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Development and implementation of non-communicable disease (NCD) prevention polices in the developing countries is a multidimensional challenge. This article highlights the evolution of a strategic approach in Pakistan. The model is evidence-based and encompasses a concerted and integrated approach to NCDs. It has been modelled to impact a set of indicators through the combination of a range of actions capitalizing on the strengths of a public-private partnership. The paper highlights the merits and limitations of this approach. The experience outlines a number of clear imperatives for fostering an enabling environment for integrated NCD prevention public health models, which involve roles played by a range of stakeholders. It also highlights the value that such partnership arrangements bring in facilitating the mission and mandates of ministries of health, international agencies with global health mandates, and the non-profit private sector. The experience is of relevance to developing countries that have NCD programs running and those that need to develop them. It provides an empirical basis for enhancing the performance of the health system by fostering partnerships within integrated evidence-based models and permits an analysis of health systems models built on shared responsibility for the purpose of providing sustainable health outcomes.
Non-communicable diseases exhort a considerable toll on individuals, societies and health systems [1,2]. Located in South Asia, Pakistan has a population of 150 million and a per-capita health expenditure of US $ 18 [3]. NCDs and injuries are amongst the top ten causes of mortality and morbidity in Pakistan [4]; estimates indicate that they account for approximately 25% of the total deaths within the country [5]. NCDs contribute significantly to adult mortality and morbidity and impose a heavy economic burden on individuals, societies and health systems [6]. In most cases, it is the economically productive workforce, which bears the brunt of these diseases. Existing population-based morbidity data on NCDs in Pakistan show that one in three adults over the age of 45 years suffers from high blood pressure [7]. The prevalence of diabetes is reported at 10% whereas 40% men and 12.5% women use tobacco in one form or the other [8,9]. Karachi reports one of the highest incidences of breast cancer for any Asian population [10]. In addition, estimates indicate that there are one million severely mentally ill and over 10 million individuals with neurotic mental illnesses within the country [11]. Furthermore, 1.4 million road traffic crashes were reported in the country in the year 1999; of these, 7000 resulted in fatalities [12].
Established evidence highlights the potential to limit NCD mortality and morbidity through appropriate public health strategies aimed at disease prevention, risk factor control and health promotion [13]. Addressing NCDs in a developing country such as Pakistan is a multidimensional challenge with implications at different levels and necessitates a two fold action. Firstly, lobbying for appropriate investments and policies to facilitate their inclusion in the development and health agenda [14], and secondly, developing scientifically valid, culturally appropriate and resource-sensitive models incorporating and integrating the multidisciplinary range of actions relevant for NCD prevention.
In Pakistan, the public-private tripartite partnership led by Heartfile (a non-profit NGO registered under the Societies Registration act of 1860 in Pakistan) and constituted additionally by the Ministry of Health and the WHO Pakistan office has recently released the National Action Plan for Non-Communicable Disease Prevention, Control and Health Promotion in Pakistan (NAP-NCD) to achieve national goals for the prevention and control of NCDs [15]. This paper discusses the strengths and limitations of this initiative and highlights the value that such partnership arrangements bring in facilitating the missions and mandates of various partners.
The present exercise is the first opportunity to mount a truly 'national plan of action' aimed at preventing and controlling NCDs with the Governments' commitment to NCD prevention as a priority and to enlist a broad range in inputs from within Pakistan for addressing a challenging issue. The NAP-NCD outlines a concerted and comprehensive approach; one that incorporates both policies and actions. It is set within a long-term and life-course perspective and calls for an institutional, community and public policy level change. It has been designed to overcome the tendency to rely on a disjointed set of small scale projects, factoring integration at six levels: grouping NCDs so that they can be targeted through a set of actions, harmonizing actions, integrating actions with existing public health systems, incorporating contemporary evidence-based concepts, combining prevention and health promotion and harnessing the potential within partnerships.
the term NCDs is technically reserved for a group of preventable diseases that are linked by common risk factors: cardiovascular diseases, some chronic lung conditions, cancer and diabetes fall within this category. However NAP-NCD also includes injuries and mental health within this framework as country requirements necessitate that these be addressed within a combined strategic framework through synchronized public health measures. There are many common grounds for combining public health actions to address these diseases.
the NAP-NCD delivers an Integrated Framework for Action (IFA) [16]; this is modelled to impact a set of indicators through the combination of actions across the range of NCDs in tandem with rigorous formative research. The IFA emanates from the concept highlighted in Fig Fig1; 1 ; within this framework, it encompasses two sets of strategies; those that are common across the entire range of NCDs and others that are specific to each NCD domain. The first strategy includes a behavioural change communication strategy, reorientation of health services strategy and surveillance, while the second pertains to legislative and regulatory matters.