Centers of Excellence showcase Oct 2013

CoE meeting

Principal investigators at the Royal Society

On Friday 4 October the 11 Centers of Excellence in non-communicable disease presented provisional findings from this multi-year multi-country initiative.


In 2008, an innovative network of Centers of Excellence in non-communicable disease (NCD) was established, pairing 11 NCD centres in developing countries – Mexico, Central America, Peru, Southern Cone (Argentina, Chile, Uruguay), Tunisia, Kenya, South Africa, India (two centres), Bangladesh and China – with academic institutions in developed countries. The network is flourishing, its researchers meeting regularly and collaborating extensively, and the group presented their inspiring work at a meeting at the Royal Society, co-hosted by C3 Collaborating for Health and the Institute for Global Health Innovation, Imperial College, London. Speakers from the centres set out the extent of the NCD crisis in the developing world, followed by information on the range of the community-based initiatives undertaken, the importance of primary and secondary prevention studies, the centres’ capacity-building efforts, and the network’s hopes for the future. It was an intriguing preview of the launch, next April, of the formal results of the initiative.

Following some opening words from Lord Darzi, Professor Naomi (Dinky) Levitt (South African centre) gave an overview of the Centers of Excellence initiative. It addresses the paucity of NCD research and action in developing countries (where there is strong competition for human resources, finance and health services) by establishing centres in the developing countries that partner with developed-country institutions. $60 million funding has been received from UnitedHealth Group and the National Heart, Lung, and Blood Institute (part of the US National Institutes of Health), with a further $40 million raised by the centres themselves. The priority is to find effective and low-cost solutions through high-quality research, training and capacity-building, and engagement of a broad range of stakeholders (including government, professional organisations and the private sector). Areas addressed include data-gathering, primary prevention, patient support and economic evaluation, and using new and traditional technologies. As noted by Professor Prabhakaran, the newly elected chair of the initiative, the World Health Organization recently established a global framework to tackle NCD, with a target of a 25% reduction in  deaths under 70 from the diseases by 2025 – and there is much to be done to achieve this.

The extent of the need for urgent action on NCD in developing countries was set out by Professor Sylvester Kimaiyo (Kenyan centre), whose talk clearly highlighted the gap between the perception and reality of NCD in developing countries: too often, NCDs are wrongly perceived as diseases only of the rich. There has been a dramatic transition from infectious disease to NCD – in Mexico, for example, NCD was the cause of death in 45.4% of cases in 1980, but this increased to 74.4% by 2009. The extent of NCD and major risk factors is striking: a study in Argentina, Chile and Uruguay found that 43.4% of the population have high blood pressure, 11.9% have diabetes and 35.5% have obesity. Indeed, there is usually a double burden of NCD and communicable disease: among Kenyan HIV patients, 19% have obesity and 8.2% have high blood pressure. While we all have to die of something, diseases such as type 2 diabetes and hypertension are happening at younger ages, and access to treatment is often very limited.

Ms Elsa Cornejo (Mexican centre) presented some of the many community-based programmes that have been established by the network. In Tunisia, a series of interconnected interventions to tackle the risk factors for cardiovascular disease are in place – in workplaces, local communities and schools (over 4,000 children have been reached). Several centres are training and empowering community health workers (CHWs) – a vital, but often overlooked, group of health professionals – including a programme in Mexico giving CHWs the tools to generate their own data, using a website that generates simple graphs that can be shared with communities, and a four-country project that trains CHWs to detect those at high risk of CVD, using a risk-assessment tool. Elsa also stressed that the social determinants of health – such as inequality and the built environment – are what will make the difference in preventing NCD, and this was a theme that was often raised during the meeting.

There is a critical need for NCD studies in developing countries, and Professor Yangfeng Wu (China centre) focused on the network’s studies in primary prevention – 16 in total (nine of which are randomised controlled trials), reaching over 1 million people. The variety of studies reflects the variety and themes of the many initiatives – for example, six are on community health education, two focus on physical activity, three are on patient health education, and three (in Latin American urban areas, India and China) are looking at mHealth (the use of mobile technology). All the studies assess outcomes in terms of the biological risk factors (such as hypertension), eight look at lifestyle-choice outcomes (such as smoking) and four address cost-effectiveness. He particularly highlighted a salt-reduction study, the China Rural Health Initiative, full results of which will be published later this year, which couples population-based education on sodium reduction (in schools and local communities) with providing a salt substitute in village shops.

Secondary prevention – working with people in the early stages of an NCD, before it causes significant morbidity – is often underfunded, particularly as cost-effectiveness data from developing countries is very limited. Dr Manuel Ramirez-Zea (Central American centre) presented the extent of the shortfall in availability of treatment – one study found fewer than 10% of people with coronary heart disease in 17 developing countries receive therapy for their condition. Among the network’s initiatives (many of which are still ongoing) are an RCT in South African primary care clinics, training nurse managers as educators, a study on the use of the ‘polypill’, and a Bangalore study of secondary prevention after a coronary event.

To make a real difference in NCD, research needs to be translated into action: the ‘know–do gap’ must be bridged. Professor Adolfo Rubinstein (South American centre) presented the centres’ work addressing policy and the health system more broadly. There is a ‘gross mismatch’ between the burden of NCD and the tiny amount of aid devoted to it, and – as both Ms Cornejo and Dr Hassan Ghannem (Tunisia centre) also noted – there are only a tiny number of NCD studies from developing countries. The centres are currently seeking to increase the profile of NCD as a policy prerogative: gathering data, running implementation studies and community-based interventions, performing economic evaluations and policy-modelling studies (for example, working with a government to establish the impact of a 10-year policy to eliminate transfats from industrially produced food), and providing clear NCD briefings for policymakers.

Capacity-building is one of the main priorities of the network, as explained by Professor Denis Xavier (Bangalore centre). The centres are channelling efforts into strengthen research leaders to make them expert in disseminating their knowledge in ways that facilitate real, practical change, providing a platform to help to direct bright young people (the next generation of researchers), building institutional capacity by collaborating across the network, and strengthening health systems. All this is critical for long-term sustainability. The network’s impact is impressive, having trained 92 leaders, over 1,500 trainees and nearly 500 community health workers. There are 20 different training programmes, aimed at young physicians (such as a mentorship programme and a summer institute on behavioural RCTs), post-docs (including training in scientific writing), biostatisticians (on advanced statistical methods), nurses and CHWs (including how to talk to patients about lifestyle and medication adherence) and undergraduate medics.

Finally, Professor Prabhakaran (New Delhi centre) highlighted the strengths on which the network can build, and its hopes for the future. It is a highly networked and diverse team with complementary skills and knowledge, well placed to take the transdisciplinary approach that is needed to tackle NCD successfully. Its research is high impact and is providing global leadership in research in developing countries. Its successes in training and capacity building are ongoing, and its goal is to connect science with policy to make a real difference. Future priorities – if continued funding is forthcoming – include a focus on standardised data collection, evaluation of initiatives to provide the proof on ‘what works’, further capacity building (including mentoring and online courses), tools to disseminate the messages of the initiative to media and public, and a global observatory for NCD in developing countries that would provide information on ‘best buys’ and other policy and advocacy areas.