The Challenge of Non-Communicable Diseases and Road Traffic ...

An Overview 37
clarity of vision and purpose, emphasizing common
elements, and facilitating efficient and effective use of
resources [200, 205]), the reality of individual countries
may be that a mixture of policies, programs,
and interventions are already in place, as was found
in the case in Ghana and Cameroon, [192, 206]. A
meeting of SSA health leaders in 2009 suggested the
value of having a generic NCD plan which integrates
palliative care, surveillance, and the reduction of risk
factors, alongside disease-specific plans that take account
of specific issues in individual diseases (such
as diagnosis and treatment) [207]. The challenge is
to find a good model that fits a specific context and
the specificities of SSA [179], and focus on achieving
outcomes. First Implementing a priority set of interventions,
such as tobacco control and salt reduction
measures, before adopting a more comprehensive
approach, has been proposed lest starting with a
comprehensive plan is too ambitious, and risks diverting
resources from moving ahead quickly with
the most productive actions [208].
There has also been debate over the place for ‘vertical’
(stand-alone) programs in health systems [209],
and concern that establishing new vertical programs
for NCDs and RTIs in resource-constrained countries
risks placing them in direct competition for scarce
funding with existing programs such as those on communicable
diseases and maternal and child health,
which is likely to be unsustainable [210]. Both advantages
and limitations of ‘vertical’, disease-specific programs
have been recognized, with calls for the lessons
learnt to be applied [211-212]. Further research has
been proposed to ascertain what ‘integration’ would
really mean in different settings and for different
services [144], and instead of a false dichotomy between
so-called vertical and horizontal approaches,
analytical and conceptual frameworks have been proposed
to help shift the debate and reframe the issues
[213-214]: for example ‘diagonal’ programs have been
proposed whereby disease-specific interventions are
designed to minimize the untoward impact on other
health programs, and/or support health systems
more. Similarly, rather than refer to specific disease
categories, there have also been proposals to rethink
health systems to be better able to encompass all diseases,
with a greater emphasis on primary health care
and community-based interventions [215-217].
While donor-driven and global health initiatives
have mobilized substantial new resources for health
in many LMIC, there is a recognized challenge to
combine disease-specific programs with broader
approaches for health improvement so that positive
synergies are capitalized upon and negative impacts
minimized [218-219]. Any approach involving
greater integration or ‘diagonalization’ may meet
with resistance if it appears to take control away
from donors and proponents of vertical programs
[215], or if it undermines existing programs and
their broader benefits [220], or fails to take account
of lessons learnt [221]. Both potential negative impact
(loss of funding and of political attention) and
positive impact (a greater commitment to investing
in health care for chronic diseases) have been seen as
potential outcomes. Nevertheless, there is increasing
enthusiasm for leveraging HIV resources, experience,
and models for the benefit of other chronic
conditions, and to ‘jumpstart’ initiatives to provide
prevention, care, and treatment services for them [5,
142, 222-225]. After all – on grounds equity and efficiency
– some argue that there is no basis for HIV/
AIDS care to be better resourced than care for other
chronic conditions, such as diabetes.
5.2. Population-Level Prevention
Population-level interventions are not reliant on
health services for delivery: costs are relatively low
and they may even generate funds; they have relatively
little “downside”; most people will be exposed
to them; and people who are at high risk or already
suffering from NCDs will benefit [226]. Population-level
prevention, particularly in resource-limited
countries, benefit from a strong regulatory and
fiscal framework, particularly for tobacco control.
Most cost-effective measures to reduce risk factors
are in the domain of agencies or ministries other
than health, such as ministries of trade, finance, agriculture,
and transport, but may challenge vested interests
and face strong lobbying by tobacco, alcohol,
and other industries. Therefore, while they include
some of the cheapest and most effective interventions
(such as tobacco and alcohol taxation), they
may be politically difficult to achieve, requiring robust,
high-level leadership and/or effective impacts
to build partnerships and garner broad support.