Two interrelated factors—the growing prevalence of chronic diseases and population aging—are placing a heavy burden on health systems. In all parts of the world except Africa, chronic diseases are by far the leading cause of death and disability, and they now account for 75 percent of global health care spend (an amount that is likely to increase in coming years).¹ Furthermore, in almost every country, the proportion of people age 60 or older is growing far faster than any other age group, a result of both longer life expectancy and declining fertility rates.² As people grow older, they are more apt to suffer from chronic diseases, but aging alone can increase their frailty—and their need for health care.

If the health care needs of the chronically ill and elderly are not adequately addressed, the consequences for both patients and health systems could be severe. The failure to appropriately manage disease often leads to worsening patient health; the failure to provide patients with carefully coordinated care can allow small problems to escalate into medical emergencies. Both scenarios can result in unnecessary hospitalizations, increased mortality, and higher health system costs.

Although the consequences of providing inadequate care to these groups are well known, most health systems have found it difficult to address their needs appropriately, in part because care delivery is often fragmented. Poor communication between general practitioners and specialists, for example, can hinder effective chronic disease management; some components of care may be duplicated, whereas others may be overlooked. The absence of a good interface between the health system and social services can allow elderly patients to “fall through the cracks” because neither side understands the full extent of the patients’ problems. Care fragmentation also frustrates patients, who find it difficult to navigate among the various providers and often feel that there is no one person who can help them get all essential services.