Division of Tropical and Humanitarian Medicine, Geneva University Hospitals and University of Geneva, Geneva , Switzerland
34 Beran
in low- and middle-income countries [3] . Non-communicable diseases and poverty have a sym-biotic relationship, with poverty increasing expo-sure to noncommunicable disease risk factors and actual noncommunicable diseases forcing in-dividuals and households into poverty as the bur-den of the cost of care falls on the individual in these countries [3] . Noncommunicable diseases also impact health systems, economies and coun-tries as a whole, as every 10% increase in noncom-municable diseases is associated with a 0.5% de-crease in economic growth.
In September 2011, the United Nations held its second health-related general assembly on noncommunicable diseases after its 2001 meet-ing on HIV/AIDS. Four diseases were prioritized by the World Health Organization, namely car-diovascular diseases, cancer, chronic respiratory diseases and diabetes, which were chosen since they contribute the largest amount to morbidity and mortality [4] . In 2013, the World Health Or-ganization’s noncommunicable disease global action plan was endorsed and aims to provide a guide to attain nine voluntary global targets, in-cluding the overall goal of a 25% relative reduc-tion in premature mortality from cardiovascular disease, cancer, diabetes and chronic respiratory disease by 2025 [4] . Although neuropsychiatric disorders contribute an estimated 13% of the global burden of disease [5] , they are not formal-ly included in the World Health Organization’s global noncommunicable diseases action plan.
Mental health is mentioned in the context of comprehensive care for noncommunicable dis-eases needing to include ‘primary prevention, early detection or screening, treatment, second-ary prevention, rehabilitation and palliative care and attention to improving mental health’ [4] .
Health systems play a key role in addressing the challenges of noncommunicable diseases, mental health and multimorbidity. The manage-ment of these requires care be provided over a long period of time, which needs the input from a multidisciplinary team of healthcare workers,
access to medicines and diagnostic tools, patient empowerment, and coordination of different ele-ments of the health system [6] .
Multimorbidity in a Low-Income Context With the number of people aged 65 years or above projected to increase from approximately 524 million in 2010 to about 1.5 billion in 2050, with the highest increase in developing countries, the issue of multimorbidity needs to be addressed. It is estimated that 1 in 4 adults suffer from multi-morbidity, with most evidence coming from high-income countries [7] . Studies from low-in-come countries have found that 53.7% of people aged above 60 years had two or more chronic conditions in Bangladesh [8] , 66.7% of people with diabetes also had hypertension in Cameroon [9] and in a nationally representative sample in South Africa it was found that 29.6% had two or more of the following conditions: hypertension, diabetes, asthma, depression, angina, stroke and arthritis [10] .
Synergies to address and integrate care for communicable and noncommunicable diseases have not been addressed [11] . The links between the four main noncommunicable diseases are clearly established through their shared risk fac-tors and high rates of comorbidity [8, 9] . In low-income country settings, however, there is not only the existence of comorbidity of noncommu-nicable diseases, but also comorbidity of non-communicable diseases with non-communicable dis-ease [12] .
The issue of multimorbidity can be linked to the causal pathways of the diseases [13] . For ex-ample, there is a link between a high burden of tuberculosis with smoking and harmful alcohol use [14–16] , or mental health with sexual behav-ior, alcohol and tobacco use [17] . Another way of looking at multimorbidity is that having one con-dition means the individual is more likely to de-velop another [13] . For example, diabetes has
Sartorius N, Holt RIG, Maj M (eds): Comorbidity of Mental and Physical Disorders.
Key Issues Ment Health. Basel, Karger, 2015, vol 179, pp 33–41 ( DOI: 10.1159/000365545 )
been associated with a threefold incident risk of tuberculosis [18–20] , HIV/AIDS causes Kaposi sarcoma and lymphoma [21] , and people with HIV/AIDS are more likely to have mental disor-ders [22] .
It is not only the condition that may lead to another condition, but also the treatments for these. One particular example relevant to low-in-come countries is the link between antiretroviral treatment and the metabolic syndrome [18] , in-creased rate of cardiovascular risk factors [23] , diabetes [24] , and other cardiac, neurological and musculoskeletal conditions [25] .
Finally, the last aspect is that proper manage-ment of both conditions is necessary in order to ensure good outcomes from each disease per-spective. Good tuberculosis management is nec-essary for good diabetes management, and good diabetes management helps ensure the success of tuberculosis treatment; however, the medicines used to treat tuberculosis may worsen blood glu-cose control [19, 20] . Management of depression is also necessary to ensure proper outcomes for noncommunicable diseases [26] .
Addressing these situations needs to be done not only from a biomedical perspective, but also from a socioeconomic angle, taking into account inequalities and poverty. Table 1 details these in-terlinkages as well as the underlying issues of age-ing and poverty.
The challenge in low-income countries is that there is a knowledge, treatment and outcome gap for noncommunicable diseases and multimor-bidity. In Mozambique the prevalence of hyper-tension is 33.1%, but only 14.8% of people who have hypertension are aware they have it [27] . Of those aware, 51.9% receive treatment and of those receiving treatment, only 39.9% are controlling their hypertension. That means for every 100 people with hypertension, only 3 know they have the disease, receive treatment and have controlled hypertension. A nationally representative survey in South Africa found that despite the high preva-lence of mental disorders and related disability, these conditions, especially depression, were less likely to be treated than physical disorders [28] . Data from the World Health Organization show that between 76 and 85% of people with mental health problems in low- and middle-income countries receive no treatment for their disorder and that resources for mental health are primar-ily assigned to mental hospitals [29] .
The health systems in low-income countries are currently failing in their management of indi-viduals with single conditions. Therefore, when a person has multiple conditions or multiple risk factors for these conditions, the health system is not organized in a manner that can face such a situation, which leads to poor outcomes for indi-viduals.
Table 1. The interplay of multiple risk factors and diseases Noncommunicable
disease risk factor
Actual
non-communicable disease
Communicable disease
Mental health
Noncommunicable disease risk factor
person who smokes and is obese
person with diabetes who smokes
obese individual with HIV/AIDS
smoking and alcohol consumption Actual non-
communicable disease
person with diabetes and hypertension
person with diabetes and tuberculosis
people with diabetes are more prone to depression
Communicable disease person with HIV/AIDS
and tuberculosis
people with HIV/AIDS more likely to have mental disorders Underlying issues include, for example, ageing and poverty.
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The Health System Barriers to Care for Multimorbidity in Low-Income Countries A health system is defined as all the ‘activities whose primary purpose is to promote, restore and maintain health’ [30] . Health systems have three main objectives: (1) to improve the health of the populations they serve, (2) respond to the popula-tion’s expectations and (3) provide financial pro-tection against the costs of ill-health [30] .
Health systems do not work in isolation of the other sociopolitical elements of a given country, and therefore different models of health systems exist [31, 32] . Certain key factors that health sys-tems need to perform are procurement and sup-ply of medicines, disposables and equipment, healthcare workers in sufficient numbers and with the right skills for the given population and disease burden, and sustainable financing and healthcare costs that do not overburden the poor and have a financial, budgetary and regulatory framework [31, 32] . Research into diabetes in low-income countries [33] found that 11 ele-ments were necessary for diabetes care. Diabetes makes a good tracer condition for health systems, from which the lessons learnt can be applied to other chronic conditions [34–36] .
The first element is organization of the health system. Currently, health systems in low-income countries are not organized to manage noncom-municable disease, let alone individuals with multiple conditions, and are more focused on in-fectious diseases [37] . Many health system re-sponses in low-income countries for HIV/AIDS and tuberculosis have focused on vertical pro-grams only addressing these specific conditions and not tackling all the challenges faced by indi-viduals in the health system [38] . Although these have shown some success, they fail to take a per-son-centered focus and do not manage all the conditions the individual may have, but only the one that is being funded, leading to fragmenta-tion of healthcare [39] . This fragmentafragmenta-tion also exists because care in urban areas is hospital based
whereas in rural areas health services focus on a specific disease (e.g. HIV/AIDS) or selective ser-vices (e.g. maternal health) [39] . In parallel, the use of traditional medicine is widespread, with 80% of the population in Sub-Saharan Africa re-lying on this as their primary source of care [13] , which has as of yet not been integrated for the management of noncommunicable diseases.
Although primary healthcare has been pro-moted in low-income countries, it has not been able to address the challenge of noncommunica-ble disease or play a role in prevention and health promotion [13, 37] . Noncommunicable disease care is still the remit of specialists in specialist centers; for example, mental health in low-in-come countries is still predominantly focused on hospital care [40] . As these specialist centers are limited, this also causes problems for referrals and counterreferrals. Specifically for the issue of multimorbidity, the degree of overspecialization may mean multiple referrals, if feasible, are made to different specialists for the individual’s multi-ple conditions.
When providing care for a person both over a long period of time and with multiple conditions, another element the health system needs to pro-vide is data collection. Data are needed at all levels of the health system in order to inform policies, medicine procurement, and staffing and individ-ual care. However, there is a general lack of qindivid-ual- qual-ity health information systems in many low-in-come countries [37] . At the level of the individual, poor use of patient records means that previous consultations or other conditions are not taken into account, thus leading to an unstructured monitoring of clinical care [37] . There is also a lack of a recall system to ensure continuity of care [38] . In terms of studies, very few have looked at the issue of multimorbidity in low-income coun-tries except for the issue of HIV/AIDS and tuber-culosis.
Another area where studies are lacking from low-income countries and which is important for the issue of multimorbidity is prevention. As
Sartorius N, Holt RIG, Maj M (eds): Comorbidity of Mental and Physical Disorders.
Key Issues Ment Health. Basel, Karger, 2015, vol 179, pp 33–41 ( DOI: 10.1159/000365545 )
mentioned previously, primary healthcare in low-income countries does not fulfill its role in terms of prevention and health promotion [33] . This is linked to lack of training, human resourc-es and culturally appropriate materials to ensure wider knowledge of noncommunicable disease and their risk factors in these settings. For exam-ple, asthma and chronic respiratory disease are underrecognized, underdiagnosed, undertreated and insufficiently prevented. With one of the main risk factors in low-income countries being the use of biomass fuel, local healthcare workers need the knowledge about these conditions in their specific context to enable them to play a pre-ventive role and not only provide care [41] . The World Health Organization has also developed
‘best buys’ for noncommunicable diseases for the four common risk factors (tobacco use, harmful use of alcohol, unhealthy diets and physical inac-tivity) and for cardiovascular disease, diabetes and cancer [42] . However, many low-income countries lack the capability of implementing, en-forcing and sustaining these.
As prevention also includes screening mea-sures, diagnostic tools and infrastructure are needed. However, health infrastructure is poor at all levels of the health system with, for example, 19 and 39% of primary healthcare facilities in Tanzania and Senegal, respectively, having access to electricity, water and sanitation [13] . In addi-tion, basic equipment is lacking in these facilities and access to diagnostic tools for diabetes has been seen to be poor in low-income countries [43] . There are also financial constraints for the individual if they need to pay for the test as well as budget limits that impact a prescribers’ ability to ask for certain tests [38] .
Besides diagnostic tools and infrastructure, health systems need to be able to procure and supply medicines to manage multimorbidity.
Looking at the issue of insulin in low-income countries, a variety of factors impact its procure-ment and supply, such as budget allocation for medicines, adequate buying procedures,
quantifi-cation of needs, efficient procurement, efficient distribution, rational prescription and proper compliance [43] .
Mental health is an example highlighting the challenge of medicine procurement and supply with such issues as prescription regulations, avail-ability and use of certain treatments, and limited expenditure (low-income countries spend 10 times less than lower-middle and 1,547 less than high-income countries, respectively) [40] . Ulti-mately, all of these factors impact the affordabil-ity and accessibilaffordabil-ity of medicines. Accessibilaffordabil-ity is linked not only to distribution, but also to where the individual lives, with urban areas having bet-ter access than rural areas. In bet-terms of affordabil-ity, government policies will impact this; for ex-ample, insulin is free in Nicaragua, while individ-uals have to pay for this in Mali because of the government policy of cost recovery [43] . Generic medicines to treat noncommunicable disease were found to be less available than medicines for communicable conditions in both the public (36.0 vs. 53.5%) and private sectors (54.7 vs.
66.2%) [44] . Specifically, antiasthmatic inhalers were available to 30.1% in the public sector and to 43.1% in the private sector. In terms of affordabil-ity, it has been found that 1 month of treatment for coronary heart disease costs 18.4 days’ wages in Malawi while for insulin in Mali the annual cost represented 38% of per capita gross domestic product [43, 45] . These conditions also place a huge financial burden on countries, with diabetes care representing 5% of the total budget for the Ministry of Health in Nicaragua and insulin rep-resenting 10% of the total medicines budget in Mozambique [43] .
An essential element of the health system is healthcare workers. Issues of availability, rational use and training need to be addressed [46] . Low-income countries face a severe shortage of health-care workers and the human resources present are inequitably distributed [13] . Specifically for mental health in the Africa region of the World Health Organization, there is significant
varia-38 Beran
tion in the number of psychiatrists, ranging from more than 10 per 100,000 to fewer than 1 per 100,000 [47] . There is also a low focus of these human resources on community care [40] . Over-all, this problem is linked to an internal and ex-ternal ‘brain drain’ with doctors preferring the private over public sector, urban over rural areas, and tertiary levels of care versus primary care [48] . In addition, this internal brain drain to non-governmental organizations specifically in the area of HIV/AIDS has impacted the availability of health professionals, e.g. 50% of medical graduates in Uganda were found to be working for an HIV-related nongovernmental organiza-tion [49] .
It is important to define the role of different cadres of healthcare workers in managing non-communicable disease and the role of specialists, such as in the initiation of treatment versus fol-low-up and continuation of treatment and how this is linked to treatment guidelines that are adapted to the local context or include the best clinical evidence. Another issue is actual training and how this training currently focuses on clini-cal management of certain diseases and not the issue of multimorbidity. Current training of health professionals, especially doctors, does not include the preventive role they can play.
Patient education is lacking both as health professionals are not trained in this area, have very little time for this, and also lack the materi-als and the means to deliver this. In addition, the view of certain diseases may impact how health professionals educate and empower their pa-tients. For example, in some settings people with mental health problems are shackled and beaten because of traditional beliefs about the causes of these conditions [47] . Therefore, issues of stig-ma also need to be addressed not only for indi-viduals with these conditions, but also in the wider community. There is also the issue of us-ing Western concepts of disease. For example, Patel et al. [50] while studying depression in Zimbabwe found a variety of presentations and
descriptions for this condition including super-natural causes. The health system may provide the majority of aspects that a person with a non-communicable disease requires; however, the burden of care falls on the individual and their family as the majority of the time spent manag-ing a noncommunicable disease is done outside of the health system [51] .
Adherence is impacted by education about the condition and the financial burden of care. In low-income countries, patient education is lack-ing for noncommunicable disease and there is still a large financial burden of care. In a system-atic review of adherence to cardiovascular medi-cations in resource-limited settings, Bowry et al.
[52] found that poor adherence was due to these factors as well as negative perceptions about med-icines and their side effects.
Community involvement and patient associa-tions can play a role in patient education and em-powerment, thereby impacting adherence, with the proper support from the health system. Many types of patient organizations (e.g. diabetes asso-ciations) exist, with varying roles, such as advo-cacy, training for patients and healthcare work-ers, and acting as a support group for patients and families, as well as being a provider of care [53] . The 2011 Mental Health Atlas [40] found that 39% of low-income countries had associations compared with 80% of high-income countries. It is not only the number of these organizations that is important, but also that many of them focus on specific diseases, such as cancer societies, diabetes associations, etc.
Overall, the health system elements described above need to be present and supported by a pos-itive policy environment. In low-income coun-tries, there is a large reliance on external funding for specific disease programs [13] . Due to this it was found that 30% of countries do not have a specified budget for mental health [47] . In paral-lel, in order to address the issue of noncommuni-cable disease properly, a multisectorial approach is needed that not only includes the health sector,
Sartorius N, Holt RIG, Maj M (eds): Comorbidity of Mental and Physical Disorders.
Key Issues Ment Health. Basel, Karger, 2015, vol 179, pp 33–41 ( DOI: 10.1159/000365545 )
but also education, trade and agriculture [33] . For mental health there is also a need to include police and judicial systems. Although many low-income
but also education, trade and agriculture [33] . For mental health there is also a need to include police and judicial systems. Although many low-income