Promoting Cardiovascular Health in the Developing World A Critical Challenge to Achieve Global Health (2010) / Chapter Skim
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8 Framework for Action
8 Framework for Action
Pages 373-436
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These realities are often not fully considered in the understandable call for needed action. This call has been driven by good intentions, but there has been less success than in other areas of global health in attracting international attention and action, despite overwhelming evidence of the need.
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ESSENTIAL FUNCTIONS REQUIRED FOR IMPLEMENTATION The effective implementation of efforts to address global CVD requires that certain actions be executed. The functions required to do this include advocacy and leadership at global and national levels, developing policy, program implementation, capacity building, research focusing on evaluating approaches in developing countries that are context specific and culturally relevant, ongoing monitoring and evaluation, and funding.
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A key challenge in this effort will be to target advocacy efforts at infectious disease, maternal and child health, health systems strengthening, and other global health programs to better communicate the reasons and opportunities to promote the integration of basic chronic disease prevention and management into their existing programs. In addition to the direct advocacy efforts of CVD and related chronic disease stakeholders, strategies using mass media, media advocacy, social marketing, and social mobilization can serve as conduits of information and mechanisms for advocacy to build support among the various other stakeholders in the global health arena: governments, multinational agencies, scientists and academic institutions, civil society organizations, public health and health care practitioners, and the general public.
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Most of these are produced by national health and nutrition agencies, national and international professional organizations, and organizations focusing on individual risk factors
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Depending on the available infrastructure, national and subnational authorities are responsible for implementing public health and health programs as well as policy initiatives in other sectors. Other program implementers include universities, NGOs and other organizations in civil society, and, in some low and middle income countries, development agencies and their subcontractors.
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This will encourage other major efforts to build the health workforce in low and middle income countries to ensure that, even if funded through disease-specific funding streams, they are supporting appropriately comprehensive health and public health training and not inadvertently creating educational programs and curricula that are narrowly focused on specific diseases to the exclusion of training in basic health promotion and chronic disease competencies. University and academic global health centers have also assumed an increasingly important role in building leadership and research capacity.
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Recently, CVD professional organizations, major global health organizations, and academic global health centers have convened international and regional meetings to share the latest developments in CVD treatment and prevention. While the global meetings provide an opportunity to gather stakeholders and focus on international issues, the regional meetings (especially those in low and middle income countries)
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• Further exploration of gender differences in CVD risk in low and middle income countries, including unique CVD risk factors in women. • Investigation of the burden and determinants of both infectious causes of CVD and disease-specific cardiovascular manifestations among individuals with HIV, TB, and other infectious diseases.
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Chapter 6: Cardiovascular Health Promotion Early in Life • Estimating the incidence and prevalence of CVD risk factors among youth in low and middle income countries through appropriate epidemiological designs, includ ing long-term cohort studies, ideally starting in pregnancy. These studies should continued
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. Part of the research endeavor should include capacity building to foster and develop high-quality research infrastructure and trained researchers in the field of global chronic disease, both in high income and low and middle income countries.
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and its part ners in the newly created Global Alliance for Chronic Disease, along with other research funders and bilateral public health agencies, should prioritize research to determine what intervention approaches will be most effective and feasible to implement in low and middle income countries, including adaptations based on demonstrated success in high income countries. Using appropriate rigorous evaluation methodolo gies, this research should be conducted in partnership with local gov ernments, academic and public health researchers, nongovernmental organizations, and communities.
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These efforts are hampered by the lack of monitoring and surveillance programs and evaluation expertise in many low and middle income countries. However, there has been substantial progress in many areas of monitoring and evaluation in global health that can offer important lessons and models to meet chronic disease measurement needs.
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Considering the full range of global health donor sources, including not only bilateral development assistance for health but also sources such as multilateral organizations, private organizations, disease membership associations, and research institutions, external funding for CVD and other chronic diseases increased from $236 million in 2004 to more than $618 million in 2008 in real terms. Much of this growth has come from private non-profit organizations and multilateral organizations.
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Going forward, support for CVD and related chronic diseases will be needed from national governments (health and nonhealth sectors) , bilateral and multilateral international agreements, private foundations, international NGOs, civic groups, community-based organizations, and public–private partnerships.
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A number of multilateral organizations, foreign aid agencies, international health NGOs, and academic global health centers have helped fund chronic disease centers in low and middle income countries, although to date these investments are generally localized and
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Conclusion 8.2: Most agencies that provide development assistance do not include chronic diseases as an area of emphasis. Given the compelling health and economic burden, these agencies will not truly meet their goals of improving health and well-being worldwide without committing to address chronic diseases in alignment with their evolv ing global health priorities.
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raising awareness about the population health and economic impact and the potential for improved outcomes with health promotion and chronic disease prevention and treatment initiatives, (2) advocating for health promotion and chronic disease prevention policies at national and subnational levels of government, (3)
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Most chronic diseases -- and indeed many communicable diseases -- also share the same social determinants. Thus, an integrated and intersectoral approach to health promotion is also appropriate and should BOX 8.2 Key Principles for Organizing for Action Around a Shared Vision • Recognize and respect the realities of multiple competing priorities • Recognize the realities of resource constraints • Integrate health promotion and prevention efforts with other diseases that share common risk factors and common social, structural, economic, and development-related determinants • Build partnerships across sectors such as agriculture, finance, education, transportation, and the private sector • Integrate health care delivery and capacity building efforts with ongoing health systems strengthening initiatives • Balance integrated approaches with disease-specific approaches where ap propriate for research, training, and clinical care
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Focusing on health promotion, shared-risk-factor reduction and framing the CVD epidemic within the broader context of other chronic diseases creates a common goal around which CVD and non-CVD organizations can concentrate their efforts and maximize the impact of their resources. This would also allow for cost saving through pooling of resources; more impactful advocacy campaigns; larger, more coordinated research and implementation efforts; and ultimately a more compelling and effective mechanism to address chronic diseases in low and middle income countries.
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can maximize their efforts by integrating advocacy, funding, evaluation, and program implementation. This integration can include a shared focus on the relationship between chronic diseases and health sys tems strengthening and the relationship between existing Millennium Development Goal commitments and chronic disease prevention and control, including the importance of addressing chronic disease preven tion within the context of sustainable development.
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TABLE 8.2 Ideal Responsibilities of Key Stakeholders Monitoring and Stakeholder Capacity Funding Advocacy Leadership Policy Implementation Research r Evaluation Building Group WHO World Bank WEF FAO UNICEF UNGASS International Aid Agencies Global Health International Research Initiatives U.S. Government International NGOs Private Donors Industry PPPs UN / WHO Regional Offices Regional Development Banks Regional Regional NGOs National Governments Ministries of Health National Research Institutes/ MRCs Local Governments Local NGOs National/Subnational Local Academia Local Donors NOTE: FAG = Food and Agriculture Organization, MRCs = Medical Research Centers, PPPs = public–private partnerships, UNGASS = United Na tions General Assembly Special Sessions, UNICEF = United Nations Children's Fund, WEF = World Economic Forum.
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Regional development banks, notably the Inter American Development Bank, have also started to support chronic disease programs. Regional banks for Asia and Africa should similarly expand their efforts to include chronic diseases.
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These include significant changes in the status of HIV and other infectious diseases. An UNGASS discussion and resolution calling for action on CVD and broader aspects of chronic diseases could serve to alert governments, NGOs, and corporations of the urgent need to address CVD and, if done right, could inject the same degree of focused action that now characterizes the HIV/AIDS debate.
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This move will require additional and sustained funding. The leading organizations described below also need to take leadership to establish agreements on priority outcomes and common messages and to bring together other NGOs into a broader coalition under a common framework for action to address chronic diseases worldwide.
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In low and middle income countries, where resources are scarce, the need for closer interaction between these potentially powerful groups needs to be far more fully developed. This could lead to better support to patients and the general public and to enhanced advocacy for effective policies.
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However, as of yet there has been no large-scale pressure placed on the pharmaceutical industry to improve access in low and middle income countries, nor have there been pushes to develop innovative funding mechanisms for CVD drugs as has occurred with many infectious diseases. As a result of leadership by WHO, pressure from the investment community, and demands by high income country governments, the food manufacturing industry (and to a somewhat lesser degree the food retail and service industries)
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Increasingly it has expanded from a more focused approach on infectious diseases to address chronic diseases. It is able to draw upon members from the food, pharmaceutical, medical device, insurance, and related sectors to build programs and public health partnerships that can be of critical importance to those involved in CVD control.
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The CVD community might, for example, increase the number of strategic alliances between the WHF and companies; draw upon companies with expertise and deployed capacity to distribute needed drugs and diagnostics to developing countries; encourage companies to detail staff to work within public health programs both to share their knowledge and to learn better about community needs; co-invest with food companies, foundations, and development agencies in developing healthful oilseeds in developing countries; and create public–private product-focused initiatives to develop more
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can be engaged to expand and intensify collaboration with international public-sector efforts to reduce dietary intake of salt, sugar, and saturated and transfats in both adults and children, and to fully implement marketing restrictions on these substances. Pharmaceutical, biotechnology, and medical device companies can be enlisted to participate in promoting the rational use of costly interventions and to focus on developing safe, effective, and affordable diagnostics, therapeutics, and other technologies to improve prevention, detection, and treatment efficacy of CVD in low and middle income countries.
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With this influence comes the opportunity for the U.S. government to take a leadership role to help ensure that the evolving global health agenda includes the threat to health worldwide due to the growth of chronic diseases.
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includes international health efforts and global health promotion in its overarching goals as an extension of its mandate to protect U.S. health and safety (Kates et al., 2009)
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and by its leadership in creating the six-research-institution Global Alliance for Chronic Disease with Canadian, British, Indian, Chinese, and Australian research support agencies. Moving forward in the context of NIH's overall commitment to global health, there is a need to build on this by deepening chronic disease research efforts through collaboration with an even wider number of institutes within NIH that focus on disease with shared risk factors, common outcomes, or common long-term care needs.
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As the burden of chronic diseases continues to rise, this expanded scope will become critical for the agency to truly meet its global health goals. Similarly, the emerging President's Global Health Initiative makes no specific mention of chronic diseases in its stated goals or its plans for resource allocations.
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In addition, because of the increase in CVD risk factors associated with these diseases, integrated chronic care approaches offer an opportunity to reduce CVD and improve overall health outcomes in this population. The size of the PEPFAR investment could allow for the emergence of novel approaches for all chronic diseases.
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also has the potential to contribute to global efforts against chronic diseases, including its strong leverage with FAO. One area in which the USDA can play a role is through funding analytic work aimed at developing agricultural policies and practices that meet nutrition needs while promoting cardiovascular health.
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Local authorities also can consider opportunities to require more thorough assessments of the potential health impact of future development of cities and urban expansion to promote planning that takes into account the needs of reducing chronic disease risk (Collins and Koplan, 2009)
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One strategy to enhance this cultivation of leadership is the creation of academic partnerships between institutions in high income countries and those in low and middle income countries. Examples of such successful academic partnerships exist, built upon the following principles: (1)
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The city also mandated that chain restaurants clearly post the calorie content of their foods on all menus and menu boards. In January 2010, the city announced the National Salt Reduction Initiative: a partnership with more than 40 city, state, and national health agencies that is working with the food and restaurant industries to reduce Americans' salt intake by at least 20% over 5 years.
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The city has also promoted the adoption of electronic medical records that include registry and clinical decision support for CVD and improved its information dissemination to ensure that physicians are up to date on research and best practices. New York City's comprehensive approach to chronic disease risk-factor prevention provides an example of how local governments and health departments can take the initiative and make meaningful steps to reduce risk factors.
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NCDnet is still in its infancy but deserves continued and future support as it has the potential to reach all governments and to frame the needs of CVD and stimulate funders to invest. If it is able to achieve its mission to unite the currently fragmented efforts in chronic disease prevention and control, this network will fill a critical gap in the leadership of global chronic disease efforts and could be an effective means of building global consensus on the most effective ways of tackling these diseases.
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Founded in 1999 as a joint program of the Global Forum for Health Research and WHO, IC Health promotes and prioritizes context-specific research on CVD in low and middle income countries and has quickly established itself as an important convener and collaborator in global CVD prevention efforts. In addition to sponsoring prevention programs in several developing countries in Southeast Asia, IC Health was also a key sponsor of the INTERHEART study discussed in Chapter 2, which established that the same key risk factors are responsible for the vast majority of CVD deaths around the world in both developed and developing countries.
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The reporting process should involve national governments from high, middle, and low income countries; leading international NGOs; industry alliances; and development agencies. An initial goal of this global reporting mechanism should be to develop or select standardized indicators and methods for measurement, leverag ing existing instruments where available.
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. Since the drafting of the PAHO Action Plan, the region has taken a number of concrete steps toward reducing the burden of chronic diseases and their risk factors.
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These mechanisms may include, for example, regional meetings for researchers, program managers, and policy makers; regionally focused publications; and registries of practice-based evidence. National and Subnational Coordination As described above, the overlap of efforts to address CVD and other global health issues and the breadth of the determinants that affect CVD mean that in countries it is necessary to coordinate not only within the broader public health and health systems but also with authorities throughout the whole of government.
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These commissions should be modeled on current national HIV/AIDS commissions and could be integrated with these commissions where they already exist. Alliances and Partnerships A theme that emerges throughout the preceding discussion is that progress in many aspects of what is needed for CVD and related chronic diseases can be accelerated when key stakeholders work together.
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A clearly defined goal is the starting point of every successful partnership. A well-defined purpose does not mean that the partnership cannot be ambitious; indeed, many of the most acclaimed global health partnerships, such as the global effort to eradicate smallpox in the 1960s and 1970s, have had extraordinarily lofty goals.
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Indeed, nearly 30 percent of deaths in low and middle income countries are now attributable to CVD, and rates are rising. This health burden is accompanied by significant economic effects that further contribute to the growing burden of CVD.
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This chapter has summarized the committee's evaluation of the factors contributing to this "action gap," its assessment of the available evidence on the implementation of intervention approaches in low and middle income countries, and its conclusions about the necessary next steps to move forward. The major messages of this report are summarized in Box 8.6, which were drawn from the report's major conclusions, shown in Box 8.7.
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Rather than competing against other global health and development priorities, the CVD community needs to engage policy makers and global health colleagues to integrate attention to CVD within existing global health missions because, given the high and growing burden, it will be impossible to achieve global health without better efforts to promote cardiovascular health.
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Conclusion 3.1: In general, CVD risks are rising among low income countries, are highest for middle income developing countries, and then fall off for countries at a more advanced stage of development. This pattern reflects a complex interaction among average per capita income in a country, trends in lifestyle and other risk factors, and health systems capacity to control CVD.
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Conclusion 5.2: Risk for CVD and related chronic diseases is increased by modifiable behavioral factors such as tobacco use; high intake of salt, sugar, saturated and transfats, and unhealthful oils; excessive total caloric intake; lack of consumption of fruits and vegetables; physical inactivity; and excessive alcohol consumption. For some of these risk factors, behavior modification and risk reduction have been successfully achieved through health promotion and prevention policies and communications programs in some countries and communities.
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Many countries do not currently have sufficient infrastructural capacity. Current efforts to strengthen health systems in many low and middle income countries provide an op portunity to improve delivery of high-quality care to prevent and manage CVD, including chronic care approaches that are applicable to other chronic diseases and infectious diseases requiring chronic management, such as HIV/AIDS.
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To truly improve health globally, funders need to take chronic disease into account, both as an expansion of their primary global health mission and as part of existing programs where objectives overlap, such as early prevention in maternal and child health, chronic care models in infectious disease, health systems strengthening, and health and economic development. Conclusion 8.4: Many chronic diseases such as diabetes, cancer, and chronic respiratory illnesses share common behavioral risk factors with CVD, including smoking, dietary factors, and physical inactivity.
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Recommendation 3: Implement Policies to Promote Cardiovascular Health To expand current or introduce new population-wide efforts to promote cardiovascular health and to reduce risk for CVD and related chronic diseases, national and subna tional governments should adapt and implement evidence-based, effective policies based on local priorities. These policies may include laws, regulations, changes to fis cal policy, and incentives to encourage private-sector alignment.
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From page 427... ...
and its partners in the newly created Global Alliance for Chronic Disease, along with other research funders and bilateral public health agencies, should prioritize research to determine what intervention approaches will be most effective and feasible to implement in low and middle income countries, including adaptations based on demonstrated success in high income countries. Using appropriate rigorous evaluation methodologies, this research should be conducted in partnership with local governments, academic and public health researchers, nongovernmental organizations, and communities.
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From page 428... ...
raising awareness about the population health and economic impact and the potential for improved outcomes with health promotion and chronic disease prevention and treat ment initiatives, (2) advocating for health promotion and chronic disease prevention policies at national and subnational levels of government, (3)
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Financial support should come from the Global Alliance for Chronic Disease, with operational support from the CDC. The reporting process should involve national governments from high, middle, and low income countries; leading international NGOs; industry alliances; and development agencies.
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TABLE 8.3 Recommendations by the Essential Functions They Support 0 Capacity Monitoring and Recommendation Funding Advocacy Leadership Policy Implementation Research Building Evaluation Recognize Chronic Diseases as a 1 Development Assistance Priority 2 Improve Local Data Implement Policies to Promote 3 Cardiovascular Health Include Chronic Diseases in Health 4 Systems Stregnthening Improve National Coordination for Chronic 5 Diseases Research to Assess What Works in 6 Different Settings Disseminate Knowledge and Innovation 7 Among Similar Countries 8 Collaborate to Improve Diets Collaborate to Improve Access to CVD 9 Diagnostics, Medicines, and Technologies Advocate for Chronic Diseases as a 10 Funding Priority 11 Define Resource Needs 12 Report on Global Progress Figure 8-2 R01642 editable vectors scaled for landscape
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TABLE 8.4 Recommendations by Targeted Actor International Regional National/Subnational FAO WEF WHO PPPs UNICEF Industry World Bank Local NGOs Private Donors Regional NGOs Local Academia U.S. Government International NGOs Ministries of Health Local Governments National Governments International Aid Agencies UN / WHO Regional Offices Regional Development Banks Recommendation Global Health Research Initiatives National Research Institutes/ MRCs Recognize Chronic Diseases as a 1 Development Assistance Priority 2 Improve Local Data Implement Policies to Promote 3 Cardiovascular Health Include Chronic Diseases in Health 4 Systems Stregnthening Improve National Coordination for Chronic 5 Diseases Research to Assess What Works in 6 Different Settings Disseminate Knowledge and Innovation 7 Among Similar Countries 8 Collaborate to Improve Diets Collaborate to Improve Access to CVD 9 Diagnostics, Medicines, and Technologies Advocate for Chronic Diseases as a 10 Funding Priority 11 Define Resource Needs 12 Report on Global Progress
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2009. The Global Alliance for Chronic Diseases.
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2009. National Heart, Lung, and Blood Institute Global Health Initiative.
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. WHO Department of Chronic Diseases and Health Promotion.
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. Towards a WHO long-term strategy for pre vention and control of leading chronic diseases.
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