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 DOI: 10.1177/1757975913500682

2013 20: 97Global Health PromotionMary Amuyunzu-Nyamongo, Jared O. Owuor and Claire Blanchard

concept to practiceThe Consortium for NCD Prevention and Control in Sub-Saharan Africa (CNCD-Africa): from

  

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Global Health Promotion 1757-9759; Vol 20 Supp. 4: 97 –103; 500682 Copyright © The Author(s) 2013, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975913500682 http://ghp.sagepub.com

500682 PED0010.1177/1757975913500682CommentaryM. Amuyunzu-Nyamongo et al.2013

1. Correspondence to: Mary Amuyunzu-Nyamongo, CNCD-Africa, African Institute for Health & Development, 2nd Floor Wood Avenue Court, P.O. Box 45259-00100, Nairobi, Kenya. Email: mnyamongo@aihdint.org

2. International Union for Health Promotion and Education (IUHPE), St Denis cedex, France.

The Consortium for NCD Prevention and Control in Sub-Saharan Africa (CNCD-Africa): from concept to practice

Mary Amuyunzu-Nyamongo1, Jared O. Owuor1 and Claire Blanchard2

Abstract: CNCD-Africa was established in July 2009 in response to and in recognition of the continuously increasing burden of diseases such as injuries, non-communicable diseases (NCDs) and mental health in low- and middle-income countries, and specifically in countries of sub-Saharan Africa. CNCD-Africa aims to comprehensively address specific and common objectives while building capacity in the region to prevent and control NCDs. With support from key partners and funders, and a keen interest in opportunities to address NCDs from health promotion and equity perspectives, the Consortium has excelled in four key areas: convening; knowledge generation and sharing; advocacy; and networking. However, the path to successful and sustainable efforts remains laden with challenges and barriers. Retaining interest of network partners through flagship efforts and continued efforts to ascertain support from local and international partners with interest in NCDs across the region remain essential to CNCD-Africa core activities.

A key lesson learnt from the early years of CNCD-Africa is that existing regional platforms can and should be used to showcase what is being done locally, and to share best practices and best-buys. In addition, partnerships and stakeholder involvement have been key for CNCD-Africa and are essential to NCD action. Sustaining such partnerships requires incentives for the various partners to keep actively involved in NCD action. This can be achieved through joint inception, project planning, implementation, monitoring and evaluation. Another ingredient for success seems to be innovative financing for NCD efforts, which is possible through the establishment and sustaining of regional and global partnerships that are robust, locally relevant and respond to country needs. (Global Health Promotion, 2013; 20 Supp. 4: 97–103).

Keywords: non-communicable diseases, low- and middle-income countries, sub-Saharan Africa, NCD Prevention, NCD Control, NCD Capacity Building, convening, knowledge generation, advocacy, networking, partnerships, NCD Action

Commentary

Background

The prevalence of non-communicable diseases (NCDs) and injuries as important contributors to the global burden of disease in low- and middle-income countries became apparent in early 2000 (1), and has recently gained additional relevance with the publication of the 2010 Global Burden of Disease (GBD) analyses in a special issue of Lancet (2). Attendant to this was the recognition by global and regional health actors of the need to build the capacity of multi-disciplinary groups of practitioners to prevent and control NCDs. Consequently, the US Centres for Disease Control and Prevention (CDC), Atlanta and

the International Union for Health Promotion and Education (IUHPE), through a cooperative agreement, supported capacity-building seminars in six African countries over a period of six years (Ghana, Gambia, Nigeria, Kenya, Uganda and Tanzania). It is on this backdrop that the Consortium for NCD Prevention and Control in sub-Saharan Africa (CNCD-Africa) was established. The Consortium has relied on limited though valuable existing resources as one of the methods towards enhancing capacity with piggy-backing on existing meeting/opportunities being one of the most successful approaches.

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The CNCD-Africa was established in July 2009 in Entebbe, Uganda in a meeting supported by CDC-Atlanta, the Department of Health (DH) of England and the IUHPE. The meeting, attended by 30 participants from various parts of the world including representatives from the CDC, the DH, the IUHPE and the World Health Organization (WHO) (Headquarters, Africa Regional Office and Uganda), discussed the role of health promotion in NCD prevention and control in the sub-Saharan African region. The participants agreed on six key objectives for the Consortium:

i. Provide a framework to engage in joint dialogue in addressing NCDs in the sub-Saharan African region, ranging from health promotion to case management.

ii. Synergise the ongoing NCD prevention and control activities in the region with a view to increasing the coherence, overall impact and visibility of actions.

iii. Build a platform for members to support the development of comprehensive and multi-sectoral policies, standards, guidelines and protocols, and to mobilise resources for addressing NCDs in the region.

iv. Create a forum for networking and partnership that builds on the capacities and expertise of members in the areas of healthcare, surveillance, policy, advocacy and implementation of NCD interventions and evaluation.

v. Identify and define the circumstances that drive the NCD burden in the region with a view to developing context-relevant strategies and responses.

vi. Articulate regional issues at the global level with a view to ensuring that NCD interventions in sub-Saharan Africa are highly visible, relevant, effective, efficient and sustainable.

The activities of CNCD-Africa support the achievement of both the Brazzaville Declaration (3) and the United Nations High Level Meeting Political Declaration (4), both recognising the role of professional associations, civil society and the private sector in tackling NCDs. The two declarations are also cognizant of the need for structured engagement that can harness the capacities of the

diverse health sector players and draw on existing and new resources for NCD interventions (5,6).

Approach – establishing sound governance for sustained efforts

The management of CNCD-Africa was a key issue of consideration with two key aspects: the hosting should be in Africa, and there had to be an African institution with the capacity and willingness to host the Consortium. The Consortium’s Secretariat was established in Nairobi in September 2009 at the African Institute for Health & Development (AIHD), with technical and financial support from the CDC and the IUHPE. Support through this partnership directly financed the Secretary’s time, annual Steering Group meetings, advocacy materials and other publications, website development and a regional workshop, in addition to regular technical support. The CNCD-Africa was launched at the 20th IUHPE World Conference on Health Promotion in Geneva, Switzerland in July 2010.

A Steering Group was established in 2009 to oversee the activities of the Consortium and given that the Consortium is hosted by the AIHD, the Board of Directors of the Institute provides oversight over its activities. An Expert Group, comprised of members with vast health experience in Africa, was constituted with the mandate of providing: (a) guidance to country and regional teams engaged in NCD policy formulation, surveillance and interventions; (b) technical inputs into NCD policies, interventions and documentation; (c) ideas and support in the implementation of innovative NCD interventions in the region; and (d) linkages to both human and financial resources within and outside the region. In addition, the Group was expected to represent the region in international NCD and other health-related forums, and advocate for NCD prevention and control in Africa.

The collective mandates of the Secretariat, Steering Committee and Expert Group were aimed at addressing the objectives of the Consortium comprehensively while building capacity in the region to prevent and control NCDs.

Achievements

The achievements of CNCD-Africa since its initiation in July 2009 to July 2012 can be broadly

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categorised into four key areas: convening; knowledge generation and sharing; advocacy; and networking.

Convening

CNCD-Africa has, in partnership with national and international partners, held several meetings aimed at advancing the interests of local, regional and international partners on NCDs. In 2010, the CNCD-Africa and the Ministries of Health of Kenya (Medical Services and Public Health and Sanitation) held the first ever National Symposium on NCDs in Kenya. The meeting brought together over 55 participants representing various civil society organisations, professional associations and international institutions. During this meeting, the members were sensitised to the initial process at the global level to focus on NCDs.

In June 2011, CNCD-Africa coordinated the second Symposium on NCDs in Kenya during which the Brazzaville Declaration was shared with over 60 participants. The members were also informed about the UN High Level meeting. The African NCD Call to Action, which was developed following a meeting organised by the African Field Epidemiology Network (AFENET) in May 2010 and the Communiqué by the Kenya National NCDs Stakeholders forum are two key documentsi with recommendations on policy, standards, guidelines, protocols and resource mobilisation for which CNCD-Africa took the lead from drafting to coordination of final edits/reviews.

In November 2011, with technical and financial support from the International Development Research Center (IDRC) Canada, through the Non-communicable Disease Prevention Program (NCDP), the Consortium hosted a regional technical meeting on Research and Capacity Building Priorities for NCDs in Africa in Nairobi alongside an open forum co-hosted by NCD Alliance (Kenya). The forum brought together participants from Nigeria, South Africa, Ghana, Canada, Uganda, Zambia, Congo and Kenya. The strategic priorities for the workshop were to: i) accelerate post United Nations High-Level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (UN-HLM) progress in the fight against NCDs in low- and middle-income Countries (LMICs); ii) increase resource prospects from

international donors to combat NCDs as a development challenge; iii) influence national governments in LMICs to rapidly support the adoption and implementation of cost-effective ‘best buys’ and policies to curb the epidemic; and iv) prioritise the strengthening of local, provincial, national and regional capacities to address and effectively combat NCDs in developing countries (Article 41 of the Political Declaration). The meeting participants agreed on the key research priorities, which resonated very well with the draft global goal and targets to combat NCDs (7).

Under the flagship project, Mainstreaming NCD Control and Prevention Partnerships in sub-Saharan Africa (2010-2011), the Consortium was represented at the World Health Organization, Regional Office for Africa (WHO-AFRO) ministerial consultative meeting on NCDs in Brazzaville that led to the Brazzaville Declaration. The Consortium was present during the Civil Society Consultative Meeting held in New York in June 2011 that sought to garner a joint position on NCDs in preparation for the High Level Summit in September 2011. In addition, CNCD-Africa was represented during the UN-HLM Summit on NCDs on 19 and 20 September 2011, where it also co-hosted a side meeting entitled: ‘Finding Integrative Approaches to the Global ‘Double Burden’: Under and Over-nutrition and Non-Communicable Diseases’.

In October 2012, the CNCD-Africa in collaboration with the WHO-AFRO hosted a consultative meeting that brought together representatives from regional communities in Africa to consider the implications of the global-level NCD goals and targets on the Member States, and explore the role of the different regional bodies. This was also in response to the UN-HLM that recognises regional bodies as key in technical support to countries and in monitoring the progress made on attaining the various targets. The meeting participants agreed to work together to ensure that NCDs remain high on the development agenda of the Member States.

Knowledge generation and sharing

The CNCD-Africa team has produced several key documents on NCDs that are freely accessible on the Internet: (i) Mapping of status of NCDs policies in sub-Saharan Africa: discussion paper; and (ii) The threat of NCDs in Africa - a call to action.ii

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Through partnership with the various partners, CNCD-Africa is currently coordinating and implementing two key research projects in several African countries that address key research priority areas on NCDs in the region.

i. Nutrition study (2012–2014): this study is being implemented in five African countries (Benin, Guinea, Mozambique, Kenya and Seychelles) with the main aim of assessing sodium, potassium, calcium and iodine in urine of adults in both rural and urban areas. The study addresses three key issues of concern for the region: (i) how much salt is being consumed; (ii) what are the main sources of salt; and (iii) what would be the effects of salt reduction on iodine (considering that salt is the main medium of iodisation). The results of this study will generate important data that will inform practice and policy.

ii. The Partnership for Child Nutrition project (2012–2015): this is being implemented in Ghana, Kenya and Zambia through the support of the IDRC. The action research project addresses the 6−14 age group. The study, to be implemented in urban and rural sites in the three countries, addresses another key area of concern at the global level but on which Africa does not have credible data (8).

The CNCD-Africa produces quarterly newsletters that are disseminated on the communication platform that has been established by the Secretariat. It also serves as a conduit of information on new research and information on NCDs to its network of 45 partners spread over 24 countries in the African region.

Advocacy

CNCD-Africa played crucial roles in advocating for African perspectives during the WHO’s consultative meeting on NCDs which resulted in the Brazzaville Declaration (April 2011), Ministerial Conference on Healthy Lifestyles in Moscow (April 2011) and the UN High Level Meeting on NCDs in New York (September 2011). The Consortium has also produced several advocacy materials with the

aim of educating communities on NCDs. These include videos, radio spots and jingles. The process of producing these materials has entailed interviewing experts and people suffering from or affected by an NCD, and the stories are told from an African perspective. These tools are available for use by other partners.

Networking

CNCD-Africa developed an interactive web platform and social media hubs including Facebook and Twitter, and integrated Google analytics that monitor the number of hits. Using the web-based e-mail/list serve manager MailChimp and other rss feed links, the platform sends health news digests and NCD updates from NCD Alliance, the World Heart Federation (WHF), the International Diabetes Federation (IDF) and American Cancer Society (ACS), among others, to those who have opted in from various fora (Health Promotion Listserve, AFENET symposium; African Group Meeting in Geneva, CNCD-Africa Listserve and others). In Kenya, the Consortium is represented in the Technical Working Group on Health Promotion coordinated by the Department of Health Promotion, Ministry of Public Health and Sanitation and the Inter-sectoral Coordinating Committee on NCDs coordinated by the Division of NCDs, of the same ministry.

Challenges

There are three key challenges for the Consortium:

• Retaining interest of network partners: being a loose and flexible outfit, partners are not tied to specific deliverables although they can access information available in the database and interact with each other through existing platforms.

• Meeting expectations: some partners are keen on obtaining funding/grants through the Consortium to advance their NCD-related activities; however, once they learn that this is not currently possible their interests wane.

• Resource availability: the Consortium continues to seek additional support from local and international partners with interest in NCDs across the region.

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A reflection on the roles of the CDC and IUHPE

Prior to the initiation of the CNCD-Africa, the CDC had a longstanding technical assistance and training relationship with the African region to address the growing burden of heart disease. With this attention to heart disease, several CDC subject matter experts in cardiovascular disease (CVD), epidemiology and health promotion in collaboration with US academic partners worked closely with their counterparts in East, West and South Africa to train multi-sectoral teams to develop CVD prevention and health promotion programmes and policies in their countries. Over the six years of this partnership, epidemiological data for the region documented the growing burden of other non-communicable diseases such as type 2 diabetes, obesity, tobacco use, some forms of cancer, and motor vehicle crashes. From the standpoint of many Ministries of Health in the African region, combatting the spread of HIV infection, malaria and other infectious diseases was considered more urgent.

The CDC was interested in supporting stakeholders in building a prevention agenda at the front end of the emerging NCD turning point.

The CDC was particularly interested in opportunities to address NCDs through health promotion. Toward this end, a special issue of Global Health Promotion was supported by the CDC that highlighted promising health promotion interventions and strategies implemented in communities in Africa to reduce NCDs (9).

In addition, the CDC participated in planning meetings of the CNCD-Africa in Kenya, Tanzania and Uganda, and shared evidence-based programmes implemented in the US for possible translation and dissemination in Africa, for example, the WiseWoman Program.

As a major partner and key contributor to CNCD-Africa, the IUHPE played a very distinct role in these efforts over the previous 5 years, that of bringing a health promotion approach and equity lens to NCD prevention and control through:

• Knowledge development, sharing and transferability;

• Support and coordination of capacity-building efforts in the region to influence improved policy and practice;

• Linking key professionals through its professional network;

• Advocacy for and articulation of health promotion and its position with regards to NCD prevention and control and the social determinants of health (10,11).

As such, the IUHPE has played an important role with CNCD-Africa in advocating for:

• An expanded role for comprehensive health promotion that embraces actions directed at strengthening the skills and capabilities of individuals to improve their health alongside actions directed towards changing social, environmental and economic conditions which have an impact on health. This is especially important in low- and middle-income countries where health promotion can contribute not only to better health but to sustainable development, equity and social justice.

• Coordinated actions that impact determinants such as education, employment, housing, income, access to healthcare and lack of access to effective health promotion that underpin the NCDs epidemic across populations and that address the structural drivers of inequitable distribution of power, money and resources, human rights and support to the Millennium Development Goals.

• Health systems to redirect resources to health promotion and prevention of NCDs and prioritise health promotion as an essential function of the Departments of Health, with the need for health systems to invest in research into the evidence of effectiveness and cost-effectiveness of health promotion policies and interventions.

• An expansion of engagement with sectors outside health where many of the economic, social and environmental policy solutions to NCDs can be best advanced.

• An increased investment in ensuring a health promotion workforce that is prominently placed and equipped with the core competencies to implement current knowledge, policies and practices.

• A specific and considered approach to the three critical areas of healthy eating, physical activity and tobacco control, which if effectively implemented, will make the most important

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contributions to reducing the burden of NCDs in the population, and an agreement on robust indicators in each of these three areas.

• A central focus on equity both between and within nations, and a specific focus on addressing the needs of disadvantaged groups, systematically more at risk and with the poorest access to health services, healthy environments and health promotion programmes.

The partnership over the years has been mutually beneficial with multi-partner advocacy efforts that have led to a strengthened voice and greater impact of conveyed messages in global and regional efforts to address NCDs. This was effectively carried out through preparatory collaborative efforts, active representations at key meetings (i.e. the 2011 United Nations High Level Meeting dedicated to NCDs and the African Regional Ministerial Consultation in Brazzaville in preparation for the September 2011 UN meeting) and contribution to resulting political declarations that are currently shaping the future of these efforts around the world (2,3). The IUHPE and CNCD-Africa have contributed their experience and expertise in health promotion and played a vital role in advising on health promotion effectiveness and mobilising members to implement the NCD strategy both in the African region and globally.

However, the lack of continued funding jeopardising sustainability of efforts on a day-to-day basis, an African context which is both enthusiastic and yet complex and challenging, key players often overburdened, and the time necessary for effective, sustainable and equitable Health Promotion work remain important barriers.

Lessons learnt and future directions

• Coordination of NCD activities continues to be a challenge in the region. A range of NCD activities are being implemented including prevention, advocacy, disease-specific case management, research and training, etc., but are not sufficiently coordinated, documented or disseminated. The convening role of CNCD-Africa has illustrated that regional platforms can be used to showcase what is being done locally and to share best practices and best-buys.

• Partnerships and stakeholder involvement are key in NCD action. It is critical that governments

(executive/cabinet, judiciary and legislative arms), Civil Society Organisations (CSOs)/non-governmental organisations, private sector, media, professional affiliations, academic and research institutions, and patient organisations work together for comprehensive NCD actions. However, governments have to take leadership while facilitating the involvement of other non-health and non-state actors so as to achieve the multi-sectoral approach needed to tackle NCDs.

• To sustain partnerships, the various partners need incentives to keep them actively involved in NCD action. This could be achieved through joint inception, project planning, imple- mentation, monitoring and evaluation.

• Funds for NCD are still limited hence the need to capitalise on existing resources and joining forces to sustain the capacity-building efforts. Piggy-backing on and working with existing infrastructures such as that of HIV/AIDs and maternal and child health, among others, should be considered as important strategies especially in the current context of a global financial crisis where resources are becoming increasingly limited.

• In terms of resource mobilisation, it is clear that innovative financing for NCD action is possible through establishing and sustaining regional and global partnerships that are robust and respond to country needs.

Funding

CNCD-Africa received financial and technical support from the US Centres for Disease Control and Prevention (CDC), Atlanta and the International Union for Health Promotion and Education (IUHPE).

Notes

i. Accessible at: http://www.aihdint.org/cncd/information.php?MenuID=3&SubMenuID=23

ii. Accessible at http://www.aihdint.org/cncd/information.php?MenuID=3&SubMenuID=23

References

1. World Health Organization. Discussion Paper: Non-Communicable Diseases, Poverty and the Development Agenda. ECOSOC/UNESCWA/WHO Western Asia Ministerial Meeting; 2009.

2. The Global Burden of Disease Study 2010. Lancet. December 15, 2012-January 4, 2013; 380(9859): 2053–2260. http://www.thelancet.com/themed/global-burden-of-disease (accessed 6 August, 2013).

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3. WHO. The Brazzaville Declaration on Noncom- municable diseases prevention and control in the WHO African region. Brazzaville, 7 April 2011. The first Africa Regional Ministerial Consultation on noncommunicable diseases (NCDs). Available from www.afro.who.int (accessed 6 August, 2013).

4. United Nations. Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. A/66/L.1. New York: United Nations; 2011.

5. World Health Assembly. Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases (NCDs). Geneva: World Health Organization (WHA A61/8); 2008.

6. Amuyunzu-Nyamongo M. Need for a multi-factorial, multi-sectoral and multi-disciplinary approach to NCD prevention and control in Africa. Glob Health Promot. 2010; 17(3): 31–32.

7. Beaglehole R, Bonita R, Horton R, Ezzati M, Bhala N, Amuyunzu-Nyamongo M, et al. Measuring progress on NCDs: one goal and five targets. Lancet. 2012; 380(9850): 1283–1285.

8. Popkin BM, Gordon-Larsen P. The nutrition transition: Worldwide obesity dynamics and their determinants. Int J Obes. 2004; 28: S2–S9. doi:10.1038/sj.ijo.0802804.

9. Community Health Promotion Strategies to address Non-Communicable Diseases in Africa. Glob Health Promot. 2010; 17(Suppl 2): 3–97. http://ped.sagepub.com/content/17/2_suppl (accessed 6 August, 2013).

10. International Union for Health Promotion and Education (IUHPE). Call for action on health promotion approaches to non-communicable diseases prevention: Key Messages from the International Union for Health Promotion and Education. Saint-Denis, France: IUHPE; 2011. http://iuhpe.org/images/IUHPE/Advocacy/IUHPE_CallToActionNCDs.pdf (accessed 31 December, 2013).

11. IUHPE. Key Messages from the International Union for Health Promotion and Education on the Social Determinants of Health. Saint-Denis, France: IUHPE; 2012. http://iuhpe.org/images/IUHPE/Advocacy/IUHPEKeyMessages_SDH.pdf (accessed 31 December, 2013).

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