Noncommunicable diseases and women's health

Noncommunicable diseases (NCDs) – primarily cancer, cardiovascular disease, diabetes and chronic respiratory diseases – represent a major health, social, and economic burden that affects women globally, yet their impact on women in low- and middle-income countries (LMICs) has not been fully recognized.¹1 Non-communicable diseases: a priority for women's health and development. Geneva: The NCD Alliance; 2011. Available from: http://www.who.int/pmnch/topics/maternal/2011_women_ncd_report.pdf.pdf [accessed 20 June 2013].
http://www.who.int/pmnch/topics/maternal... NCDs cause premature death and disability among women of all socioeconomic strata worldwide. This burden is expected to increase substantially in the coming decades, especially in LMICs, because of a combination of factors, primarily the “ageing” of the population, improvements in maternal health in LMICs and a projected increase in smoking, obesity and other risk factors for NCDs among women.²2 Global status report on noncommunicable diseases. Geneva: World Health Organization; 2011.

Discussions surrounding the post-2015 development agenda provide an important and timely opportunity to realign policies and resources in trying to meet the complex and shifting health problems faced by women globally. The focus of the realignment should be on ensuring that health systems have the capacity to equitably provide health services to women throughout their lifecourse and on maximizing collective efforts to meet women's health needs in all settings, even the poorest. Achieving this will require strengthening the control of NCDs and integrating it into women's health frameworks and platforms, allocating resources optimally and promoting the development of health systems that serve the needs of women throughout all stages of life.³3 Bustreo F, Knaul FM, Bhadelia A, Beard J, Carvalho IA. Women's health beyond reproduction: meeting the challenges. Bull World Health Organ 2012;90:478-78A. Available from: http://www.who.int/bulletin/volumes/90/7/12-103549/en/b [accessed 20 June 2013].
http://www.who.int/bulletin/volumes/90/7...

NCDs, communicable diseases and maternal conditions are interrelated in complex ways. One can lead to the other. For example, hormonal changes during pregnancy can induce the appearance of diabetes and hypertension. A pregnant woman who has diabetes, hypertension or infection with the human immunodeficiency virus (HIV) as an underlying condition is at greater risk of suffering complications during pregnancy and delivery than a woman who has none of these conditions.⁴4 PATH. The growing chronic disease burden: implications for reproductive health. Outlook 2009;26. Because of these interrelations, the limited availability and accessibility of NCD prevention and control services makes it even harder to make headway in addressing established global health priorities.

Opportunities to prevent and treat NCDs and reduce their financial and social burden on women abound, but most of the time they are missed. NCDs develop over years; it takes frequent contact with the health system to detect them at an early stage. In many settings, maternal and reproductive health services are the only potential points of contact for the secondary prevention of NCDs.

Health systems are ill-equipped to keep pace with changing patterns of disease and the need for an expanded range of health services for women of all ages. Many women who have some type of NCD also have HIV infection or a pregnancy-related health problem. Integration of NCD prevention and control efforts within existing health services is becoming increasingly necessary to bolster future progress in women's health and socioeconomic well-being and to safeguard the progress made so far in attaining the goals and targets set in the area of women's health and development.

As a post-2015 framework that will sustain such progress develops, we must work towards capturing international attention and mobilizing resources to address current disease trends and the wide-ranging health needs of women in LMICs. These efforts should build upon existing health platforms and expand services to meet the health needs of women of all ages (e.g. human papillomavirus (HPV) vaccine programmes for adolescents and NCD screening for women of post-childbearing age).

The poverty and gender divide

Many of the women being targeted for interventions in the areas of sexual and reproductive health, maternal health and HIV-related problems are the ones who are affected by health inequities that increase their risk of getting and dying from NCDs. Women in all settings, regardless of resources, get NCDs; however, poor women, especially those who live in LMICs, are the least likely to have access to affordable diagnosis, management and treatment services.⁵5 Farmer P, Frenk J, Knaul FM, Shulman LN, Alleyne G, Armstrong L et al. Expansion of cancer care and control in countries of low and middle income: a call to action. Lancet 2010;376:1186–93. doi: http://dx.doi.org/10.1016/S0140-6736(10)61152-X PMID:20709386
https://doi.org/10.1016/S0140-6736(10)61...

Simple, affordable and effective means of preventing, treating and managing NCDs exist, but they are limited, absent or unaffordable in many LMICs, where health systems continue to be primarily designed to manage acute health conditions. The chronic nature of many NCDs makes long-term care and self-management necessary and makes it critical for the corresponding services to be available and affordable within a responsive health system.

The control of NCDs and of the health problems affecting women that are prioritized under current global development goals is similarly undermined by fragile health systems, socioeconomic disparities and gender-specific barriers. A gender-based perspective is necessary to integrate NCD prevention and control within existing health platforms. Sex and gender are implicated in patterns of exposure to behavioural risk factors for NCDs (e.g. HPV infection, smoking, obesity and physical inactivity). Important and unique interrelationships also exist between NCDs and the conditions that have traditionally been the focus of women's health care: maternal, reproductive and HIV-related problems. Such interrelationships make it particularly urgent to address the problem of NCDs in women and to develop differentiated approaches to disease prevention and control for women with and without NCDs. For instance, women who develop an NCD, such as diabetes, relatively early in life have different needs for safe pregnancy, childbirth and family planning services than other women. In light of these considerations, a gender-based approach to NCD prevention and control is a necessity. Such an approach will make it possible to: (i) understand the magnitude of the NCD burden and its risk factors in women; (ii) develop appropriate and effective strategies for prevention, screening and control; and (iii) ensure that these strategies support broader women's health and development goals.

Priority actions

Given the links between NCDs, maternal conditions and infectious diseases in women, it is essential that women's health advocates and NCD experts unite in their commitment to promote women's right to health throughout the lifecourse as a central component of efforts to strengthen health systems and to protect women's health in a post-2015 environment. Current efforts to establish and implement a global framework for NCDs (e.g. the Global Action Plan 2013–2020 for NCDs, endorsed at the Sixty-sixth World Health Assembly) must be informed by a gender-based approach to addressing health challenges and must build upon the accumulated insight of women's health experts and advocates. At the same time, a post-2015 global development framework should leverage the momentum of the emergent global framework for NCDs to advocate for the health of women throughout all stages of life. The authors recommend that, within these emerging frameworks, a life-course approach to women's health embrace the following priority actions:

1. Ensuring universal access to health care. Universal health coverage is being proposed as one comprehensive strategy that addresses quality, equity and human rights in health care. It builds on past successes and encompasses a broad range of priorities in the post-2015 era.⁶6 Positioning health in the post-2015 development agenda, WHO discussion paper, October 2012. Geneva: World Health Organization; 2012. Available from: http://www.who.int/topics/millennium_development_goals/post2015/WHOdiscussionpaper_October2012.pdf [accessed 20 June 2013].
   http://www.who.int/topics/millennium_dev... Universal health care is especially important for chronic conditions that require attention throughout the health care continuum: from prevention to diagnosis, treatment and palliative care.

2. Strengthening the integration of health systems and services for the control and management of NCDs with those that address the established priorities in women's health (i.e. the health challenges prioritized under current global development goals), specifically:
– Surveillance: The collection of sex-disaggregated data on NCDs and improved health information systems that incorporate the social determinants of health as well as behavioural risk factors and disease burden are critical for sound policy and planning.
– Health promotion and disease prevention: Strengthened, better integrated health promotion and disease prevention efforts that simultaneously address maternal conditions, infectious diseases and NCDs are needed. For instance, teaching women of childbearing age about the importance of a healthy diet, avoiding tobacco and limiting alcohol intake, can optimize maternal and child health while reducing the risk of NCDs.
– Access to effective care: Strengthening health systems – e.g. infrastructure, personnel, diagnostic laboratory and pharmacy services, and drug procurement and supply chain management – is necessary for improving screening and case management and treatment services to adequately attend to women's health needs throughout the lifecourse. Doing so will guarantee women the right to health and promote health equity. For example, HIV clinics can screen female patients for cervical cancer, or existing infrastructure can be expanded to allow the integration of services for the control and management of different diseases.

3. Promoting innovative partnerships and multisectoral collaboration: Supporting and strengthening existing and novel partnerships, such as the global coordination mechanism for NCDs, is essential for establishing effective frameworks and conducting resource mobilization efforts that will enable universal access to health care and improved integration of services for all women's health priorities. Such partnerships can promote better national stewardship and steer global governance in the area of women's health.

4. Strengthening investments in women's health: The priority recommendations delineated above cannot be implemented without resource mobilization and sustained and enhanced investment in women's health as a primary foundation of global health and development efforts. Investment is needed in particular to: strengthen surveillance and research to support sound decision-making; develop new high-impact, low-cost interventions; develop effective, scalable programmes; ensure women's right to health; integrate preventive efforts; promote equity in access to disease prevention and management; and foster innovate partnerships.

With ongoing efforts to define a global framework for NCDs and discussions around the post-2015 agenda at their most intense, we are at a critical juncture in defining the priorities and strategies for promoting a healthier, more equitable future for women. Protecting the gains afforded by the Millenium Development Goals while addressing their shortcomings, will require goals and frameworks to be forged to create health systems capable of meeting women's diverse health needs within very different and dynamic socioeconomic contexts.

The post-2015 development agenda offers a critical opportunity to integrate the prevention and control of NCDs with other priority issues in women's health within a global framework designed to address women's many health challenges, improve health outcomes and strengthen health systems. Such a framework should pursue universal goals focused on health outcomes, ensure universal health coverage and access to services, and encompass the social determinants of health. Its impact would be particularly high in LMICs, where important gains in women's health and overall development must be protected.

Building on emerging, integrated models for women's health and addressing the issues highlighted above are fundamental steps towards responding to women's health needs. There is an urgent need for advocacy and technical initiatives that will increase global awareness and support for a gender-based approach to NCD prevention and control and re-kindle global interest and support for a life-course approach to women's health to respond to the evolving needs of women in LMICs.

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