The growing burden of multiple long-term chronic non-communicable diseases (MLTC-NCDs) in Sub-Saharan Africa (SSA) is creating serious health, social, and economic challenges for individuals and families. While existing strategies like the WHO’s PEN package focus on physical NCDs, they often overlook mental health conditions such as depression and anxiety, which commonly coexist with diseases like diabetes and hypertension.
Experts are calling for a shift toward responsive healthcare systems built around integrated, patient-centred chronic care models. Integrated care, as defined by Singer and colleagues, involves coordinated, multidisciplinary activities that span across healthcare sectors and include community and social supports. This approach is essential for managing the complexity of MLTC-NCDs and for addressing both physical and mental health together.
The Chronic Care Model, developed by the McColl Institute, outlines six key components for effective chronic disease management: community resources, healthcare organization, self-management support, system design, decision support, and clinical information systems. However, implementing such models in SSA remains a challenge due to limited resources and infrastructure. Most chronic care frameworks were designed in high-income countries and need to be adapted to local realities.
Task-shifting – empowering allied health professionals alongside doctors – and enhanced teamwork are key to effective integrated care in SSA. The PACEinMM framework outlines success factors including shared team values, strong interpersonal relationships, community linkage, specialized training, and patient engagement. These help ensure productive interactions between patients and care teams.
There is also increasing attention on “minimally disruptive medicine,” which aims to reduce the treatment burden on patients by tailoring care to their capacity and emphasizing coordination and prioritization from the patient’s perspective.
The Rainbow Model of Integrated Care (RMIC) adds further clarity by distinguishing three interconnected levels: the macro level (policies and governance), meso level (inter-organizational collaboration), and micro level (clinical practice and service delivery). This model encourages a “one-stop-shop” approach where medical, behavioural, and social needs are addressed under one roof.
As SSA struggles with fragile healthcare systems and rising chronic disease rates, there is an urgent need to define and implement integrated care models that are feasible in low-resource settings. Experts stress that without localized, well-functioning models, efforts to manage MLTC-NCDs will fall short, leaving millions vulnerable.
