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 Table of Contents  
ORIGINAL ARTICLE- ROUNDTABLE
Year : 2017  |  Volume : 2  |  Issue : 4  |  Page : 138-141

Evidence-based scale-up of noncommunicable disease programs: Outcomes of roundtable discussions


Department of Community Medicine, School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication22-Feb-2018

Correspondence Address:
Gursimer Jeet
School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jncd.jncd_53_17

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  Abstract 


To tap the growing burden of these groups of chronic diseases, numerous interventions are being implemented in different settings. Evidence from developed settings is promising yet warrants careful planning and evaluation before implementation and expansion. There is a need for strengthening the evidence for sustainable scale-up of noncommunicable diseases (NCDs) program. A total of 16 nodal persons (national and international program managers, academicians) from different regions participated in the roundtable discussion, proceedings of which were recorded simultaneously and summarized as SWOT analysis. NCD surveillance and information systems need to be strengthened to capture plan scale-up and capture program effects. Presented here are proceedings, recommendations, and key themes emerging out of discussions.

Keywords: Evidence, intervention, noncommunicable diseases, scale-up, SWOT analysis


How to cite this article:
Jeet G, Gogia R. Evidence-based scale-up of noncommunicable disease programs: Outcomes of roundtable discussions. Int J Non-Commun Dis 2017;2:138-41

How to cite this URL:
Jeet G, Gogia R. Evidence-based scale-up of noncommunicable disease programs: Outcomes of roundtable discussions. Int J Non-Commun Dis [serial online] 2017 [cited 2019 Oct 16];2:138-41. Available from: http://www.ijncd.org/text.asp?2017/2/4/138/225984




  Introduction Top


The determination to prevent and control the noncommunicable diseases (NCDs) remained on clutch before 2011.[1] After UN meeting on NCDs, there was the materialization of a global monitoring framework to measure the progress of NCD prevention and control efforts.[2] This however requires a implementation of uniform evidence-based policies and interventions. A set of such interventions was identified, the cost-effectiveness of which has been proven and has been proposed as “best buys” recognized for pronounced accomplishment of results, decreasing chronic diseases and related risk factors in developed and developing worlds. Further, it is supportive in securing more benefits as to overcome the economic and social constraints of the health system (like generalized elevation in taxation on tobacco and its product is one of the common examples of the very cost-effective intervention).[3] In 2013, 95 countries had executed minimum one of the four tobacco control “best-buy” very cost-effective interventions, with the highest level of accomplishment, and two countries had all four “best-buys” in place at the uppermost level. Many of the countries are making progress in implementing “best-buy” measures in low- or middle-income countries. However, scale-up of these interventions has thrown several challenges in front of program managers and policymakers in terms of effectiveness, efficiency, and cost-effectiveness during scale-up.[4] Developing countries have been encouraged to adopt large-scale community-based interventions, and many countries promulgated such initiatives through NCD prevention and control programs having a mix of primary as well as secondary prevention interventions.[5]


  Methods and Participants Top


A total of 16 nodal persons working for NCD programs were brought together along with policymakers, academicians, and key researchers to discuss the evidence on scale-up and framing recommendations to guide policies and programs for the NCDs prevention and control. Meeting was chaired by Professor Brian Oldenburg, Director of the Centre for Health Equity in the Melbourne School of Population and Global Health and moderated by the Dr. Rana J Singh, Deputy Regional Director (Tobacco and NCD Control), The Union, South East Asia Region. The proceedings of the roundtable were recorded simultaneously, and SWOT analysis of the proceedings was done to identify key external and internal factors which affect scale-up planning of interventions under the programs.

Proceedings of the meeting

The evidence base for scale-up of NCD programs was discussed by Professor Brian Oldenburg, along with the efforts being made by the Government of India. He, however, cautioned while scaling up of interventions at large scale stating, “India is in an expansion phase and expansion needs evidence.” World Health Organization's monograph helpful for planning at national, subnational levels, and for scaling up the programs was suggested as a useful tool to start. Development of national monitoring frameworks and operational guidelines under NCD programs for measuring progress was listed as a crucial step. However, considering the diversity of subpopulations and population need of different regions, the importance of conducting pilot studies with the thorough process and end evaluations was highlighted. Implementation research needs to be promoted alongside.

Speaking on country-specific implementation status, national progress on noncommunicable disease program in India (NPCDCS) was briefed by Deputy Assistant Director General, Ministry of Health and Family Welfare, Government of India. Switching over to population-based screening from opportunistic screening was listed as a major challenge in terms of population numbers and resources. Capacity building strengthening through training at all levels of the health system and provision of dedicated finance support was epitomized as key prerequisites for successful implementation. Bringing additional diseases under the umbrella of a single program to cover NCDs in an integrated manner was listed as an upcoming challenge. Strengthening of NCD surveillance through state-led initiatives or national level collaborations between national research agencies, states, and the tertiary care institutes to produce evidence on the burden of risk factors and NCDs was considered useful for program scale-up. The Punjab state in North India was found to be leading by example with its NCD risk factors survey which translated into a state-level action plan for NCDs. The survey has provided vital information to program managers in the state regarding the prevalence of risk factors, coverage of key interventions, awareness levels, and treatment needs of a population.[6] This information is crucial to scaling up. Translation of research evidence from developed nations hinders the application of their findings in developing systems due to issues of generalizability and transferability of evidence. Establishment of the formal system of testing evidence in low-income settings needs to be given more importance. It is worth mentioning that NCD program in India covers secondary and tertiary prevention also through NCD clinics, cardiac care units, and chemotherapy centers. It was further stated that successful chronic disease management would not be possible till communities participate effectively. Community mobilization under the program has been through community health workers. The effectiveness of the use of community health workers in developing countries for NCDs has been established [7] and should stay as focus area under the program.

Adoption of existing interventions packages such as WHO PEN intervention package for implementation of prevention and control of NCDs paved the way for smooth scale-up of a program in the Maldives. The strengthening of NCD surveillance has been adopted through the establishment of registries. The steering committee for National Multisectoral Action Plan for NCD campaign to reduce preventable deaths, Mental Health Strategic Plan and Policy through working groups would help to minimize the risk of NCDs in coming years. An epidemiologic transition toward NCDs was enumerated as a threat to NCD programs.

Addressing NCDs under universal health coverage initiatives and digitalization of health system through electronic health cards for families was the way forward for scaling up in a North Indian state. The digitalization of services would allow to have a permanent database of NCD patient with actual incidence, prevalence, and follow-up rates for the population. This would improve the scale-up resource need estimation, the capture of program effects, and chronic disease management under the program. Availability of operational guidelines under the program ensures uniform infrastructure strengthening. Program manager, however, highlighted lack of awareness on key risk factors in the state as limiting factor in the success of interventions. Another nodal officer representing southern states in India stated that the reorientation of the human resource to the existing standard operating procedures is important in scaling up. Importance of political will, legislation, and regulatory mechanisms were highlighted with Tamil Nadu example, wherein several policies on NCD care have been adopted linking population-based screening and strengthening of referral units for patient treatment and follow-up. One of the state program officers decorated that both developed and developing countries are taking footstep using WHO global strategy, centered on the notion of a STEPwise approach for NCD surveillance and monitoring. Immense information is now available about NCDs and their risk factors with clear indication of success using inclusive and integrated approaches to reduce their overall burden. However, designing of community based interventions in different settings still require risk factors profile specific of the community. State wide NCD surveys can provide this information in a regular and systematic way, so should be considered.

The Deputy Regional Director (Tobacco and NCD Control) summarized the meeting stating that the views of program managers will be helpful in devising new innovations and evidence by the policymakers and researchers for the NCDs prevention and control. Primarily, there is a need for invention, its exploration, and further advancement as essential to yield evidence and facts for stating resilient applicable strategies and policies in instituting large-scale NCD programs.


  Results Top


For NCD prevention to be successful, health sector cannot work in silos; information systems and private sector also need to be strengthened. Low budget allocation for scale-up, lack of regulatory environment to check the harmful behavior choices, and the consequent absence of good information and communication strategies to influence decision-making were listed as additional scale-up barriers. Evidence-based NCD surveillance and information systems need to be strengthened before the scale-up. Enhanced budget allocation toward NCD programs, health system strengthening (including referral units), training at all levels of healthcare, especially the capacity building of health workers for NCDs and application of WHO PEN intervention packages in developing settings were another recommendations. Effective implementation of monitoring processes and policy review is recommended for timely evaluation of program outcomes for scale-up. A SWOT analysis of the discussions held in the meeting has been presented in [Figure 1] which summarizes the key themes in four categories, i.e., strengths, weaknesses, opportunities, and threats. Strengths and weaknesses are reported in relation to NCD programs and opportunities and threats are from surrounding environment.
Figure 1: SWOT analysis of key themes emerging from the roundtable discussions

Click here to view



  Discussion Top


Early implementation lessons, felt needs of program managers along with challenges for implementation of large-scale NCD control programs have been reported. The challenges faced for expansion of program are huge. Proceedings of the round table have been summarized as a SWOT analysis of key themes that emerged. However, results should be seen in the light of other key research works being undertaken. In a modeling exercise, it was found that from a public health perspective, in lower-income countries, an annual per capita investment of US$ 1–3 would be required to pay for significantly reducing the enormous burden of disease from major NCDs and their underlying risk factors.[4] Although developing countries do not spend as per recommendation, underutilization of funds remains an issue. For example, many states implementing NCD program in India have still not been able to utilize the sanctioned budget completely (Author's analysis of expenditure statements of NCD cells of different states). It needs to be understood that the finances required to scale up the NCD response represent a new demand on health budgets and effective use of sanctioned budget, a responsibility of which lies on the shoulders of program managers needs to be ensured.

An absence of monitoring and surveillance deters translation of program data into effectiveness outcomes. Two-pronged approach for measuring effects in terms of strengthened monitoring of program data and establishment of robust low-cost surveillance systems to capture effects timely will be helpful in scale-up. Two North Indian states have demonstrated this after program implementation through statewide NCD risk factors surveys which will be the baseline for future evaluations for states.[6] Instead of fragmented efforts, concrete actions in the form of uniform communication and awareness strategies will help in raising the awareness levels during scale-up. Integration of NCD programs with other programs for health promotion has been tested and positive results have been found. Program managers should replicate the findings in their settings as this will reduce human and material resource wastage.[8] In addition, several low-cost evidence-based interventions need implementation focus. For example, nonimplementation of salt control interventions and lack of focus on targeted interventions being low-cost interventions stand a missed opportunity under NCD programs.


  Conclusion Top


The roundtable discussions provided expert insights and highlighted innovations being practised for NCD programs. Program managers stressed that transferable, reproducible evidence is required at the stage of selection of interventions and timely evaluation of program indicators is crucial for planning scale-ups. Rapporteur and analyst for round table's proceedings classified the proceedings and highlighted major messages that the group considered important as NCD programs are scaled up which will be helpful to inform key strategy areas and set priorities under the program. Innovation, integration optimization, and economies of scale should be given consideration while planning scale-up.

Key speakers

Brian Oldenburg, Rana Jagdeep Singh, Chinmoyee Das, Kameshwar Prasad, SK Sathpathy and nodal officers/program managers of NCD programs.

Resource persons/ Contributors

Professor Brian Oldenburg, Director of the Centre for Health Equity in the Melbourne School of Population and Global Health; Dr. Rana J Singh, Deputy Regional Director (Tobacco and NCD Control), The Union, South East Asia Region. Dr. Chinmoyee Das, Deputy Assistant Director General, Ministry of Health and Family Welfare, Government of India. Prof. J S Thakur, Department of Community Medicine, School of Public Health, PGIMER, Chandigarh; Dr. Sanjay Kumar Bhadada, Additional Professor, Department of Endocrinology at PGIMER, Chandigarh; Dr. Anil Garg, DFWO cum PO, NPCDCS, NHM UT, Chandigarh; Prof. Sudhir Kumar Sathpathy, Director KSPH, KIIT, Bhubaneswar; Dr. Jerald M. Selvam, MD, Deputy Director and State Nodal Officer, NCD Intervention Program, Department of Health and Family Welfare, Government of Tamil Nadu, India; Dr. Gopal Chauhan, State Program Officer (NHM) Directorate of Health Shimla HP; Dr. Kathirvel Soundappan, Assistant professor, Postgraduate Institute of Medical Education and Research, Chandigarh; Ms. Komal Khanna, Healthrise Program Director Medtronic foundation; Ibrahim Nizam, Public Health Program Manager, Ministry of Health, Maldives; Ms. Pathumath Shahiza, Ministry of Health Maldives; Ms. Manjushree; Dr. Anju Bhatia, NHM Chandigarh administration; Mr. R. K. Sharma, Niti Aayog.

Financial support and sponsorship

The meeting was hosted by the World NCD Congress in collaboration with MoHFW, AYUSH, and WHO.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
UN General Assembly. Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. New York: United Nations; 2011.  Back to cited text no. 1
    
2.
World Health Organisation. Global Status Report on Noncommunicable Diseases 2010. Geneva: World Health Organisation; 2011.  Back to cited text no. 2
    
3.
World Economic Forum/World Health Organisation. From Burden to 'Best Buys': Reducing the Ecomonic Impact of Non-communicable Diseases in Low- and Middle-Income Countries. Geneva, Switzerland: World Economic Forum/World Health Organisation; 2011.  Back to cited text no. 3
    
4.
World Health Organisation. Scaling Up Action Against Noncommunicable Diseases: How Much Will it Cost? Geneva: World Health Organisation; 2011.  Back to cited text no. 4
    
5.
World Health Organisation. Global Action Plan for Prevention and Control of NCDs (2013-2020). Geneva: World Health Organisation; 2013.  Back to cited text no. 5
    
6.
Thakur JS, Jeet G, Pal A, Singh S, Singh A, Deepti SS, et al. Profile of risk factors for non-communicable diseases in Punjab, Northern India: Results of a state-wide STEPS survey. PLoS One 2016;11:e0157705.  Back to cited text no. 6
[PUBMED]    
7.
Jeet G, Thakur JS, Prinja S, Singh M. Community health workers for non-communicable diseases prevention and control in developing countries: Evidence and implications. PLoS One 2017;12:e0180640.  Back to cited text no. 7
[PUBMED]    
8.
Thakur J, Jaswal N, Grover A, Kaur R, Jeet G, Bharti B, et al. Effectiveness of district health promotion model (Hoshiarpur Ambala model): An implementation experience from two districts from Northern part of India. Int J Noncommun Dis 2016;1:122-30.  Back to cited text no. 8
    


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