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Prevention in action

Pakistans action plan on chronic diseases publicprivate partnership in action

Sania Nishtar

About a decade and a half ago, public health priorities in low- and middle- income countries were centred on infectious diseases and maternal and child health issues. Subsequently, however, data published in leading medical journals and reports by multilateral agencies has shown that more than 50% of the burden of disease in developing countries is attributable to chronic diseases including heart disease, diabetes, cancers and some chronic lung conditions. The common ground for these diseases lies both in their interlinked biological and lifestyle risk factors and in the lack of recognition they have received in public health terms. The absence of chronic disease-related targets from the UN Millennium Development Goals is evidence of that neglect. Sania Nishtar describes a successful public-private partnership which is redressing the balance at the policy level, by effectively pushing chronic disease higher up the public health agenda in Pakistan.
In addition to having implications for longevity, quality of life and healthcare spending, conditions like diabetes undermine the income-generating ability of economically productive people. In low-income countries, non-communicable chronic diseases are known to be one of the foremost factors in perpetuating poverty. In Pakistan, according to conservative estimates, 5% of the

adult population over the age of 1 years has at least one chronic disease. Around 10% of adults have diabetes, and in some high-risk groups, such as in women living in urban areas, up to 30% are affected. Yet until 004, there was no countrywide programme to prevent and control chronic diseases in Pakistan, although a number of programmes were in place to address communicable diseases. Indeed, the current policy paper, which sets Pakistans healthcare agenda, National Health Policy 2001 The Way Forward, did not mention the terms diabetes or chronic disease.1 Until recently, there was no countrywide programme to prevent and control chronic diseases in Pakistan. Public-private partnership Since 1999, the Pakistan-based NGO, Heartfile, had been campaigning to bring chronic disease prevention and

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In Pakistan, 25% of the adult population over the age of 18 years has at least one chronic disease.

prevention and control to the 95 000 rural health workers who have been involved in delivering reproductive health and communicable disease services in the community. In the Plan, individual behaviour modification is supported by population-wide screening for conditions like high blood pressure, and screening among high-risk groups for diabetes and high blood lipids. Requirements are specified in terms of strengthening infrastructure, expanding human resources, and enhancing drug supply. The Plan also outlines essential legislative and policy measures. These include a review of the current focus on under-nutrition; agricultural and fiscal policies to increase access to and demand for healthy food; urban planning strategies to utilize open spaces for physical activity. In addition, the Plan highlights the need to engage religious leaders in endorsing the participation of women in physical activity. Fiscal approaches to reduce dependence on tax-generated tobacco revenues were also proposed, together with a framework for a staged ban on all types of tobacco advertising. Furthermore, under the Plan, revised legislation subjects tobacco to the stringent regulations that regulate pharmaceutical products, and assists with agricultural diversification.

control into the mainstream of the countrys healthcare planning. Heartfiles mission is to engender change in the healthcare sector in order to improve Pakistans healthcare system. The NGOs efforts led to the signing of a Memorandum of Understanding with the Ministry of Health in 003 to develop a national plan of action on chronic disease. Subsequently, a tripartite collaboration was established involving Heartfile, the Ministry of Health, and the World Health Organization (Pakistan), which in turn led to the publication of the National Action Plan for Prevention and Control of Non-Communicable Diseases and Health Promotion in Pakistan, and gave rise to the formation of a national non-communicable disease forum, comprising experts on chronic disease in Pakistan. The Action Plan envisages the implementation of a chronic disease strategy alongside existing national communicable disease prevention programmes. It presents an integrated approach to

tackling four diseases (diabetes, heart disease, chronic respiratory disease, cancer) by addressing their common risk factors (unhealthy diet, lack of physical activity, smoking, high blood pressure, abnormal lipid levels, obesity). The Action Plan tackles four diseases by addressing their common risk factors. A key initial focus of the plan is on individual behaviour change. In order to reach as many of Pakistans 160 million population as possible with limited available resources, radio- and television-mediated mass education is a principal component of the programme. Integrated, population-wide approach In addition, the Plan exploits opportunities to benefit from existing programmes in order to expand its reach. For example, it recommends transferring responsibility for chronic disease

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Prevention in action

Implementation The programme got off to a good start. The government of Pakistan contributed resources through its public sector development programme to implement the programme, and WHO allocated funds through its country budget. Heartfile provides ongoing technical support. The design of this programme enabled the roll-out of strategic interventions from the very beginning. These included gathering data through populationlevel surveillance assessing peoples knowledge, attitudes and practices, which were then targeted through behaviour change interventions. Challenges Obstacles have arisen in a number of fields. A lack of procedural clarity in relation to public-private relationships revealed the need to establish norms for public-private engagement at policy level. Other challenges stemmed from weaknesses in the healthcare system, which hindered the achievement of programme targets in general. In addition, there have been delays in the expansion of the programme which appears to be related to the perception on the part of some decision-makers that chronic diseases do not feature on the pro-poor public health agenda, given that they are not among the UNs Millennium Development Goals or the governments Poverty Reduction Strategy Paper.3 The latter, prepared in broad consultation with stakeholder agencies and development partners, including the World Bank and the International Monetary Fund, is of enormous importance to healthcare funding: public health priorities in Pakistan, as in many other developing countries, are largely donor-driven.4

A successful model Notwithstanding the challenges, it is significant that a chronic disease programme that was developed with a major contribution from an NGO is up and running. With its role in the initial processes of the programme accomplished, Heartfile will concentrate its efforts over the coming  years on facilitating the expansion of the programme and fully institutionalizing it within the Ministry of Health. The programme has been of value to all partners on a number of levels. It has created a framework for public-private, development-driven partnerships between government, development partners, and civil society. In this regard, it provides both a successful empirical model for public-private partnerships and an empirical basis for an integrated approach to chronic diseases. The Action Plan provides an empirical basis for an integrated approach to chronic diseases. Future reform The shortcomings that became apparent in the Pakistan healthcare system during the implementation process have informed Heartfiles efforts to contribute towards further healthcare reform. The first roadmap for health reform takes the shape of a series of publications the Gateway Papers. Heartfile has also signed agreements with various government agencies to assist with policy change for health reform, and support has been provided in certain strategic areas, such as strengthening the health information system. Heartfile has also produced a

mechanism to channel the contributions of civil society and other stakeholders into the policy-level decision making process through the creation of the web-based Pakistans Health Policy Forum (see website below).

Sania Nishtar
Sania Nishtar worked briefly as a cardiologist in Pakistan before setting up the NGO Heartfile. She serves on the boards of a number of international agencies.

Visit http://heartfile.org for more information.

References
1 Ministry of Health Government of Pakistan. National Health Policy 2001 The Way Forward. Government of Pakistan. Islamabad, 001.  Nishtar S. National Action Plan for Prevention and Control of Non-Communicable Diseases and Health Promotion in Pakistan. Heartfile, Ministry of Health, Government of Pakistan and WHO (Pakistan office), Islamabad, 004. 3 Poverty Reduction Strategy Paper Secretariat, Ministry of Finance. Accelerating Economic Growth and Reducing Poverty: the Road Ahead. Government of Pakistan. Islamabad, 003. 4 Nishtar S. The Gateway Paper; Health System in Pakistan a Way Forward. Pakistan Health Policy Forum and Heartfile. Islamabad, 006.

May 2008 | Volume 53 | Special Issue