‘We are here,’ so that we can have hope. I really…I really…I really have to pass this message on.” Figure 20 Global Action Plan best buys and prioritised interventions of National NCDI Poverty Commissions: a complementary agenda HPV=human papillomavirus. COPD=chronic obstructive pulmonary disease ACEi=angiotensin converting enzyme inhibitors. In the second phase of National Commission work, countries are investigating how to implement prioritised interventions through integrated delivery strategies. This work involves a baseline assessment of health system team structure, followed by recommendations for redesign of services to improve quality and access through optimal task distribution. Acting on these recommendations will require initial implementation at pilot training sites, followed by national scale-up with financial and technical support. As discussed in section 3 of this report, the cost of increasing coverage of these prioritised interventions exceeds available fiscal space in the poorest countries. Modest progress may still be possible in countries able to commit more domestic resources to health, but for many more there is an urgent need for global solidarity. Section 5: Making room for NCDI Poverty in the UHC agenda in the SDG era This Commission has analysed the pattern of the NCDI Poverty burden, identified priority interventions to address this burden, and documented gaps in NCDI Poverty financing and governance at global and national levels (panel 14 ). In this section, we make recommendations to address NCDI Poverty in the UHC agenda in the poorest countries, in SDG monitoring, and, in conclusion, as an imperative for global solidarity. These recommendations are based on our analysis and experience with NCDI Poverty Commissions and Groups. Panel 14 Key findings The burden • The burden of non-communicable diseases and injuries among the poorest billion (NCDI Poverty) is a major cause of death and suffering; compared with high-income populations, the poorest billion suffer higher morbidity and mortality from NCDIs at every age • Half of the total NCDI Poverty burden (49%) is avoidable in principle as compared with high-income regions, resulting in 2·4 million avoidable deaths and 93·8 million avoidable disability-adjusted life-years every year among the poorest billion • More than half of this avoidable NCDI Poverty burden is accrued before the age of 40 years and more than a third (39%) is accrued before the age of 20 years because death rates for conditions affecting these ages are much higher in the poor than in high-income regions Interventions • There are highly cost-effective and equitable interventions to address NCDIs; these interventions include medical, surgical, psychosocial, and rehabilitative services to treat a wide range of conditions, and are not limited to prevention alone • Addressing NCDI Poverty is one of the greatest benefits that could be realised by universal health coverage (UHC) • Integrated care teams may be helpful to deliver clusters of related health-sector interventions based on shared provider competencies and common patient characteristics • The introduction of NCDI interventions is an opportunity to build durable health institutions at primary, secondary, and tertiary levels of the poorest countries, but will only translate to health gains if accompanied by structural health system reforms to raise quality Financing • Adequate resources for NCDI interventions could bridge one of the largest gaps in UHC for the poorest billion; NCDIs account for 60–70% of the UHC financing needs in the low-income and lower-middle-income countries where the poorest billion live • Not enough is known about domestic financing directed toward NCDIs in these countries, but there is evidence that it is low; among low-income countries for which data are available, government health expenditures on NCDIs average only US$1·90 per capita • High out-of-pocket expenditures for essential NCDI services are inefficient and inequitable • Between 2011 and 2016, the fraction of development assistance for NCDIs (US$532 million in 2011) that was allocated to countries where the poorest billion live declined from 14% (US$74 million) to 10% (US$83 million), representing just 0·3% of a total of US$24·6 billion in all country-programmable health aid • Given very low national incomes in most of the poorest countries, UHC financing from domestic revenue sources will be insufficient to address NCDI Poverty by 2030 unless supplemented by increased external financing Governance • Over the past 40 years, NCDI efforts in the UN system have been on a parallel track, separate and disconnected from the agenda to address the health of the poorest billion • The UN's Sustainable Development Goals currently focus on three sets of NCDI conditions: cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes between the ages of 30 and 70 years; mental illness; and road traffic injury, failing to address the full scope of the diverse NCDI Poverty • At a national level, NCDI planning and anti-poverty strategy largely continue on the parallel tracks laid globally: NCDI Poverty is not being addressed as a priority in national planning for NCDs, poverty eradication, or sustainable development National NCDI Poverty action in the poorest billion countries By our calculations, in 2015 there were at least 55 LLMICs that had sub-national regions with more than 25% extreme poverty (section 1). These countries vary in their national prevalence of extreme poverty from 3·6% in Indonesia to 89% in South Sudan. We have found that many of these countries are already taking steps to address their NCDI burden with equity, but all should be made aware of the potentially distinct epidemiology, diversity, and effect of NCDIs among their poorest populations. Important actors in these countries include governments, professional societies, academics, and civil society organisations. In this section, we will direct our call to action, seven sets of specific recommendations, to each of these groups in turn. National governments National governments are ultimately accountable for protecting the poorest populations from the effects of NCDIs on health and financial wellbeing. Many countries have established NCD units in their ministries of health and have developed NCD strategic plans. Some have initiated partnerships to increase the quantity and improve the quality of their specialised health-care workers. Others have begun to progressively decentralise integrated NCDI interventions. Few poorest billion countries, however, have set NCDI priorities based on both a systematic review of local epidemiological data disaggregated for poverty and an intervention assessment process that takes into account both cost-effectiveness and equity. In the absence of such a process, national plans risk repetition of global or regional frameworks without regard for local epidemiology and values. Revenue generating or budget neutral intersectoral policies are important and insufficiently implemented. Many of the countries where the poorest live have very low levels of service availability to address these conditions beyond major referral centres in national or regional capitals. Local action and experimentation will be necessary for any effective response to NCDI Poverty. Here, we have focused on national governments as levers of change. First, we recommend that ministries of health in high-poverty countries consider partnering with academic and civil society groups to establish national or sub-national NCDI Poverty Commissions. As shown in the eight countries where commissions have completed the first phase of their process, these commissions can inform future NCDI policies and strategies, and help bring NCDI Poverty into focus as a priority for national NCDI implementation and global cooperation. These commissions have assessed the national NCDI burden, identified intervention priorities using multiple criteria (including equity and cost effectiveness), estimated the cost and effect of increased intervention coverage, advocated for expanded financing to reduce reliance on out-of-pocket payments for funding of priority NCDI interventions, and initiated efforts to develop integrated delivery strategies. In some countries, this analytical work focused on NCDI Poverty could be undertaken through existing national NCD coordination bodies such as technical working groups, multi-sectoral NCD mechanisms, and NCD alliances. Second, we recommend that countries consider NCDI Poverty in their poverty-reduction, NCD, and UHC strategic planning, including consideration of equity in priority setting and publicly financed benefit packages and insurance schemes. Routine health examination surveys in LLMICs typically include information about multiple dimensions of poverty to facilitate disaggregation of data for equity. In the case of NCDIs, however, the most common health examination surveys (eg, STEPS) are largely focused on behavioural and metabolic risk factors and elicit little information regarding socioeconomic status. Countries are increasingly pushing to integrate NCDIs as part of demographic and health surveys, although challenges remain with respect to sampling frames and tensions between scope and data quality. Community health workers are beginning to register mortality and undertake cause-of-death inquiries. National NCDI Poverty Commissions can help countries develop roadmaps to expand these efforts. Third, we recommend that publicly funded health examination surveys routinely include a larger set of priority NCDIs and incorporate multiple indices of poverty. Fourth, we recommend that health service delivery platforms routinely gather individual socioeconomic information as part of their data systems and integrate cause of death registration in the community. NCD divisions and programmes in health ministries are most often organised around diseases (eg, cardiovascular disease, cancer, and diabetes) or around risk factors (eg, tobacco control). This organisation can reflect donor priorities. In the intervention section of this Commission (section 3), we discuss how structural reforms to increase quality will be needed to improve health through NCDI interventions. Service redesign is an essential element of these reforms. NCDI interventions might benefit from redesigning services to be delivered through integrated care teams. These teams can deliver interventions that depend on related skills and infrastructure but address a variety of diseases. Fifth, we recommend that ministries of health invest in structural reforms to improve the quality of health services through better governance and regulation, pre-service education, building community demand, and service redesign. Sixth, we recommend that ministries of health redesign planning and delivery of NCDI services around priority integrated delivery strategies such as, for example, integrated chronic care in the community, chronic care for severe NCDs at first-level hospitals, and referral-level cancer centres. Ministries of Health should partner with teaching hospitals and universities through technical working groups that also incorporate disease-specific expertise. Addressing NCDIs in the poorest countries will require a combination of wise policies, leadership, and increased health-sector investments. We call on ministries of finance to increase fiscal space for health care though progressive revenue collection, and by allocating these general government revenues to spending on health care consistent with recent targets. 231 Heavy taxation of sugar-sweetened beverages, alcohol, and tobacco can potentially generate (modest) revenues and importantly, discourage consumption of these unhealthy products particularly by the poor. These fiscal policies are important even in countries where the poor currently have low rates of exposure to these risks and are consistent with existing global recommendations for NCD control. Finally, we recommend that governments establish formal coordinating mechanism across energy, health, agriculture, social protection, and transportation to prioritise and implement intersectoral policies addressing NCDI Poverty. For countries that have already established such intersectoral bodies in line with WHO guidance, we recommend that these groups factor in the special vulnerability and needs of those living in extreme poverty with NCDIs. National civil society organisations In countries where they exist, national civil society organisations (CSOs), such as diabetes associations, heart foundations, and non-communicable disease alliances (NCDAs) have an important role by advocating for patients affected by NCDIs (panel 15 ). A vibrant and strong civil society movement is necessary to accelerate the NCDI poverty response at national and regional levels. This civil society movement should be capable of delivering its four primary roles: advocacy, awareness raising, improving access through service delivery, and accountability. Victories in several global health and development issues, particularly HIV/AIDS, have shown the importance of strong CSOs and community-based efforts in accelerating action and ensuring that governments meaningfully engage with civil society in developing and implementing policies. The demand for and effectiveness of a unified approach to NCDI advocacy is indicated by the emergence of a network of national and regional NCDAs around the world, including in countries having large concentrations of extreme poverty. Many of these NCDAs have been led by organisations representing diabetes, cancer, and heart disease, and some have focused mainly on the limited number of conditions and risk factors prioritised globally. They have had challenges engaging and representing the experience of the rural poor. Panel 15 Voices of NCDI Poverty Fortuna Messaye, leukaemia, 14 years old (Ethiopia) * “My illness started when I was 10 years old. In the beginning, I felt sleepy when I went to school. I couldn't learn; each time I sat down, I would fall asleep. They told me I had to come to Addis Ababa because they didn't have the necessary equipment [in the village where her family lives]. My mother brought me here. At Black Lion Hospital, they took a bone marrow biopsy. It took 15 days for the results to be ready. Then they told me it was cancer. I went back to Black Lion Hospital and took a lot of chemo.” Since she was diagnosed with leukaemia, Fortuna Messaye has lived in Addis Ababa, Ethiopia where she can receive chemotherapy and treatment for opportunistic infections. First her mother and then her grandmother stayed with her. But both of them fell ill themselves and moved back to their village. And other relatives complained, “What's the point of helping her, since she will not live?” Since then, Fortuna has lived with the Mathios Wondu Ethiopian Cancer Society (MWECS), a community-based organisation founded by the parents of a child who died of leukaemia. “Now I am not going to school. I want to go to school here. I don't have anyone in the village. If I go to the village, the kids who help my grandmother complain. They say, “How can we help two people?” Also, when I go there, I get very sick. I got really sick there two times.” Fortuna's chemotherapy cost more than US$8000 over 3 years—25 times the average per capita income in Ethiopia. Fortuna would not have been able to afford her treatment without the support of MWECS. “We give services here for women and children from rural areas who have cancer,” explained Berhanu, a nurse and social worker. “We give them food, transport, access to health care, and pay for medicine.” Fortuna's goal is to become a doctor so that she can help make quality treatment available to others who need it: “The reason I want to be a doctor is to take care of people in my community and all others, to help them heal. Those who are sick have to know they can be cured. And they have to teach others that it's possible. That's what I think.” We recommend that national CSOs make special efforts to channel the voices of the poor affected by a broad group of severe NCDIs. They can do so by reaching out to providers on the front lines of delivering services to the poorest populations, especially in rural areas, and will require resources from global and local partners. CSOs should also help align service demands from patients with particular diseases into strategic alliances around integrated health service teams that address groups of related conditions (such as those affected by sickle cell disease advocating for integrated new-born screening). We also recommend that NCDAs in countries with large concentrations living in extreme poverty work alongside National NCDI Poverty Commissions in a complementary fashion to reflect the NCDI Poverty agenda in their advocacy. In high-poverty countries without NCDI Poverty Commissions, NCDAs can be important NCDI Poverty advocates in their own right. National research and educational institutions As discussed, there are major gaps in epidemiological data regarding NCDIs in the poorest countries. This Commission's review of the literature published in 11 countries over the past 10 years has found that the little data that does exist is biased toward the urban areas where researchers are located, is focused on a small set of diseases, and does not routinely incorporate socioeconomic variables. Additionally, we have identified many NCDI interventions that are attractive from the standpoint of equity but for which there is no published evaluation of cost-effectiveness. There are also gaps in research regarding the cost and effect of integrated NCDI delivery strategies. Funding to address these gaps might need to come from global or regional sources. We recommend that national research institutions and funders in high-poverty countries stimulate investigation regarding a broad range of priority NCDIs and integrated delivery channels with an additional focus on the rural poor. We also recommend that researchers in low and middle income countries work to fill evaluation gaps around the cost-effectiveness for high-equity NCDI interventions. National professional societies National professional societies have an important role in helping to establish scopes of practice and to ensure the quality of initial training and continuing professional education. It is important that these societies embrace the sharing of tasks and encourage the development of new areas of specialisation for mid-level providers to lead integrated delivery of NCDI services at first-level hospitals, health centres, and in the community. We recommend that professional societies representing physicians and surgeons work with nursing and community health worker associations to develop specialised certification and career pathways for mid-level providers and community health workers in priority NCDI service areas such as chronic care for severe NCDs, advanced women's health, emergency and high-dependency care, and integrated chronic care. Recommendations for making NCDI Poverty a global priority in the SDG era The SDGs are the framework for global cooperation over the next decade. Eight of the 17 SDGs (goals 1, 2, 3, 4, 5, 7, 8, 16, and 17) directly address some of the key dimensions of the NCDI burden globally and among the poorest. 9 In Table 2 , we discuss targets for which the Commission has identified pro-poor adaptations of agreed-upon monitoring indicators. In many cases, we call to disaggregate indicators by multidimensional indices of poverty and by disease area. Fundamentally, we call for an expanded understanding of SDG target 3.4 to more fully include NCDI Poverty. Table 2 Current Sustainable Development Goal targets, indicators, and NCDI Poverty interpretation Current indicators NCDI Poverty adaptations Measuring NCDI mortality Target 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 livebirths Maternal mortality ratio (3.1.1) Disaggregated by cause of death Target 3.2: By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 livebirths and under-5 mortality to at least as low as 25 per 1000 livebirths Under-5 mortality rate (3.2.1); and neonatal mortality rate by sex, age, wealth quintile, residence, and mother's education (3.2.2) Disaggregated by cause of death Target 3.4: By 2030, reduce by a third premature mortality from NCDs through prevention and treatment and promote mental health and wellbeing Mortality rate attributed to cardiovascular disease, cancer, diabetes, or chronic respiratory disease (between the ages of 30 and 70 years) by sex (3.4.1); and suicide mortality rate by sex and age (3.4.2) Mortality rate for all NCDs across the lifespan, disaggregated by cause, age group, sex, household nutrition, education, and living standards; mortality rates should be standardised within age groups and reported for the following specific intervals: under 5, 5–14, 15–24, 25–39, 40–59, 60–74, and 75 years and over Target 3.6: By 2020, halve the number of global deaths and injuries from road traffic accidents Death rate due to road traffic injuries by type of road user, sex, age, and income (3.6.1) Mortality rate for all injuries across the lifespan, disaggregated by cause, age group, sex, household nutrition, education, and living standards Target 16.1: Significantly reduce all forms of violence and related death rates everywhere Number of victims of intentional homicide per 100 000 population, by sex and age (16.1.1); and conflict-related deaths per 100 000 population, by sex, age, and cause (16.1.2) Disaggregated by household nutrition, education, and living standards Universal health coverage Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all Coverage of essential health services (defined as the average coverage of essential services based on tracer interventions that include reproductive, maternal, newborn and child health, infectious diseases, NCDs and service capacity and access, among the general and the most disadvantaged population; 3·8.1); proportion of population with large household expenditure on health as a share of total household expenditure or income (3.8.2) Tracer interventions should include those that address high-severity, less prevalent NCDIs (3·8.1); disaggregation by cause of expenditure (3.8.2) Social protection Target 1.3: Implement nationally appropriate social protection systems and measures for all, including floors, and by 2030 achieve substantial coverage of the poor and the vulnerable Proportion of population covered by social protection floors or systems, by sex, distinguishing children, unemployed people, people aged older than 50 years, people with disabilities, pregnant women, newborns, work- injury victims and the poor and the vulnerable (1.3.1) Disaggregated for people living with severe NCDIs Financing Target 17.2: Developed countries to implement fully their official development assistance commitments, including the commitment by many developed countries to achieve the target of 0·7% of ODA and GNI to developing countries and 0·15–0·20% of ODA and GNI to least developed countries Net official development assistance, total and to least developed countries, as a proportion of the Organization for Economic Cooperation and Development and Development Assistance Committee donors' GNI by donor, recipient country, type of finance, type of aid, sub-sector, etc (17.2.1) Disaggregated by NCDI cause, sub-national geography, and target recipient household nutrition, education, and living standards NCDs=non-communicable diseases. NCDIs=non-communicable diseases and infections. ODA=official development assistance. GNI=gross national income. Targeting mortality from NCDI Poverty (SDG targets 3.1, 3.2, 3.4, 3.6, and 16.1) Targets and associated indicators related to NCDI mortality are found under SDG 3 (ensure healthy lives and promote wellbeing for all ages), but also under SDG 16 (promote peaceful and inclusive societies). In general, these targets and indicators tend to frame NCDs as problems of older ages that are restricted to a small group of diseases, and to limit the focus of injury monitoring to road traffic accidents, homicide, and violent conflict. Whereas such a focus might be appropriate in some high-income and middle-income settings, this focus is not well aligned with the heterogeneity of NCDI Poverty that we have identified in LLMICs. The metadata for these indicators often fail to recommend disaggregation by measures of poverty. We have shown that NCDIs among the poorest are substantial causes of death in childhood, adolescence, and among adults of reproductive age. We recommend that the existing target focused on maternal mortality (SDG target 3.1) should be disaggregated by cause of death to highlight the role of underlying NCDs such as depression, rheumatic heart disease, peripartum cardiomyopathy, and uncorrected congenital heart disease as indirect causes of maternal mortality. 232 Similarly, we recommend disaggregation by cause of under-five mortality (target 3.2) to highlight, for example, congenital causes of death in this age group, as well as the importance of a variety of injuries. Meanwhile, SDG targets focused on NCDIs more specifically need to be more broadly interpreted in their scope and embrace disaggregation by multidimensional poverty indicators such as nutrition, household education, and living standards. In particular, the indicators for SDG target 3.4, which are currently restricted to deaths due to cardiovascular disease, cancer, diabetes, and chronic respiratory disease between the ages of 30 and 70 years, as well as suicide across age groups, should be expanded to include all ages and NCD causes. Particular attention should be paid to reductions in age-standardised mortality under the age of 40 years. Similarly, SDG target 3.4 should be expanded to include all causes of injury and disaggregated by cause. The data requirements to monitor a broader range of ages and NCDI cause groups are no different than for current indicators. Reporting of cause-specific maternal and under-5 mortality rates will require continued improvements in vital registration systems and facility-based delivery. Although information about the socioeconomic status of decedents might be difficult to obtain, household indices of multidimensional poverty should be more available. This Commission has shown how this information can be used through its collaboration with the INDEPTH network of Demographic and Health Surveillance sites. In the meantime, models such as those from the GBD study, can continue to be improved to make predictions for different socioeconomic groups as we have done for this Commission. 233 One way forward would be to extract and link socioeconomic information from available sources with epidemiologic data whenever possible. NCDIs in UHC (SDG target 3.8) Strategies to monitor progress toward UHC are in development and constrained by data limitations. One general tendency has been to exclude NCDIs from core indicators (such as WHO's global reference list). 234 Another approach has been to select tracers based on those common interventions routinely reported in STEPS surveys. These have primarily been interventions to address behavioural risks (eg, tobacco, diet, alcohol, and physical inactivity), and metabolic risks (eg, hyperglycaemia and high blood pressures). 235 Although STEPS surveys have been essential for monitoring interventions to address these NCD risks, they have not been adequate to monitor interventions for less common and more severe conditions and those that cause the most lifetime loss of health. Monitoring coverage of interventions to address these severe conditions will require greater investment in individual health records by governments and partners as part of strengthening health information systems. These records will also need to capture information about individual socioeconomic status. 236 Indicators of catastrophic spending (SDG target 3.8.2) will need to be disaggregated to capture disease-specific impoverishment. Household expenditure surveys could gather more information regarding the modalities and disease-specific indications for health services. Other indicators of progress toward UHC include measures of health workforce development (SDG target 3.c). We recommend that health workforce indicators should also include community health workers and be disaggregated by physician, nurse, and mid-level provider specialty (eg, generalist physician, internal medicine physician, paediatric cardiologist, oncologist, and chronic care nurse practitioner), and by level of the health system (ie, referral centre, first-level hospital, health centre, and community). This kind of disaggregation can help to monitor the development of integrated health service delivery. Social Protection for NCDI Poverty (SDG target 1.3) Social protection was the major focus of chronic disease policy in high-income countries during the early 20th century. 237 Prepayment mechanisms to avoid catastrophic expenditures due to the direct (and indirect) costs of NCDI treatment constitute one important element of social protection. An even more challenging issue is the impoverishment caused by lost household productivity due to NCDI death and disability among working-age adults. SDG 1 (end poverty in all its forms) addresses social protection (target 1.3) and calls for disaggregation relative not only to poverty, but also to disability. We have found that most of the disability among the poorest (71% of years-of-life-lived with disability) is due to NCDIs. Targeting social protection to specific groups can be both costly to administer and challenging to do precisely, but advances in biometrics and information technology will continue to make this approach more attractive.238, 239 The NCDI and disability rights agendas should be more closely linked. 240 The SDG target on social protection should disaggregate for severe NCDIs in addition to disability. Financing NCDI Poverty (SDG target 17.2) As noted in the financing section of this Commission (section 4), little DAH is going to NCDIs, even less is going to the poorest countries, and almost none is explicitly targeted to the poorest people in the poorest countries (the poorest billion). SDG 17 calls to strengthen the means of implementation; and SDG target 17·2 specifically calls on high-income countries to raise levels of official development assistance and to target around 20% of this assistance to the least developed countries. It is essential that aid be accountable for reaching the poorest. We recommend that the indicators for this target disaggregate aid recipients by NCDI cause, sub-national geography, and household indices of multidimensional poverty. Although this kind of disaggregation will introduce new data burdens for recipients, it will also encourage measurement of benefit incidence relative to poverty. The variety of pro-poor pathways for channelling public finance toward UHC has been well described previously in the 2013 Lancet Commission on Investing in Health. 241 Progress on NCDI Poverty in the SDG era We have previously discussed the gaps in global and national governance for NCDI Poverty in the SDG era. Fortunately, in the 5 years since we started this Commission at the end of 2015, we have seen signs of progress. The nine volumes of DCP3 were published between 2015 and 2018.242, 243 DCP3 lays out a far more inclusive agenda for NCDI priorities in UHC than we have previously seen in the UN System. We have made extensive use of DCP3 in our analysis of intervention priorities. Building on the work of DCP3, the Commission on Investing in Health (first published in 2013) has updated its findings to newly incorporate some NCDs (rheumatic heart disease, cervical cancer, and chronic liver disease due to hepatitis B) in its vision of a convergence agenda for infectious, childhood, and maternal deaths toward very low rates for the world's poorest people. 243 The update from the Commission on Investing in Health also placed a high priority on global investments in NCD planning and pooled procurement. The Lancet Taskforce on NCDs and Economics identified NCDs as an important cause and consequence of poverty. 194 The WHO Independent High-Level Commission on NCDs recommended expanding the 4 × 4 framework to also include mental health and environmental risk factors. 15 This recommendation for a 5 × 5 framework was adopted by the 3rd UN High-Level Meeting on NCDs in 2018. 10 The NCD Countdown 2030 collaborators have also expanded NCD mortality monitoring to go beyond the SDGs' focus on NCD deaths from four main disease categories at older ages in order to include accountability for deaths at all ages and across all NCDs. 14 The Lancet Commission on High-Quality Health systems in the SDG Era has called for a greater focus on quality health care delivery for NCDIs. 17 The NCDI Poverty agenda, however, remains unfinished. There appears to be little urgency in the global development community to include NCDIs in its agenda to prevent deaths among the poorest children and young adults. 244 In the aftermath of the 2019 UN High-Level Meeting on UHC —with its renewed global commitment “to meet the health needs of all throughout the life course, and in particular those who are vulnerable or in vulnerable situations”— 245 we hope that this Commission, with its associated National Commissions and partners, can help make addressing NCDI Poverty a priority in the SDG era. Conclusion: global solidarity for NCDI Poverty and universal health coverage Propelled by a 2001 UN General Assembly Special Session, the first decade of the 20th century saw dramatic growth in development assistance for HIV. In many cases, HIV financing has had collateral benefits for those afflicted by other conditions, but it has not been sufficient. We have estimated that around 85% of the poorest billion live in countries with a per-capita GDP of less than US$1600 in 2015 exchange-rate US dollars. Simply put, these countries do not have the domestic resources to address even their most urgent health-care needs. NCDIs have been understood by development agencies and multilateral institutions as an emerging problem associated with ageing, urbanisation, and economic growth, rather than a constituent part of the most extreme poverty. The 2011 UN High-Level Meeting on NCDs was greeted with hope for a new era of global solidarity despite the 2008 financial crisis. These hopes have not materialised. Our Commission has shown that little development assistance for NCDIs has been mobilised for NCDIs over the past decade, and that almost none has gone to the poorest countries. The framing of NCDs that crystallised through the 2011 UN High-Level Meeting was, in part, a solution to the perceived weakness inherent in the heterogeneity of a large array of non-infectious conditions. This Commission proposes that this complexity should be recognised as an inescapable part of the NCDI burden in the poorest populations. More than that, this complexity should be leveraged to build global solidarity and to catalyse structural reforms for quality and innovations in integrated service delivery for the world's poorest and most vulnerable people. To begin to remedy the shocking neglect of NCDI Poverty by rich countries, this Commission is launching an NCDI Poverty Network. This Network is composed of a growing group of National NCDI Poverty Commissions and their allies. The Network will work over the next decade to catalyse financing and technical partnerships to support implementation of integrated delivery strategies for locally prioritised interventions. The Network will also work closely with The Lancet and the NCD Countdown 2030 Group to report on progress toward locally identified goals. In doing so, we hope that this Commission will elevate an emerging NCDI Poverty movement and accountability mechanism that will contribute to health and shared prosperity for all. Addressing NCDI Poverty offers a chance for the poorest countries to build durable, high-quality health systems. It also presents an important occasion to act on the underlying social determinants of disease such as housing, household energy, food insecurity, education, and transportation. In order to be successful, these countries will require greater global commitments to health equity. Private philanthropic organisations have small resources at their disposal but can have an outsized effect on policy and research. We ask that, when funding disease-specific initiatives, these organisations consider the poorest billion and recognise the need to invest in integrated strategies that drive health system improvements. Bilateral donors must increase their investments in health in the poorest countries. When funding NCDIs as part of UHC expansion pathways, bilateral donors and multilateral institutions must also begin with the poorest billion in mind. Prospects exist to build on existing investments and to crowd-in resources for NCDI Poverty in priority countries and populations. Financing to address treatment gaps in the poorest countries should not be neglected even as resources should also be increased to support common goods for health such as research, policy, and coordination.243, 246 We call on WHO to expand its UHC monitoring and NCD action plan after 2020 to address the diverse set of diseases and conditions recognised as NCDIs in its own Global Health Estimates; intervention priority setting at WHO to give due consideration to equity (including condition severity and distribution among the poorest) in addition to cost-effectiveness and feasibility; and WHO to strengthen its work on integrated service delivery for NCDIs, and particularly to invest in development of technical packages for first-level hospitals. NCDI Poverty is one of the largest gaps and largest opportunities for UHC and global health equity in the SDG era. The Director General of WHO has called for one billion more people to benefit from UHC by 2023. 29 The scope of UHC recognised by this commitment must be broadened to include NCDI Poverty. Consistent with the SDG pledge that, “no one will be left behind”, and the SDG commitment, “to reach the furthest behind first”, the next billion to benefit from this more inclusive conception of the UHC should be the poorest billion. 1 For more on the Commission see https://www.ncdipoverty.org

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World Heart Federation Briefing on Prevention: Coronavirus Disease 2019 (COVID-19) in Low-Income Countries

Friedrich Thienemann, Fausto Pinto, Diederick Grobbee … (2020)

In December 2019, the novel coronavirus Coronavirus Disease 2019 (COVID-19) outbreak started in Wuhan, the capital of Hubei province in China. Since then it has spread to many other regions, including low-income countries.

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Publication date (Electronic): 14 September 2020

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[a ]Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa

[b ]Chain of Hope, Magdi Yacoub Heart Foundation, Aswan Heart Project, Aswan, Egypt

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Catalysing the response to NCDI Poverty at a time of COVID-19

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Global Burden of Cardiovascular Diseases: Part II: Variations in Cardiovascular Disease by Specific Ethnic Groups and Geographic Regions and Prevention Strategies

The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion

World Heart Federation Briefing on Prevention: Coronavirus Disease 2019 (COVID-19) in Low-Income Countries

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