Background
The international health focus in the past two decades has been on the problem of infectious diseases, with non-communicable diseases (NCDs) given a low priority at global level [
1]. However recognition is increasing of the double burden in developing countries of chronic communicable diseases (e.g. tuberculosis and HIV) and chronic NCDs [
2], based on emerging country-level evidence [
3]. Attention to chronic NCDs is now increasing for several reasons: 1) they have a huge negative economic impact [
4] and represent a significant impediment to human development [
5]; 2) the effects of globalisation are likely to have a particular impact on chronic NCDs, including diabetes, hypertension, smoking-related conditions and obesity; and 3) recent progress in mobilising funds and improving the response to infectious diseases (especially HIV/AIDS, tuberculosis and malaria) has enabled a shift to a broader global health outlook.
The main international focus is on those chronic NCDs (diabetes, hypertension, chronic airflow obstruction and obesity) which share the following characteristics: 1) they are becoming more common as a consequence of the effects of globalisation; 2) enough preliminary data on these conditions are available to justify the conclusion that they are contributing to epidemiological transition (a double burden of communicable diseases and non-communicable diseases) in a wide range of low- and middle-income countries; 3) they share common risk factors which are potentially amenable to behavioural modification (tobacco use, unhealthy diets, physical inactivity, and harmful use of alcohol) [
6]; 4) they can be detected using simple tests available (or potentially readily available) in primary care settings in low-income countries: hypertension (sphygmomanometer), chronic airflow obstruction (peak expiratory flow meter), diabetes (urine or blood glucose) and obesity (weight and height); 5) they can be managed in typical primary care settings in middle- and low-income countries; 6) the benefits of prevention and care extend to related conditions of public health importance, e.g. chronic kidney disease (often caused by hypertension or diabetes); and 7) they are the focus of World Health Organization efforts, such as the launch of the new global initiative in July 2009, to try to ensure that NCDs are urgently accorded greater priority in the health and development policies of poor nations and on global aid agendas [
8]. If the framework for the selected chronic NCDs proves useful, it may pave the way for structured approaches to the prevention and management of other chronic NCDs such as chronic kidney disease, chronic liver disease and chronic organic brain syndromes (e.g. the dementias).
Recent estimates and projections have revealed the extent of the global burden of chronic NCDs. The World Health Organization (WHO) predicts a 17% increase in global NCD deaths over the next decade, with the greatest increase in Africa (27%) [
8]. In 2007, it was estimated that there were 246 million people living with diabetes mellitus, 6 million new cases and 3.8 million deaths, with 70% of these patients living in the developing world [
9]. In 2000, there were an estimated 972 million people with hypertension, 65% of whom lived in the developing world, with the number predicted to grow to 1.5 billion by 2025 [
10]. Chronic obstructive pulmonary disease similarly affects large numbers of people with an estimated 300 million living with asthma [
11] and 61 million living with chronic airflow obstruction [
12], with three-quarters of the patients living in Asia and Africa. The chronic NCD burden is likely to increase further as scaled-up programmes of antiretroviral treatment (ART) of HIV-infected people lead to reduced HIV/AIDS mortality and to possible metabolic side-effects resulting from life-long ART [
13].
A worldwide goal for the prevention and control of NCDs has been proposed to complement the Millennium Development Goals, with the accompanying target of an additional 2% per year reduction in death rates attributable to the main chronic diseases (heart disease, stroke, cancer, diabetes, and chronic respiratory diseases) [
14]. WHO has developed a global strategy and action plan for the prevention and control of NCDs [
8]. This comprehensive multisectoral approach covers the development of national policy frameworks, establishment of programmes, building of capacity for an effective national response, monitoring and evaluation at different levels, and promotion of research, but does not include a framework for action to improve the primary care response to chronic NCDs. Although primary care is the health service entry point for the vast majority of people with NCDs and therefore plays a key role in the delivery of prevention and care interventions [
15], the primary care response to common NCDs is often unstructured and inadequate. There is an urgent need for an effective and affordable framework for use and adaptation by countries to improve the delivery of interventions for patients with chronic NCDs by primary care providers, including those in the government services (whether Ministry of Health services or not, e.g., social-security schemes, prisons, military) and non-government services (e.g., non-governmental organisations, and private practitioners). In practice in many developing countries, secondary and tertiary care institutions often also provide primary care.
Chronic NCDs in developing countries have often been neglected despite their huge burden of morbidity and mortality. Efforts to decrease population-level risks for NCDs need to be accompanied by action to improve the delivery of primary care interventions for people with NCDs. We propose a framework for action to ensure an effective and affordable primary care response to chronic NCDs.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
DM had the idea for the paper and drafted the manuscript. AH, RZ and DE helped to develop the idea and to draft the manuscript. All authors read and approved the final manuscript.