Prevention and control of NCDs

The prevention and control of non-communicable diseases (NCDs) constitute a development issue that low-income countries in South Asia are already facing. Both country-level  and regional-level strategies are important because many of the issues and challenges of mounting an effective response to NCDs are common to most South Asian countries, even though their disease burden profiles vary. Addressing the burden of diseases and increasing the potential benefit from the demographic transition will be effectively contributing to the economic development.
In this context, Bangladesh is in the early stages of the demographic transition, which is expected to advance in the future. The proportion of the population 65 years and older will move from 4.5 per cent in 2000 to 6.6 per cent in 2025. In 2004, NCDs accounted for 61 per cent and the remainder to communicable diseases. Of the total DALY (disability adjusted life-year) burden, cardiovascular diseases (CVD) accounts for 13.4 per cent, mental health 11.2 per cent, cancer 3.9 per cent, respiratory diseases 4.0 per cent, diabetes 1.2 per cent, and injuries 10.7 per cent.
Now the National policy options framework should help Bangladesh to develop or improve programmes for prevention and treatment of NCDs. It has four stages: Assess, Plan, Develop and Implement, and evaluate.
* In repurposing the framework to Bangladesh context, health policy makers will need to consider their disease burden, health capacity, and other country-specific factors in order to determine how much to focus on preventing disease versus treatment of those already affected.
* Population-level prevention policies are implemented by both the health sector and key non-health sector stakeholders, and are generally financed publicly. By contrast, most policies related to treatment are implemented within the health sector for both public and private providers, and are financed with both public and private resources.
* Common challenges to tackling NCDs in South Asian countries include a low level of awareness and competing priorities among policy makers, the strain on budgets, and lack of institutional units and expertise to lead efforts.
* Bangladesh should explore how, in developed countries, the private sector has been enlisted to play a major role in prevention with the goal of keeping the workforce healthy.
While the health sector bears most of the burden in the prevention and treatment of NCDs, many of the interventions to control NCDs lie outside the health sector. Policy makers should come up with such a framework to make broader systemic decisions that aim at balancing interventions and providing the optimal strategic mix of population-based interventions in the community, and of individual-based interventions within the clinical setting. For purposes of exposition, these two broad intervention modes may be given a judicious review.
Population-based interventions reduce the risk factors for NCDs and avoid or delay onset of disease and are delivered in community and/or population-based settings outside the clinical care system. A relatively small number of behaviour risk factors, tobacco intake, poor diet, physical inactivity (the latter two leading to obesity) are risk factors common to the major chronic NCDs-cardiovascular diseases (CVD), diabetes, cancer, and chronic respiratory disease. The dual goals of population-based interventions are first to avoid development of risk factors and second, when present, to reduce or eliminate them. Examples of this mode are tobacco tax policies and community-level behaviour change for health lifestyles (diet, exercise, and helmet and seat belt use to prevent injury). Individual-based interventions include preventive and treatment services delivered to individuals within the clinical care system. Treatment services include screening to detect undiagnosed cases, clinical management, and addressing complications among persons with disease.
 Preventive clinical services can and should be delivered by the health care system and include (but are not limited to) clinic-based health workers delivering individual education and counseling to reduce risk factors and to prevent disease onset.
However, from a policy perspective, this framework might be useful because population-based and individual-based interventions mobilise different parts of the non-health and health sectors and require very different inputs in terms of infrastructure, capacity, and skill sets; they also yield very different outputs and outcomes. Harmonising both intervention modes is necessary to ensure the right mix. Some important points emerge. First, this sequence is not unidirectional and it contains many feedback loops and iterations. For example, Plan efforts (at right in the figure) may identify new areas where assessments are needed and Evaluate activities will identify programme successes and failures where Develop and Implement efforts need further consideration. Thus, understanding progress at each stage and its relevance to other stages is needed.
Second, facilitating interaction between different components of the health system (e.g., service delivery, human resources) and across levels of the health sector (e.g. central, regional) is also important because many different actors may be responsible for activities at different stages.
Finally, like many countries Bangladesh is at different stages of implementation of her NCD prevention, control, and treatment programs. In such cases, we can use the framework to integrate future actions and balance efforts between population-based and individual-based interventions.
In each of the four programme management stages, action areas that play an important role in both modes of intervention for prevention and control of NCDs are identified. The population-based interventions are divided into policy options that lie within the control of the non-health and health sector. Similarly, the individual-based interventions are divided into preventive services at the clinical level and treatment options at the primary and secondary levels of care. In the policy context, the two intervention modes are not always mutually exclusive. Several areas are cross-cutting, including assessing system capacity, developing national plans and strategies and expanding human resources. Considering both modes is important and practical-although the balance depends on the situation.
Dr Muhammad Abdul Mazid, former                 Secretary and Chairman, NBR,                              currently Chief Coordinator,                             Diabetic Association of Bangladesh. [email protected]