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NCD care requires multi-disciplinary and multi-sectoral services

Care and Managament of NCDs in Primary Care - Professional priorities versus patient needs

Von Manfred Zahorka

The burden of NCDs is rapidly increasing in poorer countries. Long term drug treatment and the management of disease conditions become more important and NCD care requires a more complex set of interventions. Service needs are frequently beyond pure medical care and include social care and general life support. The coordination of such services remains frequently a challenge. WHO formulated the concept of “People centred integrated Services” as a way out. This article discusses different examples of organising health care in a beneficial way.

Care and Managament of NCDs in Primary Care - Professional priorities versus patient needs

People centred care in Eastern Europe. Photo: © SRK


It was previously thought that non-communicable diseases were mainly a problem of the wealthy countries with its aging populations and lifestyles negatively influencing their health. It is now evident that it is the poorest developing countries that rather face a double burden of communicable and non-communicable diseases (WHO, 2018).

WHO estimates that by the year 2020, non-communicable diseases account for seven out of every ten deaths in the developing regions, compared with less than half today, and lifestyle and behaviour contributing 20-25% of the global burden of disease.This proportion is rapidly increasing in poorer countries. This has a series of implications. Due to the lack of a cure option, activities related to the prevention of disease or disease aggravation is of high importance. Long term drug treatment and the management of disease conditions become more important than complex medical services. NCD care requires a more complex set of interventions, particularly when combined with multi-morbidity conditions, old age and additional social needs. Service needs are frequently beyond pure medical care and include social care and general life support. The coordination of such services remains frequently a challenge. In its World Health Assembly 2016 WHO formulated the concept of “People centred integrated Services” as a way out (WHO, 2018).

Whole-of systems and health in all policies approach for integrated care. Source: Adapted from WHO-HQ Global strategy on people-centred and integrated health services 2015


Integrated care - patients in the centre

For Lloyd et al. (2006) integrated care “..seeks to close the traditional division between health and social care. It imposes the patient’s perspective as the organising principle of service delivery and makes redundant old supply driven models of care provision. Integrated care enables health and social care provision that is flexible, personalised and seamless” (Lloyd et al., 2006, A guide for Policymakers). In this concept people and their current context of living are in the centre and services are organised around the needs of people and their immediate caretakers. Given that services are frequently organised along sector boundaries and even within sectors different levels of service provision exist, the coordination of people centred care remains complex. For the health sector for example, the linking of services between hospital care, primary and referral care but also outreach services at the level of communities and households is essential. A critical gap in current services is sharing of patient related information. Sharing this type of information across care levels and sectors is frequently limited due a lack of collaboration, a regulatory gap permitting the sharing of patient information and due to concerns about data security. Information gaps frequently lead to duplication of services and may increase health risks due to overmedication. 

Practical examples of beneficial ways of organising health care

The chronic care model, published by the American Agency for Healthcare Research and Quality (AHRQ Toolkit, 2014) describes the contributing factors between health care organisations, community support and self-management of NCDs which lead together with an informed and activated patient and proactive practice teams to improved patient outcomes. So far no country-wide application of these types of systems has been documented. However, quite a variety of options have been explored in many different contexts.

The Chronic Care Model. Source: American Agency for Healthcare Research and Quality, 2014


A classic example comes probably from the Health Maintenance Organisations (HMO) in the US market (HMO Plan), where people subscribed to the plan can access a network of service providers within one organisation. Although originally started as a way to reduce health care costs, it offers standardized, well-coordinated care, using same quality standards across all providers within the organisation, shared patient information and seamless integration across care levels (from home based care to hospital care). At the same time it limits free choice of the health care provider. The Veterans Health Administration (VHA) is the biggest provider of integrated services in the US including home based care and e-Health applications. The coordination of services in this model is done through the company administration or in the case of the VHA through national or regional government.

The physician networks in Switzerland ( are open networks of private practices, which agreed to work along common quality standards and treatment guidelines. A joint patient information system within the networks and professional exchanges through quality circles ascertain that patients are getting a similarly high quality service across providers. The coordination of services is done through the network and strengthened through regular coordination meetings.

A particularity within the Healthy Kinzigtal (Gesundes Kinzigtal) project in South-Western Germany is probably that although being a provider network it actually also covers a geographic region. The network is governed by an NGO created for this purpose by care providers in the region plus a management organisation – the OptiMedis AG. The provider network includes not only medical doctors, but also therapists, hospitals, pharmacies and other partners relevant for people’s wellbeing. An electronic network ascertains the availability of information across all network partners. Patients are actively participating through disease prevention and participating in health and care programs.


Family medicine centre in Kosovo. Photo: © Layla Barake


Swiss funded initiatives

The role of local authorities in risk reduction programs and integrated health and social care initiatives is promoted by a variety of Swiss funded initiatives in Eastern Europe and the Balkans. In Romania, Switzerland supports services integration within community centres, which host health and social services as well as community driven initiatives for the elderly. In Kosovo in the framework of the Accessible Quality Health (AQH) project Switzerland supports quality of services in family medicine and NCD risk reduction through national information campaigns, community initiatives as well as strengthening health education at the provider level. NCD patients are addressed through case management approaches as well as integrated care, particularly for the elderly. Home-based care is specifically promoted in Bulgaria (SDC and SECO project, 2012-2016) with a focus of maintaining high quality of life for elderly people living alone.

The way forward: The focus is on people’s autonomy and quality of life

Classic health systems’ organisation along professional priorities is not entirely suitable for the management of NCDs, which require a variety of multi-disciplinary and multi-sectoral services. Non-curable diseases require a focus on maintaining people’s autonomy and quality of life. Case management and integrated care systems offer an interesting alternative by organising provider networks around patients’ needs. Systems with geographic coverage might have an advantage over professional networks in the long run. Given the economic pressure on health systems, the cost-effectiveness of new ways of providing health and social services will play an important role when alternatives to current NCD care are envisaged.  


Additional Information

  • Dennis L. Kodner, Cor Spreeuwenberg (2002). Integrated care: meaning, logic, applications, and implications – a discussion paper. International Journal of Integrated Care, 2:e12. Available from:
  • Gröne O, Garcia-Barbero M. (2001). Integrated care: a position paper of the WHO European Office for Integrated Health Care Services. International Journal of Integrated Care, 1:1. Available from:
  • Hardy B, Mur-Veemanu I, Steenbergen M, Wistow G (1999). Inter-agency services in England and The Netherlands. A comparative study of integrated care development and delivery. Health Policy, 48(2):87-105. Available from:
  • WHO (2013). Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013 – 2020. Available from:
  • Leichsenring K (2004). Providing integrated health and social care for older persons – A European overview; Report to the EU Commission 5th FP : Quality of Life and Management of Living Resources on the PROCARE program.


Manfred Zahorka

Manfred Zahorka is family physician, quality auditor and senior public health expert at the Swiss Centre for International Health within the Swiss Tropical and Public Health Institute (Swiss TPH).