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Global Strategy for NCD Prevention adn Control Critical Evaluation of Recent Malarial Outbreaks in India Global Strategy for NCD Prevention and Control Jie Chen Executive Director, Noncommunicable Diseases World Health Organization A Challenge and an Opportunity 1. The rapid rise of noncomunicable diseases represents one of the major health challenges to global development in the coming century. This growing challenge threatens economic and social development as well as the lives and health of millions of people. 2. In 1998 alone, noncommunicable diseases are estimated to have contributed to almost 60% (31.7 million) of deaths in the world and 43% of the global burden of disease. Based on current trends, by the year 2020 these diseases are ex- pected to account for 73% of deaths and 60% of the disease burden. 3. Low- and middle-income countries suffer the greatest impact of communicable diseases. The rapid increase in these diseases is sometimes seen disproportionately in poor and disadvantaged populations and is contributing to widening health gaps between and within countries. For example, in 1998, of the total number of deaths attributable to noncornmunicable diseases, 77% occurred in developing countries, and of the disease burden they represent, 85% was borne by low- and middle-inconie countries. 4. There now exists, however, a vast body of knowledge and experience regarding the prevent- ability of such diseases and immense opportunities for global action to control them. Addressing common risk factors 5. Four of the most prominent noncommunica- ble diseases -- cardiovascular disease, cancer, chronic obstructive pulmonary disease and diabe- tes -- are linked by common preventable risk factors related to lifestyle. These factors are tobac- co use, unhealthy diet and physical inactivity. Action td prevent these diseases should therefore focus on controlling the risk factors in an integrat- ed manner. Intervention at the level of the family and community is essential for prevention because the causal risk factors are deeply entrenched in the social and cultural framework of the society. Addressing the major risk factors should be given the highest priority in the global strategy for the prevention and control of nonconiniunicable diseases. Continuing surveillance of levels and patterns of risk factors is of fundamental import- ance to planning and evaluating these preventive activities. Lessons learned 6. A great deal is known about the prevention of noncommunicable diseases. Experience clearly indicates that they are to a great extent preventable through interventions against the major risk factors and their environmental, economic, social and be- havioral determinants in the population. Countries can reverse the advance of these diseases if appro- priate action is taken. Such action may be guided by the lessons learned from existing knowledge and experience, which are summarized below. 7. A comprehensive long-term strategy for control of noncomniunicable diseases must necessarily include prevention of the emergence of risk factors in the first place. Strategies to reduce exposure to established risk factors and for low- ering the risk of individuals presenting clinical signs of these diseases, even when implemented together, do not achieve the full potential for prevention. 8. In any population, most people have a moderate level of risk factors, and a minority have a high level. Those at moderate risk contribute more to the total burden of noncommunicable diseases. Consequently, a comprehensive preven- tion strategy needs to blend synergistically an approach aimed at reducing risk factor levels in the population as a whole with one directed at high-risk individuals. 9. Review of risk-factor intervention studies has demonstrated that to achieve major challenges in risk factor levels and disease outcomes, in- tervention should be delivered at an adequate dose and sustained over extended periods of time, How- ever, even modest changes in risk factor levels will have a substantial public health benefit. 10. Experience indicates that success of com- munity-based interventions requires community participation, supportive policy decisions, inter- sectoral action, appropriate legislation, health care reforms, and collaboration with nongovemmental organizations, industry and the private sector. 1 1. Decisions made outside the health sector often have a major bearing on the risk factors and their determinants. More health gains in terms of prevention are achieved by influencing public policies in dornains such as trade, food and phar- maceutical production, agriculture, urban develop- ment, and taxation policies, than by changes in health policy alone. 12. The long-term needs of people with noncommunicable diseases are rarely dealt with successfully by the present organizational and financial arrangements of health care. Member states need to address the challenge in the context of overall health system reform. Towards a global strategy for surveillance, prevention and control of noncommunicable diseases 13. The global threat posed by noncomrnuni- cable diseases and the need to provide urgent and effective public health responses was recognized in resolution WHA 5 1. 1 8, in which the Health Assembly requested the Director-General to de- velop a global strategy for the prevention and control of noncommunicable diseases, The global strategy presented below is based on the lessons learned in prevention and control and on the re- commendations of the WHO consultation on future strategies for prevention and control of noncommunicable diseases (Geneva, 27-30 Sep- ternber 1999). Objectives 14. The global strategy has three main objec- tives: - to map the emerging epidemics of noncommuni- cable diseases and to analyze the social, economic, behavioral and political determinants of the diseases with particular reference to poor and disadvantaged populations, in order to provide guidance for policy, legislative and financial measures related to the development of an envi- ronment supportive of control; - to reduce the exposure of individuals and popu- lations to the major determinants of noncommuni- cable diseases and to prevent the emergence of preventable common risk factors, namely tobacco consumption, unhealthy diet and physical inactivi- ty; - to strengthen health care for people with non- communicable diseases by supporting health sector reform and cost-effective interventions, with emphasis on primary health care. Key components 1 5. To achieve the above objectives, the fol- lowing components require the support of the global community and WHO as a whole in order to give shape to a global strategy. - Surveillance is essential to quantify and track the epidemic of noncommunicable diseases and its determinants, and it provides the foundation for advocacy, national policy and global action. - Prevention is the most important component of reducing the burden of premature mortality and disability due to such diseases, and is seen as the most feasible approach for many member states. - Health care innovations and health sector management which address needs arising from the epidemic are essential. Equally important is the provision of cost-effective and equitable interven- tions for the management of established noncom- municable diseases. 16. WHO has the unique authority and the clear mandate to lead the development and imple- mentation of the global strategy for the prevention and control of noncommunicable diseases and thereby to create a better environment for world health in 2020 and beyond. As outlined below, implementation of the strategy will require action at every level, from global and regional organiza- tions and agencies to member states and individual communities. Roles of the main players International partners 17. The role of international partners is of paramount importance in the global struggle a- gainst noncommunicable diseases in order to a- chieve the necessary leverage and synergy to meet the challenge. An innovative mechanism is need- ed to ensure joint work within the United Nations system and with major international agencies, nongovernniental organizations, professional associations, research institutions and the private sector. Concerted action against these diseases on a global scale requires all partners to play a strong- er role in a global network that target areas such as advocacy, resource mobilization, capacity- building, and collaborative research. Developing such a global network will be a major part of the global strategy. International institutions for prevention and control of noncommunicable dis- eases and YMO collaborating centers will play a key role in supporting implementation and evalua- tion of the global strategy. WHO 1 8. WHO will provide the leadership and the evidence base for international action on surveil- lance, prevention and control of noncommunic- able diseases. It will set the general direction for the four-year period 2000-2003, consonant with the corporate strategy for the WHO Secretariat, and will focus on the four broad interrelated areas described below. 19- Globalpartnerships. WHO will take the lead in strengthening international partnerships for surveillance, prevention and control of noncom- municable diseases. 20. Global networking. A global network of national and regional programs for prevention and control of noncommunicable diseases will be es- tablished in order to disseminate information, exchange experiences, and support regional and national initiatives. 2 1. Technical support. WHO will support implementation of national programs by: . providing norms and standards, including definition of key indicators of noncomrnunicable diseases and their determinants, diagnostic crite- ria, and classifications of the major diseases; . providing technical support to countries in assessing the current situation, identifying strengths and constraints of existing activities, defining appropriate policies, building national capacity, and working to ensure effective pro- grams; - leading and coordinating surveillance in order to map the epidemic and measure the effectiveness of intervention; - strengthening and establishing systems for surveillance, and providing technical support for monitoring standard indicators of the major risk factors; - preparing state-of-the-fact guidance on develop- ment of national programs, incorporating recom- mendations based on the knowledge and experi- ence gained on a global scale adapted to different national context. - encouraging development of innovative organi - zational models for care of noncommunicable dis- eases to ensure the improvement of preventive and clinical care by cost-effective use of available re- sources; - ensuring the development, updating, and evaluation of regional plans for prevention and control. 22. YMO will also collaborate with member states in order to: - foster the launching of pilot projects on prevention based on integrated reduction of the three main risk factors: tobacco use, unhealthy diet and physical inactivity. The expected outcome is the creation of models in selected countries to determine that conimunity-based programs for risk factor reeducation can be effectively imple- mented in low- and middle-income countries; - conduct a critical review of the global burden of noncommunicable diseases from the viewpoint of the poor in order to identify pro-poor control policies in developing countries, taking into consideration the likely impact of globalization of trade and marketing on risk factors; - help patients to manage better their own conditions by assessing and designing appropriate models for self-management education, Emphasis will be laid on diseases that affect women in particular, in order to promote women's health and gender equity. 23. Strategic support for research and development. WHO, in close collaboration with other partners, will promote and support research in priority areas of prevention and control, including analytical, operational, and behavioral research to facilitate program implementation and evaluation. Special attention will be given to innovative research on issues of poverty, gender, cost-effective care, and genetic approaches to prevenfl on. WHOMll strengthen the role of WHO collaborating centers in supporting implementa- tion of the global prevention and control strategy, particularly in coordinating collaborative research. Member states 24. Implementation of the global Strategy at a country level should be planned along the lines set out below and coordinated within the context of the national strategic framework. - Generating a local information basefor action. A Assess and monitor mortality attributable to noncommunicable diseases, and the level of exposure to risk factors and the determinants in the population. Devise a mechanism for surveillance information to contribute policy-making,advocacy and evaluation of health care. - Fstablishing a nationalprogramforprevention of noncommunicable diseases. Form a national coalition of all stakehlders; develop a national Plan, define the strategies, and set realistic targets- Establish pilot (demonstration) prevention programs based on an integrated risk factor approach that may be extended countrywide, Build up capacity at national and community levels for development, implementation and evaluation of integrated prevention programs. Promote research on issues related to prevention and management - Tackling issues outside the health sector which influence control of noncommunicable diseases. Assess the impact of social and economic develop- ment on the burden of the major noncommunica- ble diseasesYAth a view to conducting a compre- hensive, multidisciplinary analysis. Develop innovative mechanisms and processes to help coordinate government activity as it reflects health across the various arms of government. Accord priority to activities that place prevention high on the public agenda, and mobilize support for the necessary societal action. - Ensuring health sector reforms are responsive to the challenge- Design cost-effective health care packages and draw up evidence-based guidelines for the effective management of the major non- communicable diseases. Transform the role of health care manners by vesting managers with responsibility not for institutions (e.g. hospitals) but for the effective management of resources to promote and maintain the health of a defined population. Action by the Executive Board 25. The Executive Board is invited to consider the global strategy for the prevention and control of noncommunicable diseases. Depending on dis- cussion in the Board, the Director-General may prepare a draft resolution for submission to tile Health Assembly. Critical Evaluation of Recent Malarial Outbreaks in India Diwakar Tejaswi Assistant Professor and Head, Department of Public Health Alemaya University, Egypt The National Malaria Eradication Program (NWP) is the worlds' largest (biggest) health program against a single communicable disease and continues to be the country's most comprehen- sive and multifaceted public health activity. With the implementation of NNEP in 1958, the annual incidence of malaria was reduced. Deaths due to malaria were completely eliminated. Unfortu- nately due to various factors these achievements could not be maintained. Resurgence of malaria necessitated renewed vigorous malaria incidence. The Modified plan of Operation ( WO) was im- plemented from April 1977. Since then, there has been a fluctuating trend in malaria cases.The Government of India (GOI) largely recognized the failure of MPO and has come out with the state- ment: "TheproblemofdrugresistanectoPfalci- parum malaria in several states is a cause for concern. Several operational problems and nonavaila- bility of matching funds from the States to this 50% centrally sponsored scheme ( CSS) has re- sulted in shortfalls in spray operations, decline in blood slide collections and incomplete treatment of cases, irrigation projects without adequate strategies for management of water resources and ( Indira Gandhi Canal, Ganganagar, Distt. is a glaring example) and floating labor populations to cities and major project sites has also contribut- ed to the incidence of malaria. Since 30% of all malaria cases and 60% of the more dangerous P. fale~um infections are in the tribal areas, a major intensification of efforts would be directed towards these areas." [Vil plan document, GOI, 1992 -1997]. * Under the United Nations Development Program's project. But the issue of current outbreak of malaria in different parts of the country (especially in Raj as- than, Nagaland, Manipur) needs to be closely scrutinized in the context of India's efforts to tack- le this disease. Table 3 is important as it gives an idea about the temporal dimension of the disease pattern in the context of India as a whole. Table 3 presents a disturbing trend. In this context, an in-depth evaluation of the National Malaria Program, both in terms of organizational and Program effectiveness, was done by the Op- eration Research Group (ORG) Baroda in 1988. Some of their findings were of utmost concern: At all levels there was a general consensus that the health workers become busy primarily in the achievement of a family planning target and there was hardly any time left to care for other health needs including malaria. The workers showed more concern for the Family Welfare Program (F.W.P.) because their work performance was evaluated on the basis of their achievement in family planning work. A worker in Bihar was found to spend 34% of his/ her time for F.W.P. and a worker in Hmyana about 441/o of the total fime. The fime disposal on malaria was only 711/o or the total fime of a worker in Bihar and 9% in Haryana. Monetary incentives for promoting F.W.P. were also encouraging grass- roots level workers to undertake family planning work. Further, it was found that health workers to whom the Malaria work was assigned afresh were not taking adequate interest in this program. On the other hand, the workers who had professional training and were associated with malaria eradication since long were unable to do justice to this program because of the pressure for achieving family planning targets. Not only the grass-roots level workers, it was candidly told by the Primary Health Center (PHC) doctors that they themselves paid more attention to family planning (paying half of their total time) than other health programs because they had to answer to their supervisors. In the process, they were compelled to encourage ( pressurize ) their subordinates to work for family planning. Lack of adequate logistic support had made the situation worse. In many districts, the malaria programs was functioning without a district ma- laiia officer. In his absence, the work was looked after by an assistant malaria officer, who was a non-technical man. Having this backdrop, 1 think the recent outbreak of malaria in Rajasthan and other NE states has to be seen in a wider perspective of reinvigorating the entire health service system. It is an accepted fact that, without an efficient basic health services, malaria control is not possible. The VI and VH plan integrated various programs into the general health services. This integration, however, was limited to the lower echelons while at the top family planning remained the priority Such an integration put the entire lower level infrastructure on a platter and offered it to the F.W.P. Instead of strengthening basic services, integration actually weakened them. Peripheral institutions worked for family planning targets at the cost of all other public health activities. The more worrying about malaria is that the death rate from malaria has started climbing upwards from 1973 and continue to do so to this day (Reported deaths over 500 annually are probably only a fraction of the actual deaths). The major factor underlying this is the shift in the malaria species from more benign P. vivax to the malignant Pfalciparum. Increasingly this P. faiciparum is drug resistant as well. Clearly there is a crisis here in public health, but a response to this crisis situation is just not there. "One of the most important reasons for this type of disturbing trend is the collapse of the health information system. The authorities concerned do not have the information about the outbreaks of epidemic. It is a cruel irony that this lack of a relia- ble information system is used as a weapon by the authorities concerned to get away from per- forming their elementary duty of protecting and promoting health or the people. They have also used it to indulge in misinformation to protect their narrow, vested interests. When the sheer niagni- tude of the suffering caused by a large-scale out- break of epidemic managed to break the strong barriers to reach consciousness of the elite through media reports, the instinctive response of the au- thorities is that they either flatly deny even the occurrence of the reported epidemic, or they ridi- cule the figures given as highly exaggerated and come forward with their own data based on cooked up or highly unreliable information." (State of Malaria work in India: Dr. D. Banedees). The recent outbreak of malaria in Western Rajasthen provides a very good instance of the state of public health in the country and the res- ponse of the authorities to public health calamities. The NG0s working in the area observed a sharp rise in the incidence of malaria of P. falciparum type, leading to a very large no of deaths. The Malaria control machinery of the state was almost non-existent in the affected villages. The urban biased press and electronic media reported it very late. It is significant that the response of the state and union Government was to denounce the "exaggerated" reports given to the media by the NG0s. They came out with their own "doc- tored data" based on hospital reports, as they simply did not have any information system which reached out to the villages. On inquiry it was found that the basic health workers (male multipurpose worker), who had to visit each village twice a month to detect fever cases, take blood slides, offer presumptive treat- ment and to provide radical treatment to those who were found to be positive for malaria parasite were not functional. Along with that the drug distribu- tion centers and Fever treatment depot were non existent in the area although the reports of the Rajasthan State Government showed that the malaria work done in this region is according to the programs stipulated in the Modified Plan of Operation (MPO). (State of Malaria work in India: Prof. D. Banedees). Thus under such conditions, it is too much to expect the public health system to take advanced measures to a possible outbreak of epidemic fol- lowing unpredictable rainfalls in 1994, or taking long-term measures to forestall the outbreak of the epidemic because of construction of the Indira Gandhi Canal in that region. It is also equally dis- turbing that the government spokesmen were generalist administrators who neither have the public health competence nor can theybe held accountable for their actions. Thus, the two fundamental objectives of the Modified Plan of Operation (WO) are: (i) to pre- vent deaths due to malaria and (ii) to prevent the spread ofpfalciparum has failed miserably. And the GOI personnel saw it with reason to cut down 20% of the union's health budget (1992-93) without taking account of the inflation. GOI went on to make a 40% cut for the Malaria Program. Even though these cuts were restored in subse- quent budgets, this instance shows the indecisive- ness of the Government towards the people, paffi- cularly those who live in utter misery in far-flung places like NE Indian and Western Rajasthan. Withdrawal of such massive support for the malaria program led to withdrawal of malaria workers and it could not be restored, despite restoration of the budget cut. On overall analysis of the program, it can be safely said that in their enthusiasm to launch a military style attack against malaria, the authorities overlooked some critical dimensions such as the water drainage system, mosquito behavior, coni- munity involvement, biological consequences of such widespread use of insecticide and capacity of the health service infrastructure to provide nia- laria surveillance.Conceptualization of NMEP also dealt a devastating blow to the development of health services in India. It swallowed the bulk of the budget for rural health services, thus leaving very little for developing other aspects. Ironically, NMEP itself had to pay dividends for such a nias- sive neglect of infrastructure when there was a massive resurgence because of the failure of infra- structure to maintain malaria surveillance. Keeping in view the failure of WO, the modi- fication was made in the program. in 1995. But the modifications made in 1995 to the National Malaria Control Program -- Modified Plan of Operation (NMCP-NTO) named MAP (Modified Action Plan) have been made in a hurry as a panic reaction to the large-scale deaths that took place in various parts of the country in the last year. While the blame of the epidemic should be placed squarely on the system under which the program is formulated and implemented, most of the changes that have been made are directed at the technical aspects of the program. Public health tenets have been shown the back door under the guise of a pragmatic approach to tackling ma- laiia.What the voluntary link worker( VLW )has advocated is in line with the thinking of involving the local community in tackling malaria. But the past experience with such type of scheme (village health guide scheme) is not good. We have to be careful. Laying out the duties of VLW does not mean an ensured accountability for surveillance of a standard that is desirable. MAP also mentions that "cattle sheds are not to be sprayed," in order to divert the mosquitoes from human dwellings to cattle sheds. This is a very myopic view. It loses sight of the fact that for the poor, there is not much difference between the cattle sheds and human dwellings. The policy makers are not realistic about the ground and the situation of vast masses. In Laos, such selective spraying will increase the problem. There is jargon of technical issues in ~ like rescheduling of doses to control the menace of ma-laria. But the recommendations are based on (without any field trials) theoretical background only. Some recommendations appear to be very unrealistic like there is the recommendation "to monitor the cholinesterase levels regularly." This is very ambitious, without any ground reality that such facilities are available in selected cities only, and the cost is huge. Thus, MAP will not serve as an answer to the recent epidemic because the recent epidemics were/are largely due to the collapse of the public health system itself. After ensuring an efficient health service system, we can make an effort to develop better alternatives to optimize the system. Incidentally, this was one of the tasks of the WO which was obviously not performed. Once it is ensured that public health system is optimized and it functions efficiently, urgent steps should be taken to improve investment in the earth service system. But a committed and dedicated political will is a precondition. References * An in-depth Evaluation ofN.M.E.P. -- a case study of Bihar and Haryana; ORG, B aroda, 1988. * Qadeer Imrana, Nayar KR, Baru RV. Contextu- arising Plague: A reconstruction and an analysis. Economic andpolitical Weekly Nov. 19, 1994. *Doomed to Death. Hindustan Times, Patna, India, Monday, July 3, 1994. GOI VIII Plan Document Vol . 2, 1992. GOI Annual Health Report - 1995. Sharma YD, Biswas S, Pillai CR, Ansari MA, Adak T, Devi CU. High prevalence of chloro- quine resistantplasmodiumfalciparum infec- tion in Rajasthan epidemic. Acta Trop 1996 Dec 16;62(3):135-41 Malaria Action plan (MAP) 1995.. A critical analysis Sharma AU. Malaria: Cost to India and future trends. Southeast Asian J Trop. MecL Public Health Mar 27, 1996 (l):4-14 Modified Plan of Operation -- Ministry of Health and Family Welfare ( 1977 ) Resurgence of malaria with special reference to malaria outbreak in Calcutta. Mukhopadhyay SP. Journal of Indian Medical Association Apr 1994 94(4):145-6 State ofmalaria Work in India -- Prof. Baner- jec D. Symptom of Deeper SocialMalady -- Kumar Arun, Mainstream, Oct 22,1994. Kapoor SK, Anand K, Sharmanna BR, Mullick, AK. Time utilisation pattern of staff of two primary health centres in Ballaygarh, Haryana. Indian JPublic Health. 1996 Oct-Dec.; 40(40: 112-9 Cover Page Asian Region Special Lecture Topics Papers HOME |