particularly by linking clinic-based with in-home providers. Sixth, the social determinants of health were a pervasive underlying theme. In all four countries, the populations served by HealthRise faced many persistent challenges to their health and access to health care, including poverty, lack of education, poor housing conditions, and limited access to affordable and nutritious food, among others, and many of the services that HealthRise offered sought to overcome or were designed to accommodate these known barriers. Lastly, sustainability was a common concern as grantees looked to the future and considered how the work of HealthRise could continue or whether it should be expanded to new populations or conditions. As a grantfunded program, each site faces the challenge to identify new sources of financing.
Conclusions and Implications The data collected through HealthRise and the identified successes and challenges in providing a wide range of programs for NCD prevention and treatment point to several key areas for future research. These include examining the best ways to train and utilize frontline health workers; continuing to advance technologies for care coordination; developing meaningful measures of patient empowerment; and refining and tailoring the various intervention components explored during HealthRise to be most effective and best suited to different populations. The valuable new information generated by HealthRise can also inform facility-level and local policies in the nine communities where HealthRise programs were active, and national priorities for the prevention and treatment of the growing burden of NCDs, as well as help to improve the design of NCD initiatives globally. In all four countries, high rates of NCDs and key risk factors were found at baseline, reaffirming the need to continue developing and implementing policies aimed at preventing and controlling NCDs. In Brazil, India, and South Africa, persistent weaknesses in the health system were encountered; staff shortages, medication stock-outs, long wait times, and difficulty accessing health facilities are priorities for health policy in these countries. In the United States, the findings from HealthRise suggest that greater use of community health workers and community paramedics has the potential to be a cost-effective component of care for NCDs. At the global level, the overwhelming success of including home-based providers in NCD care strongly supports the wider use of frontline health workers as a component of a wide range of health programs in a diverse set of countries. A second major implication for global policy is the need for greater emphasis in donor funding on strengthening health systems so they are better equipped to provide NCD care, as development assistance for health remains substantially skewed toward infectious diseases. HealthRise had a vast footprint through its various programs in Brazil, India, South Africa, and the United States. Tens of thousands of people were screened for NCDs, well over 3,000 health workers received additional training, and hundreds of patients in each of the nine sites were placed on pharmacotherapy. HealthRise helped over 3,000 hypertension patients and more than 1,000 diabetes patients meet clinical targets and bring their condition under control. HealthRise confirms the major contribution of NCDs to the global disease burden; the need for strong and well-functioning health systems to support complex and ongoing NCD care; the particular benefits of home visits and well-coordinated care; and the vital role of communities in supporting patients and families coping with complex illnesses.
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