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Building Back Better: Investing in healthy populations and resilient health systems for NCDs and men

An open letter to Heads of State and Government

The novel coronavirus 2019 (COVID-19) pandemic has exacerbated deep inequalities in our societies and highlighted the need to invest smarter to address the health care needs of people living with noncommunicable diseases (NCDs) – including cancer, cardiovascular disease, chronic respiratory disease, diabetes, and associated mental health conditions – and other chronic illnesses. From country to country, we need to make a massive effort to increase investments in prevention, screening, early diagnosis and appropriate treatment of these diseases, which today cause more than 70% of global deaths and are seven of the ten leading cause of deaths according to the newly published WHO Global Health estimates.

Data shows that people living with these NCDs are at a higher risk of severe complications from COVID-19, are more likely to be hospitalized, and are at a higher risk of death. Emerging studies of critically ill COVID-19 patients tell the same story around the world. Of those dying of COVID-19 in Italian hospitals, 67% were people living with hypertension and 31% with diabetes.  In Spain, 43% of people who developed COVID-19 disease were living with cardiovascular diseases. In Indonesia, 16% of reported COVID-19 deaths were people living with diabetes.  In Mexico, of deaths from COVID-19 in the Indigenous population, diabetes was the most frequent comorbidity (30%). Mortality has been high in long-term care facilities for people with dementia and other mental health conditions. Those who are lucky enough to recover from COVID-19 may well face additional long-term health challenges.

Health services and routine care have been delayed and disrupted by COVID-19 for most patient groups in almost every country, including people living with NCDs. The disruption will result in a longer-term upsurge in deaths from NCDs which overstretched health systems will struggle to manage. In the Netherlands, the number of people newly diagnosed with cancer dropped by 25%. In India, 30% fewer cardiac emergencies reached health facilities.

NCDs are the largest, and yet most underfunded, public health issue globally, where the most lives could be saved. For too long they have been overlooked by leaders and policymakers. After 20 years of underinvestment, only one-third of countries can provide drug therapy and counselling services to their populations to prevent heart attacks and strokes. In developing countries, cardiovascular diseases are the NCD that claims the largest number of lives among people aged between 30-70 years.

The result of underfunding is that more than one in five people worldwide now live with one or more NCDs. People with NCDs are more susceptible to becoming severely ill and dying from COVID-19. Age is an important factor for COVID-19 and older persons are among the most vulnerable. However, a number of uncomfortable truths have been exposed by the pandemic – one of these being that it is people living with NCDs, people living in poverty, people in institutions, and minority groups who are paying the price for many years of government underspending on health around the world.

People face the virus from very uneven starting points. The risk of exposure to COVID-19 and the severity of outcomes is strongly linked to the growth and development of children, where you live and the social, political, economic and environmental inequalities that have been allowed to fester in our societies.

We must not shy away from the hard lessons of COVID-19, but seize the opportunity to build back better – to create a new normal where equality and equity are embedded in our societies, where structural and institutional racism are eradicated, and where all people, everywhere, have access to the health care they need throughout their lives and are free from preventable suffering. This is the true meaning of Universal Health Coverage.

One indispensable pathway is to include NCDs in national COVID-19 response plans, ensuring that not only is there a continuity plan for access to essential public health functions and services for people living with NCDs during any future epidemics, with the risks for people living with NCDs factored in at an early stage. Early data from the World Health Organization shows that 120 countries report disruption to services and care for NCDs, including hypertension and diabetes management, cancer care, and rehabilitation, despite the fact that rehabilitation services are crucial for those recovering from COVID-19, and that only 16 of 87 National Country support and preparedness plans include NCDs.  A similar WHO study among 130 countries found that the vast majority (93%) had reported disruptions in one or more of their services for mental, neurological and substance use disorders.

Investing in NCDs and mental health now is an investment in a better future - the future of people, health security and economic stability.

We know what works to reduce the burden of NCDs and improve people’s lives; it’s high time governments invest in health and prevention, starting from early in life. COVID-19 has exposed the damage done by neglecting NCDs and reducing public spending over the years on health, prevention, and essential public health services in many countries. We need to invest in resilience – for health services and healthy societies – and to dismantle long-standing disparities in our societies. And we need strong social protection systems and policies in place to protect vulnerable communities and reduce inequalities.

COVID-19 also compels us to reimagine a new normal and to use this crisis to build back the environment, economies, health systems, and societies in a more equitable way. We are seeing some glimmers of hope for health and well-being within the context of climate change: air pollution substantially dropped in many countries during lockdown, and cities adapted to promote active transport such as cycling and walking through infrastructure developments and incentives.

Another opportunity is to invest in NCD prevention and implement tried and tested interventions to reduce exposure to the risk factors for NCDs. Most NCDs which manifest when people are in their 40s and 50s are caused by risk factors which people are exposed to from childhood and adolescence. In today’s world, children are bombarded with marketing campaigns for foods high in sugar, salt and fat. Even before lockdown, which severely restricted physical activity for children and adolescents, the data shows that more than 80% of young people across the globe were not getting enough physical activity. Moreover, children and adolescents across the globe are exposed to tobacco, alcohol, drugs, poor diets, air pollution and toxic chemicals such as lead early in life, predisposing them to NCDs. Investing in resilience requires us to invest in mitigating these exposures early in life, before the damage sets in. We must focus on early life prevention for children and adolescents, recognising the immense return not only on investment, but for our societies. This includes reducing salt, sugar, and trans fats from foods; promoting physical activity, coupled with urban planning that allows for safe and culturally appropriate activities; enabling public transportation and enacting policies to reduce air pollution; and implementing price and marketing measures on tobacco and alcohol.

Finally, we must invest in mental health and well-being as part of our emergency responses. The COVID-19 pandemic has necessitated lockdowns and stay-at-home orders to curb the spread of the virus, which have resulted in increases in unemployment, missed education and lost prospects, social isolation and risk of family violence. The associated distress, coupled with the fear of life‑threatening disease and lack of certainty as to when normal life can resume, is taking a huge toll on people’s short-term and long‑term mental health. Previous experiences with humanitarian emergencies in numerous countries has already shown that emergencies, despite their adverse effects on mental health, are unparalleled opportunities to build mental health services for all people in need. The opportunity to build back better health systems for NCDs and mental health should not be missed.

With crisis comes the imperative for change. The world’s fragilities and inequalities have been so painfully exposed that it is clear that we cannot simply rebuild the world as it was.  Rather, we must build fairer and more resilient societies that do not leave people living with NCDs behind. This moment provides the opening for transformations that have been long in the making but now need an extra push.

COVID-19 must be the wake-up call for governments to finally step up and invest in NCDs. We call on our fellow leaders and policymakers to ensure that we are investing in prevention, screening, early diagnosis and appropriate treatment of NCDs. That governments are investing in bringing people living with NCDs into first contact with the health system through primary health care – which is the most inclusive, effective and efficient approach to enhance people’s physical and mental health.  That we give people living with NCDs a clear signal to boost their confidence that they have access, without discrimination, to health services for NCDs without exposing them to financial hardship. That leaders truly have the courage and determination to expand benefit packages for universal health coverage to include NCDs.  That we will respond to the requests from people living with NCDs in low- and middle-income countries to enhance global financing instruments to enable health systems to meet their health-care needs. We pledge to continue to make a strong case for all governments to invest in NCD prevention and treatment as a core component of building back better for people and planet.

This will cost money. But the alternative will cost far more. This crisis underscores the need to think long term, build resilience and limit the impact of future crises. With this restart, a window of hope and opportunity opens up for achieving the Sustainable Development Goals in a healthier society everywhere across the globe.

Two decades ago, WHO’s World Health Assembly recognised that the “Long-term needs of people living with NCDs are rarely dealt with”. COVID-19 has shown just how painfully true this is. As recently as the 75th UN General Assembly in September 2020, world leaders agreed to “Further strengthen efforts to address noncommunicable diseases as part of universal health coverage, recognising that people living with noncommunicable diseases are at a higher risk of developing severe COVID-19 symptoms and are among the most impacted by the pandemic.”  The pandemic must trigger overdue action to build a more inclusive and sustainable world. We must invest in the future. •


Mr Todd Harper, President, NCD Alliance

Dr Tedros Adhanom Ghebreyesus, Director-General, WHO

Ms Henrietta Fore, Executive Director, UNICEF

Mr Dag-Inge Ulstein, Minister of International Development, Norway



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