Global public health: a scorecard

A global framework for action to improve the primary care response to chronic non-communicable diseases: a solution to a neglected problem

BACKGROUND

Although in developing countries the burden of morbidity and mortality due to infectious diseases has often overshadowed that due to chronic non-communicable diseases (NCDs), there is evidence now of a shift of attention to NCDs.

DISCUSSION

Decreasing the chronic NCD burden requires a two-pronged approach: implementation of the multisectoral policies aimed at decreasing population-level risks for NCDs, and effective and affordable delivery of primary care interventions for patients with chronic NCDs. The primary care response to common NCDs is often unstructured and inadequate. We therefore propose a programmatic, standardized approach to the delivery of primary care interventions for patients with NCDs, with a focus on hypertension, diabetes mellitus, chronic airflow obstruction, and obesity. The benefits of this approach will extend to patients with related conditions, e.g. those with chronic kidney disease caused by hypertension or diabetes. This framework for a "public health approach" is informed by experience of scaling up interventions for chronic infectious diseases (tuberculosis and HIV). The lessons learned from progress in rolling out these interventions include the importance of gaining political commitment, developing a robust strategy, delivering standardised interventions, and ensuring rigorous monitoring and evaluation of progress towards defined targets. The goal of the framework is to reduce the burden of morbidity, disability and premature mortality related to NCDs through a primary care strategy which has three elements: 1) identify and address modifiable risk factors, 2) screen for common NCDs and 3) and diagnose, treat and follow-up patients with common NCDs using standard protocols. The proposed framework for NCDs borrows the same elements as those developed for tuberculosis control, comprising a goal, strategy and targets for NCD control, a package of interventions for quality care, key operations for national implementation of these interventions (political commitment, case-finding among people attending primary care services, standardised diagnostic and treatment protocols, regular drug supply, and systematic monitoring and evaluation), and indicators to measure progress towards increasing the impact of primary care interventions on chronic NCDs. The framework needs evaluation, then adaptation in different settings.

SUMMARY

A framework for a programmatic "public health approach" has the potential to improve on the current unstructured approach to primary care of people with chronic NCDs. Research to establish the cost, value and feasibility of implementing the framework will pave the way for international support to extend the benefit of this approach to the millions of people worldwide with chronic NCDs.

The role of schools of public health: learning from history, looking to the future

There is a broad consensus on the need for high-quality public health education and research to tackle the world's many public health challenges. Public health education and research are delivered by a variety of institutions operating very different models, which collectively can be called schools of public health. Given the importance of education and research to public health systems, it is surprising how little research has been done to assess the role of schools of public health in contributing to population health. In particular, it is notable there has been very little research on the strengths and weaknesses of the different models of schools of public health that have evolved over the last 100 years. Thus, a historical perspective is crucial. To date most historical work has focused on US schools of public health. Although the evidence is patchy, a global overview of the history of schools of public health identifies three important themes: capacity building, multidisciplinarity and balancing teaching and research. Newer challenges and opportunities include addressing the impact of climate change and developments in e-learning. Schools of public health have the potential to make a central contribution to progress in public health practice in the twenty-first century.