Indian Journal of Medical Research

: 2013  |  Volume : 138  |  Issue : 6  |  Page : 1034--1035

Prevention and control of noncommunicable diseases: Guidelines for primary health care in low-resource settings

JP Narain 
 Epidemiology & EIS National Centre for Disease Control Directorate General of Health Services 22, Sham Nath Marg Delhi 110 054, India

Correspondence Address:
J P Narain
Epidemiology & EIS National Centre for Disease Control Directorate General of Health Services 22, Sham Nath Marg Delhi 110 054

How to cite this article:
Narain J P. Prevention and control of noncommunicable diseases: Guidelines for primary health care in low-resource settings.Indian J Med Res 2013;138:1034-1035

How to cite this URL:
Narain J P. Prevention and control of noncommunicable diseases: Guidelines for primary health care in low-resource settings. Indian J Med Res [serial online] 2013 [cited 2020 Jul 14 ];138:1034-1035
Available from:

Full Text

(World Health Organization, Geneva, Switzerland) 2012. 68 pages. Price: not mentioned

ISBN 978-92-4-154839-7

This book deals with the subject of noncommunicable diseases (NCDs), which clearly are the most important health issue at present. These are the leading cause of death in all the regions of the world with the exception of Africa. A sense of urgency has followed after the deliberations in the United Nations General assembly in September 2011 when, only for a second time an issue of global health has been taken up for discussion at that level in the UN. The NCDs including heart disease, diabetes, cancer and chronic obstructive pulmonary disease (COPD) contribute to nearly 80% of the NCD mortality and share a common set of risk factors linked with the people's lifestyles and daily habits. Cost-effective and evidence-based interventions and tools to prevent and control various NCDs are however, available and are best delivered in an integrated manner through the existing health system.

In this context, these guidelines from WHO are welcome and in fact long overdue especially as the title indicates that this deals with the use of primary health care approach suitable for the low and middle income countries. The guidelines form a part of an innovative and action-oriented response called Package of Essential Noncommunicable Disease Interventions or PEN initiated by WHO in 2010. The approach uses primary health care for NCD prevention and control, applicable especially for low-resource settings and envisages to deliver a prioritized set of cost-effective interventions of acceptable quality. It reinforces the strengthening of the health system by contributing to the building blocks of the health system. It is the minimum standard for NCD and promoted as an important first step for integration of NCDs into primary health care.

The guidelines provide recommendations to be followed for the management of selected NCDs in so-called low-resource settings and hence suitable for the low and middle income countries or resource-poor settings. The contents however, pertain only to two aspects: (i) diagnosis and management of type 2 diabetes in primary health care in low-resource settings, and (ii) management of asthma and COPD in primary health care in low-resource settings. Cardiovascular diseases and cancers are not included in this document and no mention is made anywhere whether the other two disease topics have been dealt with separately or subsequently. The document is meant for health care professionals responsible for developing treatment protocols on NCDs, specifically, diabetes and COPD which will be used by health care staff in primary care units in low-resource settings.

The first section describes in detail the methodology and process used in arriving at the recommendations. While the GRADE methodology is used to assess the quality of evidence and decide the strength of their recommendations, and for each intervention, the strength of evidence and feasibility scores have been provided. The document provides only recommendations relating to various interventions and it is expected that these recommendations may form the basis for individual countries or settings for developing simple treatment algorithms for training their primary health care staff on the management of NCDs in low resource settings. The group, in agreeing on the recommendations, has reviewed existing evidence-based guidelines, which included primarily those from North America and Europe and appropriate for high-resource settings and "some" are feasible in the resource poor settings. This raises the issue of the need for low and middle income countries to review the evidence base in their respective countries and develop through consensus, the recommendations for their own settings.

The second section pertains to the management of asthma and COPD. It provides evidence-based recommendations on management of asthma and COPD at primary health care in low-resource settings. The evidence is assessed according to the GRADE methodology. The recommendations provided in the document can be very useful to physicians and health care workers in guiding them how to reduce avoidable deaths and morbidity and improve health outcomes especially in settings where management facilities are limited. Each recommendation is presented according to its strength of recommendation and quality of evidence such as high, moderate, low and very low. The recommendations have been made on how to manage stable asthma, and COPD and their respective exacerbation epidodes.

This document, therefore, primarily contains recommendations on the management of two common NCDs that have emanated following deliberations among two separate sets of experts, using somewhat similar methodology. Such a uniform approach covering all the major NCDs to be managed at primary care level would indeed be useful. It may also be pointed out that the global strategy for prevention and control of noncommunicable diseases in 2008 called for integration of the cost-effective interventions against major NCDs in the health system. Integrating NCDs as a part of primary health care can assist in managing NCDs at an early stage and, therefore, a better investment than diagnosing and managing them at a later stage when it can be expensive. Also on a longer-term, investing in NCD prevention and control through evidence-based approaches can contribute to strengthening of the health system.

Overall, the guidelines are very useful to the programme managers and health care workers in the low and middle income countries working in an environment of limited resource availability for health. Joint action on the main NCD risk factors prevailing on the population is an efficient, cost effective and sustainable way forward. Integration of NCDs can ensure equity efficacy and access to cost-effective NCD services by the poor in resource constrained settings. The problem assumes added significance in poor countries and poor populations given the sky rocketing cost of health care in particular due to chronic diseases, further contributing to poverty.

Finally, the guidelines, while emphasizing primarily on the case management aspects, seem to lay limited emphasis on behavioural risk factors and risk modifications which is critically important. It would have been useful if the document provided a comprehensive guidance on how to prevent and manage NCDs at the primary care level or make a reference to where such a document could be available. While strategies and interventions are well known, such a document or guidelines could facilitate delivery at the ground level, increase coverage, and in making an impact in health outcomes.