Multiple Chronic Conditions: The Real National Emergency Calls for Bipartisan Resolve

By Asaad Taha, Ph.D., MPS®, PRINCE2®

Non-communicable diseases (NCDs) are protracted conditions which are not transmitted person-to-person or animal or host to a human being. They include cardiovascular and chronic respiratory diseases, mental health disorders, cancers, and standalone disease like arthritis, obesity, diabetes types I and II. They afflict populations throughout the world and now challenge the United States, threaten its prosperity, and represent a true national emergency. While there is no single solution for multiple chronic conditions, there is a compelling case for a bipartisan consensus on the adoption of an overarching and multi-sectoral theory of change described here as the S4F™ framework.

NCDs are generally avoidable illnesses if individuals follow a healthy lifestyle and screen for risks. Early detection plays a critical role in disease prevention and case prognosis. Low-cost lifestyle adjustments and habit changes, such as improving physical activity, ending tobacco use, eating healthy, and avoiding alcohol, can result in a substantial risk reduction or condition improvement (NCCDPHP, 2019).

The World Health Organization identifies chronic diseases as the “world’s biggest killers.” “Noncommunicable diseases (NCDs) kill 41 million people each year, equivalent to 71% of all deaths globally” (Noncommunicable diseases, 2018). “Each year, 15 million people die from a NCD between the ages of 30 and 69 years; over 85% of these ‘premature’ deaths occur in low- and middle-income countries” (Noncommunicable diseases, 2018). This number is expected to “increase to 55 million by 2030” if the current trends continue (Mendis, 2013).

The impact of non-communicable diseases goes far beyond the individual’s health consequence. It threatens global prosperity, communities’ social fabric, and hard-won moderate gains in health and development — particularly those brought about through the health-related 2015 Millennium Development Goals (Noncommunicable diseases and their risk factors, 2019) and the one envisioned in Sustainable Development Goals 2030 (Sustainable Development Goal 3, 2013). The projected economic losses between 2011–2030 due to cardiovascular, chronic respiratory, cancer, diabetes and mental health disease promise “a cumulative output loss of US$ 47 trillion in the two decades from 2011, representing a loss of 75% of global GDP in 2010 (US$ 63 trillion)” (The Financial Burden of NCDs, 2019).

The health, economic, and social burdens of chronic diseases loom large. First, NCDs threaten the sustainability of the public health response to many non-communicable and communicable diseases due to their burden on the health systems draining and incapacitating the systems’ resources. Secondly, the increasing economic and social burdens risk the achievement of Sustainable Development Goals.

The United States is no exception.

Six out of 10 Americans have stories to tell of suffering from the consequences of chronic disease, a jeopardized quality of life, shortened life expectancy, and mental and socio-economic burdens (Chatterjee, Kubendran, King, & DeVol, 2014). Four out of 10 Americans suffer from multiple chronic conditions (NCCDPHP, 2019).

“Currently, the United States also has a higher mortality rate than the global average for all NCDs and for the five leading NCDs” (Chen, Prettner, & Bloom, 2018). According to a 2017 Rand Study, “nearly 150 million Americans are living with at least one chronic condition; around 100 million of them have more than one” (Irving, 2017). The study showed that 59 percent of the U.S. population fighting one plus NCD and using 90 percent of healthcare expenditures.

Those with three plus NCDs number 28 percent of the population who use 67 percent of healthcare spending. And, 12 percent of the population report 5 or more NCDs for 41 percent of the healthcare budget (Irving, 2017). The CDC labeled chronic diseases the “Leading Drivers of the Nation’s $3.3 Trillion in Annual Health Care Cost” (Chronic Diseases in America, 2019).

Figure 1. Percentage of U.S. Adults with Multiple Chronic Conditions by Number of Chronic Conditions (2018), Christine Buttorff et al., RAND Corporation, TL-221-PFCD, 2017 (available at www.rand.org/t/TL221).

Furthermore, these conditions occur in 50 percent of people over 45. They include more women than men and more whites than blacks and Hispanics. On average, Americans with five or more chronic non-commercial diseases spend 14 times more on healthcare than people without the conditions.

The World Health Organization attributes the causation to increased urbanization, unhealthy nutrition, physical inactivity, and harmful use of alcohol and tobacco (Noncommunicable diseases, 2018). The Baby Boomer population of 76 million plus has grown because of medical advances increasing the life expectancy of the United States’ largest population block and producing an expanding aging population (Fry, 2018).

Figure 2. Health Care Spending by Number of Chronic Conditions (2014), Rand Corporation (Buttorff, Ruder, & Bauman, 2017, p. 16)

Setting aside the ethical and emotional dimensions to this problem, the economic dimension projects $4.2 trillion lost value from chronic diseases and their economic burdens, using a conservative scenario of a 42 percent increase in caseload by 2023 (Chatterjee, Kubendran, King, & DeVol, 2014).

The financial burden on individuals and families produces fear-provoking figures considering the continuous rise in the chronic disease healthcare costs, out-of-pocket expenses, and co-pay fees for those who are insured and 27 million uninsured Americans (Key Facts about the Uninsured Population, 2018).

“If the goal of medicine is to promote health — not health care — maybe we've been doing it wrong. And we’re all paying the price.” D. Khullar in The New York Times

The 2010 Affordable Care Act (ACA) made preventive care free and increased the insurance umbrella for inner-city citizens (The Balance, 2017). On the other hand, it raised the insurance premium cost for the working majority and severely affected the rural population’s access to health care (Kaiser Family Foundation, 2017). President Trump’s dismissal of the mandate attached to “Obamacare” leaves the U.S. healthcare insurance system confused, and we cannot calculate the outcomes for some time.

There is no single solution for the multiple chronic diseases crisis. Any solution requires (1) a robust and master theory of change and (2) an integrated and multi-sectoral approach to creating the desperately needed shift. It must address the current caseload and give priority to prevention. Unfortunately, present and previous attempts have been fragmented and unilateral efforts lacking the necessary holistic vision for change.

No Single Solution: Only Bipartisan Consensus Can Manage the NCDs Threat to US Prosperity

The partisan political divide about health policy in the U.S. and its direction has resulted in repeated cycles of policy construction and destruction between the two political parties’ respective administrations. Although NCDs pose a national security issue and existential matter in the long term, the U.S. leadership lacks the unifying vision to prepare or manage.

The US healthcare sector’s scarce resources are progressively depleted in expenditures on treatment responses (86% of health care costs) rather than on prevention strategies (Health and Economic Costs of Chronic Diseases, 2019). Effective prevention requires a multi-sectoral response, a public-private partnership (PPP) to create an enabling environment for U.S. . citizens promoting healthy choices and praise well-being.

Any PPP must pursue contiguous paths: legislative, promotional, prevention and treatment lanes.

• The Legislative path must focus on rules and regulations to protect citizens and consumers by increasing transparency about food nutrition and by enforcing smoking cessation.
• The Promotional lane must incentivize employers with tax benefits for wellbeing programs and facilitate insurance affordability and accessibility.
• Prevention and Treatment of multiple chronic conditions are limited to unilateral efforts exerted by a health sector based on a linear project or program concept. They run parallel but lack the seeds for sustainment.

Figure 3. The “Black Box” phenomena (Image © Asaad Taha 2014).

They are illustrated here in Figure 3 as a set of activities in “Black Boxes” without linking the investment to results, unknown cause-effect pathways, assumptions, and risks. They sit in isolation without a nationwide master theory of change.

This incomplete graphic asks how we proceed from Resources and Social Investments to desired ends like (A) Health Equity, (B) Improved Health-related Quality of Life, and (C ) Promotion of Healthy Quality of Life across All Life’s Stages.

US healthcare must learn to design and implement transformational change such as are found in the Private Sector Development (PSD) and financial sectors. Those sectors have established best practices for bringing about complex transformational change and bridging the gap (the Black Boxes and other shapes in Figure (3) between investments and results.

A proposed framework for transformational change

Figures 4, 5, and 6 below illustrate a multisector delivery system framework to help the U.S. health systems address the multiple chronic disease crisis in a holistic-system thinking, community-based, human-centered interventions, and portfolio-management approach. Any investment must be results-driven, based on a proactive intervention at the community level rather than too late at curative healthcare system, where it is too expensive, and the damage has already occurred.

“The rise in NCDs is due to broken biological, behavioral, social, environmental, economic and other systems.” B. Lee in Forbes

The concept differs little from personal financial portfolio management. That is, individuals invest in high-return investments planning for results. They seek to balance the quick wins and long-term revenue tail (sustainment).

1. They should start with understanding their circumstances and goals (issue-based).
2. They should gather in-depth information (evidence-based) about the best investments where there are high sustainable yields (planning).
3. Successful investors should have an appetite for risks, a willingness to allocate some money for startups stocks (innovative).

The scale-up of the basics of personal financial portfolio management in healthcare systems is a missing gear between the investments and its envisioned results in Figure 4.

Figure 4. The proposed system is a strengthening framework to bridge the gap between NCD investments and results. (Image © Asaad Taha 2014).

S4F Solutions™ (System for Future Solutions) offers this poly-functional framework as a working delivery system illustrated below as Figure 5. It shows the integration of:

1. A Trans-Disciplinary Framework capable of empowering wide-range adopters by providing an inventory of evidence-based toolkits representing the best-of-the-best known global practices.
2. A Strategic-Execution Framework to translate strategy into sustainable benefit realization and results;
3. A Problem-Solving Methodology to link intended changes, benefits, and strategic objectives; and
4. A Sustainable Systems-Strengthening Framework balancing business-as-usual and investments in transformational change.

The framework also has five integrated phases: (1) Systems Review, (2) Planning and Strategic Alignment, (3) Delivery and Change Management, (4) Innovative Solutions, and (5) Sustainment.

These phases parallel those in a MER₂L approach to Monitoring, Evaluating, Research, Reporting, and Learning. The components have 20 associated steps across the MER₂L phases. The delivery framework challenges the concept of “one size fits all” and emphasizes the fact that we need various best practices to address our diverse needs and complex issues.

The S4F Solutions™ framework is built to be flexible and responsive to system dynamics and its interaction with systems of systems (S₂OS₂) and global ecosystems. It puts a particular focus on systems thinking, human-centeredness, change management, innovation, and sustainment. It provides a toolbox for strategic planning and delivery, starting from identification of root-causes through to sustainment.

Figure 5. The twenty subcomponents (Steps) of the proposed delivery system. (Image © Asaad Taha 2014)

Every intervention must be F⁴: fit for purpose, fit to use, fit to context, and fit in time (See Figure 6). Neither system thinking, human-centered design, agile methodology, and more will address complex issues nowadays. There is no “silver bullet,” or super “snake oil,” or universal wrench. All these best practices need to work in an integrated manner and be available as toolkits in a toolbox. The use of every tool or more supposed to be based on the F⁴ Principles (See Figure 6).

Figure 6. S4F.Solutions™ Human-centered Design Framework. The framework is a sub-step of the proposed delivery system twenty steps and overarching framework for S4F.Solutions™ Scaled Agile Methodology for design thinking and human-centeredness (Image © Asaad Taha 2014).

The organizations which benefit most from S4F™ have:

• Robust mandates and drivers for transformational change and measurable impacts;
• Clear strategies and objectives to achieve their desired goals; and
• Accountability to deliver Value for Money (VfM) with sustainable results.

The S4F™ approach incorporates more than 25 transformational change practices and scientific research conducted on systems thinking, human-centered design, and strategic execution. Our framework enables transformational change, using evidence-based best practices from diverse bodies of knowledge and experiences, such as development, humanitarian, health, energy, aviation, and high-risk business sectors. These sector experiences and knowledge domains have resulted in a set of best practices for achieving complex transformational change useful in bridging any gap between organization investments and its envisaged results.

S4F™ components can be parsed within existing programs and projects to resilience, enabling bureaucracy, agility, integration, high reliability, equity and maximize value for money (See Figure 7). For instance, a multi-agency Portfolio Integration Office (PIO) might adopt it as an operating system to manage interdependencies — between the government agencies, private sectors, social impact actors, public-private partnerships, public-public partnerships, private-private partnerships, and organizational-level programs and projects including rigorous results-based monitoring, evaluation, review, and learning systems — to ensure Value for Money.

Figure 7. S4F.Solutions™ Transformation change Framework Benefits. (Image © Asaad Taha 2014)

With S4F™, PIO can build an intrinsic ability to leverage interdependencies, reduce redundancies, promote efficiencies, and create sustainable improvements. It acts as an integrator, enabler, facilitator, and mentor for organizations to reduce waste, create highly reliable systems, promote resilience, and continue improvement.

U.S. opportunities and challenges

The U.S. faces opportunities and challenges to its population’s health emerging from accelerating technologization of its economy, the relocation of younger populations from rural areas to urban economic hubs where urban diets, close-built environments, and tech advances lead to poorer nutrition, less physical activity, and consequent multiple chronic diseases.

The U.S. must embrace a national vision to combat its existential challenge. It is neither an individual responsibility, a social or ethnic group issue, nor an individual agency function. It is a collective social and existential conundrum, deep-rooted in economic disparity, political inertia, and slavery’s legacy.

This is an anomaly of capitalism requiring the full horizontal and vertical integration of community awareness, activism, and mobilization. It needs the full understanding, embrace, and commitment of government agencies, private and public sectors, and social impact actors in a bottom-up and top-down strategic alignment, coordination, and synergy to define, articulate, and enable effective politics and policies.

A Multiple Chronic Diseases Prevention Program requires an overarching governance framework to guide the nation’s efforts. This framework will enable all stakeholders and actors in the U.S. to coordinate their efforts under one national umbrella and align their activities with the goals and priorities of global indexes.

This shared framework will enable the U.S. to use resources efficiently and coordinate with the major stakeholders, as well as other entities of interest. Moreover, it will prepare us to leverage resources, ensure VfM, and maximize impact. It will encourage all parties to realize better interventions targeting established priorities and preventing duplication of effort.

Three Ones Principles: I encourage NCD actors and stakeholders to adopt the Three Ones principles to fit a country the size of a continent with its multiple diverse communities. Three Ones principles were first identified through a global collaboration initiated by UNAIDS in cooperation with the World Bank and the Global Fund to Fight AIDS, TB, and Malaria.

Incorporating Three Ones principles in the development of multi-sectoral interventions has proven effective in promoting coordination between competing stakeholders and various levels of federal and states authorities to ensure every effort is strategically aligned, and resources are invested wisely. I believe it is the highest-return/lowest-risk choice to address challenges unique to the U.S.

The Three Ones principles of continuous stakeholder engagement and communication will integrate self-coordinating entities, partnerships, funding, and implementation mechanisms for concerted NCD prevention efforts. Encouraging actors’ commitment to consensus-building will help all parties cooperate even when there is no ideological agreement, standard blueprint, or applicable prescription to enable the U.S. to optimize roles and relationships throughout society.

I) One National NCD Prevention Coordinating Authority:

I encourage the formation of a single national coordinating umbrella with:

1. Broad-based, multi-sector mandate: A National Health Coordinating Authority requires legal status and a formal mandate defining the authority’s governance structure, accountability, capabilities, and parameters. It will clarify the autonomy of its actors specifying their reporting lines to multi-agency authorities, federal and state parties, private-sector partners, community-based organizations, non-formal, and other civic entities. And, it must specify areas of accountability in terms of policy implementation, partner inclusion, and prevention activities outcomes and goals for every actor.
2. Consensual oversight: The Coordinating Authority must have trusting relationships enabling policy synergism, resources optimization, and oversight, including regular information sharing and reporting.
3. Empowering ownership: The Coordinating Authority must have a clearly defined role including “custodial functions” for an agreed-upon NCD Strategic Action Framework (NCD-SAF). This will require developing, negotiating, monitoring and evaluating the NCD-SAF. After coordination and implementation, the authorized actors would coordinate the resource mobilization and optimization determined by national priorities. And, NCD-SAF would seek federal budget supporting of its core operational expenditures.
4. Serving umbrella functions: A National Coordinating Authority must earn the trust of partners and funding mechanisms within the Action Framework. It must demonstrate credibility by committing to broad inclusion and participation, including full membership by actors. Each of these partners, in turn, must accept and respect the NCD-SAF and the role of the Authority. The Authority must assure partners of their organizational independence to serve their own mandates. It must assure partners no partnership of funding mechanism has privileged ownership of the Authority. And, it must require stakeholders to cooperate within the shared framework of monitoring, evaluation, and accountability.
5. Enabling partnership arrangements: Any such Authority requires a broader, enabling, organizing mechanism. This common arena must be accessible and inclusive. Partnership arrangements must encourage leadership, provide a vision for expanding NCD-SAF funding through Medicaid and Medicare and guiding existing and emerging funding mechanisms.

II) One agreed NCDs Action Framework

Healthy People 2030 Vision and Goals: We need a shared results-based action framework like Healthy People 2030 Vision and Goals to enable coordination across stakeholders, partnerships, and funding and implementation mechanisms. It will empower the National Coordinating Authority to be effective in aligning activities across the U.S. with the NHS (National Health Service) and the U.S. National Vision 2030.”

“Since the Healthy People initiative was first launched, the United States has made significant progress. Achievements include reducing major causes of death such as heart disease and cancer; reducing infant and maternal mortality; reducing risk factors like tobacco smoking, hypertension, and elevated cholesterol; and increasing childhood vaccinations. During these decades, the importance of collaborating across agencies at the national, state, local, and tribal levels, and with the private and public health sectors has been demonstrated” (Healthy People 2020 Topics and Objectives, 2019).

Alignment with Healthy People 2030 Vision and Goals requires critical elements:

1. Priorities: Any framework must incorporate clear priorities for resource allocation and accountability, making it possible to link priorities and resource equity, based on the national priorities and outcomes/results-utilization.
2. Reviews/Consultation: The framework must offer systems ensuring regular joint reviews and consultation on the progress including all partners and actors.
3. Commitment to coordinate: All actors in the U.S. must organize within the action framework consistent with their organization’s mandates.
4. Linkages: Any framework that would align with Healthy People 2030 must recognize connections and interdependencies between public and private sector health activities, interventions by Department of Health and Human Services (HHS) and Centers for Disease Control and Prevention (CDC), and multi-sectoral and crosscutting activities.
5. Managing partnerships: The framework must affirm and optimize the growing drive to engage health actors and the private sector in productive partnerships.

III) One agreed a MER₂L System

We need a framework encompassing a formal assessment and measuring system to monitor, evaluate, report, research, and learn. While most non-governmental social impact actors use monitoring and evaluation systems, they all function at various levels of maturity.

Meeting and managing the shared threat of NCDs without a robust MER₂L system leaves data falling through the cracks, creates poor-quality data, and restricts the monitoring of performance and formation of learning-based policies for the future. For example, the autonomous affinity of health insurance companies represents a serious challenge to comprehensive data, delivery, and prevention.

The Healthy People 2030 Vision and Goals present the CDC with a valuable opportunity to provide support and guidance that will forge a more reliable system throughout the U.S. guided by these principles:

1. Best Practices alignment: Stakeholders and actors must align their efforts to ensure accountability for achieving the Healthy People 2030 goals. They must agree on core elements of a nation-level MER₂L system that addresses these needs.
2. National system linked to the NCD-SAF: Under the leadership of the National Coordinating Authority, the NCD-SAF should be supported by a core system for monitoring progress towards achieving NHS and the Healthy People 2030 goals.
3. Agreed investment strategies: National-level stakeholders should prioritize assessments of existing MER₂L systems. Stakeholders should agree on how systems can be improved and how to set up a shared core system that provides high-quality data to analyze country performance.

A logical conclusion favors proactive best practices

Given what everyone knows about the consequences of Non-Communicable Diseases in the United States, there is no logic in continuing the waste of the country’s energy and resources in political polarization. The cost of political inaction will be tremendous.

Solutions remain in limbo without making proactive moves now toward better outcomes. Inaction means expending more resources later, exposing many people to harm and losing more lives. Understandably, it may be easier to react to visible and immediate issues or threats thereby focusing on superficial quick-wins.

For example, illegal migration is a symptom of deep-rooted causes. Enforcing a more robust migration policy and building a higher border wall alone will not address the issue. Robust migration policy and border security must work in tandem with investment in illegal migration’s deep-rooted cause. It is critical to strengthening stabilization in Central American countries and to promoting transparency, good governance, and anti-corruption policies. Such measures will prevent the Central American countries’ fragility and free-fall, which consequently will reduce human trafficking, illegal migration, and drugs smuggling to the U.S.

U.S. Border Patrol stands watch during border fence reinforcement. In Nov. 15, 2018 photo U.S. Border Patrol Agents at Border Field State Park in Imperial Beach watch over personnel that are reinforcing the border fence with concertina wire. (Photos: Mani Albrecht / CBP.gov)

The same concept applies to diseases although the multiple chronic disease impact may seem less visible and immediate. For example, when threats from Zika and Ebola viruses (communicable diseases) arose, the US government spent heavily on transoceanic and across border prevention efforts. The efforts halted the risk of a global pandemic and consequent catastrophic impact on the US economy and American lives. It is value for money to invest in prevention and proactive risk mitigation rather than wait until risks materialize and become a protracted national issue.

What is needed is the adoption of Ebola proactive best practices to manage NCDs crisis. It is essential to look for health solutions through a broader lens, drawing interconnection and interdependency between health and macro-environmental factors. The current health system is driven by a dysfunctional curative apparatus (hospitals and clinics), a source of health risks itself.

Most legislated policies and strategies are not grounded on LONG-STEEPLED analysis. They are driven by lobbyist interests and election cycles rather than a minimal national vision. Despite the fact, they interact with complex system dynamics. Any executive order, legislation, policies, and strategies must be grounded on an in-depth analysis for LONG-STEEPLED factors: “L” Local, “N” National, “G” Global, “S” Social, “T” Technological, “E” Economic, “E” Environmental, “P” Political, “L” Legal, “E” Ethical, and “D” Demographic factors

There is value earned on money invested in the development of well-grounded health policies, strategies, and proactive risk management rather than waiting to address the risks arising as a protracted national threat. And, the S4F Solutions™ framework here provides an overarching delivery system for national health investments; it offers organizational resilience, bureaucratic enablement, and sustainable agility to support the execution of strategies like the Healthy People 2030 Vision and Goals and other strategic initiatives.

Author: Asaad Taha, PhD, MSP®, PRINCE2® is a social entrepreneur and principal advisor with multisectoral expertise in global and national organizations across continents including UN agencies, Donors DFID, U.S. Government and European Union agencies, The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), International Non-Governmental Organizations, Non-Governmental Organizations, and Community-based Organizations.

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