Promoting Cardiovascular Health in the Developing World A Critical Challenge to Achieve Global Health (2010) / Chapter Skim
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4 Measurement and Evaluation
4 Measurement and Evaluation
Pages 149-184
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This provides a compelling rationale for aggressively reducing risk factors that lead to CVD globally. Measurement is the basis for determining the scale of the global CVD epidemic and for understanding how best to intervene, and it will be critical to the success of efforts to reduce disease burden.
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This cycle applies to decision making at any level of stakeholder, from global to local, and at any scale of intervention, from a demonstration project to a global action plan. First, it is used to assess the magnitude of the problem at the level of the population and subpopulation and informs the mitigation of risk factors.
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o Health impact FIGURE 4.1 Measurement-based decision-making cycle. Figure 4-1
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CONTEXTUAL FACTORS: Existing Policies; Economics; Financing; Existing Capacity; Soci al and Cultural Norms; Population Demographics Baseline Intervention Intermediate IMPACT Status Approaches Outcomes Population- Based Interventions Quality Individual Behavioral Delivery of Risk-Factor Risk Behavior Interventions Interventions Change: MEASUREMENT MEASUREMENT MEASUREMENT Clinical Interventions Knowledge Reduced Individual Risk Provider Provider and Payer Initiatives Policy Maker Improved Health Systems Changes in Individual and Capacity Baseline Building Initiatives and Status Population Health MEASUREMENT Feedback, Transparency, Availability, Use of Data FIGURE 4.2 Role of measurement in achieving health impact. Figure 4-2 R01642 editable vectors
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Although there may be necessary complexity in the design of measurement systems, this complexity should be converted into relatively simple reporting of the data. The number and variety of determinants that contribute to cardiovascular disease means that no single set of measures or data collection system will suffice for all goals or settings.
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; and measures of global action. Some of these measures need to be disease specific, while others need to be harmonized and coordinated with measurement strategies for related chronic diseases and for other areas of health and development.
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The World Health Organization (WHO) has convened an epidemiology reference group, drawing on headquarters and regional offices, to develop guidance for chronic disease surveillance systems and to agree on core indicators that will be used to monitor the major chronic diseases and their risk factors (Alwan, 2009, personal communication)
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. Limits in local capacity to conduct both analysis and operations research have left some national governments hesitant to take on new measurement initiatives as they could overwhelm already fragile health information systems (Bennett et al., 2006)
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Although there is limited publicly available information and analysis of the costs to implement population measurement strategies, some estimates for country spending on health data suggest that comprehensive measurement can be affordable for developing countries. For example, the Health Metrics Network (HMN)
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For comparable use of data across sources and levels, there also needs to be agreement on what is to be measured and how it is disseminated. To address global CVD, the methods described here draw from successful CVD measurement strategies and programs from the developed and the developing world where available, as well as from significant advances in measurement in other areas of global health, especially HIV/AIDS.
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. However, there is an emerging movement to use more evidence-based policy at all levels in low and middle income countries, and it is crucial to be sure that this movement does not continue to develop without being applied to policies related to chronic diseases.
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Therefore, to comprehensively measure policy effects on CVD, there needs to be shared understanding of target outcomes as well as comparable indicators and integrated measurement approaches to determine the health impact on chronic diseases of policies in areas such as agriculture, urban planning, and development initiatives from donors and governments. Population Measurement One of the key challenges hampering many low and middle income countries is the lack of baseline and trend data on population prevalence and incidence of cardiovascular disease.
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The Regional Core Health Data Initiative collects information on both communicable and noncommunicable diseases, including indicators relating to cause-specific CVD mortality, overweight and smoking prevalence, and select health systems measures. However, the vast majority of indicators are related to identifying communicable disease risk (PAHO Health Analysis and Statistics Unit, 2007)
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To the extent feasible, these could also potentially be supplemented with more in depth analyses of demographic subpopulations and surveys of additional indicators such as behavioral and biological risk factors, disease outcome measures, biomarkers, economic measures such as national spending and household expenditures, and health-system measures such as service utilization. Each method offers a unique opportunity for the global CVD community to draw upon existing models and lessons learned from their implementation, and in some limited cases to integrate with existing infrastructure to avoid duplication of resource expenditures.
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. Given the importance of accurate cause of death reporting for understanding the impact of cardiovascular disease on population health, this presents a potential opportunity for the global CVD community to partner with existing actors to increase awareness and support for vital registration.
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. Health Information Systems Finally, health information systems (HISs)
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Therefore, it is important for the global CVD community to ensure that metrics related to CVD and chronic diseases are integrated within these systems in developing countries, especially given the growing international focus on the integration and coordination of disparate HISs (Stansfield, 2009)
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Therefore, they have the potential to be future partners in CVD burden data collection efforts. One major effort to develop chronic disease-specific survey tools is WHO's STEPwise Approach to Chronic Disease Risk Factor Surveillance (STEPS)
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This will require evaluation of costs of implementation and the sustainability of these methodologies for serial surveillance, for example, by evaluating the potential burden associated with different numbers and types of indicators. As with the expansions of surveillance and health information systems, future assessments of STEPS and other population surveys should also consider the opportunity costs of committing local capacity to assessing CVD and behavioral risk factors compared to other priorities.
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Governments should al locate funds and build capacity for long-term sustainability of disease surveillance that includes chronic diseases. Efforts to scale up, expand, or adapt any of the existing routine data collection methods described above to develop better chronic disease measurement in low and middle income countries need to take into account potential areas of duplication of efforts and resources and to carefully consider how best to incorporate or take advantage of existing international initiatives.
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. For example, unlike the long-term, sustained services needed to address chronic diseases, many infectious diseases have a narrow range of treatment or vaccine options (which in some cases confer lifetime protection)
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Thus, measurement and evaluation of health systems is another area in which it is important for the global CVD community to engage in these emerging initiatives and ensure that metrics that are relevant to the quality, costs, and financing of chronic care are integrated as health systems indicators are developed. This will help ensure that measurement of health systems going forward will be informative in terms of the capacity of these systems to address CVD and related chronic diseases.
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An extensive review of methodologies for intervention research and program evaluation is beyond the scope of this report and is information that can be found elsewhere in the literature for evaluations not only of programs for CVD and related chronic disease but also for HIV/AIDS, mental
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In other cases, accurate data collection may be occurring, but the transfer of this information is hampered by limited mechanisms available to facilitate dissemination of the results. The available evidence base for intervention research and program evaluation for CVD and related chronic diseases in low and middle income countries will be discussed in more detail in Chapters 5, 6, and 7.
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Along with this growing emphasis on evaluation in global health efforts, many tools have been developed that provide models and support for program evaluation in low and middle income countries. The majority of these have been either developed or initiated by the infectious disease community, but the principles and approaches have the potential to be adapted for CVD and related chronic diseases.
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. Avoiding this duplication by identifying CVD indicators that can meet the needs of both the program and the health information system as well as encouraging the integration of reporting with the national systems where appropriate will be important considerations as global CVD programs expand in developing countries.
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While there is a need for much more research on the training, infrastructure, and cost barriers to introducing new technology and mobile data collection devices, they present a rapidly growing field of research and investment on which global health initiatives have already begun to capitalize (United Nations Foundation, 2010)
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. Some organizations, such as AMPATH in Kenya, have already begun to adapt their antiretroviral therapy focused electronic medical records systems to include measures for diabetes and cardiovascular disease (Braitstein et al., 2009)
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An epidemiology reference group has also been working with WHO staff from headquarters and regional offices to develop guidance for chronic disease surveillance systems and to agree on core indicators that will be used to monitor the major chronic diseases and their risk factors (Ala Alwan, World Health Organization, 2009, personal communication)
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As a result, although there exists greater awareness about which risk factors require the most attention, less is known about what intervention approaches will be most effective and feasible in the resource-constrained settings of low and middle income countries. This lack of knowledge about program and policy effectiveness within local realities not only constrains program implementers, but also prevents national governments, nongovernmental organizations, and multilateral organizations from effectively making and implementing decisions to address the cardiovascular disease epidemic.
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2007. The bur den and costs of chronic diseases in low-income and middle-income countries.
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2009. The global alliance for chronic diseases.
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2006. Global burden of disease and risk factors.
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2009. Using the INDEPTH HDSS to build capacity for chronic non-communicable disease risk factor surveillance in low and middle-income countries.
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Presentation at the Public Information Gathering Session for the Institute of Medicine Committee on Preventing the Global Epidemic of Cardiovascular Disease, Washington, DC. Stansfield, S
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Geneva: World Health Organization. WHO Health Metrics Network.
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