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Introduction1

There is growing recognition that chronic diseases represent a major health threat in low- and middle-income countries, accompanied by significant economic consequences. Yet most governments, global health institutions, and development agencies have largely overlooked chronic diseases when investing in health in developing countries (IOM, 2010). These countries have limited resources and many competing demands, from basic development priorities to a range of important health needs. However, despite these challenges, a recent Institute of Medicine report, Promoting Cardiovascular Health in the Developing World (2010), concluded that not only is it possible to reduce the burden of cardiovascular and related chronic diseases in developing countries but such a reduction will be critical to achieving global health and development goals. To reduce the burden of chronic diseases in these countries, the report concluded that it will be necessary to

•   improve local data and mechanisms for monitoring and evaluation;

•   build knowledge of effective, affordable, and feasible interventions and programs as well as how to implement these interventions and programs in the settings where they are needed;

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1 This report has been prepared by the workshop rapporteur, with the assistance of the project staff, as a factual summary of what occurred at the workshop. The planning committee’s role was limited to planning and convening the workshop. The views contained in the report are those of individual workshop participants and do not necessarily represent the views of all workshop participants, the planning committee, or the Institute of Medicine.



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1 Introduction1 T here is growing recognition that chronic diseases represent a major health threat in low- and middle-income countries, accompanied by significant economic consequences. Yet most governments, global health institutions, and development agencies have largely overlooked chronic diseases when investing in health in developing countries (IOM, 2010). These countries have limited resources and many competing de- mands, from basic development priorities to a range of important health needs. However, despite these challenges, a recent Institute of Medicine report, Promoting Cardiovascular Health in the Developing World (2010), concluded that not only is it possible to reduce the burden of cardiovascular and related chronic diseases in developing countries but such a reduction will be critical to achieving global health and development goals. To reduce the burden of chronic diseases in these countries, the report concluded that it will be necessary to • improve local data and mechanisms for monitoring and evaluation; • build knowledge of effective, affordable, and feasible interventions and programs as well as how to implement these interventions and programs in the settings where they are needed; 1 This report has been prepared by the workshop rapporteur, with the assistance of the proj- ect staff, as a factual summary of what occurred at the workshop. The planning committee’s role was limited to planning and convening the workshop. The views contained in the report are those of individual workshop participants and do not necessarily represent the views of all workshop participants, the planning committee, or the Institute of Medicine. 1

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2 COUNTRY-LEVEL DECISION MAKING • align the effort with local characteristics and needs, such as disease burden, priorities, capacity, and resources; • recognize the realities of resource constraints and competing priori- ties that require difficult choices; • set clear, measurable goals; • build successful collaborations within and beyond the health sector; • integrate efforts across chronic diseases with common risk factors; and • integrate efforts with existing health and development priorities. The authoring committee for that report recognized that a key next step would be to identify practical ways to assist low- and middle-income coun- tries in taking the most appropriate actions for improved control of chronic diseases through approaches that are driven by a country’s circumstances and led by a country’s key decision makers and stakeholders. As part of a series of follow-up activities related to the 2010 report, the Institute of Medicine convened a committee of experts who were charged with advising the planning of a workshop exploring the recommendation to establish a framework to assess “the future financial and other resource needs . . . to prevent and reduce the burden of CVD [cardiovascular dis- ease] and related chronic diseases” (IOM, 2010, p. 336). The workshop planning committee chose to explore the process of assessing resource needs and planning resource allocation as part of a broader process of planning, priority setting, and decision making to support chronic disease control through locally-driven approaches that are aligned with local reali- ties. Thus, the workshop built on two key messages from the 2010 report. First, it is critical for countries to use evidence and ongoing monitoring to inform decision making and to plan for implementation of chronic disease programs. Second, to achieve this, countries need evidence that is relevant to local circumstances, including the ability to define resource requirements that reflect real costs at the country level. The resulting workshop on decision making and planning for control of chronic diseases at the country level was held in July 2011. The workshop’s primary goal, planning committee chair Rachel Nugent explained in her introductory remarks, was to identify what tools could serve to support country-led planning for effective, efficient, and equitable chronic disease control programs. As Nugent noted, the 2010 report offered a model of the decision- making and planning process (Figure 1-1). The model is idealized, she said, but it does reflect a complex process that already takes place. “Policymakers and the public are constantly asking these kinds of questions.” The planning committee intended the workshop to help identify ways in which tools can be most useful to countries as they build on what they

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Assess Needs • Measure context-specific disease burden using population data Assess Capacity • State of current efforts, workforce, infrastructure, resources, political will Determine Priorities and Set Realistic Goals Design and Develop Interventions/Programs Have the Goals Been Met? • Design based on determinants research, demonstrated effectiveness, and likely • Disseminate knowledge gained feasibility • Develop using formative research, tailoring, and adaptation for context and scale • Implement best practices at increasing scale • Scale depends on evidence base, resources, capacity Implement Interventions/Programs Are Current Needs the Same? • Monitor and evaluate inputs (e.g., costs and other resources required), processes (e.g., fidelity of implementation), and outputs (e.g., quality of delivery) Evaluate Effects/Outcomes of Interventions/Programs Are Current Priorities the Same? • Intermediate outcomes • Health impact FIGURE 1-1 Measurement-based decision making cycle. 3 SOURCE: IOM (2010). new figure 1-1

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4 COUNTRY-LEVEL DECISION MAKING are already doing. Many countries are already taking steps, Nugent said, “but there is much more to do in many places.” She added that the plan- ning committee also hoped that the discussions would reflect the fact that priority setting is “not simply a technical matter . . . but also a politi- cal matter.” While the workshop was not intended to produce a finished product, Nugent noted, the committee hoped that it would help advance the conversation about key components that need to be incorporated in a process of decision making, planning, and resource prioritization, including • assessment of baseline status and progress over time related to chronic disease control; • a priority-setting process to incorporate country-specific objectives and values; • the synthesis and analysis of the best available global and country- specific evidence to guide priorities and choices for resource invest- ment; and • communications strategies aimed at policy makers and other key stakeholders. The workshop included two main groups of presentations. In the first, representatives from six economically, demographically, and geographically diverse countries described their experiences, progress, and lessons learned in planning and implementing chronic disease control efforts at the country level, including the availability and gaps in useful, country-level data. The second consisted of examples of tools, models, and methods to inform pos- sible components of a toolkit that could support countries in their decision making related to chronic diseases. The full workshop agenda can be found in Appendix A. The workshop was attended by policy makers; clinical, public health, and policy experts; economists; and public- and private-sector leaders from a range of countries and institutions. Time for discussion was a focus of the workshop, and those in attendance participated in a robust series of conversations along with the workshop presenters and panelists. This re- port describes the presentations from the workshop and the main themes that emerged from the discussions that took place. Unfortunately, it is not feasible in this report to capture all views and comments contributed by the discussants and participants nor the full depth of the discourse over the 3 days of the workshop. Chapter 2 provides an overview of perspectives from six countries on progress they have already made, how decisions for health have been made, lessons learned, and the needs going forward. Chapter 3 provides a closer look at available data and gaps in four countries. Chapter 4 dis- cusses approaches to costing, economic modeling, and setting priorities in

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5 INTRODUCTION a climate of limited resources. Chapter 5 discusses promising ways that international partners can support low- and middle-income countries and how the experiences and efforts of select stakeholders relate to the goals of a toolkit for country-level planning. The final chapter draws together themes from the presentations and discussions throughout the workshop, focusing on the considerations that could be most useful in the develop- ment and implementation of a toolkit to support country-level planning for control of chronic diseases.

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