Integrated Population-Based Surveillance of Noncommunicable Diseases

Abstract

The escalating burden of noncommunicable diseases (NCDs) worldwide warrants an urgent public health response. Resource constraints and other factors necessitate an integrated and concerted approach to the range of NCDs. A necessary prerequisite for effective planning, implementation, and evaluation of NCD prevention programs is access to reliable and timely information on mortality, morbidity, risk factors, and their socioeconomic determinants. However, there is limited experience in the setting up of integrated NCD surveillance models in low-resource settings.

As part of the National Action Plan for the Prevention and Control of NCDs in Pakistan, an integrated, systematic, and sustainable population-based NCD surveillance system is being established, and will be maintained and expanded over time. This is 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. In addition, the model has been adapted for program 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 paper outlines the first activity in this sequential process, including its merits and limitations.

Introduction

Noncommunicable diseases (NCDs) accounted for an estimated 33.4 million deaths worldwide in the year 2002; of these, 72% occurred in the developing countries.¹ South Asia has one of the highest prevalence of coronary artery disease (CAD) compared to other world regions.² In Pakistan, NCDs and injuries are among the top ten causes of mortality and morbidity.³ Estimates indicate that they account for approximately 25% of total deaths.⁴ One in three adults aged >45 years suffers from high blood pressure.⁵ The prevalence of diabetes is reported at 10%, whereas 40% of men and 12.5% of women use some form of tobacco.6, 7 Karachi reports one of the highest incidences of breast cancer among Asian populations.⁸ In addition, estimates indicate that there are 1 million severely mentally ill and >10 million individuals with neurotic mental illnesses.⁹ Furthermore, 1.4 million road traffic crashes were reported in the country in 1999. Of these, 7000 resulted in fatalities.¹⁰

Against this background, the National Action Plan for Prevention and Control of Noncommunicable Diseases and Health Promotion in Pakistan (NAP-NCD) is the first concerted approach to develop and implement a national program aimed at preventing and controlling these diseases in Pakistan.¹¹ This program is a collaborative initiative of the Pakistani Ministry of Health, World Health Organization (WHO) Pakistan office, and nongovernmental organization Heartfile, described as a public–private partnership, mandated to develop and implement a long-term national strategy for the prevention and control of noncommunicable diseases and health promotion.¹²

The plan, officially released on May 12, 2004, defines NCDs in an extended context. By convention, the term “noncommunicable” disease refers to major chronic diseases inclusive of cardiovascular diseases, diabetes, cancer, and chronic respiratory diseases and their risk factors. As part of this initiative, however, the chronic conditions of mental illnesses and injuries have also been grouped alongside the conventional ones, as country requirements necessitated that these be addressed through synchronized public health measures within a combined strategic framework. Based on the priority areas identified in the Integrated Framework for Action,¹³ the first phase of its implementation has already commenced. As part of this, the setting up of a surveillance process is the first step. This paper discuses the surveillance methodology adopted and its strengths and weaknesses.