Edinburgh Research Explorer Global Alliance for Chronic Disease researchers' statement on multimorbidity

We present the first Global Alliance for Chronic Diseases (GACD) Researchers’ Statement on Multi-Morbidity. The GACD network is an alliance of multidisciplinary health-care professionals, researchers and health-research funders. We aim to reduce the impact of noncommunicable diseases (NCDs) through a focus on implementation research in low and middle-income countries (LMICs), and vulnerable populations in high-income countries (HICs).

John R Hurst, Julia Dickhaus, Pallab K Maulik, J Jaime Miranda, Sonak Pastakia, Joan B Soriano, Trishul Siddharthan and Rajesh Vedanthan on behalf of The GACD Multi-Morbidity Working Group (see below for list of contributing authors).
In 2018 the Global Alliance for Chronic Disease (GACD) research network issued a first researchers' statement on multi-morbidity:

"The GACD research network believes that a greater focus on multi-morbidity is overdue and necessary to successfully improve global health outcomes".
The GACD is an alliance of health-research funders, whose research teams form a network of multidisciplinary health-care professionals and researchers. We aim to reduce the impact of non-communicable diseases (NCDs) through a focus on implementation research in low and middle-income countries (LMICs), and vulnerable populations in high-income countries (HICs). The GACD has commissioned research in hypertension, diabetes, chronic respiratory diseases, mental health and -most recently -'scale up' of hypertension and diabetes interventions. We particularly recognise the importance and challenge of co-existing physical and mental health multi-morbidity arising from epidemiological transitions and rapid population ageing. Whilst our initial programmes have not explicitly considered multimorbidity in the context of cancer and chronic infectious diseases such as TB and HIV-AIDS, we recognise that multi-morbidity in relation to these conditions is also a burgeoning challenge. Notably, there has been very little research addressing the co-existence of, and potential for reciprocal interactions between the course of NCDs and the natural history of acute and/or long-term infections.
Our collaborative approach resulted in the realisation that multi-morbidity was a challenge for all our members, and to address this we formed a multidisciplinary Multi-Morbidity Working Group. This Group identified six common themes of importance across all our research programmes: 1. The relevance of multi-morbidity to all health-care professionals.
2. The general under-recognition of multi-morbidity in health-care provision and research, including research to explore new models of care delivery.
3. The absence of evidence-based guidelines on approaches to managing patients with multi-morbidity leading to under-mis-and over-treatment (in part driven by the absence of primary evidence due to exclusion of many people with multi-morbidity from efficacy trials).
4. The need to provide greater access to expert, pro-active holistic primary care that integrates NCDs. 5. The need for better integration of health-care education, both to health-care providers and also to patients and their families, specifically in relation to multi-morbidity including how best to access current models of care.
6. The need for further research assessing interventions that address the challenge of multimorbidity in LMIC settings, for example low-cost combination interventions and holistic prevention programmes.
The full version of the GACD Researchers' Statement, available on our website [1], highlights specific data that we considered when collating these themes, and an exemplar case history that illustrates the challenges for those living with multi-morbidity in LMICs.
To achieve the GACD aim of reducing the impact of multi-morbidity in LMICs with a switch to healthy active ageing, we have identified three strategic objectives: 1. Greater policy awareness and focus on multi-morbidity through integrated proactive chronic care, rather than systems that address single NCDs. Practical examples of this would include support for education, training and guideline development that focus on multimorbidity, and policies which make implementation of simple universal interventions around diet, exercise and reduced exposure to tobacco, indoor and outdoor air pollution and alcohol attractive, effective and practical to implement.

Changes to the way that research is commissioned, funded and delivered when
considering NCDs in LMICs -particularly the promotion of working across and between traditional disease, primary care and specialist boundaries. Pragmatic trial designs are one approach to ensure the effects of interventions are considered holistically, in the situations in which they arise and are treated, using shared data dictionaries of disease and broad outcome definitions.

Health systems research aligned with Universal Health Coverage.
In particular, greater consideration of the role of pro-active Primary Care and (where appropriate) Community Health Workers in developing knowledge and skills to deliver effective integrated multimorbid NCD care. Addressing multi-morbidity will help improve health systems and efficiencies, particularly when such systems are weak or fragmented.
We present the case for a greater focus on multi-morbidity, specifically in relation to NCDs in LMICs and vulnerable populations in HICs. Our current disease-specific approaches hinder research and patient care, and our ability to maximise improvements in health outcomes. Only by working collaboratively will we be able to achieve international health targets such as the Sustainable Development Goals, especially those in relation to NCDs, mental health and long-term communicable diseases. Success will require working across traditional boundaries, and the GACD Network provides a practical example of how this can work. With our latest funding call in relation to 'scale up' of hypertension and diabetes research in partnership with delivery organisations, our shared data dictionaries and our multidisciplinary working groups the GACD is leading the development of novel approaches to addressing multi-morbidity in LMIC.
This statement reflects the perspectives of researchers from the GACD but does not necessarily reflect the perspective of the funding agencies.