Correspondence Community health workers for noncommunicable diseases A UN high-level meeting on the progress achieved in the prevention and control of non-communicable diseases (NCDs), held on July 10–11, 2014, showed that progress has been insufficient and uneven, especially in developing countries. Despite the joint call of the UN and WHO for a 25% reduction in NCDs by 2025,1 NCDs are inadequately prioritised on the global agenda, and quite whom we can mobilise to achieve this target remains unclear. One of the possibilities could be task shifting of prevention, diagnosis, and treatment of NCDs to community health workers (CHWs), which was not mentioned as an opportunity during the UN review meeting. Almost half the member states of WHO have fewer than one physician per 1000 population.2 However, the world has seen major improvements in human health over the past two decades. Some of the key actors often unrecognised for their contribution to improved global health indicators are CHWs. According to WHO, there are more than 1·3 million CHWs worldwide. 3 Despite their limited training, education, experience, and expertise, they have shown that they can be mobilised to reduce mortality and morbidity. 4 However, CHW contributions thus far have been largely limited to maternal and newborn health and infectious diseases.5 Although communicable diseases are still an important cause of preventable deaths, NCDs are now the leading cause of death in many lowincome and middle-income countries. At present, 85% of NCDs occur in the poorest countries of the world. NCDs www.thelancet.com/lancetgh Vol 2 October 2014 also pose the single biggest threat to women’s health, causing 65% of all female deaths.6 NCDs are also a major cause of catastrophic health expenditure among the uninsured.7 The growing global burden of NCDs in poor countries has been neglected by policy makers, major multilateral and bilateral aid donors, and academics.8 Although there has been a significant increase in global aid for health in the past 10 years, investment in the field of NCDs is still negligible, accounting for less than 3%.9 One study in Pakistan showed that lay health workers could deliver health promotion materials for blood pressure and achieve effective lowering of blood pressure levels in the population.10 And the ability of non-physician health workers to detect and manage diabetes and high blood pressure has been shown in countries such as South Africa11 and Iran.12 The hitherto sparse projects and testimonies of CHWs involved in the control of NCDs are not enough to generalise specific roles or responsibilities on a global stage. But the sheer scale and impact of the global epidemiological transition, as well as the promising results of the few innovative initiatives, makes it imperative that more studies and pilot projects be done to further specify the beneficial roles of CHWs in addressing NCDs. 1 We declare no competing interests. 11 2 3 4 5 6 7 8 9 10 Copyright © Neupane et al. Open access article published under the terms of CC BY. *Dinesh Neupane, Per Kallestrup, Craig S McLachlan, Henry Perry [email protected] Center for Global Health, Department of Public Health, Aarhus University, 8000 Aarhus C, Denmark (DN, PK); Rural Clinical School, University of New South Wales, Sydney, NSW, Australia (CSM); and Johns Hopkins Bloomberg School of Public Health, Baltimore, MS, USA (HP) 12 UN. Political declaration of the high-level meeting of the general assembly on the prevention and control of non-communicable diseases. http://www.who.int/nmh/events/ un_ncd_summit2011/political_declaration_ en.pdf (accessed Sept 5, 2014). WHO. Density of physicians (total number per 1000 population, latest available year). http:// www.who.int/gho/health_workforce/ physicians_density/en/ (accessed Sept 5, 2014). WHO. World health statistics 2011. http:// www.who.int/whosis/whostat/2011/en/ accessed Sept 5, 2014). Perry HB, Zulliger R, Rogers MM. Community health workers in low-, middle-, and high income countries: an overview of their history, recent evolution and current effectiveness. Annu Rev Public Health 2014; 35: 399–421. Lewin S, Munabi-Babigumira S, Glenton C, et al. The effect of lay health workers on mother and child health and infectious diseases. Cochrane Database of Syst Rev 2010; 3: CD004015. UICC, International Diebetes Federation, World Heart Federation, International Union Against Tuberculosis and Lung Disease. Non communicable diseases: a priority for women’s health and development. http://www.worldheart-federation.org/fileadmin/user_upload/ images/Global_Health_Agenda/Women%20 and%20NCDs_Final.pdf (accessed Sept 5, 2014). Heeley E, Anderson CS, Huang Y. Role of health insurance in averting ecnomic hardship in families after acute stroke in China. Stroke 2009; 40: 2149–56. Beaglehole R. Globalisation and the prevention and control of non-communicable disease: the neglected chronic diseases of adults. Lancet 2003; 362: 903-908. Nugent R, Feigl A. Where have all the donors gone? Scarce donor funding for noncommunicable diseases. http://www.cgdev. org/publication/where-have-all-donors-gonescarce-donor-funding-non-communicablediseases-working-paper (accessed Sept 5, 2014). Jafar TH, Islam M, Hatcher J, et al. Communitybased lifestyle intervention for blood pressure reduction in children and young adults in developing country: cluster randomised controlled trial. BMJ 2010; 340: c2641. Coleman R, Gill G, Wilkinson D. Noncommunicable disease management in resource-poor settings: a primary care model from rural South Africa. Bull World Health Organ 1998; 76: 633–40. Farzadfar F, Murray CJL, Gakidou E. Effectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: a nationally representative observation study. Lancet 2012; 379: 47–54. e567
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