Picture a district hospital in a lower-middle-income country. Its outpatient department was designed around acute episodes: a child with fever, a woman in labour, a man with a cough that won’t clear. It is good at diagnosing, treating and sending people home.
Now picture the patient it sees more and more: a 52-year-old with high blood pressure who needs a pill every day for the rest of her life, a blood pressure check every few months, and someone to notice when she stops coming. The building, the drug supply, the data system and the funding model were not built for her.
That mismatch is the real story of noncommunicable diseases in emerging markets. The epidemiology has changed. The systems, and the money, mostly have not.
The shift has already happened
According to the WHO, noncommunicable diseases killed at least 43 million people in 2021, equivalent to 75% of non-pandemic deaths worldwide. Of those, 18 million died before age 70, and 82% of those premature deaths occurred in low- and middle-income countries. Cardiovascular disease alone accounted for at least 19 million deaths, followed by cancers, chronic respiratory disease and diabetes.
This is not a future transition. It is the present. The 82% figure says it plainly: dying early from a chronic disease is overwhelmingly a problem of poorer countries, not rich ones.
And yet the global health architecture still largely reflects the priorities of the early 2000s.
Where the money goes
The Institute for Health Metrics and Evaluation, which tracks development assistance for health, has found that NCDs have received only around 1 to 2% of that assistance for two decades. By comparison, infectious disease programmes for HIV, tuberculosis, malaria and vaccines have commanded large, dedicated funding streams.
There are defensible reasons for this. Infectious disease programmes produce measurable results quickly. A vaccination campaign has a clear start, a count of children reached and a visible drop in cases. Donors like that.
NCD care looks different. It is lifelong, largely delivered in primary care, dependent on a steady supply of cheap generic drugs, and its benefits are measured in heart attacks and strokes that don’t happen years later. It is hard to put on a slide.
The uncomfortable implication is that the funding mix reflects what is fundable, not what is killing people. And because vertical programmes built their own supply chains, staff and data systems, emerging-market health systems now often run excellent parallel infrastructure for one disease next to a thin, underfunded primary care system trying to handle everything else.
Hypertension shows both the scale and the fix
The WHO’s global hypertension report, released in September 2025, estimated that 1.4 billion people were living with hypertension in 2024, and only just over one in five had it under control. Only 7 of 25 low-income countries reported that all five WHO-recommended hypertension medicines were generally available in pharmacies or primary care.
That last fact is revealing. Hypertension treatment does not require new science. The drugs are generic, cheap and decades old. The gap is mostly delivery: diagnosis, a reliable supply of medicines and follow-up.
The same report highlighted what works. South Korea reached national control rates of nearly 60% through reforms including low-cost medicines and capped co-payments. The Philippines achieved 65% control in facilities taking part in a demonstration project.
Neither involved a breakthrough. Both involved making routine care routine.
The lesson from the infectious disease era
Here is where the conventional take deserves a push. NCD advocates often argue that infectious disease programmes crowded them out. There is some truth in that. But those programmes also taught health systems exactly what NCD care needs.
HIV treatment in particular proved that low-income countries could keep millions of people on lifelong daily medication, using simplified protocols, task-shifting to nurses and community workers, reliable drug supply and patient tracking. That is a chronic disease model. It is the same thing a hypertension or diabetes programme needs.
The question for emerging markets is not whether to shift attention from infectious disease to NCDs. It is whether the delivery machinery built for HIV can be opened up to serve the patient with high blood pressure sitting in the same waiting room.
What a realistic agenda looks like
- Start with hypertension. It is common, cheap to treat and a major driver of heart attacks and strokes. A working hypertension programme builds the backbone for other chronic conditions.
- Fix the drug supply before the guidelines. A protocol is useless if the medicine is out of stock half the time.
- Integrate, don’t bolt on. Adding NCD screening to existing HIV and TB services reaches people already in care.
- Use domestic revenue. Tobacco and sugar-sweetened beverage taxes both reduce risk and raise money, and they don’t depend on donor priorities.
Why chronic care breaks acute-care systems
It is worth being precise about why an NCD patient is so hard for a system built around acute and infectious disease.
An acute episode has a beginning and an end. A child with malaria is diagnosed, treated and, usually, recovers. The system’s job is complete in days. Success can be counted in episodes treated.
A patient with hypertension or diabetes has no end point. Her treatment works only if it continues, month after month, for decades. She needs regular measurement, adjustment of doses, a supply of medicines that never runs out, and someone who notices when she misses a visit. Most of the time she feels fine, which means she has little immediate reason to come back.
In practical terms, that requires things acute-care systems rarely have: patient registers that track individuals over time, appointment and recall systems, dispensing arrangements that give several months of medicines at once, and staff whose job includes following up people who stop coming. It also requires a financing model that pays for continuity, not just for visits.
The difference between an acute system and a chronic one is not mainly about clinical knowledge. It is about memory. A chronic care system has to remember every patient, every month.
A worked example: one district, two programmes
Picture a district in a lower-middle-income country with a long-established HIV programme. Its HIV clinic has a patient register, a dedicated pharmacy stock, community workers who trace people who miss appointments, and a data system that reports how many patients are on treatment and how many have suppressed viral loads.
Next door, in the same health centre, the general outpatient department sees people with high blood pressure. There is no register. Each visit is recorded in a paper book by date, not by patient. Antihypertensive medicines are ordered through the general supply chain and are frequently out of stock. Nobody knows how many hypertensive patients the facility has, how many are controlled, or how many stopped coming.
Now imagine the district decides to use the HIV infrastructure for hypertension. The HIV clinic already screens its own patients for high blood pressure. The register is extended to include hypertension. Community workers who trace HIV patients also follow up those with hypertension. Multi-month dispensing, already routine for HIV medicines, is applied to antihypertensives.
The additional cost is modest compared with building a separate hypertension programme. The main barriers are not technical. They are institutional: separate budgets, separate reporting lines to separate donors, and a worry that adding NCDs will dilute a programme that works.
The strongest counterargument
The strongest objection to integration comes from people who built successful infectious disease programmes, and it deserves respect.
Vertical programmes worked partly because they were focused. A dedicated HIV programme with its own funding, staff and targets could be held accountable for results. Folding other diseases into it risks overloading staff, confusing priorities and diluting the performance that saved millions of lives. There is also a financing risk: if donors see NCDs being handled by HIV clinics, they may reduce HIV funding, assuming the platform is now self-sustaining.
This argument partly holds. Integration done badly, adding tasks without adding staff or money, will harm the programmes that currently work. And donor funding for HIV, tuberculosis and malaria is itself under pressure.
But the alternative is worse. Keeping NCD care in a separate, underfunded track condemns the much larger number of people with chronic disease to fragmented care. And many patients have both. People living with HIV are ageing and increasingly have hypertension, diabetes and other chronic conditions. A clinic that manages only one of their diseases is not serving them well either. The answer is integration with resources, not integration by stealth.
Second-order effects
Domestic financing will have to carry more of the load. With NCDs receiving only a small share of development assistance, most of the funding for chronic care will come from domestic budgets, insurance schemes and out-of-pocket payments. The last of these is the most dangerous, because lifelong medicines paid out of pocket drive households into poverty and lead people to stop treatment.
Primary care becomes the battleground. The shift to NCDs puts primary care at the centre. Countries with weak primary care will see more patients presenting late, with strokes, heart attacks and kidney failure that are far more expensive to treat.
Data systems must change. Counting visits won’t capture whether chronic disease is controlled. Countries will need patient-level data, even simple registers, to know whether their programmes work.
The cost of doing nothing is already being paid
It is tempting to see NCD investment as a new cost that stretched health budgets cannot absorb. In practice, the cost is already being paid, just later and at a higher price. A person whose blood pressure is never controlled may arrive at a hospital years later with a stroke, heart failure or kidney disease. Those are expensive admissions, often requiring specialist care that low-income systems are least equipped to provide, and they frequently push households into catastrophic spending.
The WHO hypertension report estimated that cardiovascular diseases, including hypertension, caused economic losses of about 2% of GDP in low- and middle-income countries between 2011 and 2025. Whatever the precise figure for any one country, the direction is clear. Cheap daily pills in primary care are almost always less costly than emergency care for the complications they prevent.
What this means for decision-makers
For ministries of health, it means making NCD care a core function of primary care, with a defined package of essential medicines, protocols and registers, and using fiscal tools such as tobacco and sugar taxes to help fund it.
For donors and global health agencies, it means allowing and encouraging existing programmes to extend their platforms to chronic disease, and counting that as a success rather than mission drift.
For hospital and district managers, it means recognising that most NCD care should not happen in hospitals, and supporting primary care teams to manage stable patients close to home.
For clinicians, it means treating blood pressure and blood sugar as vital signs in every encounter, including in HIV and TB clinics, and making sure patients leave with enough medicine to last until their next visit.
What to watch next
Watch whether countries report hypertension control rates, not just the number of people screened. Watch whether national budgets increase spending on essential NCD medicines. And watch whether integration efforts in countries with strong HIV platforms are evaluated and published, so others can learn what works and what doesn’t.
The takeaway
The world has spent two decades building remarkable systems to fight infectious disease in emerging markets. Those systems now sit alongside a much larger and growing burden of chronic disease that gets a sliver of the funding.
The fastest route forward is not a new vertical programme for NCDs. It is to take what worked for HIV, a lifelong, protocol-driven, community-supported model of care, and make it the default for everyone.
Is your health system using infectious disease infrastructure to deliver chronic care yet? Tell us what’s working, and what’s in the way.
