The rise of NCDs necessitates a range of adjustments by health systems. Please discuss this statement, with reference to a particular country or region.
Noncommunicable diseases (NCDs), are chronic in nature and resulting from combination of several factors namely; physiological, genetic, behavioural and environmental. NCDs contribute for 41 million deaths annually, which represent 71% of the total deaths occur in all over the world. Low- and middle-income countries have the highest burden reporting 32 million deaths which is more than 75% of all NCD deaths occurred globally. Further, out of 15 million premature deaths (less than 70 years of age) occur in every year globally due to NCDs, more than 85% of these deaths reported in low- and middle-income countries. Cardiovascular diseases, cancers, chronic respiratory diseases and diabetes are the four main group of diseases which accounts for more than 80% of all premature deaths due to NCDs. 
In order to respond this rising NCDs burden, health systems must be strengthened in every aspect facilitating health promotion, prevention, screening and detection, treatments, rehabilitation and palliative care. According to the World health report in year 2000; “A health system consists of all the organizations, institutions, resources and people whose primary purpose is to improve health”. There are different types of health systems operating in all over the world and Sri Lankan health system is selected here for describing how the system has been adjusted so far and necessary modifications of the system which required for addressing rising burden of NCDs.
Sri Lanka is an island surrounded by the Indian Ocean and owning the land area of 65 610 km2. Total population is 20.3 million in 2012 and majority of the population (77.4%) reside in the rural sector while 18.2% live in urban areas and 4.4% reside in estate sector. According to the World Bank classification, Sri Lanka is a Lower Middle-Income country and GDP per capita is USD 4,073 in 2017. Irrespective of the relatively low total expenditure on health (3.89% of the GDP in 2016) , Sri Lanka has accomplished a comparatively high health status not only among South East Asian countries, but also among most of the developing countries in the world. That indicates as under-5 mortality rate was 9.4 per 1,000 live births in 2014 and maternal mortality ratio was 26.8 per 100,000 live births in 2013.  Recently WHO certified Sri Lanka as a country free of malaria and measles. This remarkable achievements in maternal and infant mortality rates are partly due to the effective and integrated maternal and child health (MCH) services broadly available throughout the country for the last six decades. Easily accessible healthcare services with highly successful interventions which have greater coverage like; childhood immunisation, antenatal care and institutional deliveries; have been facilitating for prevention and control of communicable diseases.
Despite of the achievements in communicable disease control and Maternal & child health, NCDs are on rise in Sri Lanka parallel to other low- middle income countries in the world, challenging its health system. According to the Noncommunicable diseases country profiles 2018 published by WHO, NCDs represent 83% of all deaths occurred in Sri Lanka; out of that cardiovascular diseases account for 34% of NCD deaths and Cancers, Chronic respiratory diseases, Diabetes and other NCDs represent 14%, 8%, 9% and 18% respectively. Sedentary lifestyle, rapid unplanned urbanization and population aging collectively predispose the NCD risk factors namely; tobacco consumption, harmful use of alcohol, unhealthy diets and physical inactivity; all of which ultimately increase the risk of NCDs, and related mortality globally. Metabolic risk factors namely; high blood pressure, elevated blood glucose and lipids levels and obesity resulting from unhealthy diets and physical inactivity, could lead to cardiovascular disease which is responsible for majority of the premature deaths due NCD.
Global Burden of Disease 2010 report explains that, dietary risks, high blood pressure, and household air pollution from solid fuels are the three main risk factors which are responsible for the most disease burden in Sri Lanka and ischemic heart disease, self-harm, and diabetes mellitus were the main causes of Disability-adjusted life years (DALYs) in 2010. According to the UN World Population Prospects published in 2017, old-age dependency ratio of Sri Lanka will be 39% in 2050.  Those aging population will contribute to further rise of NCDs in Sri Lanka, which subsequently lead to increase the healthcare cost of the country. Appropriate adjustments in the health system are required for addressing this huge burden due to NCDs while preserving and protecting the existing strengths of the current health system, particularly the achievements in maternal and child health (MCH) through high quality MCH services available island wide.
WHO health system framework model is useful to explain the necessary adjustments in the health system.
WHO health system framework (WHO,2007)
In Sri Lanka, health system is decentralized and Ministry of Health, Nutrition and Indigenous Medicine (Line ministry) is the main actor of the Sri Lankan health system and it is responsible for development of health policies and guidelines for the entire country, monitoring health programmes and provide necessary technical assistance, procurement and distribution of medicines and supplies to the public healthcare institutions throughout the country, training and development of health workforce and functioning of tertiary health care institutions. Provincial health ministries are the main decentralised units which is nine in number and each unit is led by a Provincial Director of Health Services (PDHS). Further division of those units are identified as health districts and twenty-six in number, each of which led by a Regional Director of Health Services (RDHS). Ensure proper functioning of preventive, primary, and secondary health care services is the main responsibility of them, and they are assisted by both line and provincial health ministries.
Considering the adjustments required in governance and leadership to address the NCD burden, it is important to explore; the role of service providers and funders in terms of accountability and governance for improving performance of the system, what are the new services and reforms introduced in to the system and involvement with other sectors and broader development agenda to address the changes in public policies. Reorientation of health services by introducing new policies and reforms are vital in this stage; to reorganize the access to quality, highly efficient and people-centred health services and to ensure the range of primary care services for the community throughout their life cycle. Policies related to reorganisation of Primary Health Care, Human resources for health, patient referral system and health information system, must be strengthened and reformed while introducing new policies according to the current requirements.
Leadership skills are essential for collaborating with various stakeholders involved in addressing this burden and influence of high-level political leadership will ease the implementation of multisectoral action plan with the national development plans. It is important to improve the governance and partnership with private healthcare providers who involved in NCD services through monitoring and applying regulations to safeguard the quality of services. Introduction of guidelines for operational, financial and clinical practices and licensing system will help to improve clinical governance not only related to NCDs but for all other diseases.
In Sri Lanka, there are enough evidence to prove the commitment of higher level political leadership and governance to combat the NCD burden and National Health Policy (1992), “Mahinda Chinthanaya” (2005), and Health Master Plan 2007- 2016 of Sri Lanka are some of the examples where prevention and control of NCDs has been recognised as a priority area of work. Additionally, Sri Lanka is a member of the WHO Framework Convention on Tobacco Control (FCTC) agreement and having endorsed that treaty, legislations for control of tobacco and alcohol was enacted in Sri Lanka as the first Asian country and fourth in the world, which was a requirement under the agreement. Having identified the nature of NCD burden and risk factors for increasing NCDs in Sri Lanka accurately, the National Policy & Strategic Framework for Prevention and Control of Chronic Non-Communicable Diseases was introduced in 2009 aiming to reduce the NCD burden in Sri Lanka.
Moreover, several guidelines were issued and several remedial actions were taken to reduce the NCD risk factors and following are some examples for ;
a.) To reduce the dietary risk factors
Guidelines for a healthy canteen in workplaces was introduced in 2013.
- Conducting School Canteens & Taking foods during school time- circular was introduced in 2011 by the Ministry of Education, Sri Lanka
- In 2016, traffic light labelling system has been introduced to soft drinks and according to the sugar content, soft drinks are labelled in green, orange and red in colours. Further, it has been planned to implement a traffic light coding system for packaged foods according to the sugar, salt and fat content of the food in 2019.
b.) To reduce the tobacco consumption and aiming to fully implementation of FCTC
- Implemented 80% pictorial warning in cigarette packets
- Ban illegal trade of tobacco products
- Prohibition of all forms of tobacco advertising, point of sale display and sponsorships to sports and other community activities.
c.) Do necessary amendments to National Authority on Tobacco and Alcohol (NATA) Act for prevention of all forms of advertising and point of sale display as well as prohibition of smoking in public places; which ensures outdoor environment totally free of tobacco smoke. Enforcement of laws on retail sales of cigarettes and sales of smokeless tobacco products, formulate policies on smokeless tobacco use, investion for avoiding importation of e-cigarettes and implementation of plain packing and single stick sales are the main areas to be considered in NATA act.
Delivery of health services according to increasing demand on NCD care is a formidable task to any health system and being a lower middle-income country, Sri Lankan health system has also been exploited by rise of NCDs. Health authorities of Sri Lanka have identified Primary Health Care (PHC) is a key measure for responding to the NCD burden and some NCD specific responses have also to be included additionally. Integration of preventive primary care services provided through the Medical Officer of Health (MOH) system, and Primary Medical Care Institutes (PMCIs) comprising Primary Medical Care Units (PMCUs) and Division Hospitals (DHs), to form a comprehensive package of primary medical services including services for common NCDs, to a specified catchment population is one suggested reform for providing quality health service. The service package will consist of health promotion, primary prevention, primary medical services, referrals and community-based follow-up services.
Further, Healthy Lifestyle Centres (HLCs) were established throughout the country aiming to address the increasing trend of NCDs among Sri Lankan population and screening for NCDs and guiding for lifestyle modification are the main services provided through these HLCs. Though HLCs are easily accessible and services are provided free of charge, utilization of these services among the population is not satisfactory.
In order to expand the coverage and increase the services provided by HLCs, health authorities have identified several strategies as follows;
- Strengthen HLCs allocating necessary staff, including instructors, councillors, and officers for physical education, nutrition, and lifestyle modification.
- Facilitate daily NCD screening at HLCs instead of specific days and carry out active screening in the community. Mobile screening programmes should be targeted to reach the inaccessible communities like farmers, housewives ect.
- Support to provide services at HLCs like; measuring blood pressure, assessment of CVD risk and body-mass index (BMI); cholesterol testing; and ECG and follow-up referred patients.
- Create a care package for NCDs like MCH package and different packages should be introduced according to the age groups.
- Develop other supportive care like guidance for healthy diet, centres for physical activities etc.
- Allocate one PMCU for 3 Grama Niladari (GN) divisions (the smallest administrative unit of the country).
- Introduce sound patient referral system defining protocols and pathways and both forward and back referrals should be included there and use one standard referral form across levels and sectors.
- Authorize the PMCU act as a gatekeeper to the secondary and tertiary levels.
Comprehensive health information system is crucial for functioning of health systems from planning to service delivery as evidence-based practices are solely depend on reliable and timely data. Therefore, it is necessary to ensure proper collection, analysis and use of information for executing health services. Health Management Information Systems (HMIS) of Sri Lanka covers larger amount of preventive care services, but curative care services do not have comprehensive system for tracking patients’ information and integration of various systems is required for improving the HMIS. Moreover, establishment of sound referral system and introduction of a unique health identification number for each person will help to share information among the service providers and ensure the continuity of care which is highly relevant to management of NCDs as those are chronic conditions requiring long term care as well as involvement of different types of care providers like general physicians, medical specialists in cardiology, oncology, endocrinology etc and allied health workers.
Development of quality standards for main NCD services and establishment of an appraisal system for determining level of performance compared to standards will help to monitor and evaluate the services. Introduction of morbidity and mortality reviews for NCDs and clinical audits will also enhance the information sharing. Establishment of Health Information Unit (HIU) at Base hospitals and above healthcare facilities further facilitates data collection, analysis and dissemination of information consistent with national guidelines and currently, some tertiary care institutions are having HIU and gradually it should be expanded to other hospitals throughout the country. Integration of currently available health information systems like disease surveillance and notification, hospital information management system and medical supplies management information system; will improve the health information system which facilitates cross reference of information and prevents duplication of data collection and analysis.
Healthcare financing plays a major role in any healthcare system and it determines most of the functions happening in the system like what services can be provided to the community, what type of facilities can be provided at the healthcare institutions, what type of workforce can be recruited etc. Healthcare cost represents significant amount of national expenditure in any country and it consists of expenses for health care services, drugs and supplies, investigations and other related activities. For calculating national health expenditure both public and private spending are considered, and public sector spends through tax revenues and private sector spends through out-of-pocket expenditures by patients. Due to chronic nature of NCDs which requires long term and specialized care, eventually leads to increase the health care cost of the country.
Increasing the government financing on healthcare is one option for address this issue. However, weak tax policies adversely affect the government revenue collection and it is hardly possible to increase health financing. In order to overcome this burden several strategies were identified such as improving efficiency of the system by strengthening PHC, giving more attention to primordial and primary prevention of the diseases as well as early diagnosis and management which are more cost effective than delayed identification and management of the NCDs. Public- private partnership is another strategy which can be used to address this problem though there is no common programme developed currently for addressing NCD burden in Sri Lanka. As the public sector has good preventive health set up through Medical Officer of Health (MOH) areas, health education programmes for the community can be carried out by the public sector to make aware about the common diseases and their implications which is essential for control the diseases. The private health sector can do blood investigations and medical examinations required to diagnose NCDs through a screening programme.
Health workforce is crucial for providing quality health service to the population, specially to expand the services for NCDs. Trained staff is essential to perform NCD screening and providing care at the PHC level. They should be trained on new guidelines issued by the NCD unit of the Ministry of Health, ensuring those guidelines are widely available. Training on NCDs prevention and management need to be included in undergraduate curriculum as well. In Sri Lanka, medical workforce is distributed in inequitable manner where more numbers tend to be scattered in main cities and less or no specialists in some remote areas. In order to ensure equitable distribution of health workforce for providing specialized medical care in remote areas, staff must be re-distributed by implementing annual transfer scheme properly.
At present, MO- NCDs are allocated to each RDHS office and he/she is mainly responsible for screening people for NCDs and if any chronic condition is detected, those patients should be referred to a hospital for management of the condition. Further, it was suggested to introduce an officer like PHI specially for NCD, who will be responsible for prevention and monitoring activities of NCDs.
Access to essential medicines is another important building block of health system framework and according to the demand of the community; which is mainly determined by the disease trends of the community, medicines and other necessary supplies should be provided to the healthcare institutes to treat patients. In this instance, supply Chain Management (SCM) of those medicines are crucial for ensuring the receipt of Right items, in the Right quantity and Right quality, to the Right place at the Right time with minimal waste. Without drugs and other therapeutic and diagnostic items, it is impossible to provide quality health service at any level of health care institute. Considering the rise of NCDs among the population, it is necessary to ensure continuous supply of medicines for managing those patients as NCDs are chronic conditions and once you get it usually require to be on medication rest of the life, most probably delayed diagnose cases. Requirement of large number of items (along with various dosages and strengths), in larger quantity with limited lifespan of medicines and the long lead time for manufacturing and supply, complicate the supplement of medicine timely and exert huge pressure on the health system.
In Sri Lanka, Medical Supplies Division (MSD) of the Ministry of Health is the central organisation which is responsible for supplying medicines and other items required for health care services provided by public hospitals and other health care institutions. Estimation of national need, indentation, storage, control processes. distribution of drugs and accounting, together with surveillance and monitoring of medical supplies provided to public health institutions in Sri Lanka, are the main functions of MSD while State Pharmaceutical Corporation is the procuring entity for MSD. Drugs are distributed directly to the healthcare institutes under the line ministry and other institutes which are under provincial councils receive drugs through the Regional Medical Supplies Divisions (RMSD)s.
In order to manage the NCD patients, Ministry of Health, Sri Lanka has taken a policy decision to ensure availability of 16 essential drugs which are used to treat common NCDs, at the PMCUs where HLCs were placed. Higher level institutes are having more NCD drugs except 16 essential drugs.
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