(2003; 211 pages)
Over the past few decades we have witnessed several phases in the development of approaches aimed at ensuring that patients continue therapy for chronic conditions for long periods of time. Initially the patient was thought to be the source of the "problem of compliance". Later, the role of the providers was also addressed. Now we acknowledge that a systems approach is required. The idea of compliance is associated too closely with blame, be it of providers or patients and the concept of adherence is a better way of capturing the dynamic and complex changes required of many players over long periods to maintain optimal health in people with chronic diseases.
This report provides a critical review of what is known about adherence to long-term therapies. This is achieved by looking beyond individual diseases. By including communicable diseases such as tuberculosis and human immunodeficiency virus/acquired immunodeficiency syndrome; mental and neurological conditions such as depression and epilepsy; substance dependence (exemplified by smoking cessation); as well as hypertension, asthma and palliative care for cancer, a broad range of policy options emerges. Furthermore, this broader focus highlights certain common issues that need to be addressed with respect to all chronic conditions regardless of their cause. These are primarily related to the way in which health systems are structured, financed and operated.
We hope that readers of this report will recognize that simplistic approaches to improving the quality of life of people with chronic conditions are not possible. What is required instead, is a deliberative approach that starts with reviewing the way health professionals are trained and rewarded, and includes systematically tackling the many barriers patients and their families encounter as they strive daily to maintain optimal health.
This report is intended to make a modest contribution to a much-needed debate about adherence. It provides analysis and solutions, it recommends that more research be conducted, but critically acknowledges the abundance of what we already know but do not apply. The potential rewards for patients and societies of addressing adherence to long-term therapies are large. WHO urges the readers of this report to work with us as we make the rewards real.