A Prioritized Research Agenda for Noncommunicable Diseases (LMIC and implementation issues)

1. A Prioritized Research Agenda for Noncommunicable Diseases(LMIC and implementation issues) Dr Shanthi Mendis Coordinator, Chronic Disease Prevention and Management Assistant World Health Organization Geneva, Switzerland

2. The Noncommunicable Disease Burden • Responsible for up to 60% of global deaths, 80% are in low- and middle-income countries. • Major noncommunicable diseases: • Cardiovascular diseases • Diabetes • Cancers • Chronic respiratory diseases • Shared preventable risk factors: • Tobacco use • Unhealthy diet • Physical inactivity • Harmful use of alcohol • Major inequalities between and within countries • NCDs are undermining development

3. Six Objectives for the Global NCD Action Plan 1. Integrating NCD prevention into the development agenda 2. Establishing/strengthening national policies and programmes 3. Reducing/preventing risk factors 4. Prioritizing research on prevention and health care 5. Strengthening partnerships 6. Monitoring NCD trends and assessing progress made at country level

4. Global Strategy Plan 2008-2013Implementation of Objective 4 on Research ACHR March 2008 WHO Meeting on A Prioritized Research Agenda Geneva, 25-26 August 2008) Ministerial Forum on Research for Health, Bamako, 17-19 November 2008

5. Draft NCD Research Agenda Major domains for research Cross cutting domains • Social determinants and NCDs • Health systems and primary health care • Diet, physical activity and obesity • Tobacco control • Genetics of chronic diseases • Cost-effectiveness of interventions Disease specific research priorities • Cardiovascular diseases • Cancer • Chronic respiratory disease • Diabetes

6. Draft NCD Research Agenda Diet, physical activity and obesity Priority areas that require further research: • develop economic models of structural change and behavioural programs to demonstrate the potential benefits of specific actions to improve nutrition and physical activity at a population level; • To develop methods to ensure that nutrition and physical activity intervention achieve sustainable change; • To identify effective ways to address inequitable social gradients in diet and physical activity within LMICs; • To identify positive roles the private sector can play in improving nutrition and physical activity in the community; • To study the appropriate use of food regulation and legislation to improve nutrition and reduce the risk of obesity; • To develop effective national and international standards for food labelling and signposting; • To determine effective programs and policies for inclusion in a portfolio of actions to prevent weight gain and obesity; • To improve nutrition and physical activity through worksite programs in LMICs; • To develop mechanisms to reduce the impact of marketing of energy dense – nutrient poor foods to children; • To validate criteria and tools for defining and measuring the energy density of foods and simple and accurate tools for assessing physical activity levels in LMICs; • To identify components of physical activity that should be targeted to best improve physical activity levels and help prevent weight gain; • To study the effects of palm oil and other saturated fats, folic acid, B12, Vitamins A and D on the development and prevention of major NCDs.

7. Draft NCD Research Agenda Tobacco control Priority areas that require further research: • Assessment of the local context • Impact of tobacco use and cessation on additional health outcomes (e.g. TB) • Role of the tobacco industry • Integrating tobacco within national development strategies (e.g. PRSP) • Equity-oriented research: • Interrelationship between tobacco and poverty • Economic research to inform policy • Assessing economic and social impact of tobacco use • Cost-effectiveness of interventions: • Supply-related research • Research to facilitate demand reduction: • Communication • Cessation • Counter advertising • Affordable, accessible cessation pharmacotherapies • Health professionals and health systems • Improving multisectoral action

8. Draft NCD Research Agenda Cardiovascular diseases (1) • Develop country specific information, to make compelling arguments to political leadership for placing CVD in the development agenda; • Develop methods for monitoring trends of CVD/RF and evaluation of the effectiveness of policies/ programs for integrated prevention and control of CVD; • To evaluate macroeconomic and social impact of CVD disease and cardiovascular interventions; • To study social, cultural, economic determinants of behavioural and other cardiovascular risk factors; • To develop models of effective combinations of interventions (policy, environmental and individual) to address cardiovascular risk factors in diverse settings; • To understand system related barriers to care and develop feasible approaches to apply cost-effective primary and secondary interventions through a primary health care approach;

9. Draft NCD Research Agenda Cardiovascular diseases (2) : • Validate cost effective screening approaches, risk prediction methodologies and clinical algorithms applicable to LMIC settings; • Determine the impact of policy interventions aimed at reducing social stratification and reducing vulnerability/ exposure of disadvantaged populations to cardiovascular risk factors; • Evaluate screening programs based on absolute risk in a total cardiovascular risk intervention trial using fixed dose combinations at a given threshold (e.g. 30% ) of coronary risk; • Develop appropriate resource allocation models for medical technology and high technology interventions in order to maximize health benefits and equity; • Develop vaccines and safer and affordable medicines for addressing rheumatic heart disease and Chagas disease; • Develop observational cohort studies including the influence of societal factors on health behaviours and risk factors in both adults and children.

10. Draft NCD Research Agenda Cancer (1) Priority areas that require further research: • To track the cancer burden and its social determinants; • To establish and/or improve cancer registration, especially in Africa; • To collect other data needed on cancer (including prevalence of major risk factors, human resources, staging, treatment, use of opiates, economic impact of cancer etc); • To identify means for down staging of detectable cancers through public awareness programmes and local successes, e.g. in downstaging and treatment, and apply more widely; • To develop means to train health professionals on all aspects of cancer control, including leadership and management of cancer control programmes with a public health approach at the national, state and district levels; • To develop effective approaches to influence politicians on needs for cancer control;

11. Draft NCD Research Agenda Cancer (2) Priority areas that require further research: • To develop innovative ways to facilitate the development or reinforcement of cancer control programmes that can accelerate improvement processes on a wider scale in LMI countries; • To identify the determinants that result in cancer being diagnosed at an advanced stage; • To develop cost-effectiveness of alternative technologies and feasibility and utility of teleimaging and telepathology as tools for improved diagnosis and education in LMI countries; • Evaluation of models for implementing effective screening programmes in different socioeconomic settings; • To establish a comprehensive vaccination programme for hepatitis B and oncogenic human papilloma viruses; • To identify means to reduce barriers to access to diagnosis and treatment, rehabilitation and palliative care;

12. Draft NCD Research Agenda Chronic respiratory disease Priority areas that require further research: • Asthma • To estimate the burden, risk factors and mortality of its various subtypes and co- morbidities; • To determine the prevalence of various subtypes; • To assess gaps in access to essential asthma drugs; • To estimate the impact of interventions in disadvantaged populations. • COPD • To determine the prevalence, risk factors and co-morbidities; • To estimate the attributable fraction of risk of COPD and other CRDs; related to tobacco smoke, solid fuel combustion, outdoor pollution and allergens;

13. Draft NCD Research Agenda Diabetes (1) Priority areas that require further research: • To optimize introduction of proven treatments for late complications into LMIC; • To develop models to assess cost-effectivenss of interventions in LMIC; • To develop health systems to manage the increasing burden of NCDs; • To develop low-risk prevention programs with lifestyle intervention in high risk individuals, including elderly individuals; • To prevent and manage gestational diabetes mellitus with lifestyle intervention during pregnancy and after delivery.; • To develop and test fixed-dose, low-cost combination pill to manage diabetes and other risk factors; • To develop multifactorial interventions in prevention of complications in Type 1 diabetes;

14. Draft NCD Research Agenda Diabetes (2) Priority areas that require further research: To revise diagnostic criteria for Type 2 diabetes based on evidence from epidemiological and clinical studies; Estimate the lifetime risk of Type 2 diabetes using both cross-sectional and prospective approaches; To assess quality-of-life, quality of care and cost in selected cohorts from different countries; To assess insulin and blood glucose monitoring affordability and accessibility; To develop low-cost reliable blood tests to screen and diagnose diabetes and high risk states.

15. Draft NCD Research Agenda Genetics Priority areas that require further research: • To develop methods and instruments for: assessing the epidemiology of genetically-determined disorders; economic evaluation; surveillance; education; information provision; • To develop approaches applicable in primary health care, for genetic risk assessment, information and counselling; • To develop medical records systems to include genetic and family history information; • To develop lower-cost methods for genetic testing, to enable ready health service access to large-scale DNA diagnostic facilities; • To develop scientific principles of community genetics, based on an integrated over-view of the potential of genetic approaches in health care at all stages of life; • To develop an Internet-based systems for delivering community genetic resources for health decision makers, for professional education, and for patient information; • To develop service models for prevention and control of monogenic diseases in LMIC; • To monitor ethical, social and legal issues concerned with implementation of new genetic knowledge at the health care practice.

16. Draft NCD Research Agenda Social determinants and NCDs (1) Priority areas that require further research: • To improve understanding of the role of social determinants in prevention and control of NCDs partly through better disaggregation of population health data; • To develop ways of getting policies of different government departments to complement each other for NCD prevention and control and health equity; • To study of the impact on NCDs of state provision of universal social protection/ health services and education funded through taxation and social insurance; • To develop legislative and regulatory frameworks that ensure means of public revenue generation and greater equity in access to health and education services; • To generate evidence on the effectiveness of measures to reduce health inequities related to NCDs through action on social determinants;

17. Draft NCD Research Agenda Social determinants and NCDs (2) Priority areas that require further research: • To design, implement and evaluate pro-poor NCD prevention and control programmes that better reach and impact on vulnerable sub-populations; • To conduct a systematic gender analysis of all NCD policies and services to improve gender equity; • To develop mechanisms for people who are the intended beneficiaries of NCD policies and actions to participate in their design, delivery and resource allocation; • To develop mechanisms to enable civil society organizations to play a pivotal role in advocacy, monitoring of accountability of stakeholders and social mobilization for addressing NCDs; • To identify means of cultivating a responsible press that encourages social dialogue and debate on issues of inequity and social responsibility.

18. Draft NCD Research Agenda Health systems and primary health care (1) Priority areas that require further research: • Barriers in health systems that prevent diagnostics, technologies and treatment interventions from reaching the poor and context specific solutions to overcome such barriers. • Health financing mechanisms that reduce out of pocket health care expenditure and catastrophic spending related to NCDs. • Qualitative research to examine the motivations of patients and practitioners, and barriers to making changes in existing systems. • Monitor changes in coverage and in the equity of provision of evidence based NCD interventions. • Means to regulate the health care market and reform the referral system to facilitate long-term care. • Innovative methods of using information technology to address issues related to health literacy and adherence to long-term therapy.

19. Draft NCD Research Agenda Health systems and primary health care (2) Priority areas that require further research: • Sector analysis studies to obtain information on the role and contribution of the private health sector and its impact on health equity. • Means of training, improving performance and retention of the health workforce to address NCD prevention and control. • Service delivery models that provide continuity of care across different NCD and co-morbidities, different levels of care and between public and private sectors. • Roles and functions of all levels of PHC based system as a means of explicitly defining the technologies, equipment, infrastructure, medicines and health workforce requirements. • Cost-effectiveness of settings-based, multisectoral, primary care worker coordinated programmes in resource constrained settings.

20. What do we want to achieve through a prioritized NCD Research Agenda? • Awareness and recognition of the prioritized NCD research agenda in global, regional and national research and development efforts; • Ministerial level political support, financial commitment and investment of Member States to strengthen research capacity and for NCD research ; • Support of the prioritized research agenda by donor and development agencies with sustainable funding ; • Establishment of institutional mechanisms to facilitate effective use of available research evidence in NCDs in health decision-making, policy development and implementation ; • Strengthened capacity of LMIC to address priority research for prevention and control of major NCDs and to inform policy making; • Improved cooperation for NCD research among research funders and other key partners to align resources with NCD research priorities; • Recognition of WHOs leadership in NCD research; • Existence within the national NCD policy of a NCD research plan that articulates clear research priorities and provides a framework for a NCD research effort focused on public health needs.

21. Thank you