Public Health Capacity Building for NCDs in LMICs
by
Mohammed K. Ali, Swathi Sekar
  • LAST REVIEWED: 15 June 2015
  • LAST MODIFIED: 25 February 2014
  • DOI: 10.1093/obo/9780199756797-0087

Introduction

Non-communicable diseases (NCDs) such as cardiovascular diseases (CVDs), diabetes, cancers, and chronic respiratory diseases are chronic, silent, and progressive conditions that lead to disabling and often fatal complications (e.g., heart attacks, amputations, etc.). Major societal advances, increases in life expectancies, and changes in environments and individual lifestyles during the 20th century have led to these diseases now accounting for two-thirds of worldwide deaths, and 80 percent of these occur in low- and middle-income countries (LMICs). NCDs are multifactorial—in other words, genetic, lifestyle-related, economic, and psychosocial factors all contribute to development of these diseases. As such, NCDs must be addressed at multiple levels (individual behaviors, programs, health-care delivery, and policies). There are several proven cost-effective policies (e.g., tobacco taxation), preventive services (e.g., cancer screening), and individual behavioural interventions (e.g., lifestyle modification, medication adherence) that have been shown to reduce morbidity and mortality associated with NCDs. However, NCDs are also chronic—meaning that they require long-term prevention efforts (sustained initiatives to address tobacco, physical inactivity, unhealthy diet choices) and care delivery (sustained adherence to therapies and regular preventive screenings for early signs of diseases when they are still treatable, e.g., cervical cancer screening) and cannot be resolved with single, one-time therapies. So, addressing NCDs requires appropriate capacity (the human, financial, and infrastructural resources) that is organized within sustainable systems. For example, delivering NCD preventive and care services requires extensive human resources (e.g., physicians, nurses, allied health staff, community health workers, and administrative staff) and clinics or community facilities. LMICs face particular challenges (e.g., competition for government resources by other sectors, weak health systems, few data to guide health policies), all of which reflect low capacity to address NCDs. Since capacity is broadly defined as human, financial, and infrastructural resources, capacity building or capacity development refers to a broad range of activities (e.g., training, fundraising, institutional development) that can be aimed at individuals, institutions, or society to improve health, wellbeing, and economic opportunities/development. Scholars in this field note that capacity building is most effective when based on a conceptual framework (e.g., the World Health Organization’s “building blocks of health systems”) and incorporates organizational development. In this article, we share and summarize published resources regarding human and infrastructural capacity-building initiatives to address NCDs in LMICs. Although we do not focus on growing financial capacity or advocacy for this, there are several nongovernmental organizations (NGOs) involved in capacity building to address NCDs (e.g., the NCD Alliance). Since there are few texts on this topic, we systematically searched a health journal database (the National Library of Medicine or PubMed) to identify, categorize, and share useful sources of information describing human and infrastructure development programs or policies that support delivery of preventive or care services and health systems enhancement in LMICs. As this is a nascent literature and doesn’t cover the range of topics described in traditional health systems conceptual frameworks, this article is categorized and presents the resources focused on NCD capacity by disease type (overview, CVD, risk factors, cancers, or chronic respiratory diseases). The studies are further sub-classified into sources that identify the capacity challenges or sources that propose or evaluate capacity-building solutions for NCD prevention and control. The article concludes with a short section describing limitations in the research to date and future development.

General Overviews

Defining and addressing capacity needs for NCDs has become an area of major interest following the 2011 United Nations High-Level Meeting on NCDs, as governments and agencies seek efficient approaches to deliver effective NCD care and prevention policies and services. Some of the literature regarding NCDs globally is broad, and tends to have both global and regional foci, but deals with the whole category of NCDs, as opposed to each disease individually. Most of these studies refer to cardiovascular disease (CVD), diabetes, cancers, and chronic respiratory diseases, while injuries and mental health conditions, which are also chronic NCDs, don’t have as much literature devoted to them. This chapter, similarly, does not include mental health and injuries.

Sources that Identify Capacity Challenges

The published commentaries in this area cover the spectrum of defining challenges, advocacy for solutions and/or resources, studies or discussions of specific aspects of capacity that must be addressed (e.g., essential medicines), or suggested approaches to address NCD burdens more effectively in LMICs. Specifically, Mendis, et al. 2007 and Ali, et al. 2013 offer more global commentaries on the availability of supplies and human capacity to address NCDs. Dans, et al. 2011 describes the growing NCD burdens in southeast Asia with a focus on the health system and facilities needed to address this, while Ghannem 2011 advocates for more capacity and community focus on addressing NCDs.

  • Ali, M. K., C. Rabadan-Diehl, J. Flanigan, C. Blanchard, K. M. Venkat Narayan, and M. Engelgau. 2013. Systems and capacity to address global chronic diseases in low- and middle-income countries. Science Translational Medicine 5:181cm4.

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    Amid disparities in NCD burdens and outcomes between countries, this article offers an analysis of the general challenges faced by LMICs and possible recommendations to strengthen capacity and systems for NCD prevention and control in these settings. In particular, the article proposes that evaluating capacity and system needs is important in determining how to strengthen these and effectively deliver NCD prevention and care.

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    • Dans, A., N. Ng, C. Varghese, E. S. Tai, R. Firestone, and R. Bonita. 2011. The rise of chronic non-communicable diseases in southeast Asia: Time for action. Lancet 377.9766: 680–689.

      DOI: 10.1016/S0140-6736(10)61506-1Save Citation »Export Citation »E-mail Citation »

      This paper describes the rise of chronic diseases in Southeast Asia. Although attempts to control NCDs are increasing, this paper makes the argument that more needs to be done including redesigning health-care systems to deliver chronic care (founded on existing primary health-care facilities, but supported by strong referral systems).

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      • Ghannem, H. 2011. The need for capacity building to prevent chronic diseases in North Africa and the Middle East. Eastern Mediterranean Health Journal 17.7: 630–632.

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        In this article, authors outline the problems facing Africa and the Middle East with regard to chronic diseases and discuss the urgent need for capacity-building and community-based programs in order to enhance regional capability for tackling chronic diseases such as CVD, stroke, cancer, and diabetes.

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        • Mendis, S., K. Fukino, A. Cameron, et al. 2007. The availability and affordability of selected essential medicines for chronic diseases in six low- and middle-income countries. Bulletin of the World Health Organization 85.4: 279–288.

          DOI: 10.2471/BLT.06.033647Save Citation »Export Citation »E-mail Citation »

          This study assessed the availability and affordability of medicines used to treat CVD, diabetes, chronic respiratory disease, and glaucoma and to provide palliative cancer care in Bangladesh, Brazil, Malawi, Nepal, Pakistan, and Sri Lanka. The authors noted low accessibility and propose that context-specific policies are required to improve access to essential medicines plus advocate that generic products should be promoted through educating professionals and consumers.

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          Sources That Propose or Evaluate Capacity-Building Solutions

          There are several articles that propose potential avenues to strengthen systems and infrastructure capacity to address NCDs. The recently published book chapter Barry, et al. 2013 discusses the importance of developing competencies as guiding principles when designing workforce training programs for health promotion delivery. Beaglehole, et al. 2008 and Kim, et al. 2006 discuss how care and prevention services can be packaged and delivered through primary care. Meanwhile, Rabkin and Nishtar 2011 specifically proposes leveraging the HIV care delivery platform for NCD health service delivery, and conversely, Mamo, et al. 2007 suggests nurse-based care for diabetes and epilepsy which may have lessons for HIV care. More specific approaches are proposed by Nissinen, et al. 2001, which involves mobilizing communities; Choi, et al. 2008, which discusses the importance and implementation of NCD surveillance; and Samb, et al. 2010, which suggests that as health systems mature, evaluating how they manage NCDs offers a method of comparing the system’s maturity.

          • Barry, M. M., B. Battel-Kirk, and C. Dempsey. 2013. Developing Health Promotion workforce capacity for addressing non-communicable disease globally. In Global Handbook on NCDs and Health Promotion. Edited by D. V. McQueen, 417–440. New York: Springer.

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            This chapter describes competencies that are needed for a health promotion workforce in LMICs. The authors argue that defining competencies is a key aspect of capacity development efforts and increases the likelihood of effective and sustained implementation of health promotion policies and practices. Furthermore, the chapter describes the research on training needs in LMICs for health promotion.

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            • Beaglehole, R., J. Epping-Jordan, V. Patel, et al. 2008. Improving the prevention and management of chronic disease in low-income and middle-income countries: A priority for primary health care. Lancet 372.9642: 940–949.

              DOI: 10.1016/S0140-6736(08)61404-XSave Citation »Export Citation »E-mail Citation »

              The authors describe how management of chronic diseases is fundamentally different from acute care and discuss the importance of an integrated approach to the management of chronic diseases through primary health care. In many countries, this will need to be achieved through non-physician clinicians, due to a lack of doctors. These non-physician health workers will have a leading role in preventing and managing chronic diseases.

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              • Choi, B. C., D. V. McQueen, P. Puska, et al. 2008. Enhancing global capacity in the surveillance, prevention, and control of chronic diseases: Seven themes to consider and build upon. Journal of Epidemiology and Community Health 62.5: 391–397.

                DOI: 10.1136/jech.2007.060368Save Citation »Export Citation »E-mail Citation »

                This paper provides examples and ideas, based on experiences and publications as well as review of the literature, which might enhance global capacity for surveillance of chronic diseases and their prevention and control. These ideas were grouped around seven themes, identified by the acronym “SCIENCE”: Strategy, Collaboration, Information, Education, Novelty, Communication, and Evaluation.

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                • Kim, J. J., J. A. Salomon, M. C. Weinstein, and S. J. Goldie. 2006. Packaging health services when resources are limited: The example of a cervical cancer screening visit. PLoS Medicine 3.11: e434.

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                  This paper presents an analytical framework for packaging multiple interventions during a single point of contact, in an effort to reduce cervical cancer risk. The intention is to take full advantage of the single-visit opportunity to provide additional services. Results show that this type of packaging of other interventions during a one-time visit has potential to increase health gains.

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                  • Mamo, Y., E. Seid, S. Adams, A. Gardiner, and E. Parry. 2007. A primary healthcare approach to the management of chronic disease in Ethiopia: An example for other countries. Clinical Medicine 7.3: 228–231.

                    DOI: 10.7861/clinmedicine.7-3-228Save Citation »Export Citation »E-mail Citation »

                    This paper discusses a community care program that has been developed at Jimma University Hospital in rural southwest Ethiopia. The program involves general-duty nurses who are trained to provide care for chronic disease patients, also allowing for treatment to be provided away from the main hospital. This article is specifically focused on diabetes and epilepsy care and presents a model that can be replicated in more or less developed countries and might also be relevant for HIV care programs.

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                    • Nissinen, A., X. Berrios, and P. Puska. 2001. Community-based non-communicable disease interventions: Lessons from developed countries for developing ones. Bulletin of the World Health Organization 79.10: 963–970.

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                      Offering a perspective from the 1980s, this paper describes how the focus of programs expanded from CVD to NCDs, mainly because of the common risk factors. This focus has also extended to developing countries, where the prevalence of NCDs is growing. The paper provides examples that support the premises that community-based NCD programs are in need of international collaborations and should involve all sectors of the community.

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                      • Rabkin, M., and S. Nishtar. 2011. Scaling up chronic care systems: Leveraging HIV programs to support noncommunicable disease services. Journal of Acquired Immune Deficiency Syndromes 57 (Suppl. 2): S87–S90.

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                        This paper first describes how HIV programs have developed systems, tools, and approaches to support continuity of care in local contexts. The paper then continues to describe how, in many cases, HIV programs have developed practical and contextually appropriate resources that might be used to support nascent programs to address NCDs.

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                        • Samb, B., N. Desai, S. Nishtar, et al. 2010. Prevention and management of chronic disease: A litmus test for health-systems strengthening in low-income and middle-income countries. Lancet 376.9754: 1785–1797.

                          DOI: 10.1016/S0140-6736(10)61353-0Save Citation »Export Citation »E-mail Citation »

                          Most chronic diseases are neglected in the dialogue about global health systems strengthening, despite the fact that NCDs will account for 69 percent of all global deaths by 2030 with 80 percent of these deaths in LMICs. This paper concludes that chronic diseases should be a litmus test for health-systems strengthening.

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                          Cardiovascular Disease (CVD)

                          Cardiovascular diseases (CVDs) are diseases of the heart and blood vessels. Heart attacks and strokes are the commonest CVDs and are the leading causes of death and disability worldwide. CVDs most commonly involve atherosclerosis, a gradual hardening and narrowing of arteries supplying important organs (heart, brain, kidneys, and limbs) due to a combination of inflammatory, blood coagulation, and other metabolic abnormalities (high cholesterol, high blood pressure, and diabetes). CVD prevention and care involves controlling metabolic and lifestyle risk factors, both before and after disease develops, and may involve drugs and modifying lifestyle. Acute care for cardio-metabolic diseases requires recognition, accessible health facilities, and availability of therapeutic options to re-vascularize or at least minimize organ damage. However, CVDs can also be congenital (commonly, structural abnormalities of the heart) or develop on account of infections (e.g., rheumatic heart diseases). Infectious origins of CVD are most commonly seen in LMICs, but not high-income countries.

                          Sources that Identify Capacity Challenges

                          The published articles in this domain discuss human resources (e.g., community health worker approaches), infrastructure and operational needs of delivering complex care (e.g., for congenital heart surgeries), and role of large agencies and policy development. While Deaton, et al. 2011 provides an overview of global CVD burdens, Joubert, et al. 2008 and Mateen 2011 provide focused commentaries on addressing stroke in rural communities and delivery of neurocritical care for developing countries. Rao 2007; Aryanpur Kashani, et al. 1981; and Saxena 2012 all describe the provision of cardiology services, with the former two focused on care and research priorities in pediatric cardiac care. Jabbour, et al. 2003 discusses the use of information technology in supporting CVD prevention services and programs.

                          • Aryanpur Kashani, I., M. Paydar, and J. G. Shakibi. 1981. Priorities of pediatric cardiology in the developed and developing countries. Paediatrician 10.1–3: 148–157.

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                            In this article, the priorities existing in developed and developing countries concerning the approach to pediatric cardiology problems are discussed from the point of view of patient load, facilities available, plus teaching and research in this large field of highly specialized pediatric practice.

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                            • Deaton, C., E. S. Froelicher, L. H. Wu, C. Ho, K. Shishani, and T. Jaarsma. 2011. The global burden of cardiovascular disease. European Journal of Cardiovascular Nursing 10 (Suppl. 2): S5–S13.

                              DOI: 10.1016/S1474-5151(11)00111-3Save Citation »Export Citation »E-mail Citation »

                              This chapter provides background on the global burden of CVD and addresses the role of nurses in helping reverse the trends. If CVD risk factors are left unchecked, it is predicted that CVD will ravage populations in the coming decades.

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                              • Jabbour, S., S. Nishtar, D. Prabhakaran, et al. 2003. Information and communication technology in cardiovascular disease prevention in developing countries: Hype and hope. Report of the International Collaboration on Information Use in Cardiovascular Health Promotion in Developing Countries. International Journal of Cardiology 92.2–3: 105–111.

                                DOI: 10.1016/S0167-5273(03)00093-7Save Citation »Export Citation »E-mail Citation »

                                This paper discusses how information technology (IT) can help sensitize the lay public to the magnitude of cardiovascular diseases, creating awareness about risk states, and can highlight preventive strategies. Several initiatives such as the Global Cardiovascular Infobase have used IT to promote CVD prevention. However, IT must be viewed as part of a broader strategy that addresses the unmet information needs for CVD prevention globally.

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                                • Joubert, J., L. F. Prentice, T. Moulin, et al. 2008. Stroke in rural areas and small communities. Stroke 39.6: 1920–1928.

                                  DOI: 10.1161/STROKEAHA.107.501643Save Citation »Export Citation »E-mail Citation »

                                  This review addresses the issue of setting up appropriate services in rural settings for stroke care. Authors also discuss barriers concerning the feasibility of developing programs according to best-practice recommendations within models that are adapted to local conditions.

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                                  • Mateen, F. J. 2011. Neurocritical care in developing countries. Neurocritical Care 15.3: 593–598.

                                    DOI: 10.1007/s12028-011-9623-7Save Citation »Export Citation »E-mail Citation »

                                    Neurocritical illnesses place a heavily burden on the developing world, and this paper discusses possible steps to improve the global practice of neurocritical care. Additionally, the authors summarize reported mortality rates among neurocritically ill patients in African countries in recent years as an example.

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                                    • Rao, S. G. 2007. Pediatric cardiac surgery in developing countries. Pediatric Cardiology 28.2: 144–148.

                                      DOI: 10.1007/s00246-006-1452-7Save Citation »Export Citation »E-mail Citation »

                                      This paper discusses the challenges associated with employing evolving and adapted methods to cater to pediatric cardiac surgery needs in developing countries. These challenges are especially present when the needs of a very large number of children with congenital heart defects must be dealt with alongside the backdrop of severe budgetary constraints and quick turnover of trained medical professionals.

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                                      • Saxena, A. 2012. Strategies for the improvement of cardiac care services in developing countries: What does the future hold? Future Cardiology 8.1: 29–38.

                                        DOI: 10.2217/fca.11.80Save Citation »Export Citation »E-mail Citation »

                                        This paper discusses the current situation of needing to control the CVD epidemic and improving care of affected populations in developing countries and how resources are not only limited, but also underutilized. Generating relevant data regarding the actual burden, risk factors, morbidity and mortality, policy interventions for the control of risk factors, raising public awareness about the various CVDs, and building research capacity are all necessary for controlling the CVD epidemic.

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                                        Sources that Propose or Evaluate Capacity-building Solutions

                                        In terms of the literature proposing or testing interventions to improve CVD capacity, Wilson, et al. 2003 and Mensah 2003 provide macro-level perspectives on the role of large agencies and policy in addressing heart attacks and strokes. Chow, et al. 2009 and Chan and Kaufman 2009 describe more grass-roots approaches, through health worker capacity and mobile phones as conduits to improve care and prevention. Nordet, et al. 2008 discusses rheumatic heart disease prevention, while Liu 2009 and Talwar, et al. 2008 describe experiences in education for pediatric cardiology care delivery and potential avenues to reduce surgical costs for congenital heart disease repairs. Hauswald and Yeoh 1997 provides a more focused commentary that estimates costs and benefits of pre-hospital care for CVD.

                                        • Chan, C. V., and D. R. Kaufman. 2009. Mobile phones as mediators of health behavior change in cardiovascular disease in developing countries. Studies in Health Technology and Informatics 143:453–458.

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                                          This paper discusses the growing market and properties of mobile phones that permit opportunities for innovation in promoting CVD self-management. As mobile phones support many modes of communication, they can be utilized as a means for achieving behavior modification. This paper explores both the opportunities and challenges of using mobile phones to support lifestyle and behavior modification in developing countries.

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                                          • Chow, C. K., R. Joshi, A. K. Gottumukkala, et al. 2009. Rationale and design of the Rural Andhra Pradesh Cardiovascular Prevention Study (RAPCAPS): A factorial, cluster-randomized trial of 2 practical cardiovascular disease prevention strategies developed for rural Andhra Pradesh, India. American Heart Journal 158.3: 349–355.

                                            DOI: 10.1016/j.ahj.2009.05.034Save Citation »Export Citation »E-mail Citation »

                                            The investigators aimed to implement and evaluate a CVD prevention program in rural India using a cluster-randomized trial. The two strategies of CVD prevention evaluated include an algorithm-based care approach and a health promotion campaign. The results of a study like this will provide evidence of effectiveness of a practical mechanism for CVD preventive care designed for resource-poor areas of India.

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                                            • Hauswald, M., and E. Yeoh. 1997. Designing a prehospital system for a developing country: Estimated cost and benefits. American Journal of Emergency Medicine 15.6: 600–603.

                                              DOI: 10.1016/S0735-6757(97)90167-4Save Citation »Export Citation »E-mail Citation »

                                              This study estimated the costs and benefits of developing a pre-hospital care system for Kuala Lumpur, Malaysia, which currently has no emergency medical services (EMS). If a North American EMS model is used as a template, it would cost approximately $2.5 million per year and might save seven lives. The authors conclude that developing countries should consider alternate, more cost-effective models.

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                                              • Liu, J. 2009. Challenges and progress of the pediatric cardiac surgery in Shanghai Children’s Medical Center: A 25-year solid collaboration with Project HOPE. Seminars in Thoracic Cardiovascular Surgery: Pediatric Cardiac Surgery Annual 12–18.

                                                DOI: 10.1053/j.pcsu.2009.01.020Save Citation »Export Citation »E-mail Citation »

                                                Although congenital heart disease (CHD) has remained a health challenge for children and families, only a limited number of children with CHD in this region of China were able to be operated for lesion repair. This paper, however, discusses how the situation has changed since the 1990s and treatment for pediatric CHDs has been greatly improved and developed in China through collaboration with Project HOPE, an international health professional education organization.

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                                                • Mensah, G. A. 2003. A heart-healthy and “stroke-free” world through policy development, systems change, and environmental supports: A 2020 vision for sub-Saharan Africa. Ethnicity and Disease 13.2 (Suppl. 2): S4–S12.

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                                                  Although sub-Saharan Africa is a region affected by many infectious and parasitic diseases, CVD and other chronic NCDs are on the increase and represent significant burdens for public health services. To support heart-healthy choices, emphasis must be placed on policy development, system changes, and issues concerning the social environment which influence risk factor development (such as tobacco, physical activity, and poor nutrition).

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                                                  • Nordet, P., R. Lopez, A. Dueñas, and L. Sarmiento. 2008. Prevention and control of rheumatic fever and rheumatic heart disease: The Cuban experience (1986–1996–2002). Cardiovascular Journal of Africa 19.3: 135–140.

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                                                    Authors describe the methods and results of epidemiologic studies in selected areas of Cuba that were aimed at estimating the prevalence and characteristics of rheumatic fever (RF) and rheumatic heart disease (RHD). It was shown that there was a progressive decline in the occurrence and severity of RF and RHD, and that the implementation of the program did not incur high health-care costs.

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                                                    • Talwar, S., S. K. Choudhary, B. Airan, et al. 2008. Reducing the costs of surgical correction of congenitally malformed hearts in developing countries. Cardiology in the Young 18.4: 363–371.

                                                      DOI: 10.1017/S1047951108002448Save Citation »Export Citation »E-mail Citation »

                                                      This review discusses the problems in managing patients in developing countries who require surgical correction of congenitally malformed hearts. The paper explores the importance of containing costs through a multipronged approach.

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                                                      • Wilson, E. E., and World Heart Federation. 2003. The role of the World Heart Federation in cardiovascular health promotion and disease prevention in developing countries with a special emphasis on sub-Saharan Africa. Ethnicity and Disease 13.2 (Suppl. 2): S164–S166.

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                                                        This article discusses the role that the World Heart Federation (WHF) is playing in building capacity through the newly established African Heart Network (AHN) and the Pan-African Society of Cardiology (PASCAR). These organizations will work together in the areas of tobacco control and hypertension to build sustained capacity for health promotion, effective clinical interventions, and ultimately, policy change.

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                                                        CVD Risk Factors

                                                        The INTERHeart study of first onset heart attacks across multiple countries showed that nine risk factors accounted for 90 percent of all heart disease. Diabetes, hypertension, elevated lipid levels, tobacco use, obesity, physical inactivity, and unhealthy diets are commonly described risk factors for cardiovascular disease (CVD). Similarly, the INTERStroke study showed that a similar group of risk factors account for most strokes. Each risk factor is individually associated with elevated coronary vascular and cerebrovascular risk, and when they occur together, these risk factors elevate the risk in a multiplicative fashion. Most of these CVD risk factors can be addressed by lifestyle modifications, medications, or a combination. Delivering cardio-metabolic prevention and control, therefore, requires a combination of motivated health workers that are skilled in facilitating and maintaining lifestyle modifications among their patients, as well as a supply of medications that effectively contain metabolic abnormalities in the body.

                                                        Sources that Identify Capacity Challenges

                                                        Prevention and control of cardio-metabolic risk factors through lifestyle changes and medications are described in the published resources included below, at the community, clinic, and policy levels. Beran, et al. 2005 and Beran, et al. 2006 describe the inadequate supply of insulin for managing diabetes in African clinics, using case studies and a situational assessment. Meanwhile, at the community level, Ezenwaka and Eckel 2011 suggests how educational programs might help with preventing diabetes complications. In both Engelgau, et al. 2003 and Reddy, et al. 2012, large issues like diabetes care/prevention and tobacco control are viewed from a macro-perspective and discussed in the context of the challenges in integrating these into routine systems in LMICs.

                                                        • Beran, D., J. S. Yudkin, and M. de Courten. 2005. Access to care for patients with insulin-requiring diabetes in developing countries: Case studies of Mozambique and Zambia. Diabetes Care 28.9: 2136–2140.

                                                          DOI: 10.2337/diacare.28.9.2136Save Citation »Export Citation »E-mail Citation »

                                                          In this paper, authors describe the barriers to care for patients with insulin-dependent diabetes in Mozambique and Zambia, collecting information through interviews, discussions, site visits, and document reviews. There are problems with equitable distribution of insulin and availability of syringes and testing equipment in these settings.

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                                                          • Beran, D., J. S. Yudkin, and M. de Courten. 2006. Assessing health systems for type 1 diabetes in sub-Saharan Africa: Developing a “Rapid Assessment Protocol for Insulin Access.” BMC Health Services Research 6:17.

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                                                            This paper reviews the development of the Rapid Assessment Protocol for Insulin Access, comprising of a series of questionnaires and protocol for gathering the required data. This situational analysis for Type 1 diabetes is aimed at helping make recommendations to national Ministries of Health and Diabetes Associations. It provides information on patients’ access to insulin, syringes, monitoring, and care in Mali, Mozambique, and Zambia.

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                                                            • Engelgau, M. M., K. M. Narayan, J. B. Saaddine, and F. Vinicor. 2003. Addressing the burden of diabetes in the 21st century: Better care and primary prevention. Journal of the American Society of Nephrology 14.7 (Suppl. 2): S88–S91.

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                                                              This article discusses the strategies and elements required to mitigate the human and economic burdens of the worldwide diabetes pandemic. Efficacious treatments are currently available, but the quality of diabetes care being delivered is suboptimal in both developed and developing countries. Some progress to improve quality has been made through national strategies.

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                                                              • Ezenwaka, C., and J. Eckel. 2011. Prevention of diabetes complications in developing countries: Time to intensify self-management education. Archives of Physiology and Biochemistry 117.5: 251–253.

                                                                DOI: 10.3109/13813455.2011.602692Save Citation »Export Citation »E-mail Citation »

                                                                Describing the burdens faced globally by diabetes-related deaths, this paper describes the importance of culturally adaptable educational interventions to address diabetes which consider the economic constraints. The paper concludes that diabetes-related deaths could be reduced in developing countries through culturally appropriate diabetes self-management education.

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                                                                • Reddy, K. S., A. Yadav, M. Arora, and G. P. Nazar. 2012. Integrating tobacco control into health and development agendas. Tobacco Control 21.2: 281–286.

                                                                  DOI: 10.1136/tobaccocontrol-2011-050419Save Citation »Export Citation »E-mail Citation »

                                                                  This paper explores how the Framework Convention on Tobacco Control can be effectively implemented. This implementation requires multi-sectoral efforts that can integrate tobacco control into broader health and development agendas such as food and water security, environment, the right to education, and human rights, especially in developing countries like India.

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                                                                  Sources that Propose or Evaluate Capacity-building Solutions

                                                                  Three papers focus on tobacco control at multiple levels: Hovell, et al. 2004 on clinician leadership, while Nichter, et al. 2010 and Abdullah and Husten 2004 pilot and discuss the integration of individual-focused cessation programs, and Lando, et al. 2005 examines institutions and resources to support global tobacco control efforts. Focusing on diabetes, Amoah, et al. 2000 and Abbas, et al. 2011 describe educational programs to improve diabetes care and prevent complications, while Ajay and Prabhakaran 2011 describes the use of mobile phones to support diabetes self-management.

                                                                  • Abbas, Z. G., J. K. Lutale, K. Bakker, N. Baker, and L. K. Archibald. 2011. The ‘Step by Step’ Diabetic Foot Project in Tanzania: A model for improving patient outcomes in less-developed countries. International Wound Journal 8.2: 169–175.

                                                                    DOI: 10.1111/j.1742-481X.2010.00764.xSave Citation »Export Citation »E-mail Citation »

                                                                    This paper explains the “Step by Step” Diabetic Foot Project in Tanzania. The project was initiated to train health-care personnel in diabetic foot management, facilitate transfer of knowledge and expertise, and improve patient education. It is described how this project improved foot ulcer management for persons with diabetes and resulted in permanent foot clinics across the country.

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                                                                    • Abdullah, A. S. and C. G. Husten. 2004. Promotion of smoking cessation in developing countries: A framework for urgent public health interventions. Thorax 59.7: 623–630.

                                                                      DOI: 10.1136/thx.2003.018820Save Citation »Export Citation »E-mail Citation »

                                                                      This article explores smoking cessation as a means of reducing disease burden, examines the factors that might make smoking cessation difficult to achieve in developing countries, and proposes a framework for public health action. The framework integrates the expertise of health-care professionals with national commitment, strengthening community participation, developing clear guidelines, and even mobilizing the business community.

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                                                                      • Ajay, V. S., and D. Prabhakaran. 2011. The scope of cell phones in diabetes management in developing country health care settings. Journal of Diabetes Science and Technology 5.3: 778–783.

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                                                                        The authors explore how cell phones can be used as a tool for surveillance, service delivery, evidence-based care, and supply chain management for diabetes (e.g., providing health messages as part of diabetes education in primary care settings). Cell phones can act as a vehicle for continuing medical education and even patient education, self-management, and compliance. This paper describes the importance of evaluations of cell phone applications to properly utilize this resource.

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                                                                        • Amoah, A. G., S. K. Owusu, J. W. Acheampong, et al. 2000. A national diabetes care and education programme: The Ghana model. Diabetes Research and Clinical Practice 49.2–3: 149–157.

                                                                          DOI: 10.1016/S0168-8227(00)00140-6Save Citation »Export Citation »E-mail Citation »

                                                                          This paper provides an account for how a national diabetes care and education program was developed in Ghana and the role of international collaborators, medical schools, industry, and government health-care institutions. This approach is described as a top-down approach and is recommended for other developing countries which intend to incorporate diabetes care and education into their respective health-care systems.

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                                                                          • Hovell, M., S. Roussos, L. Hill, N. W. Johnson, C. Squier, and M. Gyenes. 2004. Engineering clinician leadership and success in tobacco control: Recommendations for policy and practice in Hungary and Central Europe. European Journal of Dental Education 8 (Suppl. 4): 51–60.

                                                                            DOI: 10.1111/j.1399-5863.2004.00324.xSave Citation »Export Citation »E-mail Citation »

                                                                            This paper discusses important ways that health-care professionals can counter the tobacco industry’s influence on patients and communities in Hungary and Central Europe. The components of a successful tobacco control program are described in this paper, incorporating recommendations for research, practice, and policy that are necessary to establish a culture that removes the harm of the tobacco industry on the society.

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                                                                            • Lando, H. A., B. Borrelli, and K. E. Warner. 2005. The landscape in global tobacco control research: A guide to gaining a foothold. American Journal of Public Health 95.6: 939–945.

                                                                              DOI: 10.2105/AJPH.2004.047167Save Citation »Export Citation »E-mail Citation »

                                                                              Authors describe the existing resources, both financial and structural, to support global tobacco control research and strengthen research capacity in developing countries. The authors identify key organizations that support these international efforts and provide examples of partnerships between developed and developing countries, resulting in recommendations for advancing global tobacco research.

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                                                                              • Nichter, M., M. Nichter, M. Muramato, et al. 2010. Project Quit Tobacco International: Laying the groundwork for tobacco cessation in low- and middle-income countries. Asia-Pacific Journal of Public Health 22.3 (Suppl.): 181S–188S.

                                                                                DOI: 10.1177/1010539510373023Save Citation »Export Citation »E-mail Citation »

                                                                                This article describes pilot interventions being launched in ten medical colleges in India and Indonesia to (a) integrate tobacco into their four-year training programs, (b) establish illness-specific cessation clinics, and (c) involve colleges in community outreach efforts to promote smoke-free households. This article reports on successes, challenges, and lessons learned.

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                                                                                Cancers

                                                                                Cancers are highly feared diseases and are characterized by aggressive mutated immortal cells replicating and forming tumors that invade tissues and organs in the body causing destruction and eventual death. Cancers have been linked to genetic (e.g., breast cancer genes), viral (e.g., hepatitis B), environmental (e.g., pollutants), and lifestyle (e.g., tobacco use) risk factors. Detection usually requires imaging of the body or testing body fluid or tissue specimens. Treatments often require surgical, radiotherapeutic, or chemotherapeutic approaches to remove or reduce the size of the tumor(s) and its (their) impacts. Early detection through screening may be beneficial for some cancers and there are guidelines for screening for most types of cancers (e.g., breast, cervical, colon). To achieve high levels of coverage for screening requires knowledge and empowerment among the general population as well as human capacity, laboratory facilities, and treatment or referral options.

                                                                                Sources that Identify Capacity Challenges

                                                                                The published resources included below have more articles related to breast and cervical cancer and discuss the roles of human resources, vaccines, and agencies that develop guidelines. Five articles focus on breast cancer. Agarwal, et al. 2009; Yip, et al. 2011; Smith, et al. 2006; Anderson, et al. 2003; and Harford, et al. 2008 all discuss breast cancer in the context of developing countries and describe common challenges to detection, diagnosis, and treatment, as well as guidelines to overcome these obstacles. Agarwal, et al. 2009 reports findings and discussions from a 2007 conference on breast surgeries, while Yip, et al. 2011 and Smith, et al. 2006 both describe resource challenges discussed at the 2010 and 2005 Breast Health Global Initiative meetings, respectively. Anderson, et al. 2003 and Harford, et al. 2008 were sequential reports examining the development of breast care guidelines and then the implementation of these guidelines in systems and practice, respectively. Meanwhile, Underwood, et al. 2009 discusses gaps in cervical cancer prevention and control nursing. Biellik, et al. 2009 and Andrus, et al. 2008 both describe financing options and lessons learned to implement vaccination to prevent cancerous changes of the cervix.

                                                                                • Agarwal, G., P. Ramakant, E. R. Forgach, et al. 2009. Breast cancer care in developing countries. World Journal of Surgery 33.10: 2069–2076.

                                                                                  DOI: 10.1007/s00268-009-0150-zSave Citation »Export Citation »E-mail Citation »

                                                                                  This article provides a collective edited summary of the presentations at a symposium titled “Breast Cancer Care in Developing Countries,” held as part of the Breast Surgery International program at the International Surgical Week, Montreal, Canada, August 2007.

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                                                                                  • Anderson, B. O., S. Braun, R. W. Carlson, et al. 2003. Overview of breast health care guidelines for countries with limited resources. Breast Journal 9 (Suppl. 2): S42–S50.

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                                                                                    This paper provides an overview of information covered during the Global Summit Consensus Conference. The purpose of this conference was to begin the process of developing guidelines for improving breast health care in countries identified by the World Health Organization as either low- or medium-level income. Breast cancer experts and panels discussed how limited resources can best be applied to improve three areas of breast health care—early detection, diagnosis, and treatment.

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                                                                                    • Andrus, J. K., J. Sherris, J. W. Fitzsimmons, M. A. Kane, and M. T. Aguado. 2008. Introduction of human papillomavirus vaccines into developing countries: International strategies for funding and procurement. Vaccine 26 (Suppl. 10): K87–K92.

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                                                                                      The authors of this paper explore different international vaccine financing and procurement strategies used by the Pan American Health Organization, United Nations Children’s Fund, the Global Alliance for Vaccines and Immunization, the Gulf Cooperation Model, and Advanced Market Commitments. The aim of this paper is to identify lessons learned to help ensure equitable distribution of life-saving vaccines for cervical cancer prevention, with a specific emphasis on sustainability.

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                                                                                      • Biellik, R., C. Levin, E. Mugisha, et al. 2009. Health systems and immunization financing for human papillomavirus vaccine introduction in low-resource settings. Vaccine 27.44: 6203–6209.

                                                                                        DOI: 10.1016/j.vaccine.2009.08.003Save Citation »Export Citation »E-mail Citation »

                                                                                        This descriptive article synthesizes findings regarding health system and immunization financing that were collected through formative qualitative research studies in India, Peru, Uganda, and Vietnam using a non-probability sample of national and sub-national stakeholders. The study recommends appropriate and effective strategies for HPV vaccine delivery in low-resource settings.

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                                                                                        • Harford, J., E. Azavedo, and M. Fischietto. 2008. Guideline implementation for breast healthcare in low- and middle-income countries: Breast healthcare program resource allocation. Cancer 113.8 (Suppl.): 2282–2296.

                                                                                          DOI: 10.1002/cncr.23841Save Citation »Export Citation »E-mail Citation »

                                                                                          This report describes how health-care systems in LMICs can design, implement, and measure the performance of a breast care program (BCP). Health ministers, other policymakers, health-care personnel, administrators, and anyone else involved in developing a BCP can use and adapt this framework to improve outcomes and ensure more effective use of resources.

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                                                                                          • Smith, R. A., M. Caleffi, U. S. Albert, et al. 2006. Breast cancer in limited-resource countries: Early detection and access to care. Breast Journal 12 (Suppl. 1): S16–S26.

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                                                                                            This paper explores the results of the Breast Health Global Initiative (BHGI) summit in January 2005. The Early Detection and Access to Care Panel affirmed that all women should be supported in seeking care and should have access to appropriate, affordable diagnostic tests and treatment and stated that there should be some enhancements to facilities both for symptomatic and asymptomatic women.

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                                                                                            • Underwood, S. M., E. Ramsay-Johnson, A. Dean, J. Russ, and R. Ivalis. 2009. Expanding the scope of nursing research in low resource and middle resource countries, regions, and states focused on cervical cancer prevention, early detection, and control. Journal of the National Black Nurses Association 20.2: 42–54.

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                                                                                              This report provides an overview of cervical cancer epidemiology and etiology, and identifies “gaps” in the nursing literature specific to cervical cancer prevention and control. These gaps are emphasized in this report as areas for consideration by nurses within the practice setting.

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                                                                                              • Yip, C. H., E. Cazap, B. O. Anderson, et al. 2011. Breast cancer management in middle-resource countries (MRCs): Consensus statement from the Breast Health Global Initiative. Breast 20 (Suppl. 2): S12–S19.

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                                                                                                This paper explains how the pattern of disease is shifting from infectious diseases to NCDs in middle-resource countries. The Middle Resource Scenarios Working Group of the Breast Health Global Initiatives 2010 Global Summit identified common issues and obstacles to breast cancer detection, diagnosis, and treatment—these included sustained government financing, better access to anticancer drugs, and rehabilitation programs for survivors.

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                                                                                                Sources that Propose or Evaluate Capacity-building Solutions

                                                                                                In terms of addressing cancers, Baig and Ali 2006 and Azenha, et al. 2011 approach breast cancer through the lens of individual-focused approaches to improve detection and institutions involved in different breast cancer awareness and treatment roles. For cervical cancer, Agurto, et al. 2006; Gajalakshmi, et al. 1996; and Mauad, et al. 2010 propose ways to improve screening in LMIC settings—improving screening in primary care, training village health workers to screen for cervical cancer, and using mobile units to screen, respectively. Aswani, et al. 2012 describes lessons learned while setting up a head and neck cancer unit in developing country settings, while Qaddoumi and Bouffet 2009 describes the experiences of using telemedicine to improve pediatric neuro-oncology.

                                                                                                • Agurto, I., J. Sandoval, M. De La Rosa, and M. E. Guardado. 2006. Improving cervical cancer prevention in a developing country. International Journal for Quality in Health Care 18.2: 81–86.

                                                                                                  DOI: 10.1093/intqhc/mzi100Save Citation »Export Citation »E-mail Citation »

                                                                                                  This article explores how to enhance delivery of services for cervical cancer prevention, using continuous quality improvement, in a primary health-care system in El Salvador. Indicators that were used included the number of women screened for the first time, turnaround time, and follow-up time.

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                                                                                                  • Aswani, J., K. Baidoo, and J. Otiti. 2012. Establishing a head and neck unit in a developing country. Journal of Laryngology and Otology 126.6: 552–555.

                                                                                                    DOI: 10.1017/S0022215112000333Save Citation »Export Citation »E-mail Citation »

                                                                                                    This paper explores the challenges and avenues to establishing a head and neck center in developing countries. Providing surgeons and support personnel, increasing cancer awareness in local communities, and establishing a dedicated head and neck institute are all crucial. The paper uses the Karl Storz Fellowship in Advanced Head and Neck Cancer at the University of Cape Town, South Africa, as an example of a leader in this field.

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                                                                                                    • Azenha, G., L. P. Bass, M. Caleffi, et al. 2011. The role of breast cancer civil society in different resource settings. Breast 20 (Suppl. 2): S81–S87.

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                                                                                                      This report reviews organizational features and program activities of 154 nongovernmental organizations (NGOs) involved in breast cancer control from thirty-five countries to demonstrate how civil society, or NGOs, can play an essential role in breast cancer control. Breast cancer programs respond to the local breast cancer burdens and reflect the available community-based resources for cancer control within the country or region they serve.

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                                                                                                      • Baig, S., and T. S. Ali. 2006. Evaluation of efficacy of self-breast examination for breast cancer prevention: A cost effective screening tool. Asian Pacific Journal of Cancer Prevention 7.1: 154–156.

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                                                                                                        This paper evaluates the efficacy of breast self-exams as an early and cost-effective cancer screening measure among Pakistani women. The paper also explores the role of community health nurses as well as lady health workers in educating women, to possibly lower the cancer burden. The paper stresses the importance of these screening measures as breast cancer is the second most common cause of cancer deaths among Pakistani women.

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                                                                                                        • Gajalakshmi, C. K., S. Krishnamurthi, R. Ananth, and V. Shanta. 1996. Cervical cancer screening in Tamilnadu, India: A feasibility study of training the village health nurse. Cancer Causes Control 7.5: 520–524.

                                                                                                          DOI: 10.1007/BF00051884Save Citation »Export Citation »E-mail Citation »

                                                                                                          This study in Tamil Nadu, India, examined whether village health nurses (VHNs) could be trained quickly to identify a cervical abnormality by visual inspection so that cervical cancer could be found at an earlier stage. Within two years, 6,459 eligible women in the study area were screened and there was 95 percent agreement in results between VHNs and gynecologists.

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                                                                                                          • Mauad, E. C., S. M. Nicolau, U. A. Gomes, et al. 2010. Can mobile units improve the strategies for cervical cancer prevention? Diagnostic Cytopathology 38.10: 727–730.

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                                                                                                            This study evaluates the application of mobile units (MUs) for cervical cancer screening in Brazil. Many barriers to accessing medical care, stemming from inequity of the public health system, are explored. The study shows that MUs can significantly overcome the gaps in accessibility of the public health system.

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                                                                                                            • Qaddoumi, I., and E. Bouffet. 2009. Supplementation of a successful pediatric neuro-oncology telemedicine-based twinning program by e-mails. Telemedicine Journal and E-Health 15.10: 975–982.

                                                                                                              DOI: 10.1089/tmj.2009.0043Save Citation »Export Citation »E-mail Citation »

                                                                                                              This paper evaluated the impact of e-mail exchanges on the development of a neuro-oncology twinning program between the King Hussein Cancer Center (KHCC) in Amman, Jordan, and the Hospital for Sick Children in Toronto, Canada, to address the growing gaps between developing and developed countries in the availability of treatment for pediatric subspecialties.

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                                                                                                              Chronic Obstructive Pulmonary Disease (COPD)

                                                                                                              Chronic respiratory diseases include asthma and chronic obstructive pulmonary diseases (COPDs) such as emphysema and chronic bronchitis. Tobacco use is a potent risk factor for COPD and longstanding use results in emphysema (destruction of lung tissue leading to collapse of airways during exhaling) or chronic bronchitis (characterized by inflammation of large airways and chronic mucus production plus cough) or both. Treatment involves smoking cessation and methods to manage symptoms and distress. The most relevant study related to capacity for chronic respiratory disease was by Khan, et al. 1995 which is focused on auditing asthma care and found important care gaps.

                                                                                                              • Khan, J. A., S. Saghir, G. Tabassum, and S. F. Husain. 1995. An audit on hospital management of bronchial asthma. Journal of the Pakistan Medical Association 45.11: 298–300.

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                                                                                                                The purpose of this study was to see if care given to patients with asthma meets accepted international standards. Several gaps were identified through the audit, such as poor documentation of signs indicating severe asthma. This review concluded that care given to asthma patients is far from satisfactory and not currently meeting international standards.

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                                                                                                                Limitations and Future Directions

                                                                                                                There are a number of limitations of this work. First, this article is based on what is available in the published literature, and unfortunately, the data and articles regarding capacity building for NCDs in LMICs is limited. Second, this is an emerging topic, and as more data and experiences regarding institutional development surface, there will be more to discuss in this realm. Third, as it stands currently, the article combines data regarding human and infrastructural development, as well as merging data and studies reporting capacity development programs for prevention and treatment. As the literature on these issues grows, it is hoped that these can be separated clearly and more clear themes and best practices can be generated and disseminated. Lastly, health systems and service delivery achieve the best outcomes when suited to the context and needs of the populations they serve. Chalkidou, et al. 2010 describes the importance of decision-making based on local needs and values. They describe how funding agencies and institutions like the National Institute of Health and Clinical Excellence (NICE) in the United Kingdom are partnering with national governments to find ways to improve local data collection and usage for decision-making. To date, the literature on these issues is scattered, and this makes it hard for local systems and governments to make decisions when the data and experiences are based on other communities or countries. It is encouraged that implementation sciences and research regarding capacity and capacity development should be a key element of every LMIC government’s health agenda going forward. With greater local evidence, capacity development, alignment of priorities, and functioning of systems will all benefit greatly.

                                                                                                                • Chalkidou, K., R. Levine, and A. Dillon. 2010. Helping poorer countries make locally informed health decisions. BMJ 341:c3651.

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                                                                                                                  This article describes how increased funding for health in poor countries must be coupled with effective decision-making to expand access, reduce financial burdens, and improve health. To strengthen local decision-making, NICE International partners with in-country stakeholders and governments to collect, analyze, and use data for decision-making. The article uses case examples from countries in Africa, Asia, and Latin America to illustrate.

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