Resources Topic 4: How can we make health policies to reduce the burden of NCD?

The health policy framework and its application in the prevention of CVD and diabetes

Public policy and the challenge from NCDs - from the World Bank. As this document outlines, “the appropriate policy response to NCDs will entail avoiding the looming NCD burden to the extent possible, for example, through public health interventions and improved health care, while simultaneously preparing to deal with the health system and cost pressures arising from the increase in NCDs resulting from demographic forces. Policy makers should be aware of both issues. An exclusive focus on prevention may lead to unrealistic expectations of a disease-free future, and thus a lack of readiness for emerging challenges. An overemphasis on ageing, however, could result in a mistaken belief that policy cannot make a difference. The case for the World Bank and its clients to respond with action on both fronts is compelling.”

Breaking down the silos of Universal Health Coverage: towards systems for the primary prevention of non-communicable diseases in Africa places policy in the context of Universal Health Coverage and two points from the summary are:

African countries are not on track to achieve global targets for non-communicable disease (NCD) prevention, driven by an insufficient focus on ecological drivers of NCD risk factors, including poor urban development and the unbridled proliferation of the commercial determinants of health.

As the risk factors for NCDs are largely shaped outside the healthcare sector, an emphasis on downstream healthcare service provision to the exclusion of upstream population-level prevention limits the goals of universal health coverage (UHC) and its potential for optimal improvements in (achieving) health and well-being outcomes in Africa.

Promoting cardiovascular health in developing countries - from the Institute of Medicine (Summary). This report from the Institute of Medicine (IOM) includes discussion of two essential goals in promoting CV health in the developing world: (1) creating environments that promote heart healthy lifestyle choices and help reduce the risk of chronic diseases, and (2) building public health infrastructure and health systems with the capacity to implement programs that will effectively detect and reduce risk and manage CVD. To meet these goals the IOM recommends several steps, including improving cooperation and collaboration; implementing effective and feasible strategies; and informing efforts through research and surveillance.

Here is an example The evolution of non-communicable diseases policies in post-apartheid South Africa. Despite the particular situation in South Africa, the finding and conclusion "While a multi-sectoral approach is part of public policy discourse, its application in the implementation of NCD policies and programmes is a challenge...NCD prevalence remains high in South Africa. There is need to adopt the multi-sectoral approach in the implementation of NCD policies and programmes" will apply to many, if not all, countries!

Also from South Africa, but relevant more widely, Urgency for South Africa to prioritise cardiovascular disease management "more aggressive approaches are required to manage NCDs in South Africa and other developing countries. These include scaling up treatment of hypertension and dyslipidaemia and empowering nurses by effective training on NCD management."

Management of diabetes and associated cardiovascular risk factors. This paper indicates that: "Five strategies can help reduce the burden of diabetes at the population level: (i) case prevention through reductions in modifiable risk factors such as obesity; (ii) screening coupled with pharmacological or lifestyle interventions targeting individuals with pre-diabetes; (iii) improved diagnosis and control of blood glucose among individuals with diabetes; (iv) improved management of microvascular complications, including renal disease, retinopathy, diabetic foot and other neuropathies; and (v) improved management of associated cardiovascular risks. It is essential to understand how well health systems are performing in terms of these five strategies and the role of health system and individual attributes such as physical access, financial access, provider quality and patient education and motivation."

Promoting increase in physical activity. WHO has a Global Strategy on Diet, Physical Activity and Health. A review of best practice in interventions has identified the most essential prerequisites for large-scale physical activity programs in developing countries. Essential prerequisites are: high political commitment/guiding national policy; funding; support from stakeholders; and a coordinating team. Other important factors are: clear program objectives, integration of physical activity within other related interventions; multiple intervention strategies; target whole population as well as specific population groups; clear identity for the program; implementation at different levels; implementation within the ‘local reality’; leadership; dissemination of the intervention; evaluation and monitoring; and national physical activity guidelines.

There is also some evidence that mHealth interventions using mobile phones may be effective in encouraging an increase in physical activity.

The impact of poverty reduction and development interventions on non-communicable diseases and their behavioural risk factors in low and lower-middle income countries: A systematic review finds: "Though many interventions addressing poverty and development have great potential to impact on NCD prevalence and risk, most fail to measure or report these outcomes. Current evidence is limited to behavioural risk factors, namely diet and suggests a positive impact of agricultural-based food security programmes on dietary indicators. However, studies investigating the impact of improved income on obesity tend to show an increased risk. Embedding NCD impact evaluation into development programmes is crucial in the context of the Sustainable Development Goals and the rapid epidemiological transitions facing LLMICs."

A systematic review of primary care models for non-communicable disease interventions in Sub-Saharan Africa, concludes: "For this review there was a near-consensus that passive rather than active case-finding approaches are suitable in resource-poor settings. Modifying risk factors among existing patients through advice on diet and lifestyle was a common element of healthcare approaches. The priorities for disease management in primary care were identified as: availability of essential diagnostic tools and medications at local primary healthcare clinics and the use of standardized protocols for diagnosis, treatment, monitoring and referral to specialist care."

The importance of and barriers to the incorporation of evidence into the development and implementation of health policies to reduce the burden of illness

Online resource on global tobacco control. With a funding commitment of $375 million, the Bloomberg Initiative to Reduce Tobacco Use represents the largest-ever effort to fight tobacco in the low- and middle-income countries that are now home to a majority of the world's smokers. This site offers free instructional training for policy makers, researchers, educators and the general public. It helps participants develop and implement effective tobacco control programs, advocate for substantial anti-smoking regulations and craft media campaigns that make a difference. The multimedia educational modules feature tobacco control experts from around the world. The curriculum was developed by faculty at the Johns Hopkins Bloomberg School of Public Health.

Threats, bullying, lawsuits: tobacco industry's dirty war for the African market. An experienced health reporter has found a major barrier: "British American Tobacco (BAT) and other multinational tobacco firms have threatened governments in at least eight countries in Africa demanding they axe or dilute the kind of protections that have saved millions of lives in the west, a Guardian investigation has found. BAT, one of the world’s leading cigarette manufacturers, is fighting through the courts to try to block the Kenyan and Ugandan governments’ attempts to bring in regulations to limit the harm caused by smoking. The giant tobacco firms hope to boost their markets in Africa, which has a fast-growing young and increasingly prosperous population."

In The institutional context of tobacco production in Zambia, the authors found; "Respondents uniformly acknowledged that growing the country's economy and ensuring employment for its citizens are the government's top priorities. Lacklustre coordination and collaboration between the institutional actors, both within and outside government, contributes to an environment that helps sustain tobacco production in the country." and concludes: "As with other low-income countries involved in tobacco production, there is inconsistency between Zambia's economic policy to strengthen the country's economy and its FCTC commitment to regulate and control tobacco production....this industry risks being run according to the desire and demands of multinational tobacco companies, with few, if any, checks against them."

The 21st-century great food transformation starts with the statement: "We can no longer feed our population a healthy diet while balancing planetary resources. For the first time in 200 000 years of human history, we are severely out of synchronisation with the planet and nature...The dominant diets that the world has been producing and eating for the past 50 years are no longer nutritionally optimal, are a major contributor to climate change, and are accelerating erosion of natural biodiversity. Unless there is a comprehensive shift in how the world eats, there is no likelihood of achieving the Sustainable Development Goals (SDGs)—with food and nutrition cutting across all 17 SDGs...Industry too has lost its way, with commercial and political interests having far too much influence, with human health and our planet suffering the consequences." The paper references the publication of Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems - which describes "a universal healthy alternative diet to standard current diets, many of which are high in unhealthy foods. Scientific targets for a healthy reference diet are based on extensive literature on foods, dietary patterns, and health outcomes. This healthy reference diet largely consists of vegetables, fruits, whole grains, legumes, nuts, and unsaturated oils, includes a low to moderate amount of seafood and poultry, and includes no or a low quantity of red meat, processed meat, added sugar, refined grains, and starchy vegetables."

WHO pocket guidelines for the assessment and management of cardiovascular risk. Optional resource. These pocket guidelines provide evidence-based guidance on how to reduce the incidence of first and recurrent clinical events due to coronary heart disease (CHD), cerebrovascular disease (CeVD) and peripheral vascular disease in two categories of people. They include: (1) People with risk factors who have not yet developed clinically manifest cardiovascular disease (primary prevention); and (2) People with established CHD, CeVD or peripheral vascular disease (secondary prevention).

The accompanying World Health Organization/International Society of Hypertension (WHO/ISH) risk prediction charts enable the estimation of total cardiovascular risk of people in the first category. The evidence-based recommendations given in Part 1 of these guidelines provide guidance on which specific preventive actions to initiate, and with what degree of intensity. People in the second category have high cardiovascular risk and need intensive lifestyle interventions and appropriate drug therapy as elaborated in Part II of these guidelines. Risk stratification using risk charts is not required for making treatment decisions in them.

Secondary prevention. This study determined the extent of secondary prevention of CHD and CVD in low- and middle-income countries, within which a significant proportion of patients with at least two modifiable risk factors do not receive appropriate medications. There are considerable missed opportunities for prevention of recurrences in those with established CVD in low- and middle-income countries.

The role of economic evaluation for priority setting in health care

In Saving 100 million lives by improving global treatment of hypertension and reducing cardiovascular disease risk factors, the comment is made that "The global direct medical costs of hypertension are estimated at $370 billion per year, with the health care savings from effective management of blood pressure projected at roughly $100 billion per year. For every death from CVD, there are up to 3 other serious CVD events, which also incur medical and social costs; it is estimated that CVD costs 2%‐4% of gross national income in low‐ and middle‐income countries...Even though most CVD is preventable through simple, effective, and inexpensive interventions, control rates of blood pressure remain very low on a global scale because these interventions are underused in most of the world...3 key interventions to reduce CVD—improving treatment of hypertension from the current global control rate of 14% to a target of 50%, reducing current levels of sodium intake by 30%, and completely eliminating artificial trans‐fat from the food supply...Health systems that are successful in supporting their patients to bring blood pressure under control do so by ensuring provision of a technical package with 5 key components.

• Treatment protocols that establish a standard treatment of patients that is simple and practical yet provides sufficient detail, including specific medications and dosages and a schedule for titration or the addition of medications if blood pressure is uncontrolled.
• Community‐based care and task sharing so health care workers who are most accessible to patients can provide care, including adjusting and intensifying medication regimens that follow physician‐directed protocols, allowing every member of the health care team to be optimally involved in supporting patient care.
• A regular and uninterrupted supply of quality‐assured medications and equipment for accurate monitoring of blood pressure, including blood pressure measurement in homes, pharmacies, and other public settings.
• Patient‐centered services that reduce barriers to adherence, including low‐cost or free medical visits and medications; convenient medical visits and medication refills; once‐daily treatment regimens with 3‐month refills for stable patients; the use of fewer tablets through combination medications; ready access to free blood pressure monitoring; and public education to increase awareness of the importance of controlling blood pressure.
• Information systems that allow for real‐time feedback on adherence and blood pressure control of individual patients, and assessment of control rates by different treatment systems to strengthen tracking and accountability and facilitate continuous, real‐time program improvement."