CME
programmes
practically relevant training packages into their work-plans in liaison with the District Health Departments. It is also feasible to introduce such modules into the work-plans of LHWs of the National Programme for Family Planning and Primary Health Care. This has already been initialized as part of the first stage of the first phase of implementation of the Action Plan.22
Structuring CME programmes on an ongoing basis for physicians,
particularly those in the private sector, on the other hand, is a more complex situation as no formal and sustainable training mechanisms exist with which to integrate such efforts. The Action Plan recommends the structuring of a comprehensive CME programme to ensure ongoing capacity-building of private and pubic sector physicians. Such a programme will ensure training of in-service doctors as a permanent function of the healthcare system in
Pakistan. However, pending such a structural and sustainable change, the existing models of healthcare provider training need to be evaluated for effectiveness and sustainability and adapted to the prevention of NCDs.
The prevention of NCDs can also be developed as a form of specialization for non-physician healthcare providers. The feasibility of this approach needs to be further explored.
2.2.2.b Infrastructure at healthcare settings: assessed from the perspective of the prevention and control of NCDs, infrastructure requirements of healthcare facilities are modest. An assessment of basic health facilities was recently conducted in the outskirts of Islamabad in collaboration with the Geneva-based CVD Unit of WHO.25 This revealed that blood pressure measurement devices and weighing scales are universally available in all healthcare facilities; however, only around 50% of them were found to be in working order; there was also no system for calibrating and maintaining equipment. Ensuring the availability of a calibrated blood pressure measurement apparatus should be made universal as this is a prerequisite for stepping up screening for high blood pressure. Simple risk assessment tools such as tape measures and apparatus to measure urine sugar are affordable; efforts should be made to make these available at all levels of healthcare facilities.
2.2.2.c Drugs at the basic healthcare level: the availability of and accessibility to several drugs is important in the context of the prevention of NCDs. These include beta blockers, ACE inhibitors, aspirin, penicillin, phenobarbitone, chlorpromazine, imipramine, procyclidine, diazepam, sulphonylureas and insulin; however, this list is in the process of being updated. In addition, nicotine replacement should be made available wherever feasible. A review of the Essential Drug List (EDL) in Pakistan reveals that most of these drugs are listed on the EDL. The Drugs Act 1976 makes it necessary for these medicines to be available throughout the country.26 However, an on-ground assessment has revealed that there are several gaps in the availability of these medicines in healthcare facilities. A facility capacity assessment conducted in collaboration with the WHO CVD Unit has revealed that many of the essential drugs necessary for primary and secondary prevention of NCDs were not available at all times in healthcare facilities even though they were affordable and widely available in the market.25 It is, therefore, essential that necessary steps be taken to ensure that
these drugs are made available and accessible at all levels of the healthcare system.
2.2.3 Research
This Action Plan attempts to bridge the gap between academic researchers and policy makers and administrators engaged in planning evidence-based strategies for bringing about an improvement in health outcomes. Several research dimensions have been flagged as priority areas as part of this Action Plan. These research areas underlie the need to move away from the sole focus on risk factor and etiological research towards surveillance and intervention research to facilitate an assessment of the effectiveness of current policies, disease trends and future health needs.
A necessary prerequisite for effective planning, implementation and evaluation of NCD prevention programmes is access to reliable and timely information on mortality, morbidity, risk factors and their socio-economic determinants. This approach has been validated in several settings: WHO STEPwise approach to Surveillance (STEPS),27 the Behavioural Risk Factor Surveillance System (BRFSS),28 of the Centers for Disease Control (CDC) in USA, and the use of various database sources such as the WHO Global NCD InfoBase and those used as part of the CINDI and CARMEN regional programmes of WHO. The need to bring together and display existing data is a useful starting point for assessing its quality and availability from the perspective of its ability to give meaningful data over time; it can act as an entry point for activities related to the prevention of NCDs. Standardised epidemiological information greatly facilitates comparative analysis and ongoing modification of interventions. In Pakistan, lack of comprehensive databases for NCDs presents an obstacle to effective priority setting,
targeting of programmes to various population groups, evaluation of process-related activities and long-term evaluation of preventive interventions. The adoption of practical and economical systems to meet these needs have, therefore, been recognized as part of the Action Plan.
There is some potential for strengthening and upgrading conventional data sources such as those that presently exist within administrative systems, public health and primary healthcare structures, individual files, death records and hospital data within the healthcare system in Pakistan. These data
sources, however, suffer several limitations. These include lack of systematic data collection systems and population-based data on NCDs; lack of data for population subgroups with heterogeneous health characteristics; relatively small sample sizes in cross-sectional surveys; lack of longitudinal studies;
and self-selection bias in sampling methods. By and large, existing data sources in Pakistan do not serve the purpose of monitoring population parameters, which this Action Plan aims to impact. For this reason, a more comprehensive, integrated, systematic and sustainable population-based data collection infrastructure needs to be established, maintained and expanded over time. This can then be supplemented by facility-based data collection systems and stand-alone data sources wherever applicable. Appropriate linkages with institutions such as the Pakistan Medical Research Council (PMRC), which can provide sustainable support for surveillance activities,
With the exception of cancer and stroke, disease surveillance is not appropriate for Pakistan as deaths are not registered. This notwithstanding, the feasibility of establishing a mortality sentinel site must be assessed; such data sources can provide adequate information to generate reasonable estimates of mortality in large populations. However, in view of the limited resources that may be available for surveillance monitoring, the IFA has developed a common population surveillance mechanism for all NCDs (with the exception of cancer). The model includes population surveillance of main risk factors that predict many NCDs and combines modules on population surveillance of injuries, mental health and stroke. Guidance has been sought from the WHO STEPWise approach; this offers standardized methods and materials for country-specific information on adult populations. Optional STEPS modules on mental health, injury and stroke have also been included in the surveillance model. The model has also incorporated components from the BRFSS module. In addition, it has been adapted for programme
evaluation; this will enable it to track implementation processes using appropriate indicators, facilitating an assessment of how interventions work and which components contribute most to success. This will enable the surveillance model to measure outcomes and evaluate processes both
qualitatively and quantitatively. Efforts will be made to build on similar data that have already been collected in Pakistan.29
Cost-effectiveness studies have been identified as another priority area for research as part of this Action Plan. While data on the subject exist, there are not enough studies that are applicable and relevant to our setting. Since the results of such studies can better inform decision making for policy purposes, these must be actively disseminated to policy makers, professional
practitioners and the community. Cost-effectiveness of preventive strategies can significantly contribute to gaining support from healthcare authorities for such programmes.
The third priority area for research focuses on identifying causal associations for risk factors that have implications for setting targets for preventive interventions. This has been referred to in detail in the relevant sections.