Rethinking health-care systems: a focus on chronicity.

Health-care systems, including those in countries of the Organisation for Economic Co-operation and Development, face a crisis of an increasing burden of chronic disease aggravated by ageing populations and complicated by the continuing risks of infectious diseases and global pandemics. The issues for health-care systems in low-income and middle-income countries are compounded by persistent diseases of poverty, and the inadequately understood comorbidities of both infectious and non-communicable diseases. The structure of health-care systems refl ects an underlying understanding of health and disease in which acute episodes result in help-seeking, with the expected outcome of a cure or death. In this model, chronic conditions are treated as serial acute episodes with multiple interactions with the health-care system. As the capacity to manage acute phases of chronic conditions improves, disease prevalence rises, resulting in a fi nancial burden that will begin to dwarf costs in other parts of the health system. For example, Uganda, supported by international aid, has achieved 16% coverage of its HIV-positive population with highly active antiretroviral therapy (HAART), moving the treated few from the category of acute to chronic. The expectation follows of a lifelong commitment to the already treated few, with an implicit promise to manage the remaining 84% as funds become available. Without ongoing global health funding, and in view of the cost of HAART and the cost to the health system of lifelong treatment, it is hard to imagine that this situation will be sustainable. Similarly, the cost of diabetes care per patient in Cameroon was US$489 per year in 2002. This cost exceeds the annual per head income by 1·5 times, and exceeds the per-head governmental health spending by around 50 times. Cameroon is not alone with emerging evidence of a diabetes epidemic across many of the poorest countries in sub-Saharan Africa. In essence, as the technology to lengthen the lives of those with chronic conditions is developed, the fi xed costs of the health system increase. The fi nancial burden will necessitate socially and politically uncomfortable trade-off s. The current focus on health systems is therefore timely. However, discussions to date largely centre on delivering the familiar model of acute-centric care, albeit with some concentration on tackling the weaknesses in the six key components of health systems: service delivery, fi nance, governance, technologies, workforce, and information. Other issues under discussion include the need for universal coverage and equity. These issues are placed within the broader context of systems needed to deliver vertical disease-focused programmes for infectious and noncommunicable diseases. Although this approach might be appropriate for acute conditions, and arguably for higher-income countries, it is unaff ordable and unsustainable with the increasing burden of chronic disease in lowerincome and middle-income countries. And although reducing the burden of chronic diseases in younger and middle-aged people might succeed, the increasing burden of chronic conditions is an inescapable reality of ageing populations. The challenge for health-care systems is to explore and address the implications of chronicity which capture the complexity of addressing disease conditions—regardless of cause—characterised by long duration and often slow progression. Chronicity has wide-ranging implications for, among other things: health promotion and preventive strategies that address risk factors; fi nancing and planning of healthcare systems; training of the health workforce; and the nature and location of health infrastructure. Chronicity provides a framework for exploring an alternative integrated response to a continuum of ill-health within Published Online November 11, 2010 DOI:10.1016/S01406736(10)61856-9