for the Lancet NCDI Poverty Commission Study Group Executive summary"As we embark on this great collective journey, we pledge that no one will be left behind. Recognizing that the dignity of the human person is fundamental, we wish to see the goals and targets met for all nations and peoples and for all segments of society. And we will endeavour to reach the furthest behind first."Transforming our world: the 2030 agenda for sustainable development 1

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Context and objectivesNon-communicable diseases and injuries (NCDIs) comprise a large share of mortality and morbidity in low-income countries (LICs), many of which occur earlier in life and with greater severity than in higher income settings. Our objective was to assess availability of essential equipment and medications required for a broad range of acute and chronic NCDI conditions.DesignSecondary analysis of existing cross-sectional survey data.SettingWe used data from Service Provision Assessment surveys in Bangladesh, the Democratic Republic of the Congo, Ethiopia, Haiti, Malawi, Nepal, Senegal and Tanzania, focusing on public first-referral level hospitals in each country.Outcome measuresWe defined sets of equipment and medications required for diagnosis and management of four acute and nine chronic NCDI conditions and determined availability of these items at the health facilities.ResultsOverall, 797 hospitals were included. Medication and equipment availability was highest for acute epilepsy (country estimates ranging from 40% to 95%) and stage 1–2 hypertension (28%–83%). Availability was low for type 1 diabetes (1%–70%), type 2 diabetes (3%–57%), asthma (0%–7%) and acute presentations of diabetes (0%–26%) and asthma (0%–4%). Few hospitals had equipment or medications for heart failure (0%–32%), rheumatic heart disease (0%–23%), hypertensive emergencies (0%–64%) or acute minor surgical conditions (0%–5%). Data for chronic pain were limited to only two countries. Availability of essential medications and equipment was lower than previous facility-reported service availability.ConclusionsOur findings demonstrate low availability of essential equipment and medications for diverse NCDIs at first-referral level hospitals in eight LICs. There is a need for decentralisation and integration of NCDI services in existing care platforms and improved assessment and monitoring to fully achieve universal health coverage.

Recent studies have found an increasing burden of noncommunicable diseases in sub-Saharan Africa. A compressive search of PubMed, Medline, EMBASE, and the World Health Organization Global Health Library databases was undertaken to identify studies reporting on the prevalence, risk factors, and interventions for hypertension and diabetes in Malawi. The findings from 23 included studies revealed a high burden of hypertension and diabetes in Malawi, with estimates ranging from 15.8% to 32.9% and from 2.4% to 5.6%, respectively. Associated risk factors included old age, tobacco smoking, excessive alcohol consumption, obesity, physical inactivity, high salt and sugar intake, low fruit and vegetable intake, high body mass index, and high waist-to-hip ratio. Certain antiretroviral therapy regimens were also associated with increased diabetes and hypertension risk in human immunodeficiency virus patient populations. Nationwide, the quality of clinical care was generally limited and demonstrated a need for innovative and targeted interventions to prevent, control, and treat noncommunicable diseases in Malawi. Noncommunicable diseases (NCDs)-including cancer, diabetes, cardiovascular diseases, and chronic lung diseases-account for >80% of all premature NCD deaths [1]. This burden is likely to become larger over the next decade as urbanization and lifestyle changes progress and the mean age of the population increases [2]. In sub-Saharan Africa, NCDs are projected to account for almost 50% of all deaths by 2030 [3], presenting a major barrier to development [2]. NCDs and their risk factors are becoming major public health problems in Africa [4]. Recent data in Malawi show a high burden of hypertension, diabetes, and their risk factors (including tobacco, alcohol, and physical inactivity, all of which are increasing in prevalence) in both urban and rural areas [5,6]. Increasingly, hypertension and diabetes has been affecting individuals of younger ages and of relatively low or normal body mass index [5]. Complications of hypertension and diabetes, such as heart failure, stroke, myocardial infarction, hyperglycemia, and renal failure, are common reasons for admissions to medical departments in Malawi [7].

Noncommunicable diseases and injuries (NCDIs) account for nearly 70% of deaths worldwide, with an estimated 75% of these deaths occurring in low- and middle-income countries. Globally, the burden of disease from noncommunicable diseases (NCDs) is most often caused by the “big 4,” namely: diabetes, cardiovascular diseases, cancer, and chronic lung diseases. However, in Malawi, these 4 conditions account for only 29% of the NCDI disease burden. The Malawi National NCDI Poverty Commission was launched in November 2016 and will describe and evaluate the current NCDI situation in Malawi, with a focus on the poorest populations. The National Commission will investigate which NCDIs cause the biggest burden, which are more present in the young, and which interventions are available to avert death and disability from NCDIs in Malawi, particularly among the poorest segments of the population. The evidence gained through the work of this Commission will help inform research, policy, and programme interventions, all through an advocacy lens, as we strive to address the impact of NCDIs among all populations in Malawi.