Emerging support for chronic disease prevention and control in developing countries
The tide might be turning…
Von Derek Yach & Stig Pramming
This article highlights significant recent developments that suggest the tide might be turning in favour of sustainable support for chronic disease prevention and control. Developments include publication of significant new reports by the World Bank, WHO and the U.S. National Institutes of Health; establishment of new alliances and partnerships such as the Oxford Health Alliance and the Global Alliance for Prevention of Obesity and Chronic Disease; and the announcement of funding by players previously not involved in global health, including support for tobacco control by the Bloomberg Foundation and support for broader aspects of chronic diseases by United Health Care and the PepsiCo Foundation.
Over the last two years, signs have steadily emerged that chronic diseases in developing countries are at last being taken seriously. For decades, evidence has shown that the epidemiological transition was well under way in low- and middle-income countries but that it was taking a form not seen in developed countries. Julio Frenk, former Mexican Minister of Health, characterised this almost 20 years ago as “protracted polarised epidemiological transition” to emphasise that these countries suffered simultaneously from infectious and non-infectious chronic diseases as well as from injuries. (1) However, the problem of chronic diseases has historically received little attention from governments and even less from those funding health research and interventions.
Many reasons for the neglect have been proposed (2) and are addressed elsewhere in this edition. This article highlights significant recent developments that suggest the tide might be turning in favour of sustainable support for chronic disease prevention and control. They include publication of major new reports; establishment of new alliances and partnerships; and the announcement of significant funding for chronic disease prevention by players previously not involved in global health.
Solid and indisputable evidence
There has been a steady production of academic journal articles since 2004 that have provided new global and national estimates of the burden of disease attributable to the risk factors – poor diet, tobacco use, lack of physical activity – driving the epidemic of chronic disease. The evidence has been used in three major reports: the WHO report Preventing Chronic Diseases: A Vital Investment (2005) (3); the report of the Developing Country Priorities project DCP2 (2006) (4); and the World Bank report on Public Policy and the Challenge of Chronic Noncommunicable Diseases (2007). (5) Between them, these reports now provide solid and indisputable evidence of the epidemiological and economic impact of chronic diseases in developing countries. Each report was subject to intense review within agencies with complementary roles in addressing the problem: the WHO has lead responsibility for policy and strategy development; the World Bank is key to providing financial support and economic advice to governments; and the U.S. National Institutes of Health (one of the primary players in the Developing Country Priorities project work) and more particularly its International Fogarty Center, has a key role in setting priorities for, and supporting, global health research.
It is anticipated that these reports will stimulate these agencies to step up their investment, advocacy and general support for chronic disease prevention and control. This is evident within WHO with the increased focus on implementation of the WHO Framework Convention on Tobacco Control (6) and the development of an action plan for the Global Strategy for Diet, Physical Activity and Health. (7) The latter is to be discussed at the World Health Assembly in May 2008.
In addition to these global reports, there has been progress at country level, a recent example being the publication by the South African Medical Research Council of an extensive national effort to quantify the contribution of major risks to health. In the Medical Research Council report, 17 major risks were analysed, with hypertension, tobacco use, increased body mass, physical inactivity and other risks for chronic diseases ranking among the top-ten contributors to the burden of disease. (8) This is particularly significant in a low-middle-income country beset with HIV/AIDS and high levels of violence.
Advocating for funding and action
While these research and policy documents are necessary, without supportive financial investment and the creation of human and institutional capacity there can be no action at country level. This has been recognised by non-governmental organisations that have started to work together to advocate for funding and action. An example of this is the establishment of the Global Alliance for the Prevention of Obesity and Chronic Disease, which includes the World Heart Federation, the International Obesity Task Force, the International Diabetes Federation, the International Association for the Study of Obesity, the International Pediatric Association and the International Union of Nutritional Science. (9)
Three new investments were recently announced with the potential to have global
First, in mid-2006, Michael Bloomberg, mayor of the city of New York and head of the Bloomberg Foundation, announced the award of 125 million US$ for global tobacco control to be administered through a web of NGOs and the WHO. (10) This grant will significantly contribute to accelerated action in implementing the provisions of the Framework Convention on Tobacco Control in selected countries. If programmed wisely, it will also lead to the development of a stronger cadre of tobacco-control policy experts within those countries.
Secondly, Lois Quam announced in 2006 that Ovations, a UnitedHealth Group company, would provide 15 million US$ to support development of centres of excellence to address chronic diseases in developing countries. (11) The hope is that these centres will work with established groups in developed countries to create a much-needed pool of expertise in developing countries, capable of leading development of chronic disease prevention and management systems. Ms Quam’s announcement was made during the 2006 Clinton Global Initiative in a special session devoted to chronic diseases – in itself an important milestone in the growing acceptance of the need for action. (12)
Thirdly, the PepsiCo Foundation announced a grant of 5.2 million US$ in September 2007 to support an Oxford Health Alliance community-based research initiative to be initiated by groups in India, China, Mexico and the United Kingdom. The project, Community Interventions for Health, will evaluate how best to reduce chronic disease risks (tobacco use, poor diet and physical inactivity) through interventions in schools, workplaces, communities and health-care centres in developing countries and communities. (13)
These are not the only ongoing chronic disease initiatives – they build on years of work undertaken by Salim Yusuf from McMaster University in Canada, Stephen MacMahon from the George Institute in Sydney, Sir Richard Peto from Oxford University and Stig Wall from Umeå University in Sweden. Further, it should be recognised that these are still only modest investments when compared to the size of the burden of disease today and the emerging burden based on current levels of risk, or the level of financial and political support given to AIDS, malaria or tuberculosis. But they represent an important start.
New partnerships and alliances
The development of new partnerships and alliances is the third major development. As mentioned above, the Oxford Health Alliance (OxHA) is the first private-public partnership with resources to convene major players and to carry out the strategic research required to provide clear evidence for why chronic diseases demand more attention. (14) It receives its core funding from Novo Nordisk – a Danish-based global pharmaceutical company with a deep and proven commitment to tackling diabetes and related health conditions globally. OxHA’s annual meetings have brought together people from a range of NGOs, international health agencies, private food, pharmaceutical and insurance companies and academia to foster a better understanding of each group’s role in addressing chronic diseases. What has emerged is a growing sense that profits and public health goals can coincide, and that market forces could be a far more effective tool in tackling chronic diseases then previous models of philanthropy or public-sector actions.
A major article in The Economist very recently called for a greater focus on chronic disease. (15) The same publication not too long ago opposed action, saying that chronic diseases are due to a failure of personal responsibility, are mainly the concern of the affluent and the old, and do not warrant special attention. (16) This reversal of attitude may well represent a realisation that failure to address chronic diseases is bad for profits – a theme so well documented in recent World Bank and Oxford Health Alliance reports (17), and discussed in depth at the first-ever meeting between the World Health Organization and the World Economic Forum in Dalian, China during September 2007. That meeting highlighted the cost-effectiveness of workplace interventions to address chronic diseases and called for implementation of what works – with a greater focus on adapting knowledge from developed countries to workplaces in developing countries.
Future progress will require that serious investment be made by governments; that corporations carefully review how they could contribute more tangibly to the health of their employees and, where their core business involves products or marketing practice that influence public health, that they seek ways of advancing both their profitability and public health.
The initiatives described here are, on the whole, modest and fragmentary. If they work together and are able to attract funding and political support, there is great potential to scale up these efforts.
*Dr. Derek Yach is Director Global Health Policy PepsiCo in New York.. Until 2004, he worked at the World Health Organisation where he established the Tobacco Free Initiative and where he was responsible for developing a new global “Health For All” policy, which was adopted by all governments in May 1998. From 2005 to early 2007, he was at the Rockefeller Foundation, heading its global health programmes. Prior to that, he was Professor of Global Health at Yale University. Contact: firstname.lastname@example.org.
Dr. Stig Pramming is Executive Director Oxford Health Alliance in London. He worked in the Danish National Health Service and also in Norway and Sweden. He is a widely published author with over 50 papers to his name, and several coauthorships of professional textbooks. He is a fellow of Harris-Manchester College, Oxford, an honorary consultant to the UK NHS, and a professor of the University of Oxford. Contact: email@example.com
- Frenk et al. (1989) Health transition in middle-income countries: new challenges for health care. Health Policy Plan 4(1): 29–39.
- Yach D, Hawkes C, Gould CL, Hofman KJ (2004). The global burden of chronic diseases: overcoming impediments to prevention and control. JAMA 291(21): 2616–2622.
- World Health Organization (2005). Preventing Chronic Diseases: A Vital Investment. Geneva.
- World Bank (2006). Disease Priorities in Developing Countries. Washington, DC.
- Adeyi O, Smith O, Robles S. (2007). Public Policy and the Challenge of Chronic Noncommunicable Diseases. World Bank. Washington, DC.
- World Health Organization (2003). Framework Convention on Tobacco Control. Geneva.
- World Health Organization (2004). The Global Strategy on Diet, Physical Activity and Health. Geneva.
- South African Comparative Risk Assessment. SAMJ 2007; 97 (8), Part 2: 635-790.
- Global Alliance for the Prevention of obesity and related chronic disease. www.preventionalliance.net/index.htm
- WHO named as one of five partners to implement Michael Bloomberg’s 125 US$ million initiative to promote freedom from smoking: www.who.int/mediacentre/news/statements/2006/s16/en/index.html
- Quam L, Smith R, Yach D (2006). Rising to the global challenge of chronic diseases. The Lancet 368(9543): 1221–1223.
- See ‘Request for proposals announced’ (24 July 2007), www.oxha.org/alliance-alert/
- Community Interventions for Health: www.oxha.org/initiatives/cih
- See www.oxha.org and www.3four50.com.
- The maladies of affluence/ The Economist, 11 August 2007: www.economist.com/world/international/displaystory.cfm?story_id=9616897
- Less Mary Poppins, The Economist, 9 November 2006: www.economist.com
- Adeyi et al., op cit. Suhrcke et al. (2006), Chronic Disease: An Economic
Perspective. Oxford Health Alliance.