Intended for healthcare professionals


The challenge of chronic conditions: WHO responds

BMJ 2001; 323 doi: (Published 27 October 2001) Cite this as: BMJ 2001;323:947

The sooner governments act, the better

  1. JoAnne Epping-Jordan, scientist (Eppingj{at},
  2. Rafael Bengoa, director,
  3. Rania Kawar, technical officer,
  4. Eduardo Sabaté, medical officer
  1. Department of Management of Noncommunicable Diseases, World Health Organization, CH-1221 Geneva 27, Switzerland

    Education and debate p 990

    Chronic conditions are expected to become the main cause of death and disability in the world by 2020,1 contributing around two thirds of the global burden of disease with enormous healthcare costs for societies and governments.24 These conditions include non-communicable diseases such as diabetes, chest and heart disease, mental health disorders such as depression, and certain communicable diseases such as HIV infection and AIDS. Mental health problems account for nearly a third of the chronic disability affecting the world's population now and comprise five of the top 10 causes of disability.5 Yet many healthcare providers are ill equipped to manage chronic conditions effectively, and many governments cannot cope with the escalating disease burden and costs.

    Strategies to improve clinical care and outcomes for chronic conditions

    Develop health policies and legislation to support comprehensive care

    Reorganise healthcare finance to facilitate and support evidence based care

    Coordinate care across conditions, healthcare providers, and settings

    Enhance flow of knowledge and information between patients and providers and across providers

    Develop evidence based treatment plans and support their provision in various settings

    Educate and support patients to manage their own conditions as much as possible

    Help patients to adhere to treatment through effective and widely available interventions

    Link health care to other resources in the community

    Monitor and evaluate the quality of services and outcomes

    These strategies are based on WHO's review of innovative best practice and affordable healthcare models

    What can healthcare workers do? Firstly they can make better use of the resources already available, as several papers in this issue of the BMJ show. Healthcare providers can do more to engage patients in managing their own conditions and to use treatments properly: we know that most patients who do not adhere to treatment have poorer health outcomes.6 In developed countries only around half of the people prescribed treatments for chronic conditions actually take their medicines.7 For instance, hypertension affects 43-50 million adults in the United States, but only 51% of those treated adhere to their prescribed treatment.810 Adherence is worse in poorer countries—in one study in the Gambia only 17% of people diagnosed as having hypertension were even aware that they had the disorder, and 73% of those prescribed treatment had stopped it.11 The problem is so great that Haines et al have suggested that increasing the effectiveness of interventions to increase adherence to treatments may have a far greater impact on health than further improvement in biomedical treatment.7

    What should policymakers do? The real answer is that they should help to transform health care, moving away from systems focused on episodic care for acute illness. Some governments and healthcare systems are already making the switch. Cheah's paper in this issue describes how Singapore has recognised the growing burden of chronic disease and has begun to redesign its healthcare system to meet people's long term needs (p 990).12 To help healthcare systems around the world to innovate and change in this way, the World Health Organization has launched a project—“Innovative Care for Chronic Conditions”—to analyse and help to disseminate examples of good, affordable care for people with chronic conditions. The strategies arising so far from WHO's review (see box) will be developed further and published soon, giving concrete recommendations for governments and healthcare systems. A wide range of the world's healthcare leaders and policymakers are being consulted by WHO as part of this project, and we would be pleased to hear from BMJ readers too. In the meantime, the policymakers and healthcare leaders who met at WHO headquarters in May 2001 have come to several conclusions. Firstly, it is clear that no nation will escape the burden unless its government and healthcare leaders decide to act: the prevalences of all chronic conditions are growing inexorably and are seriously challenging the capacity and will of governments to provide coordinated systems of care. Secondly, the burden of these conditions falls most heavily on the poor. Thirdly, unidimensional solutions will not solve this complex problem: health status and quality of life will not be improved solely by medication and technical advances; and thus healthcare systems will have to move away from a model of “find it and fix it.” Lastly, these solutions cannot be delayed—the sooner governments invest in care for chronic conditions, the better.


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