COHESION – a challenge to Frenk and Gómez-Dantés

In The Lancet, in February 2017 ( S0140-6736(16)30181-7), two leading thinkers in global health, Julio Frenk and Octavio Gómez-Dantés, challenged the status quo of many of today’s public health and healthcare delivery processes through a detailed assessment of a variety of dichotomies that exist in global health. Frenk and Gómez-Dantés’ main message was the need for integration in global health across a wide range of challenges. This interesting piece led to a thought provoking discussion within the COHESION Team where we asked ourselves: are we operating within or beyond those scenarios of dichotomies?

The first dichotomy they describe is the prevention versus treatment debate. How does COHESION address this first dichotomy? For non-communicable diseases (NCD), even if all prevention measures are successful some people will still develop some of the conditions included in this overarching group. For Neglected Tropical Diseases (NTD) the “endgame” for many of these diseases is envisionable given the existence of medicines which provide a “magic bullet” to cure people and/or break the cycle of transmission. However, for both NCDs and NTDs people have already been exposed to some of the risk factors, have biological changes (e.g. high blood pressure; infected with Cysticercosis) and therefore require care. Yet, both NCDs and NTDs share fundamental root causes that determine its existence: poverty and exclusion. We cannot address treatment solely without the broader need for prevention.

The next “clash” described is the vertical versus horizontal debate. For NCDs and NTDs this debate is mute as the main driver of vertical programmes was funding. As was seen for HIV/AIDS funds were allocated to create complete vertical systems for distribution of medicines, training of health professionals, delivery of care, etc. For both groups of diseases that COHESION focuses on this funding is lacking thus vertical solutions are not implemented. That said NTDs are more at risk of becoming “verticalised” given the higher level of funding available in comparison to the burden, the “easier” solutions of mass drug administration (for some NTDs) and the defined populations that are impacted by some diseases. COHESION through its research and development of interventions will try to ensure a horizontal approach in order to benefit not only those with NCDs and NTDs, but any one requiring health care at primary level. We are allowing ourselves to redefine the interaction of an individual with the existing healthcare system where chronicity and continuity of care are fundamental.

Number three on Frenk and Octavio Gómez-Dantés’ list is primary versus specialized care. As mentioned above the main focus of COHESION is on primary health care. Given that our emphasis is on NCDs and NTDs which are both chronic in nature this will enable a strengthening of primary health care to guarantee continuity of care. Traditionally primary health care has been successful in maternal and child health, delivery of HIV/AIDS care (with significant funding) and acute care. However, with the burden of chronic disease a shift in the role of primary health care is needed. Through its formative research and interventions COHESION will focus its efforts on developing this level of the health system. We are not denying care, but aim integrate chronic care at primary health care as well as facilitate referral to specialized care when needed.

By design COHESION lays the fourth dichotomy to rest, the noncommunicable versus communicable disease prioritisaiton. By including NCDs and NTDs together within the core of its project COHESION wanted to focus on models of delivery of care versus mode of transmission. Leprosy and Type 2 diabetes from a delivery of care perspective share many similarities despite being communicable and noncommunicable. Need for proper diagnosis and initiation of treatment; patient education and empowerment; address issues of stigma; and prevention of complications.

Finally, the latest dichotomy posed the challenge between knowledge generation versus action. Again, COHESION is in a unique position thanks to the funding mechanism developed by the Swiss National Science Foundation and Swiss Agency for Development and Cooperation. The funding COHESION has received will not only enable the generation of new knowledge on NCDs and NTDs, at policy, health system and community level, but also to use this to co-create innovative interventions working closely with local partners through.

The title of Frenk and Octavio Gómez-Dantés’ comment includes the word “integrative”. COHESION in the design of its team and project has had this word as a guiding principle. Integration of different expertise from a variety of countries, institutions and individuals; different diseases and disease groups; different methodological approaches; local partners and stakeholders in the research and intervention development. As COHESION we would add another dichotomy to the list proposed by Frenk and Octavio Gómez-Dantés that is how solutions in global health are developed. Most solutions to date have had their roots in meetings at the World Health Organization, the minds of the best and brightest academics and in the offices of Ministries of Health. Our approach proposes a bottom up approach where interventions are informed by this, but designed by beneficiaries. To date although different normative documents exist on how to tackle the burden of NCDs and NTDs success is still far away. We hope through our innovative approach to find ways of addressing NCDs and NTDs as well as contributing to breaking down the dichotomies that Frenk and Octavio Gómez-Dantés highlight.


Written by David Beran and Jaime Miranda for COHESION