8
Framework for Action

The actions needed to prevent and treat cardiovascular disease (CVD) in individuals are at first glance beguilingly simple. People should follow healthful balanced diets, remain active throughout their lives, never smoke, and seek health care regularly. Declarations have called on governments to invest more in CVD, to develop laws and policies to protect the health of people, and to provide health services that respond to the CVD needs of people. International conference recommendations have demanded that companies restrict the marketing of certain products such as tobacco and unhealthful foods and beverages to children; eliminate transfats, reduce salt, and introduce healthful oils in their products; and make healthful foods more affordable and available to communities.

The reality is much more complex. Each action is subject to a cascade of breakdowns. Behavior change is difficult, and individual choices are influenced by broader environmental factors. Governments need to juggle many competing priorities, and some countries have limited infrastructure and capacity to address the problem. Companies need to meet the needs of their shareholders. 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. The failure to have the scaled impact needed has been due to concern that attention to CVD would detract from other health needs; uncertainty about the effectiveness and feasibility of policies, programs, and services in the contexts in which they need to be implemented; fragmentation of efforts among stakeholders and a need for focused lead-



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8 Framework for Action T he actions needed to prevent and treat cardiovascular disease (CVD) in individuals are at first glance beguilingly simple. People should follow healthful balanced diets, remain active throughout their lives, never smoke, and seek health care regularly. Declarations have called on governments to invest more in CVD, to develop laws and policies to protect the health of people, and to provide health services that respond to the CVD needs of people. International conference recommendations have demanded that companies restrict the marketing of certain products such as tobacco and unhealthful foods and beverages to children; eliminate transfats, reduce salt, and introduce healthful oils in their products; and make healthful foods more affordable and available to communities. The reality is much more complex. Each action is subject to a cascade of breakdowns. Behavior change is difficult, and individual choices are influenced by broader environmental factors. Governments need to juggle many competing priorities, and some countries have limited infrastructure and capacity to address the problem. Companies need to meet the needs of their shareholders. 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 overwhelm- ing evidence of the need. The failure to have the scaled impact needed has been due to concern that attention to CVD would detract from other health needs; uncertainty about the effectiveness and feasibility of policies, pro- grams, and services in the contexts in which they need to be implemented; fragmentation of efforts among stakeholders and a need for focused lead- 

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD ership and collaboration centered on clearly defined goals and outcomes; a lack of financial, individual, and institutional resources; and 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. Deeper reflection suggests that to prevent and control CVD in the de- veloping world, a number of essential functions are needed to develop and implement effective approaches. Successfully carrying out these functions will require the combined efforts of many players over long periods of time. This chapter first describes these essential functions. This is followed by a discussion of the relative strengths and responsibilities for key play- ers, proposing new or expanded accountabilities and responsibilities where needed and highlighting the need for more effective coordination of efforts to address CVD. Taken together, these functions and key stakeholders form a framework for implementing the actions needed to address the global epidemic of cardiovascular disease. 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 evaluat- ing approaches in developing countries that are context specific and cultur- ally relevant, ongoing monitoring and evaluation, and funding. All of these also require resources—financial, technical, and human. These functions and resource needs are described below, with examples of their role in CVD and indications of how they are tied to messages from previous chapters. Advocacy and Leadership Advocacy for policy change and for individuals to take actions in their everyday lives are not the same. Both approaches are critical and need to be led by recognized leaders who might be drawn from the community, academia, industry, or government. The first targets governments at local, national, and international levels to encourage policies that will support prevention and control efforts, which is discussed in more detail here. The second focuses on influencing and supporting individuals within their homes and communities to follow healthful lifestyles throughout their lives. National governments, nongovernmental organizations (NGOs), lo- cal media, and local governments can each be well placed to do this; these approaches were discussed in Chapter 5. International advocacy efforts to raise awareness of the growing CVD

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 FRAMEWORK FOR ACTION epidemic in low and middle income countries have continued to grow with increasing intensity over the past several decades. Professional organizations (national and international) as well as CVD and chronic disease advocacy organizations initially spearheaded this push, organizing a steady stream of declarations, campaigns, and conferences to raise awareness (see Chapter 1 for a more detailed description of these efforts). These succeeded in catching the attention of the international community, which, over the course of the 1990s and early 2000s, has begun to embrace the cause. Since the mid-1990s, the World Health Organization (WHO) has joined in these advocacy efforts, sponsoring a series of white papers, declarations, and events aimed at convincing donor agencies and national ministries of health of the importance of addressing CVD as well as preparing a tool- kit for chronic disease advocacy efforts (WHO Department of Chronic Diseases and Health Promotion, 2006). These efforts have yet to result in significant investment; however, they do appear to have had some success in starting to convince some in the international development assistance and global health donor community that chronic diseases should be a part of the global health agenda. Part of the reason for this lack of success in stimulating investment in chronic disease prevention is that, although there are many advocacy groups working on chronic disease issues, there is little coordination and communication among them, and thus efforts can be fragmented and lack unified messages. More recently this has begun to change, most notably through a partnership for chronic disease advocacy among the World Heart Federation, International Diabetes Federation, and International Union Against Cancer (International Diabetes Federation et al., 2009). The challenge for advocacy efforts, moving forward, will be to convince ministries of health in low and middle income countries, development as- sistance agencies, and other donors that investment in CVD prevention and control is critical despite their highly constrained health budgets and many competing health and development priorities. 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 integra- tion 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 agen- cies, scientists and academic institutions, civil society organizations, public health and health care practitioners, and the general public.

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD The media can interpret and convey scientific information and govern- ment policies to the public, and at the same time they can represent the concerns of the general public to policy makers and global health leaders (WHO, 2002). For example, the United Nations has advocated a strategic use of mass media in the effort to control the global HIV/AIDS epidemic, recognizing mass media’s role in influencing public attitudes, behavior, and policy making (UNAIDS, 2005). A similar strategic use of mass media can be used in the global CVD effort in countries where media coverage is reli- able and operates within a system that guarantees freedom of the press and thus contributes to a robust and balanced public discourse. Policy Policies include national and international norms and standards, regu- lation, fiscal and trade policies, and professional and clinical guidelines. They indirectly affect individual choices and behavior by changing the available default options. In countries that have adequate regulatory and enforcement capacity, policy makers have a range of policy solutions that are related to CVD, which were discussed in detail in Chapter 5. They include, for example, clinical guidelines, tobacco taxes, restrictions on marketing of certain foods to children, school physical education policies, and subsidies or import duties on certain foods. This is not an exhaustive list but does show the diversity of approaches available. Because the determinants of CVD extend beyond the realm of the health sector, coordinated approaches are needed so that policies in non-health sec- tors of government, such as agriculture, urban planning, transportation, and education, can be developed synergistically with health policies to reduce, or at least not adversely affect, risk for CVD. In addition to coordinating among different sectors of government, policies in each of these domains can be developed with input from civil society and the private sector. This coordinated, intersectoral approach can help determine the balance of regulatory measures, incentives, and voluntary measures that is likely to be most effective and realistic in the local political and governmental context, especially when the feasibility of policy changes is challenged by economic aims that may be in conflict with goals for improving health outcomes. Some approaches work best when initiated globally, like the WHO Framework Convention on Tobacco Control (FCTC). Other approaches do well when initiated locally. Still others, such as clinical guidelines, are best developed and implemented by national agencies or professional societ- ies. There are numerous sets of standards and guidelines in existence that articulate the best practices for CVD care. Most of these are produced by national health and nutrition agencies, national and international profes- sional organizations, and organizations focusing on individual risk factors

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 FRAMEWORK FOR ACTION or related diseases (such as tobacco, obesity, and diabetes). Unfortunately, as described in Chapter 5, a significant barrier can be that guidelines are not sufficiently disseminated or followed up with training, making it difficult to ensure provider adherence. Program Implementation A broad-based set of programmatic initiatives will need to be imple- mented in a sustained fashion in order to control global CVD and promote cardiovascular health. These programs need to include a range of ap- proaches such as the provision of health services to patients, including clini- cal prevention as well as diagnosis and treatment; health communications and education in communities; and policy initiatives in a range of sectors. Depending on the available infrastructure, national and subnational author- ities 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. For all implementers, leveraging existing infrastructure and engaging the local workforce to implement programs and deliver services is crucial for successful solutions in the short term, while building the skills and capacity locally to develop, manage, and maintain programs is a crucial goal for longer-term, sustainable approaches to address the burden of CVD and related chronic disease programs. Ideally, programs conducted by implementing agencies will be evidence- based. As described earlier in this report, at this time the strength of evi- dence is variable with limited knowledge about direct applicability to low and middle income settings. However, implementation of initiatives need not wait for full evidence to be generated. It is clear that there is potential for substantial impact on global CVD with adaptations of current knowl- edge and available tools. The practical solution both to begin to intervene and to build the knowledge base is to conduct research on effectiveness and impact alongside the implementation of programs. This can be achieved through partnerships between research funders and implementation agen- cies, with the development of pilot programs that are designed from the beginning with the ultimate goal of feasible scale-up in mind. Capacity Building Among the most enduring investments in public health over the past century have been those that established institutions that trained leaders in public health, health care, and health research and supported their career development over decades. Nonetheless, there remains an absolute shortage

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD of public health and clinical workers to mount and sustain public health or health care delivery programs in low and middle income countries (Crisp et al., 2008; World Health Organization, 2006). The focus of investments in global health capacity has to date mainly addressed infectious diseases and maternal and child health. However, to truly meet the health needs of the developing world, strategies to address the workforce shortage need to broaden their scope to include better preparation for CVD and related chronic diseases in training programs for clinical health care, public health, epidemiology, health research, health communications, economics, health systems and program management, and behavioral disciplines. To meet gaps in chronic disease capacity needs in low and middle income countries will require years of sustained support to have a meaningful impact, includ- ing building the necessary academic, NGO, and government institutions, as well as training government health officials in the effective use of relevant policies. A health and public health workforce that is well equipped to ad- dress CVD and related chronic disease also needs to include training beyond technical competencies to understand the broader systemic and social de- terminants of health and to be prepared to participate in the policy process as well as in partnerships across disciplines and sectors. The WHO Global Health Workforce Alliance, a partnership of national governments, civil society, international agencies, finance institutions, re- searchers, educators and professional associations dedicated to working toward solutions for the global health care workforce shortage issue, needs to explicitly include chronic disease needs as part of its efforts in order to truly address global health workforce needs. This will encourage other major efforts to build the health workforce in low and middle income coun- tries 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. In addition to training the next generation of global health leaders, these centers also support and collaborate with training and research centers in low and middle income countries, thereby building workforce and expertise locally. Because the majority of these centers are interdisciplinary, they also provide an opportunity for the collaboration of experts from seemingly disparate specialties. In general, these global health centers in high income countries and the training programs in low and middle income countries tend to lack any strong emphasis on chronic disease. Gathering more information about the current status and gaps in the chronic disease cur- ricula of medical schools, schools of nursing, and schools of public health

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 FRAMEWORK FOR ACTION in both global health programs in high income countries and institutions in low and middle income countries could inform systematic plans to develop future public health and health care leaders and workforce who are better prepared with chronic disease competencies. Another critical component of capacity building is the dissemination of knowledge. Recently, CVD professional organizations, major global health organizations, and academic global health centers have convened inter- national and regional meetings to share the latest developments in CVD treatment and prevention. While the global meetings provide an opportu- nity to gather stakeholders and focus on international issues, the regional meetings (especially those in low and middle income countries) are key opportunities to provide local providers with training and information that they might otherwise not have access to. In addition to convening meetings, a number of professional organizations publish journals that highlight the latest advances in research. Most of these journals, however, focus on clini- cal and technological advances and place little emphasis on global CVD prevention research. ProCor is a wide-reaching global network that serves as a model in its innovative use of low-cost communication technologies to provide people in clinical, community, advocacy, and policy-making settings in developing countries and other low-resource environments with the information they need to promote heart health through access to cost- effective preventive strategies and noninvasive medical management of cardiac conditions. Research Research should underpin all actions and is a critical element of the overall package of global CVD efforts. Although the health and economic burden of global CVD have been elucidated as described in Chapters 2 and 3, further research will be required to develop initiatives to control global CVD. While 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 implement- ers, but also prevents national governments, NGOs, and multilateral orga- nizations from effectively making and implementing decisions to address the cardiovascular disease epidemic. Some broad-based priorities for chronic diseases have recently been defined at the global level (Daar et al., 2007), and illustrative examples of the research needs described throughout this report are summarized in Box 8.1. An agenda for CVD research priorities needs to address the di- versity of actions required for successful impact. In general, research funds

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0 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD BOX 8.1 Summary of Research Needs Chapter 2: Epidemiology and Cardiovascular Disease • Future prospective epidemiological studies (including birth cohort studies) to deter- mine the role of specific factors in causing CVD in low and middle income countries, including their interaction with infectious and environmental factors as well as factors in pregnancy, infancy, and childhood such as early nutrition. • Better data from large-scale community-based intervention studies in developing countries that address multiple individual and environmental risk factors to confirm causal relationships of the determinants of CVD. • Improvement of national and regional statistics on CVD prevalence, mortality, and risk factors to improve both surveillance and global burden of disease data. • Investigation of the effects of nutrition transitions, changes in physical activity, and changes in dietary patterns—including types of oils and the amount of sugar—on CVD risk in low and middle income countries, including overweight and obesity. • Investigation into the relationship between food production, food distribution, food trade patterns, and food consumption in different parts of the world, including com- parative studies of whole diets. • Further research on psychosocial determinants of CVD risk in low and middle income countries (e.g., depression, income inequality). • Additional research on genetics of CVD, including the interactions between genetic susceptibility and environmental risk factors in the development of CVD in low and middle income countries. • 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. Chapter 3: Development and Cardiovascular Disease • Future research with greater uniformity in definitions and methods to allow compara- tive assessments across countries and regions of both the economic impact of CVD and the impact of development on CVD. • Additional use of panel datasets of CVD and social and health inequalities in developing countries in order to develop explicit approaches to reduce such inequalities. • Measures of microeconomic impacts that focus on impacts on employment and earnings, disaggregated by sex and across the life cycle, based on labor market studies. • Research in collaboration with employers and insurance companies to explore the workplace impacts of CVD and how they relate to household consequences of CVD.

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 FRAMEWORK FOR ACTION Chapter 4: Measurement and Evaluation • Costs of measurement including national surveillance, surveys, and ongoing pro- gram evaluation with the goal of better informing budgeting decisions. • Improved long-term program evaluation tools for CVD interventions in low and middle income countries that can also inform local and national level information gathering and decision making. • Improved tools for identifying the transferable and scalable components of existing interventions. • Improved tools for measuring clinical practice and quality of care for CVD in low and middle income countries. • Development of standardized proxy metrics for behavioral risk factors. • Refinement of risk stratification tools that are relevant to developing country settings. • Research on the impact of measurement and data on policy and programmatic decision making in developing countries and on the best ways to report and present data for greatest influence. Chapter 5: Reducing the Burden of Cardiovascular Disease: Intervention Approaches • Identification of interventions that will be low-cost, effective, and feasible in low and middle income countries with constraints on resources and capacity. • Adaptation and evaluation of CVD interventions that have proven effective in high income countries. • Setting-specific and culturally relevant programs: formative research, tailoring, adaptation. • Partnerships between research funders and implementation agencies to develop pilot programs for interventions that are designed from the beginning with the ulti- mate goal of feasible scale-up in mind. • Health services research to develop models for improving health care delivery. • Implementation research to evaluate methods to implement large-scale interven- tions and manage complex evolving large-scale programs. • Research on how to disseminate successful programs. • Research on different social and private insurance models and their ability to reach different population segments, especially the poor. • Policy effectiveness studies for intersectoral policies, with assessment of unintended negative consequences across sectors as well as cost analyses. This should include examples of public–private sector collaborations intended to change investor and market choices. • Research on financing models to determine how best to pay for approaches imple- mented across multiple sectors. 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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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD BOX 8.1 BOX 8.1 Continued emphasize the developmental origins of CVD, including prenatal, infancy, and early childhood risk factors. • Gathering qualitative data for identifying beliefs, attitudes, and social norms influ- encing risk behaviors in young people as well as the barriers to change. • Identifying risk behavior surveillance systems that can be easily and inexpensively integrated into the routine health care and educational systems of low and middle income countries. • Studying the geographic, socioeconomic, gender, and cultural correlates of CVD risk factors in different youth populations. • Identifying effective interventions that can influence the early life determinants of adult CVD. should be invested primarily in projects that generate knowledge about how to translate what is already known into action and implementation— in other words, to close the knowledge–action gap. This research agenda will need to be multidisciplinary, spanning basic sciences, behavioral and social sciences, media and communication analysis, information technol- ogy and engineering, epidemiology, health policy and economics, clinical trials, and service delivery and implementation science. CVD research should also extend beyond traditional basic, clinical, and community- based research into areas of agriculture, economics, health systems, and intersectoral actions. As described in Chapters 5, 6, and 7, to date research has been exten- sively carried out in developed countries, and going forward it is critical that the research agenda be refined to meet the needs of specific countries. The priority needs to be research aimed explicitly at adapting what works in developed countries for developing-country realities, as well as work to develop novel solutions that draw on developing-country opportunities and innovation. The Institute of Medicine (IOM) has recently stated that the U.S. re- search community, in collaboration with global partners, should leverage its traditional strength and area of competitive advantage—the creation of knowledge through research—to further the global health agenda (IOM, 2009). Part of the research endeavor should include capacity building to foster and develop high-quality research infrastructure and trained re- searchers in the field of global chronic disease, both in high income and low and middle income countries.

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 FRAMEWORK FOR ACTION Chapter 7: Making Choices to Reduce the Burden of Cardiovascular Disease • Primary cost-effectiveness studies in low and middle income countries. • Integrating treatment gap analysis with cost-effectiveness studies to provide bet- ter epidemiological and macroeconomic context to evaluate potential investment options. • Economic evaluation of innovative intersectoral interventions, including valuation of social, environmental, and health benefits and consequences. • Modeling of policy changes in multiple sectors, such as trade and agriculture, to define potential winners and losers as a result of policy changes to promote cardio- vascular health, including possible compensation schemes. • Analysis of system constraints to close treatment gaps in CVD. Recommendation: Research to Assess What Works in Different Settings The National Heart, Lung, and Blood Institute (NHLBI) 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. This will serve to promote appropri- ate intervention approaches for local cultural contexts and resource constraints and to strengthen local research capacity. A. Implementation research should be a priority in research funding for global chronic disease. B. Research support for intervention and implementation research should include explicit funding for economic evaluation. C. Research should include assessments of and approaches to improve clinical, public health, and research training programs in both de- veloped and developing countries to ultimately improve the status of global chronic disease training. D. Research should involve multiple disciplines, such as agriculture, environment, urban planning, and behavioral and social sciences, through integrated funding sources with research funders in these

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD BOX 8.8 Recommendations Recommendation 1: Recognize Chronic Diseases as a Development Assistance Priority Multilateral and bilateral development agencies that do not already do so should explicitly include CVD and related chronic diseases as an area of focus for technical assistance, capacity building, program implementation, impact assessment of develop- ment projects, funding, and other areas of activity. Recommendation 2: Improve Local Data National and subnational governments should create and maintain health surveillance systems to monitor and more effectively control chronic diseases. Ideally, these sys- tems should report on cause-specific mortality and the primary determinants of CVD. To strengthen existing initiatives, multilateral development agencies and WHO (through, for example, the Health Metrics Network and regional chronic disease network, NCDnet) as well as bilateral public health agencies (such as the CDC in the United States) and bilateral development agencies (such as USAID) should support chronic disease sur- veillance as part of financial and technical assistance for developing and implementing health information systems. Governments should allocate funds and build capacity for long-term sustainability of disease surveillance that includes chronic diseases. 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. To maximize impact, efforts to introduce policies should be accompanied by sustained health communication campaigns focused on the same targets of intervention as the selected policies. Recommendation 4: Include Chronic Diseases in Health Systems Strengthening Current and future efforts to strengthen health systems and health care delivery funded and implemented by multilateral agencies, bilateral public health and development agencies, leading international nongovernmental organizations (NGOs), and national and subnational health authorities should include attention to evidence-based preven- tion, diagnosis, and management of CVD. This should include developing and evaluat- ing approaches to build local workforce capacity and to implement services for CVD that are integrated with primary health care services, management of chronic infectious diseases, and maternal and child health. Recommendation 5: Improve National Coordination for Chronic Diseases National governments should establish a commission that reports to a high-level cabinet authority with the specific aim of coordinating the implementation of efforts to address the needs of chronic care and chronic disease in all policies. This authority should serve as a mechanism for communicating and coordinating among relevant

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 FRAMEWORK FOR ACTION executive agencies (e.g., health, agriculture, education, and transportation) as well as legislative bodies, civil society, the private sector, and foreign development assistance agencies. These commissions should be modeled on current national HIV/AIDS com- missions and could be integrated with these commissions where they already exist. Recommendation 6: Research to Assess What Works in Different Settings The National Heart, Lung, and Blood Institute (NHLBI) 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 interven- tion approaches will be most effective and feasible to implement in low and middle income countries, including adaptations based on demonstrated success in high in- come 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. This will serve to promote appropriate intervention approaches for local cultural contexts and resource constraints and to strengthen local research capacity. A. Implementation research should be a priority in research funding for global chronic disease. B. Research support for intervention and implementation research should include explicit funding for economic evaluation. C. Research should include assessments of and approaches to improve clinical, public health, and research training programs in both developed and developing countries to ultimately improve the status of global chronic disease training. D. Research should involve multiple disciplines, such as agriculture, environment, urban planning, and behavioral and social sciences, through integrated funding sources with research funders in these disciplines. A goal of this multidisciplinary research should be to advance intersectoral evaluation methodologies. E. In the interests of developing better models for prevention and care in the United States, U.S. agencies that support research and program implementation should coordinate to evaluate the potential for interventions funded through their global health activities to be adapted and applied in the United States. Recommendation 7: Disseminate Knowledge and Innovation Among Similar Countries Regional organizations, such as professional organizations, WHO observatories and chronic disease networks, regional and subregional development banks, and regional political and economic organizations should continue and expand regional mechanisms for reporting on trends in CVD and disseminating successful intervention approaches. These efforts should be supported by leading international NGOs, development and public health agencies, and research funders (including the Global Alliance for Chronic Disease). The goal should be to maximize communication and coordination among countries with similar epidemics, resources, and cultural conditions in order to encour- age and standardize evaluation, help determine locally appropriate best practices, en- courage innovation, and promote dissemination of knowledge. These mechanisms may include, for example, regional meetings for researchers, program managers, and policy makers; regionally focused publications; and registries of practice-based evidence. continued

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD BOX 8.8 Continued Recommendation 8: Collaborate to Improve Diets WHO, the World Heart Federation, the International Food and Beverage Association, and the World Economic Forum, in conjunction with select leading international NGOs and select governments from developed and developing countries should coordinate an international effort to develop collaborative strategies to reduce dietary intake of salt, sugar, saturated fats, and transfats in both adults and children. This process should include stakeholders from the public health community and multinational food corpo- rations as well as the food services industry and retailers. This effort should include strategies that take into account local food production and sales. Recommendation 9: Collaborate to Improve Access to CVD Diagnostics, Medi- cines, and Technologies National and subnational governments should lead, negotiate, and implement a plan to reduce the costs of and ensure equitable access to affordable diagnostics, essential medicines, and other preventive and treatment technologies for CVD. This process should involve stakeholders from multilateral and bilateral development agencies; CVD-related professional societies; public and private payers; pharmaceutical, biotech- nology, medical device, and information technology companies; and experts on health care systems and financing. Deliberate attention should be given to public–private partnerships and to ensuring appropriate, rational use of these technologies. Recommendation 10: Advocate for Chronic Diseases as a Funding Priority Leading international and national NGOs and professional societies related to CVD and other chronic diseases should work together to advocate to private foundations, charities, governmental agencies, and private donors to prioritize funding and other resources for specific initiatives to control the global epidemic of CVD and related chronic diseases. To advocate successfully, these organizations should consider (1) 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) engaging the media about policy priorities related to chronic disease control, and (4) highlighting the importance of translating research into effective individual- and population-level interventions.

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 FRAMEWORK FOR ACTION Recommendation 11: Define Resource Needs The Global Alliance for Chronic Disease should commission and coordinate case studies of the CVD financing needs for five to seven countries representing different geographical regions, stages of the CVD epidemic, and stages of development. These studies should require a comprehensive assessment of the future financial and other resource needs within the health, public health, and agricultural systems to prevent and reduce the burden of CVD and related chronic diseases. Several scenarios for different prevention and treatment efforts, training and capacity building efforts, tech- nology choices, and demographic trends should be evaluated. These assessments should explicitly establish the gap between current investments and future investment needs, focusing on how to maximize population health gains. These initial case studies should establish an analytical framework with the goal of expanding beyond the initial pilot countries. Recommendation 12: Report on Global Progress WHO should produce and present to the World Health Assembly a biannual World Heart Health Report within the existing framework of reporting mechanisms for its Ac- tion Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. The goal of this report should be to provide objective data to track progress in the global effort against CVD and to stimulate policy dialog. These efforts should be designed not only for global monitoring but also to build capacity and support planning and evaluation at the national level in low and middle income countries. Financial sup- port 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. An initial goal of this global reporting mechanism should be to develop or select standardized indicators and methods for measurement, leveraging existing instruments where available. These would be recommended to countries, health systems, and prevention programs to maximize the global comparability of the data they collect.

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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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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD REFERENCES Bill & Melinda Gates Foundation. 2008. Agricultural development fact sheet: Working to break the cycle of hunger and poverty. http://www.gatesfoundation.org/topics/Documents/ agricultural-development-fact-sheet.pdf (accessed March 12, 2010). Bill & Melinda Gates Foundation. no date. Bill & Melinda Gates Foundation Global Health Program. http://www.gatesfoundation.org/global-health/Pages/overview.aspx (accessed June 30, 2009). Black, R. E., M. K. Bhan, M. Chopra, I. Rudan, and C. G. Victora. 2009. Accelerating the health impact of the Gates Foundation. Lancet 373(9675):1584-1585. CARICOM (Caribbean Community) Heads of Government. 2007. Declaration of Port-of- Spain: Uniting to stop NCDS. http://www.caricom.org/jsp/communications/meetings_ statements/declaration_port_of_spain_chronic_ncds.jsp (accessed February 9, 2010). Cheng, M. H. 2009. WHO’s Western Pacific Region agrees tobacco-control plan. Lancet 374(9697):1227-1228. Collins, F. 2009. Constituents meeting with NIH director Dr. Francis Collins. http://videocast. nih.gov/launch.asp?15263 (accessed November 10, 2009). Collins, J., and J. P. Koplan. 2009. Health impact assessment: A step toward health in all policies. Journal of the American Medical Association 302(3):315-317. Crisp, N., B. Gawanas, and I. Sharp. 2008. Training the health workforce: Scaling up, saving lives. Lancet 371(9613):689-691. Daar, A. S., P. A. Singer, D. L. Persad, S. K. Pramming, D. R. Matthews, R. Beaglehole, A. Bernstein, L. K. Borysiewicz, S. Colagiuri, N. Ganguly, R. I. Glass, D. T. Finegood, J. Koplan, E. G. Nabel, G. Sarna, N. Sarrafzadegan, R. Smith, D. Yach, and J. Bell. 2007. Grand challenges in chronic non-communicable diseases. Nature 450(7169):494-496. Daar, A. S., E. G. Nabel, S. K. Pramming, W. Anderson, A. Beaudet, D. Liu, V. M. Katoch, L. K. Borysiewicz, R. I. Glass, J. Bell, A. S. Daar, E. G. Nabel, S. K. Pramming, W. Anderson, A. Beaudet, D. Liu, L. K. Borysiewicz, R. I. Glass, and J. Bell. 2009. The Global Alliance for Chronic Diseases. Science 324(5935):1642. de Beyer, J., and L. W. Brigden, eds. 2003. Tobacco control policy: Strategies, successes, and setbacks. Washington, DC: World Bank and International Development Research Centre. Declaration of Commitment of Port of Spain: Securing our citizens’ future by promoting hu- man prosperity, energy security, and environmental sustainability. 2009. Port of Spain, Trinidad and Tobago: Fifth Summit of the Americas. Einterz, R. M., S. Kimaiyo, H. N. Mengech, B. O. Khwa-Otsyula, F. Esamai, F. Quigley, and J. J. Mamlin. 2007. Responding to the HIV pandemic: The power of an academic medical partnership. Academic Medicine 82(8):812-818. Epping-Jordan, J. E., G. Galea, C. Tukuitonga, and R. Beaglehole. 2005. Preventing chronic diseases: Taking stepwise action. Lancet 366(9497):1667-1671. Foundation Center. 2006. International grantmaking update: A snapshot of U.S. Founda- tion trends. http://foundationcenter.org/gainknowledge/research/pdf/intl_update_2006. pdf (accessed June 30, 2009). Frieden, T. R., and M. R. Bloomberg. 2007. How to prevent 100 million deaths from tobacco. Lancet 369(9574):1758-1761. Frieden, T. R., M. T. Bassett, L. E. Thorpe, and T. A. Farley. 2008. Public health in New York City, 2002-2007: Confronting epidemics of the modern era. International Journal of Epidemiology 37(5):966-977. The Global Fund to Fight AIDS, Tuberculosis and Malaria. 2009. Pledges and contributions. http://www.theglobalfund.org/en/pledges/ (accessed December 2, 2009).

OCR for page 373
 FRAMEWORK FOR ACTION Healthy Weight Commitment Foundation. 2009. About us. http://www.healthyweightcommit. org/about (accessed March 10, 2010). Henry J. Kaiser Family Foundation. 2009. Fact sheet: The Millenium Challenge Corportation & global health. Washington, DC: Kaiser Family Foundation. International Diabetes Federation, UICC (International Union Against Cancer), and World Heart Federation. 2009. Time to act: The global emergency of non-communicable dis- eases. In Report on Health and Development: Held Back by Non-Communicable Dis- eases. Geneva: International Diabetes Federation, UICC, and World Heart Federation. International Food and Beverage Alliance. 2009. IFBA update since November, 00. Pre- sentation presented to the World Health Organization on August 31, 2009. Geneva, Switzerland. Inui, T. S., W. M. Nyandiko, S. N. Kimaiyo, R. M. Frankel, T. Muriuki, J. J. Mamlin, R. M. Einterz, and J. E. Sidle. 2007. AMPATH: Living proof that no one has to die from HIV. Journal General Internal Medicine 22(12):1745-1750. IOM (Institute of Medicine). 2009. The U.S. Commitment to global health: Recommendations for the new administration. Washington, DC: The National Academies Press. Jean, M.-C., and L. St-Pierre. 2009. Applicability of the success factors for intersectorality in developing countries. France: IUHPE. Background paper commissioned by the Commit- tee on Preventing the Global Epidemic of Cardiovascular Disease. Kates, J., J. Fischer, and E. Lief. 2009. The U.S. Government’s global health architecture: Struc- ture, programs, and funding. Washington, DC: Henry J. Kaiser Family Foundation. Kraak, V. I., S. K. Kumanyika, and M. Story. 2009. The commercial marketing of healthy lifestyles to address the global child and adolescent obesity pandemic: Prospects, pitfalls and priorities. Public Health Nutrition:1-10. Levine, R., and D. Kuczynski. 2009. Global nutrition institutions: Is there an appetite for change? Washington, DC: Center for Global Development. Madon, T., K. J. Hofman, L. Kupfer, and R. I. Glass. 2007. Public health. Implementation science. Science 318(5857):1728-1729. Matsudo, S. M., V. R. Matsudo, D. R. Andrade, T. L. Araújo, E. Andrade, L. de Oliveira, and G. Braggion. 2004. Physical activity promotion: Experiences and evaluation of the Agita São Paulo program using the ecological mobile model. Journal of Physical Activity and Health 1(2):81-94. McCoy, D., G. Kembhavi, J. Patel, and A. Luintel. 2009. The Bill & Melinda Gates Founda- tion’s grant-making programme for global health. Lancet 373(9675):1645-1653. Moran, M. 2005. A breakthrough in R&D for neglected diseases: New ways to get the drugs we need. Public Library of Science Medicine 2(9):e302. NHLBI (National Heart, Lung, and Blood Institute) Global Health Initiative. 2009. National Heart, Lung, and Blood Institute Global Health Initiative. http://www.nhlbi.nih.gov/ about/globalhealth/index.htm (accessed June 30, 2009). Nugent, R., and A. Feigl. 2010. Scarce donor funding for non-communicable diseases: Will it contribute to a health crisis? Washington, DC: Center for Global Development (forthcoming). NYDHMH (New York Department of Health and Mental Hygiene). 2010. Cut the salt get the facts: The national salt reduction initiative. http://www.nyc.gov/html/doh/downloads/ pdf/cardio/cardio-salt-nsri-faq.pdf (accessed January 12, 2010). OECD (Organisation for Economic Co-operation and Development). 2009. Development aid at its highest level ever in 00 (press release). http://www.oecd.org/document/35/ 0,3343,en_2649_34447_42458595_1_1_1_1,00.html (accessed on December 2, 2009). Office of Global AIDS Coordinator. 2009. The U.S. President’s Emergency Plan for AIDS Relief: Five year strategy. Washington, DC: Office of Global AIDS Coordinator.

OCR for page 373
 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD PAHO (Pan American Health Organization). 2007. Regional strategy and plan of action on an integrated approach to the prevention and control of chronic diseases. Washington, DC: Pan American Health Organization. PAHO. 2008. Trans fat free americas: Declaration of Rio de Janeiro. Rio de Janeiro, Brazil: Pan American Health Organization. PAHO/WHO Task Force. 2007. Trans fat free Americas: Conclusions and recommendations. Washington, DC: Pan American Health Organization. PEPFAR (President’s Emergency Plan for AIDS Relief). 2009. The United States President’s Emergency Plan for AIDS Relief. http://www.pepfar.gov/ (accessed June 30, 2009). Reddy, K. S., and P. C. Gupta. 2004. Report on tobacco control in India. New Delhi, India: Ministry of Health & Family Welfare, Government of India, Centers for Disease Control and Prevention, USA, & World Health Organization. Silver, L. 2009. Multisectoral approaches to preventing cardiovascular disease: The New York experience. Presentation at Public Information Gathering Session for the Institute of Medicine Committee on Preventing the Global Epidemic of Cardiovascular Disease, Washington, DC. Slutkin, G., S. Okware, W. Naamara, D. Sutherland, D. Flanagan, M. Carael, E. Blas, P. Delay, and D. Tarantola. 2006. How Uganda reversed its HIV epidemic. AIDS and Behavior 10(4):351-360. Sridhar, D., and R. Batniji. 2008. Misfinancing global health: A case for transparency in dis- bursements and decision making. Lancet 372(9644):1185-1191. Stuckler, D., L. King, H. Robinson, and M. McKee. 2008. WHO’s budgetary allocations and burden of disease: A comparative analysis. Lancet 372(9649):1563-1569. UNAIDS (The Joint United Nations Programme on HIV/AIDS). 2005. Getting the message across: The mass media and the response to AIDS, UNAIDS best practice collection. Geneva: UNAIDS. U.S. Department of State. 2010. Implementation of the Global Health Initiative: Consultation document. Washington, DC: U.S. Department of State. Warren, C. W., S. Asma, J. Lee, and M. J. 2009. The GTSS atlas. Atlanta: The CDC Foundation. WHO (World Health Organization). 2002. The world health report 00—reducing risks, promoting healthy life. Geneva: World Health Organization. WHO. 2005. Preventing chronic diseases: A vital investment. http://www.who.int/chp/chronic_ disease_report/full_report.pdf (accessed April 23, 2009). WHO. 2006. WHO country health information. http://www.who.int/nha/country/en/ (ac- cessed February 17, 2010). WHO. 2008a. 00-0 action plan for the global strategy for the prevention and control of noncommunicable diseases. Geneva: World Health Organization. WHO. 2008b. The global burden of disease: 00 update. Geneva: World Health Organization. WHO. 2009. Healthy cities and urban governance. http://www.euro.who.int/en/what-we- do/health-topics/environmental-health/urban-health/healthy-cities/who-healthy-cities- network (accessed December 12, 2009). WHO. no date. Public-private partnerships for health. http://www.who.int/trade/glossary/ story077/en/ (accessed June 30, 2009). WHO Department of Chronic Diseases and Health Promotion. 2006. Stop the global epidemic of chronic disease: A practical guide to successful advocacy. Geneva: World Health Organization. WHO Western Pacific Regional Office. 2004.The Establishment and Use of Dedicated Taxes for Health Manila.

OCR for page 373
 FRAMEWORK FOR ACTION Widdus, R. 2001. Public-private partnerships for health: Their main targets, their diversity, and their future directions. Bulletin of the World Health Organization 79(8):713-720. World Bank. 2007. World development report 00. Washington, DC: World Bank. Yach, D., and C. Hawkes. 2004 (unpublished). Towards a WHO long-term strategy for pre- vention and control of leading chronic diseases. Geneva: World Health Organization.

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