WHO second consultation on a comprehensive global monitoring framework, including indicators, and a set of voluntary global targets for the prevention and control of NCDs

Today we issued our EFPC response, endorsed by our membership, which we hope will make Primary Care more visible in the way WHO wants to monitor NCDs and Health Systems reacting to the NCD epidemic.

EFPC highlights two major aspects which were not present in the framework yet:
1. To include in the framework the recognition of the importance of multi-morbidity and challenging the WHO to work on outcome targets in relation to the multi-morbidity problem.
2. To mention clearly within the chapter on "Policy reviews" the role of Primary Care when it comes to surveillance of NCDs and the available capacity of health systems to deal with NCDs.

Read the full response:

European Forum for Primary Care (EFPC) response on a comprehensive global monitoring framework including indicators and a set of voluntary global targets for the prevention and control of non-communicable diseases
 
Introduction EFPC
 
As a membership organization, the European Forum for Primary Care (EFPC) aims at strengthening primary care in Europe, emphasizing community orientation and interprofessional approach as outstanding features of primary care. As an essential bridge between cure and care activities and public health, strong primary care both provides health  care to individuals and contributes to public health including surveillance. The Primary Care professional, who brings the best of integrative medicine with a holistic approach is a most needed guide in our complex health care systems. The General Practitioner as a core professional in Primary Care, ensures medical quality and comprehensiveness in care provision.

General reflections of the EFPC: NCDs and a comprehensive global monitoring framework!
 
This response can be read in line with the second broad policy direction of the WHR 2008: "service delivery reforms that re-organize health services around people's needs and expectations, so as to make them more socially relevant and more responsive to the changing world, while producing better outcomes" (1).
Disease prevention and health promotion have become institutionally and functionally lacking as a result of weaknesses inherited from the past as well as recent reforms and structural changes, such as decentralization and privatization of health care services, conducted without appropriate planning and investment in preventive services (2).
Public health and primary care practitioners who understand the complementary nature of their disciplines can mobilize each other?s resources more effectively (3). In the basic curricula for primary care professionals, public health principles including surveillance, should be taught and they should be refreshed and explored in greater depth throughout the career of a primary care professional (4).
When policy makers want to integrate Public Health and Primary Care, possible policy options for this integration process should be characterized and key implementation considerations should be delineated (5). Although in certain Southern European countries, such as Greece, integrated primary health care remains a neglected issue (6) and many attempts have been made to implement family practice research using a stepwise model tailored to countries with limited resources and capacity (7). In Bellagio (Italy) in 2008, 24 primary care experts from policy, management and practice with different professional backgrounds agreed that health systems must become more pro-active, helping populations and individuals to stay healthy and prevent the development of (additional) chronic conditions. Primary care as a hub linking health care and social services, as first contact care, accessible by all, guaranteeing a sustained and trustworthy partnership between providers and patients, providing comprehensive, coordinated care for a predetermined population, activated by patient choice plays an essential role in improving health care systems altogether (8).
To quote Margaret Chan at her closing remarks during the latest World Health Assembly in May last year: "The rise of chronic non-communicable diseases, which you also discussed, adds tremendous urgency to the agenda for building stronger health systems. It is good that you adopted a resolution on non-communicable diseases as we strengthen our positions ahead of the major event in September. Of course we need population-wide preventive measures for NCDs, developed with other sectors, but we also need to help individual people. We need to detect early, treat, manage complications, and often provide prolonged or even life-long care. It is my strong view that primary health care is truly the only efficient and effective way to do so. I have no doubt that the new global health sector strategy on HIV/AIDS, which calls for greater integration with existing services, will also contribute to health system strengthening."
This general reflection ends with our advice to the WHO based on the WHA 2009 resolution WHA62.12 - Agenda item 12.4 on Primary Health Care, including health system strengthening, that states " The World Health Assembly, urges member states":
"to encourage that vertical programs, including disease-specific programs, are developed, integrated and implemented in the context of integrated primary health care!"
 
References
1. WHR 2008 "Primary Care, Now More Than Ever!",
2. Strengthening Public Health Capacities and Services in Europe: A Framework for Action Interim draft; WHO Regional office for Europe,  First meeting of the European Health Policy Forum for High-Level Government Officials, Andorra la Vella, Andorra, 9-11 March 2011
3. Alison Hill, Sian Griffiths, Stephen Gillam. Public health and primary care: partners in population health. Oxford, New York: Oxford University Press, 2007, pp 217, ISBN 978 0 19 850853 3
4. Diederik Aarendonk. Book review - Public health and primary care: partners in population health. International Journal of Integrated Care, 7 July 2008 -  ISSN 1568-4156
5. C. Van Weel, J. De Maeseneer, R. Roberts. Renewing primary health care: Integration of personal and community health care. Lancet 2008;372:871 - 2.
6.  C. Lionis, EK. Symvoulakis, A. Markaki, C. Vardavas, M. Papadakaki, N. Daniilidou, K. Souliotis, I. Kyriopoulos. Integrated primary health care in Greece, a missing issue in the current health policy agenda: a systematic review. International Journal of Integrated Care 2009; 9: 1-14.
7.  C. Lionis, EK. Symvoulakis, and CL. Vardavas. Implementing family practice research in countries with limited resources: a stepwise model experienced in Crete, Greece. Family Practice 2009; 1-7.
8. Bellagio Primary Care Conference http://www.hpm.org/en/Events/Bellagio_Primary_Care_Conference.html

Specific response on the second WHO discussion paper (version dated 22 March 2012)
 
The global prevalence of all leading non-communicable diseases (NCDs) is continuously increasing. Between 70% and 86% of deaths have been attributed to NCDs (World Health Organisation Europe, 2006; Centers for Disease Control and Prevention, 2007). However the impact of NCDs goes far beyond mortality. The aspect of no cure is relevant as well as the fact that NCDs co-occur so many patients have more than one (multi-morbidity).
Half of people aged over 65 suffers from 3 NCDs and 20% even has more than five. In general practice multi-morbidity is becoming the rule rather than the exception. Patients concomitantly taking over 10 different drugs are not uncommon which leads to interaction and additional medical consumption. Despite the fact that  an increasing number of chronically ill suffers from co-morbidities disease management programmes constitute a single-disease approach and tend to neglect co-morbidities. This related to the fact that most evidence has been collected in single disease trials excluding patients with comorbidity.
 
A focus on data collection on multi-morbidity and co-morbidity can be seen as an area where an additional action of the WHO is needed. Such research covers many domains, and seeks comprehensive tools to elucidate the co-morbidity disease course, while such endeavours expects to seek a different taxonomy and impact on disease management costs.
Surveillance priorities should change away from research on possible treatments of individual NCDs to research on successful lifestyle intervention programmes and behavioural change programmes which might have a much broader effect.
 
We need practice based research on primary care service's capability to implement effective interventions. Any research deepening the understanding of NCDs management in primary care, reflecting both patient and health professional perspectives, will be very helpful.
It is very important that future studies can be planned that would be able to generate the evidence base for real clinical practice, where comorbid conditions are included. Due to the lack of evidence on multi-morbidity, projects to define multi-morbidity clusters and interactions between concomitant health conditions could be a good starting point. Data collection should focus on long term care programmes which improve the quality of life of those suffering from NCDs.
 
The electronic health record (EHR) represents the backbone of all major international eHealth developments. When it comes to non-communicable diseases it is key to have available comprehensive longitudinal health information for all members of the population, with the potential for accessing and contributing to these records by multiple users working across a range of healthcare settings.
 
At WHO level, data collection on the coordination and cooperation in primary care settings should be promoted. Moreover, data collection on the complexity of the management of combination of several NCDs in one patient and his family is necessary to improve the care for chronically ill. EFPC wants to emphasize that at least 85% of all health related problems are solved in the Community with an important role of primary care professionals. As a consequence, Primary Care professionals can play an important role in the surveillance of NCDs.
 
In addition, more communication and transparency about different policies and different successes in all Member States can lead to uniformisation and to the adaption of successful policies.
 
Coordinated data collection, analysis and reporting efforts are needed, requiring a capacity in primary care research which is not always available in all member states. In order to gradually fill this gap, initiatives need to be taken to actively develop and disseminate relevant research expertise and to exchange and share relevant information and strategies. It may be useful to consider the development of a common framework of data to be collected on Disease Management Programmes at a global level .
The diversity of health care systems has the potential to be a laboratory for NCD care experiments and comparisons. Different conditions and effects can be studied in a scientifically sound way and results of local and national evaluations will be shared among the research community.
Member states are requested to invest more in studying their own health care provision and support the comparative research, in particular how health systems with a strong Primary Care add to better health outcomes for their citizens suffering from NCDs.
 
Primary care research in certain European countries assists the understanding of disease' burden, while it can explore certain hidden determinants of NCDs and conditions.
 
Stepwise models can be implemented in countries with limited capacity and resources that do not have the ability to conduct research in family practice. Stepwise models can include; to be able to identify common ill conditions and health problems, to start with an assessment of population health needs, to identify the burden of common diseases and measure diagnostic probabilities .
With regard to data on NCDs, EFPC suggests to generalise the use of electronic patient files/electronic patient records (EHR) in general practices, by promoting and subsidizing standards and guidelines. In addition, Information Communication Technology (ICT) is key for creating electronic health records systems and to improve patient safety, facilitates medical auditing and enhances research in primary care settings.  An EU FP7 project TRANSFoRm  is currently in progress to serve this purpose.
 
In conclusion the EFPC would like to make two major recommendations:
 
1. To include in the framework the recognition of the importance of multi-morbidity and challenging the WHO to work on outcome targets in relation to the multi-morbidity problem.
 
2. To mention clearly within the chapter on "Policy reviews" the role of Primary Care when it comes to surveillance of NCDs and the available capacity of health systems to deal with NCDs.