Dementia

For resource-poor settings, such as in many LMIC, WHO’s Mental
Health Gap Action Programme (mhGAP) (181) has explicitly
acknowledged the need for building health systems. An important
component of the programme is capacity-building and task-shifting
(i.e. from specialists to the much more numerous nonspecialist
health and social care professionals) if coverage of effective care is
to be extended to all who need it. Task-sharing may be a more
appropriate term, since specialists have an essential role in all
health systems, whether in planning services or in training, supporting
and supervising those who deliver care at the primary care
level. Thus capacity-building is necessary at all levels of the health
and social care systems, providing relevant knowledge and skills to
nonspecialists and increasing the number and variety of specialists
to support them. The role of caregivers as important service providers
– together with their needs for information, education and skills
training – must not be forgotten. It will require years of sustained
support and investment to meet gaps in capacity needs in LMIC
and to have a meaningful impact. Engaging academia, NGOs and
government institutions, as well as training government health
officials in the effective use of relevant policies and the effective
management and maintenance of programmes, is crucial.
The dominant global health agenda is undergoing a paradigm shift,
marked by the recent United Nations high-level meeting on noncommunicable
disease prevention and control (8). Strengthening
the health systems and the workforce to prevent, treat and control
major chronic diseases provides opportunities and threats – opportunities
because chronic disease care paradigms apply equally to
dementia care as to diabetes, and threats because dementia, the
most costly and disabling of all chronic disease conditions, is not
prioritized in the newly emerging consensus for action. Nevertheless,
the impetus for international action resulting from the highlevel
meeting and its focus on noncommunicable diseases presents
an unprecedented opportunity to raise the priority of dementia
worldwide.
Research and evaluation
Research evidence should underpin all actions and is a critical
element of the overall package of global dementia efforts. Each
country should determine a priority research agenda. There is also
need for international collaboration and private / public sector
partnerships to address important shared concerns such as the
development of new and more effective treatments. In general,
more should be invested in projects that generate knowledge about
how to translate what is already known into action and implementation
– in other words, to close the knowledge – action gap. This
agenda will be multidisciplinary, spanning basic sciences, health
services, health systems and health policy research. Countries
need to monitor the course of the dementia epidemic for changes
in prevalence and incidence that might indicate the success or
failure of measures taken to control it, and for uptake of services to
assess progress towards closing the treatment gap. Significantly
more research is needed to better understand the causes of
dementia and how and when lifestyle factors influence the risk for
developing it; such knowledge can inform effective prevention
strategies. A balance must be struck between research into treatment,
care and cure on the one hand and pharmacological and
psychosocial intervention approaches on the other.
To date, most research has been carried out in high-income countries.
As well as adapting what is known to work in high-income
countries and applying it to LMIC realities, there may be opportunities
to draw on health system and service innovation from resourcepoor
LMIC in order to increase the efficiency and effectiveness of
care in all settings.
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