Inequalities in non-communicable diseases and effective responses

Summary

In most countries, people who have a low socioeconomic status and those who live in poor or marginalised communities have a higher risk of dying from non-communicable diseases (NCDs) than do more advantaged groups and communities. Smoking rates, blood pressure, and several other NCD risk factors are often higher in groups with low socioeconomic status than in those with high socioeconomic status; the social gradient also depends on the country's stage of economic development, cultural factors, and social and health policies. Social inequalities in risk factors account for more than half of inequalities in major NCDs, especially for cardiovascular diseases and lung cancer. People in low-income countries and those with low socioeconomic status also have worse access to health care for timely diagnosis and treatment of NCDs than do those in high-income countries or those with higher socioeconomic status. Reduction of NCDs in disadvantaged groups is necessary to achieve substantial decreases in the total NCD burden, making them mutually reinforcing priorities. Effective actions to reduce NCD inequalities include equitable early childhood development programmes and education; removal of barriers to secure employment in disadvantaged groups; comprehensive strategies for tobacco and alcohol control and for dietary salt reduction that target low socioeconomic status groups; universal, financially and physically accessible, high-quality primary care for delivery of preventive interventions and for early detection and treatment of NCDs; and universal insurance and other mechanisms to remove financial barriers to health care.

Introduction

Non-communicable diseases (NCDs) cause 35 million of the 53 million annual deaths worldwide; more than three-quarters of these deaths occur in low-income and middle-income countries.1, 2 A substantial amount of the worldwide NCD burden is attributable to behavioural, dietary, environmental, and metabolic risk factors3, 4, 5—a fact that has attracted worldwide attention to NCDs as a major global health issue and has shown the need for improved prevention and treatment.¹ In particular, NCDs were the subject of a UN high-level meeting in September, 2011. Goals and targets for NCD mortality and risk factors have been proposed, and mechanisms envisioned to increase accountability to the commitments made by measurement and reporting of progress in NCD outcomes, risk factors, and treatment.6, 7

Several studies, mainly from high-income countries, have shown that NCD rates are higher in disadvantaged and marginalised people and communities than in groups with higher socioeconomic status.8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 Less is known about within-country NCD inequalities in low-income and middle-income countries, and about how inequalities differ in relation to the stage of economic and epidemiological development. Furthermore, within-country NCD inequalities have not received explicit attention in global NCD discussions. Although the Millennium Development Goals (MDGs) do not specifically address within-country equity, social inequalities in MDGs and their interventions are large, and reduction of these inequalities will help to achieve the MDGs.²⁶ The scarcity of similar worldwide evidence for NCDs creates difficulties in formulation and implementation of actions that reduce NCD inequalities, and in assessment of how these actions might help to decrease the total NCD burden.

Key messages

Key actions to reduce non-communicable diseases (NCDs) and NCD inequalities, globally and within countries, are:

• Enhancement and improvement of early childhood development programmes and education for all social groups, and removal of barriers to secure employment

• Taxation of tobacco and alcohol, regulation of their production and sales, and restriction of advertising and marketing of these products

• Reduction of dietary salt intake by regulation, well-designed public education, and mass media campaigns that target disadvantaged and marginalised social groups, and perhaps negotiated voluntary actions by food manufacturers

• Improvement of financial and physical access of disadvantaged and marginalised social groups to healthier diets, including fresh fruits and vegetables, healthy fats, and whole grains through subsidies, agricultural policies, and possibly through improved availability in grocery stores; and implementation of taxes and regulations or restrictions of foods that contain high amounts of sugars, processed carbohydrates, and saturated fats

• Implementation of universal, financially and physically accessible, high-quality primary care to reduce NCD risk factors through clinical interventions and to enhance early detection and treatment of NCDs

• Implementation of universal health insurance or other mechanisms to remove financial barriers to health care, reduction of physical and behavioural barriers to health-care use, and improvement of quality of care in disadvantaged communities

We provide an overview of global and within-country inequalities in NCD outcomes, risk factors, and interventions, with examples from countries at all stages of economic development and in different regions. Although we discuss NCDs in general, in examples we refer specifically to cancers, cardiovascular diseases, diabetes, and chronic respiratory diseases—four disease groups that together account for more than 80% of NCD deaths and are included in global goals.⁶ We then focus on effective actions to reduce NCD inequalities.