Preventing Chronic Diseases: Taking Stepwise Action

In this article, the authors state that scientific knowledge to achieve a new global goal for the prevention of chronic diseases - a 2% yearly reduction in rates of death from chronic disease over and above projected declines during the next 10 years - already exists. However, many low-income and middle-income countries must deal with the practical realities of limited resources and a double burden of infectious and chronic diseases. This paper presents a planning framework that can be used in these contexts: the stepwise framework for preventing chronic diseases. Countries such as Indonesia, the Philippines, Tonga, and Vietnam have applied the stepwise planning framework. According to the paper, their experiences illustrate how the stepwise approach has general applicability to solving chronic disease problems without sacrificing specificity for any particular country. The stepwise framework offers a flexible and practical approach to assist ministries of health in balancing diverse needs and priorities while implementing evidence-based interventions.

The framework is guided by a set of principles based on a public health approach to chronic disease prevention and control:

• The national level of government provides the unifying framework for chronic disease prevention and control, so that actions at all levels and by all stakeholders are mutually supportive.
• Intersectoral action is necessary at all stages of policy formulation and implementation because major determinants of the chronic disease burden lie outside the health sector.
• Policies and plans focus on the common risk factors and cut across specific diseases.
• As part of comprehensive public-health action, population-wide and individual interventions are combined.
• In recognition that most countries will not have the resources to immediately do everything implied by the overall policy, activities that are immediately feasible and likely to have the greatest impact for the investment are selected first for implementation. This principle is the heart of the stepwise approach.
• Locally relevant and explicit milestones are set for each step and at each level of intervention with a particular focus on reducing health inequalities.

Across these and other countries, the following factors have been associated with successful implementation:

• A high-level political mandate to develop a national policy framework.
• A committed group of advocates who are often involved with estimating need, advocating for action, and developing the national policy and plan.
• International collaboration providing political and technical support.
• Wide consultation in the process of drafting, consulting, reviewing, and re-drafting the policy until endorsement is achieved.
• Development and implementation of a consistent and compelling communication strategy for all stages of the process.
• Clarity of vision on a small set of outcome-oriented objectives.