The Year In Review – COVID-19, Universal Health Coverage And Noncommunicable Diseases: Three Public Health Advocates Take Stock 
One-year-old Shukulu Nibogore sits on her mother’s lap while Athanasie Mukamana, a PIH community health worker in Rwanda since 2005, measures her arm for signs of malnutrition.
One-year-old Shukulu Nibogore sits on her mother’s lap while Athanasie Mukamana, a PIH community health worker in Rwanda since 2005, measures her arm for signs of malnutrition.

Indian lockdowns, telehealth in California, a “sin tax” on alcohol and cigarettes in the Philippines – three public health advocates reflect on how these and other events have shaped the narrative around non-communicable diseases (NCDs).  The three included Apoorva Gomber, a medical doctor; Gina Agiostratidou, a philanthropic donor; and civil society leader Katie Dain, found time to meet in a virtual “coffee table” conversation during a busy week for global health.  In a year dominated by news of the COVID-19 pandemic, they took stock of trends and responses to the “parallel pandemic” of NCDs – which the world must confront to achieve the goal of universal health coverage.

The week began with: the launch of the NCD and Injuries (NCDI) Poverty Network, a framework building on the recent findings of the Lancet NCDI Poverty CommissionMid-week, on 9 December 2020, WHO released dramatic new data showing that 7 out of the top 10 major causes of death globally are now NCDs – including diabetes for the first time ever.  The week concluded with the commemoration of Universal Health Coverage (UHC) Day, 12 December, in which public health leaders worldwide reviewed progress towards the goal of ensuring worldwide access to quality, affordable health services by 2030.

Apoorva Gomber
Gina Agiostratidou
Katie Dain

The interlocuters: Apoorva Gomber, is an Indian medical doctor and public health advocate living with Type 1 diabetes; Gina Agiostratidou, is a programme director at the US-based Helmsley Charitable Trust; and Katie Dain is CEO of the NCD Alliance.  Drawing on their doctor, donor and advocate roles, Apoorva, Gina and Katie’s conversation covered topics ranging from person-centred approaches to prevention and treatment to better integration of NCDs within other global health priorities. 

Katie Dain: Even before the systemic shock of COVID-19, living with a chronic NCD was already a huge challenge. But now there are added delays in diagnosis and accessing essential treatment; there’s the fear of just going outside, as you’re so vulnerable to getting seriously ill with COVID-19. This has had a huge impact on how people living with NCDs have accessed healthcare.

Since 2007, the National Cancer Institute (INCAN) of Mexico has offered free treatment and care to all women against breast cancer.
Since 2007, the National Cancer Institute (INCAN) of Mexico has offered free treatment and care to all women against breast cancer.

Apoorva Gomber: Yes, the pandemic means we’re all more alone. But for people with NCDs, it’s even worse, as many have been forced to manage their diseases alone.

Gina Agiostratidou: It is important to add that the economic impact of people living with NCDs being isolated and struggling to access care is not just faced by the person but also by the government and health care providers. 

Katie: Yet, despite all this, NCDs have been put on the backburner. WHO reports disruption to NCD services in about 70 per cent of countries. It’s not high income countries versus low income countries. This is a global challenge – income irrespective – borne of a lack of preparedness and investment in public health. 

Through the NCD Alliance’s new report ‘Protecting everyone’, which includes eight case studies on integrating NCDs in UHC during the pandemic period,  we saw the countries that have coped better with COVID-19 are those who were already integrating NCDs into UHC. For example, Rwanda already had decentralization, task-shifting [tasks are moved from highly specialized to less specialized health workers] and made sure screening, diagnosis and treatment for NCDs was covered by health insurance. 

PIH staff care for Hodgkin's Lymphoma patient Wilson Ngamije at Butaro District Hospital in Rwanda.
Partners In Health staff care for Hodgkin’s Lymphoma patient Wilson Ngamije at Butaro District Hospital in Rwanda.

Earlier investments in prevention and resilience have also brought dividends. For example, Australia’s anti-tobacco efforts since the 1980s have helped protect its population from COVID-19 in 2020. We’ve seen that smokers are at higher risk, so a population with a lower proportion of smokers is better protected.

Apoorva: Whereas in India, draconian measures were imposed, without planning, which left people with less than 24 hours to procure supplies, food and medicine. People were forced to ration insulin or to buy it on the black market. The government said it was an essential medicine but provided no support to people to access it. 

As doctors, we felt helpless. We told people with ketoacidosis complications not to come in to the hospital. There were huge lines of people, some even sleeping outside, as they had a dire need for services and didn’t have internet or phones to access them another way. 

Gina: You’ve raised a key issue, sourcing and addressing the concerns of health care workers is vital. In the US, at the beginning of the crisis, Helmsley sent a letter to health facilities asking: what do you need? They came back with requests for insulin pens and glucose monitoring devices. We then reached out to companies and lots provided supplies at cost or free. 

Diverse stakeholders can come together to make change happen. 

Apoorva: Healthcare has also since become more collaborative in India, with more public-private partnership. Private doctors have started alternative ways to use telemedicine in their daily practice though it’s still in its nascent phase. 

The government for its part has worked to increase uptake of telehealth services and motivated patients to take care of their own health.  

Gina: Helmsley has supported Project ECHO [using videoconferences to connect generalists with teams of specialists for training and support for treating patients] to provide tailored care beyond major cities like LA or San Francisco and to save people driving three hours to access specialised care. It has been really impactful and ECHO is looking to expand in India.

We have to meet people where they are, not just in terms of where they’re located but also in what they’re going through. It should be about a holistic approach centered on the person. It shouldn’t be about typing people based on their condition but understanding the totality of people’s lives and the interacting web of health, economic and social challenges they face. 

Voices of NCDI Poverty – trailer from VoicesofNCDIPoverty on Vimeo.

I’ve had the opportunity to meet with young people living with type 1 diabetes in Rwanda, wanting to see though their eyes, what it means to have the condition. One young man in Rwanda was diagnosed on time because his local district hospital, which was five mins away, offered PEN-Plus [an expansion of the WHO Package of Essential Noncommunicable Interventions for Primary Care (PEN)]. Were it not for this hospital, he might well not be alive today. 

Katie: Those kinds of stories were previously a missing piece of the NCD movement, which is why NCD Alliance launched the ‘Our Views, Our Voices‘ initiative which seeks to meaningfully involve people living with NCDs in the NCD response. 

As well as listening to communities, the pandemic has also shown the importance of civil society in building trust with communities, which is absolutely essential. 

Apoorva: Completely. A lot of people in India don’t trust their doctors and go with alternative therapies instead because they don’t want that lifelong dependence on insulin. Trust can really help with compliance, as diabetes is not a case of treat today and “I’m fine!” tomorrow. 

That personal touch can make all the difference. The maternal and child health system in India has achieved lots of wins because community health workers go door to door. We can use that model to expand NCDs services and in turn UHC, even with smaller investments. 

Gina: Can we be agnostic and build coalitions across diseases? HIV is a chronic disease at this point. There are lessons for the NCD community to learn from the HIV community and vice versa. 

Community Health Workers attend a training session on HIV accompaniment in Kirehe, Rwanda.
Community Health Workers attend a training session on HIV accompaniment in Kirehe, Rwanda.

Katie: Speaking of HIV, the Global Fund is developing its new strategy at the moment. There is a real case to be made as to why NCDs should be factored in, as so much of that supports and orientates health systems in LMICs. For too long, global health has worked in siloes, which completely ignores the reality that a lot of people live with several chronic conditions, for example diabetes and TB, or HIV and cardiovascular disease. As we said before, it’s time to look at the whole person, and all the conditions they’re living with, including their mental health, and not just one disease at a time.

NCDs are very much left behind, as indicated by only 1-2% of development assistance spent on addressing them in LMICs. COVID is a moment to both rethink financing and going back to tried and tested models. The ‘Protecting everyone’ report gives some excellent examples of countries with different economic contexts integrating NCDs into UHC. For example, Philippines finances UHC in part via its taxation on unhealthy commodities such as tobacco, alcohol and sugar sweetened beverages.

ApoorvaYes, COVID has unleashed crisis but also opened windows of opportunity. The same logic is seen behind the ACT-Accelerator [the global collaboration to accelerate development, production, and equitable access to COVID-19 tests, treatments, and vaccines] could be used for NCDs. 

Gina: COVID-19 vaccines will have to travel globally in freezers – a huge operation. Can we use this infrastructure to distribute essential medicines, for insulin delivery, now and into the future?

As important as addressing type 1 diabetes is to Helmsley, COVID is also giving us a chance to have an impact beyond just the one disease. We’ve been thinking about health systems, resilience. For people to be healthy, we need all the factors to come together. Integration is key.


Apoorva Gomber is a doctor and youth advocate living with type 1 diabetes, who has been working in hospitals in India during the COVID-19 pandemic. Twitter: @ApoorvaGomber.

Gina Agiostratidou is the program director for the Helmsley Charitable Trust’s type 1 diabetes program, which aims to advance research, treatments, technologies, and services that improve the lives of people with type 1 diabetes. Twitter: @GinaAgios

Katie Dain is CEO of the NCD Alliance, a global network of civil society organisations dedicated to transforming the fight against NCDs. Twitter: @katiedain1

This conversation has been edited for clarity, flow and focus. 


Image Credits: Cecille Joan Avila / Partners In Health, PAHO/Sebastian Oliel.

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