5

Approaches to Supporting
Country-Led Action

There are many different ways in which global organizations provide support to low- and middle-income countries. The NCD Alliance and World Bank are two examples of organizations using global mechanisms and infrastructure to address chronic diseases in ways that contribute to country-led processes. These two organizations have been particularly inspiring, said moderator Derek Yach. The NCD Alliance has been a leader in organizing the civil society sector both globally and within countries in the lead-up to the September United Nations meeting, and the World Bank has had a fundamental role in raising the visibility of global chronic disease for at least 20 years.

The current approaches of these two organizations were highlighted on the final day of the workshop as a complement to the country-level approaches and discussions from the preceding two days of the workshop. As described below, their work has allowed them to bring a large base of evidence related to chronic diseases together with country-specific data to support programs, planning, and priority setting at the national level. Both Johanna Ralston of the NCD Alliance and Montserrat Meiro-Lorenzo of the World Bank emphasized that planning for chronic disease control will require an approach that is multisectoral, ensuring that all policies and strategies are aligned to promote a healthy nation. A decision-making toolkit could supplement the work of international organizations by facilitating the sharing of expertise and ideas between countries as well as assisting leaders as they work in their unique country contexts to coordinate multiple sectors for chronic disease control.

The following sections summarize the content of each of their presenta-



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5 Approaches to Supporting Country-Led Action T here are many different ways in which global organizations provide support to low- and middle-income countries. The NCD Alliance and World Bank are two examples of organizations using global mechanisms and infrastructure to address chronic diseases in ways that contribute to country-led processes. These two organizations have been particularly inspiring, said moderator Derek Yach. The NCD Alliance has been a leader in organizing the civil society sector both globally and within countries in the lead-up to the September United Nations meeting, and the World Bank has had a fundamental role in raising the visibility of global chronic disease for at least 20 years. The current approaches of these two organizations were highlighted on the final day of the workshop as a complement to the country-level ap- proaches and discussions from the preceding two days of the workshop. As described below, their work has allowed them to bring a large base of evidence related to chronic diseases together with country-specific data to support programs, planning, and priority setting at the national level. Both Johanna Ralston of the NCD Alliance and Montserrat Meiro-Lorenzo of the World Bank emphasized that planning for chronic disease control will require an approach that is multisectoral, ensuring that all policies and strategies are aligned to promote a healthy nation. A decision-making tool- kit could supplement the work of international organizations by facilitating the sharing of expertise and ideas between countries as well as assisting leaders as they work in their unique country contexts to coordinate multiple sectors for chronic disease control. The following sections summarize the content of each of their presenta- 63

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64 COUNTRY-LEVEL DECISION MAKING tions. Chapter 6 incorporates the key considerations raised in this session with the presentations and discussions from throughout the workshop. THE NCD ALLIANCE The NCD Alliance was founded in 2009 to identify and pursue the goals that are shared by stakeholders concerned with four noncommunica- ble diseases: cardiovascular disease (in particular heart disease and stroke), diabetes, cancer, and chronic lung disease, explained Johanna Ralston of the World Heart Federation and the NCD Alliance. The World Health Organi- zation identified these four diseases as responsible for the greatest portion of the global disease burden, and it also identified tobacco use, unhealthy diets, insufficient physical activity, and harmful use of alcohol as the most significant modifiable risk factors for those diseases.1 The NCD Alliance was founded to help increase recognition of the significance of the burden of these diseases as part of the global health and development agendas. To illustrate the problem, she quoted an opinion ex- pressed in The Economist in 2006: “The World Health Organization needs to help sick people, not be a nanny. Dr. Chen must cure the agency’s addic- tion to noisy campaigns against obesity, smoking and other non-infectious ailments. Many of these afflictions arise from personal choice and are not contagious.” This mindset has been difficult to combat, Ralston said, citing a leader in the field, Sir George Alleyne, who observed that the problem is not a lack of data or knowledge but rather the need to “raise the issue to a high-enough level in the political agenda and maintain it there, as without that, there will be no material progress.” The NCD Alliance came together through collaboration among the In- ternational Union Against Cancer, the Union for TB and Lung Disease, the International Diabetes Federation, and the World Heart Federation, Ralston said, and it now has 900 member associations in 170 countries as well as a Common Interest Group of 350 additional member organizations. There are also now 24 country-based and two regional noncommunicable disease alliances. The NCD Alliance’s key objectives are to identify shared messages across these diseases, coordinate advocacy and other efforts, and push non- communicable disease “high on the development agenda,” Ralston said. The NCD Alliance’s most important accomplishments to date include its efforts related to the United Nations High-Level Meeting on noncommu- nicable diseases. In particular, the alliance has been active in coordinating civil society input to the modalities resolution and the outcomes document 1 Ralston noted the importance of mental health as another contributor to the noncommu- nicable disease burden, and also commented that the Alliance is currently considering ways to involve neurological health, particularly dementia and Alzheimer’s disease, in its work.

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65 APPROACHES TO SUPPORTING COUNTRY-LED ACTION for the United Nations meeting. Part of the alliance’s goal in this process was to widen the circle of involved stakeholders. “It’s not just a health is- sue,” Ralston said. “You need to have agriculture at the table, urban plan- ning at the table, employers, the private sector, education. The solutions lie not just with the whole of government, but the whole of society.” As part of this process, the alliance engaged with regional and country-level leaders to generate tailored input, and NCD Alliance members in coun- tries around the world were also able to initiate activities in their home countries. The NCD Alliance also worked with the Lancet NCD Action Group to prepare a list of priority actions in the categories of leadership, international cooperation, accountability, monitoring and reporting, and investment in prevention and treatment (Beaglehole et al., 2011). In its ef- forts to contribute to the draft outcomes document for the United Nations meeting, the alliance highlighted these priorities along with other key points such as the necessity and urgency of a multisectoral approach, the possibil- ity of finding “new and adequate financial resources without jeopardizing current and future funding of the prevention and control of communicable diseases,” integrating chronic disease control efforts into existing health systems strengthening, and accelerated implementation of the Framework Convention on Tobacco Control. Looking beyond the United Nations High-Level Meeting, future priori- ties of the NCD Alliance include monitoring and advocacy to ensure com- mitments made at the meeting are kept and continuing to build the evidence base, particularly regarding operations research focused on affordable, fea- sible integrated approaches to delivery of care and prevention. The alliance also hopes to build capacity and strengthen programs at the country level, including supporting the growing NCD alliance movements in countries so that strong coordination and connections will exist and in turn foster international communication and support for the NCD control movement. Ralston highlighted recent successes applying the models that the alliance has developed in both Nigeria and India; in both countries policy makers have become more engaged, and innovative ways to find needed resources are being explored. An NCD Alliance was initiated in Nigeria with support from World Heart Federation and the International Diabetes Federation. The organi- zation grew quickly and was able to attend an interactive United Nations (UN) hearing on noncommunicable diseases that preceded the September 2011 High-Level Meeting on NCDs. Members of the NCD Alliance re- ported back to the Minister of Health in Nigeria and then published a paper online calling for their head of State, Goodluck Jonathan, to attend the UN high-level meeting. India is another country that has the enthusiasm and willingness to focus on noncommunicable disease efforts, Ralston said. She mentioned

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66 COUNTRY-LEVEL DECISION MAKING the work of Srinath Reddy of the Public Health Foundation of India, who believes that India will need to address its shortage of human resources, and focus on task-shifting, technical assistance, and a general restructur- ing of health systems to better address noncommunicable diseases. Ralston also said that India has plans for taxes that will support noncommunicable disease control efforts and reduce the country’s reliance on external donor funding. In the future, she concluded, the key to success against NCDs will be to find ways to be responsive to opportunities as they arise. There is no one algorithm will that work for every country, she said, but “there is a lot we can do without significant additional resources.” If people continue to be flexible and adaptable, integrating and preparing systems where possible and assessing their country’s readiness for certain tools, then they will be able to effectively use the resources when they do become available. THE WORLD BANK Derek Yach noted that it was a 1993 report from the World Bank that first used disability-adjusted life years (DALYs) as a metric and gave greater visibility to noncommunicable diseases. The World Bank played a funda- mental role in the prioritization of noncommunicable diseases, he added, by supporting the study of the economics of tobacco use, which reduced the resistance of government leadership around the world to anti-tobacco measures. The World Bank also provided a “SWAT team” of economists who worked with countries to guide them in developing tobacco control policies, Yach said. This history offers an important context for thinking about the bank’s current efforts related to chronic diseases. These current World Bank efforts were described by Montserrat Meiro-Lorenzo. The role of the World Bank, Meiro-Lorenzo explained, is not to dictate the policies that countries should have, but rather to support their plan- ning—particularly priority setting—and their programs. The bank works with other institutions to develop decision-making tools that are based on evidence. The bank’s starting principle is that where there are resources, there are tradeoffs to be made, and it is important to be explicit about the potential results of possible choices so that countries “make their decisions understanding what the potential results of their actions are.” Politically, when leaders have a short political view it’s difficult to sell something like chronic disease programs that are going to have an effect in 10 or 20 years. Understanding the actual tradeoffs, in the short, medium, and long term, is work that needs to be done to support a more constructive dialogue in countries, a dialog that includes ministers of finance. The two elements the bank has found most useful in supporting prior-

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67 APPROACHES TO SUPPORTING COUNTRY-LED ACTION ity setting, Meiro-Lorenzo said, are country characteristics and global evi- dence. Meiro-Lorenzo emphasized that for countries to adopt general tools for prioritization, it is crucial to take into consideration country-specific underlying determinants and socioeconomic characteristics to understand what interventions to undertake and what policies may work better than others. For individual countries the World Bank supports systems analysis of such issues as access to care; equity in the distribution of care; financial flows, such as national health account reviews, public health expenditure reviews, and public and private expenditure reviews; information systems; and system capacity. These microeconomic tools are placed in a macroeco- nomic framework to aid countries in making sure that they structure their systems in ways that best move them toward their development goals. Using these country-specific analyses while also building on what is known from global evidence on determinants, costs, and economic and fiscal impact provides the basis for planning and adaptation. Having such a basis— which, she observed, is also the goal for the toolkit under discussion at the workshop—would be “an enormous contribution to the technical and policy dialogue.” There are many ways for countries to prioritize and make health-related policy decisions, but these tools can help countries make their priorities explicit. In term of specific noncommunicable disease efforts, Meiro-Lorenzo said, the World Bank has long been investing in this issue, and has spent approximately $4.2 billion on NCDs since the mid-1990s. About half of the money is spent through the health sector and the other half through other sectors, including efforts related to indoor air pollution and road traffic safety. Despite significant investment in NCDs, the bank has missed some opportunities, and Meiro-Lorenzo identified areas where the bank could increase or strengthen its involvement. The bank is working to build on les- sons learned from past programs, especially revisiting and strengthening ef- forts using the economics of tobacco control to influence the policy process in countries. The bank also supports impact evaluations and results-based financing efforts, Meiro-Lorenzo explained, and both of these mechanisms could be applied more in the context of chronic disease control. The World Bank also hopes to improve its own capacity to assess multisectoral con- straints as part of systems analysis and multisectoral expenditures as part of financial reviews. She views effort in this area as an important founda- tion for building a multisectoral approach. At the policy level, for example, the bank should be focusing more effort on exploring countries’ existing policies in such areas as urban planning, tobacco taxes, and agricultural subsidies, including studying the impact of these policies. “Let’s make [the multisectoral ideal] very palpable,” she said, “by identifying which poli- cies within a country are contradictory” when it comes to contributing to

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68 COUNTRY-LEVEL DECISION MAKING versus reducing the chronic disease burden. The World Bank and others working in chronic diseases need to be opportunistic, Meiro-Lorenzo said, to not only identify opportunities in the health sector but also to put efforts together in ways that are a win-win for our environmental colleagues, our energy colleagues, and colleagues in other sectors, and then to make sure that we measure and showcase each other’s successes.