Promoting Cardiovascular Health in the Developing World A Critical Challenge to Achieve Global Health (2010) / Chapter Skim
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From page 1... ...
In fact, as the leading cause of death worldwide, CVD now has a major impact not only on developed2 nations but also on low and middle income countries,3 where it accounts for nearly 30 percent of all deaths. The increased prevalence of risk factors for CVD and related chronic diseases4 in developing countries, including tobacco use, unhealthy dietary changes, reduced physical activity, increasing blood lipids, and hypertension, reflects significant global changes in behavior and lifestyle.
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In response to its charge, the committee undertook an examination of the current state of efforts to reduce the global epidemic of CVD based on a review of the available literature and of information gathered from various stakeholders in CVD and global health. In this analysis, the committee evaluated why there has not been more action to address chronic diseases and assessed the available evidence on intervention approaches to prevent and manage CVD, emphasizing knowledge and strategies pertinent to their implementation in low and middle income countries.
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Along with the need to recognize these realities in the effort to implement policies and programs, the committee identified several key barriers to progress in controlling the global epidemic of CVD. There is concern that attention to CVD would detract from other health needs; there is uncertainty about the effectiveness and feasibility of policies, programs, and services in the contexts in which they need to be implemented; efforts among stakeholders are fragmented and there is a need for focused leadership and collaboration centered on clearly defined goals and outcomes; there is a lack of financial, individual, and institutional resources; and there is insufficient capacity to meet CVD needs in low and middle income countries, including health workforce and infrastructure capacity as well as implementation and enforcement capacity for policies and regulatory approaches.
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In order to lay the groundwork to achieve this synergy, governments in low and middle income countries, global health funders, and development agencies need to give CVD and related chronic diseases more equal footing as a development and health priority. Currently, however, most agencies providing development assistance do not include chronic diseases as an area of emphasis.
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Low and middle and income countries have resource constraints, cultural contexts, social structures, and social and behavioral norms that are distinct from high income countries 5 The term "multilateral development agencies" is used throughout the recommendations to refer to international, multilateral entities that provide health and development assistance, such as the World Health Organization and World Bank and regional development banks. 6 The term "bilateral development agencies" is used throughout the recommendations to refer to national agencies that provide foreign development assistance, such as the U.S.
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While the needs, capacity, and priorities will vary across countries, the available intervention and economic evidence suggests that substantial progress in reducing CVD can be made in the near term through strategies to reduce tobacco use; to reduce salt consumption; and to improve delivery of clinical prevention in high-risk patients. These goals have credible evidence for lowered CVD morbidity, demonstrated likelihood of costeffectiveness, and examples of successful implementation of programs with the potential to be adapted for low and middle income countries.
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A policy approach supported by a strong evidence base in high income countries is implementation of the Framework Convention for Tobacco Control, which emphasizes measures such as taxation; protection from exposure to tobacco smoke; health warnings and public awareness campaigns; tobacco cessation services; and controls on tobacco advertising, illicit trade, and sales to minors. In addition, a collection of successful strategies to reduce salt in the food supply and in consumption in high income settings could potentially be adapted to low and middle income settings and are already being initiated in some developing countries.
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Recommendation 3: Implement Policies to Promote Cardiovascular Health To expand current or introduce new population-wide efforts to pro mote cardiovascular health and to reduce risk for CVD and related chronic diseases, national and subnational governments should adapt and implement evidence-based, effective policies based on local pri orities. These policies may include laws, regulations, changes to fiscal policy, and incentives to encourage private-sector alignment.
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In particular, capacity building could include enhancing curricular development to include chronic diseases in training programs in clinical, public health, research, economic, epidemiology, behavioral, health promotion, and health communications disciplines. In addition to building local workforce capacity, strengthening health systems to better meet the needs of both chronic disease and other health needs in low and middle income countries will require low-cost approaches to deliver high-quality care by improving equitable access to affordable health services and essential medicines, diagnostics, and technologies for prevention and treatment; monitoring clinical practice and improving the quality of care; introducing risk-pooling mechanisms for financing health services; and using information technologies.
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9 The term "leading international nongovernmental organizations" is used throughout the recommendations to refer to NGOs with a mission to address CVD and/or related chronic diseases, such as the World Heart Federation and the World Hypertension League, as well as those with a mission to advance global health more broadly, such as the International Union for Health Promotion and Education and the Global Forum for Health Research.
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The approaches that need to be evaluated are broad and include population surveillance methods; population-based health promotion and CVD prevention approaches; health education; financing of health care, interventions and incentives to improve the quality of care, models for efficient delivery, and integration of health care services; and integrated community-based approaches. The health sector and public health community in high income countries also stand to learn from what works in resource-constrained contexts in low and middle income countries.
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These efforts offer the potential to contribute to the available knowledge base of feasible and effective solutions for CVD in low and middle income countries. However, there is insufficient evaluation and reporting of these programs and policies, and inadequate systematic mechanisms for disseminating what has worked in one context to other similar contexts.
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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. Prevention Early in Life Accumulation of cardiovascular risk begins early in life, and evidence on rising rates of childhood obesity and youth smoking in low and middle income countries as well as emerging evidence on the effects of early nutrition on later cardiovascular health support the value of starting health promotion efforts during pregnancy and early childhood and continuing prevention efforts throughout the life course.
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In addition, as described earlier, the determinants of CVD and related chronic diseases extend beyond the realm of the health sector. Thus, an integrated approach focused on health promotion is warranted, with partnerships across sectors such as health, agriculture, development, civil society, and the private sector.
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can be engaged to expand and intensify collaboration with international public-sector efforts to reduce dietary intake of salt, saturated fats, transfats, unhealthy oils, and sugars in both adults and children, and to fully implement marketing restrictions on unhealthy products. Pharmaceutical, biotechnology, medical device, and information technology companies can be enlisted to develop, provide, and distribute safe, effective, and affordable diagnostics, therapeutics, and other technologies to improve prevention, detection, and treatment of CVD in low and middle income countries.
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This investment could occur as an expansion of their primary global health mission and also as part of existing programs where objectives overlap and minimal new investment would be needed, such as early prevention maternal and child health programs; chronic care models for infectious and noninfectious disease; health systems strengthening; and health and economic development. In order to marshal the resources needed to implement actions that are aligned with the priorities outlined in this report, CVD and other chronic disease stakeholders need to build a case for investment by more effectively communicating with existing and potential new funders.
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Conducting such analysis at the country level in low and middle income countries will be an important planning tool for national and subnational governments as well as for funders and development agencies. Recommendation 11: Define Resource Needs The Global Alliance for Chronic Disease should commission and coor dinate case studies of the CVD financing needs for five to seven coun tries representing different geographical regions, stages of the CVD epidemic, and stages of development.
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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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