Tracey Koehlmoos: Institute of Medicine’s workshop on country level decision making for NCDs

Tracey KoehlmoosIn a previous blog I mentioned that I attended the Institute of Medicine’s workshop on country level decision making for control of chronic diseases, which was held on 19-21 July at the House of Sweden in Washington, DC.  However, I had promised more details of the meeting and then promptly disappeared for two weeks of vacation (which I will tell you about if you read to the end).

The workshop was held to identify the requirements needed to create tools for country led planning for implementing chronic disease control programmes, with an eye on the important elements of effectiveness, efficiency, and equity.  The meeting and resulting work are timed to precede the United Nations General Assembly’s high level meeting on non-communicable disease control and prevention, to be held in New York on 19-20 September 2011.

The 100+ attendees included policy makers from developing countries, agenda setters in non-communicable diseases (NCDs), public and private sector leaders, scientists working in NCDs, economists, and a handful of others. It was a good mix of people, some familiar faces from the NHLBI-UnitedHealth Group network of centres were there, and there were also many who were there for the first time to tackle this common challenge. For example, the newly rebranded FHI360 (the non-governmental organisation formerly known as Family Health International along with its new acquisition, AED) has thrown its hat into the global health NCD area. Although best known for its work on family planning and HIV, the sheer global reach of its operation is promising, especially perhaps for countries that are not yet engaged in the NCD discussion.

The workshop was built around four case studies that were commissioned by the Institute of Medicine in Grenada, Kenya, Rwanda, and Bangladesh. On the first day, a health ministry representative from each country presented on the progress and needs for NCD care within their country and also on how decisions were made within each health sector. I was impressed by the various levels of progress within each country as well as the needs for NCD care. I was particularly haunted by one of the health ministry representatives stating the urgent need for health economists who understood the national context and the issues around NCD planning and implementation — and who would be available and willing to come and help.

On the second day the authors of a case study presented on data availability and gaps in NCD control and prevention. (This is why I was there, talking about the Bangladesh case study.) More than just talking about demographic and health surveys or WHO-STEPS surveys, the authors also talked about barriers in data collection, for example, asking women if they used tobacco, or not feeling that field workers had the capacity to undertake blood pressure readings, or political barriers in which NCDs as a public health issue pale in comparison to the urgency of the ambitious objectives set by the Millennium Development Goals. The afternoon featured presentations about costing and economic modelling for NCDs. A day talking about data and economic modelling might sound dry but the material was accompanied by a lively discussion about the appropriateness of models and tools and also on the best way for developing countries to apply these tools in their setting.

The third day of the meeting focused on global support for country level planning in low and middle income countries. It featured talks by Derek Yach from Pepsico, Johanna Ralston from the NCD Alliance, and Montserrat Meiro-Lorenzo from the World Bank. Derek challenged us to think about how the world will change on 21 September after the UN meeting. Where are we going? How are we going to get there? But it was Montserrat who had me sitting on the edge of my seat while she spoke passionately about how policy makers live in the present (and increasing spending on health for NCDs may not appeal to them now when cost effectiveness may tell them it is best to do nothing). She said that there are lost opportunities and challenges at three levels: 1) the service provision level;  2) the policy level, which goes well beyond health policy so that it includes urban planning, tobacco farming, taxes, indoor air pollution, and public transportation; and 3) the accountability of the government. There was a lively discussion around the development of NCD SWAT teams or experts available to provide high level technical support to countries taking action on NCDs. Examples of such expertise would include health systems, economics, and medical support. However, looking beyond health, this team would have to be able to help bridge the multisectoral gaps between urban planning, agriculture, and road traffic.

The development of a website housing the webcasts as well as the conference report is in progress. I will provide those links in the comments to this blog when those items become available. The case studies are not available for circulation yet either—but I will let you know the details when the situation changes. I feel strongly that a case study looking at burden, policies, and programmes is an important first step in designing strategies for NCDs in developing countries. These four case studies will hopefully serve as a model.

As for the vacation, you might be thinking, what does this have to do with NCDs? I won’t regale you with tales of beaches, hiking, and sunburn, but rather I wanted to provide a perennial update on electronic cigarettes (e-cigarettes).  In December 2010, the US Food and Drug Administration lost an appeal to have e-cigarettes branded a drug delivery device.  Since April 2011 efforts have been under way to regulate e-cigarettes as a tobacco product under the federal Tobacco Control Act; however, the success of that implementation is unclear to me. This summer my boys were exposed to radio commercials and television commercials for e-cigarettes while in the US.  At least we did not see kiosks selling e-cigarettes in shopping malls like we had previously, but I only made one trip to a mall while in the US.

In other tobacco news, when I returned with the boys to Jakarta for the start of the school year, one of them dutifully pointed out that the Marlboro Man is back. After a year’s hiatus during which we were treated to first white, then black, horses on Marlboro advertisements, everyone’s favorite tobacco promoting cowboy has been resurrected on billboards around Jakarta. Indonesia remains one of the few countries not to have ratified the Framework Convention on Tobacco Control.

Tracey Koehlmoos is programme head for health and family planning systems at ICDDR,B and adjunct professor at the James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh.