23 November 2015

Attempts to prioritize NCDs: What can nutrition learn?

I really like articles that pose questions that are pretty fundamental.  Here is one from 2012 that I somehow missed.

The paper is “Political priority in the global fight against non-communicable disease” by Anthony Maher and Devi Sridhar in the Journal of Global Health (Vol 2, No 2, 2012). 
The paper asks two fundamental and interrelated questions (1) “Why is there such meagre funding on the table for the prevention and control of NCDs?" And (2) “Why has a global plan of action aimed at halting the spread of NCDs been so difficult to achieve?”  The questions are posed because (a) NCDs are responsible for a large and growing share of the global burden of disease, (b) a number of cost effective “best buys” have been identified by WHO and yet (c) the top donors in global health (the US Government, the World Bank and the Bill and Melinda Gates Foundation are mentioned) allocate less than 2% of their budgets to NCDs.

They use the Shiffman’s political priority tool (Shiffman, Bulletin of the World Health Organisation, 2009) as a way of addressing the questions. Shiffman’s framework identifies 3 variables that are essential to raising the priority of a given issue (a) ideas, (b) institutions, and (c) policy communities.

Using this framework the authors point out things holding back the prioritization of the NCD community:
1.  Labelling something as “non” might mean it is a non-starter or a non issue and it also fails to communicate that NCDs are communicable, not through infection routes, but via social norm routes.

2. The diseases have not been humanized—we cannot put a human face to the suffering as we can to say polio.

3. There is a lack of a short causal chain and so NCD generation cannot be attributed to the “deliberate actions of specific actions” (unlike smoking).

4. The frequent use of the term “epidemic” may stimulate urgency in some policymakers but others consider it a barrier to innovation (ie patents are no longer moral) and a guarantor of ineffectual drugs. 

5. The power of the private sector to frame and set norms must not be ignored and indeed must be taken into account when designing strategies for prioritizing NCDs. Rather than see the private sector as a structural force to be resisted, they argue that social movements begin within communities and so it is important to participate in a process of “socialization through which boundaries between contested and shared ideas are debated, articulated and redefined”.  The authors cite the Pan American Health Organisation’s Forum for Action on Chronic Disease which brings the 32 countries in the region together with business representatives under a clear set of rules on inclusion, admission and removal.

Overarching all of this, the authors make the case that objective evidence is important to convince policymakers, but many more influences are subjective.  All routes need to be pursued, in orchestra, by all stakeholders. 

There are many lessons for malnutrition.

On messaging we are not doing well (stunting, micronutrients, SAM etc). 
We can only humanize the problems when they are very extreme (several acute wasting or obesity and many would argue that the way we do it dehumanizes the victims).
The long causal chain to malnutrition allows bickering between sectors (although multisectoral platforms have helped) and permits ideological divides about personal responsibility and the environmental drivers of individual behavior to rumble on. 
And on the private sector, we are all over the place.  We seem terrified of dialogue-the very thing the article says is the way forward.  I had not read this paper until November 2015 and was pleased to see the alignment with the Global Nutrition Report's 2015’s recommendation for the 4 major UN agencies (call to action 9) to establish a Forum or Commission that formulates norms of participation, conduct and behavior. 

FAO, WHO, UNICEF and WFP—please get going on setting up a structured forum for this dialogue about and with private sector representatives on nutrition.  Divided communities are unattractive propositions for future investors.

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