Meeting Report
SECOND INTERCOUNTRY TRAINING WORKSHOP ON SUBNATIONAL INITIATIVES FOR CARDIOVASCULAR DISEASE PREVENTION, CONTROL AND MANAGEMENT IN THE MEKONG COUNTRIES
20–23 February 2017 Ho Chi Minh City, Viet Nam
Second Intercountry Training Workshop on Subnational Initiatives for Cardiovascular Disease Prevention, Control and Management in the Mekong Countries
20–23 February 2017 Ho Chi Minh City, Viet Nam
WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC RS/2017/GE/19(VNM) English only
MEETING REPORT
SECOND INTERCOUNTRY TRAINING WORKSHOP ON SUBNATIONAL INITIATIVES FOR CARDIOVASCULAR DISEASE PREVENTION, CONTROL AND MANAGEMENT IN THE MEKONG COUNTRIES
Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC
Ho Chi Minh City, Viet Nam 20–23 February 2017
Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines July 2017
NOTE
The views expressed in this report are those of the participants of the Second Intercountry Training Workshop on Subnational Initiatives for Cardiovascular Disease Prevention, Control and Management in the Mekong Countries and do not necessarily reflect the policies of the conveners.
This report has been prepared by the World Health Organization Regional Office for the Western Pacific for Member States in the Region and for those who participated in the Second Intercountry Training Workshop on Subnational Initiatives for Cardiovascular Disease Prevention, Control and Management in the Mekong Countries in Ho Chi Minh City, Viet Nam from 20 to 23 February 2017.
Contents SUMMARY 1. INTRODUCTION 1.1 Background ................................................................................................................................................... 3 1.2 Objectives ..................................................................................................................................................... 3 1.3 Participants ................................................................................................................................................... 3 1.4 Organization ................................................................................................................................................. 3 2. PROCEEDINGS 2.1 Opening session ............................................................................................................................................ 4 2.2 Progress reports and updates in CVD prevention, control and management ................................................ 4 2.3 Global/Regional CVD initiatives and updates .............................................................................................. 5 2.4 Salt reduction (SHAKE) technical package training .................................................................................... 5 2.5 Field visit on salt reduction ........................................................................................................................... 6 2.6 Action planning for CVD prevention and control ........................................................................................ 6 2.7 Workshop evaluation .................................................................................................................................... 7 3. CONCLUSIONS AND RECOMMENDATIONS 3.1 Conclusions .................................................................................................................................................. 7 3.2 Recommendations......................................................................................................................................... 8 3.2.1 Recommendations for Member States ................................................................................................... 8 3.2.2 Recommendations for WHO ................................................................................................................. 8 ANNEXES Annex 1. List of participants .............................................................................................................................. 9 Annex 2. Programme of activities .................................................................................................................... 12 Annex 3. Participants’ workbook ..................................................................................................................... 15 Annex 4. Workshop evaluation ........................................................................................................................ 52 7 4 1 3
Key words Chronic disease – prevention & control / Chronic disease / Regional health planning/ Mekong Valley
SUMMARY
Noncommunicable diseases (NCDs) account for 50% of premature mortality in the Western Pacific Region. The probability of dying prematurely from one of the four major NCDs (cardiovascular disease, diabetes, cancer or chronic respiratory disease) is 18% in Cambodia, 24% in the Lao People’s Democratic Republic and 17% in Viet Nam. The majority of deaths from NCDs in these countries are due to cardiovascular disease (CVD). This NCD burden reflects a high prevalence of risk factors, in particular raised blood pressure (approximately 20% of males and females 18 years and older in each of these countries) and low coverage of clinical interventions for CVD risk reduction. In 2015, the first intercountry training on subnational initiatives for CVD prevention and control was held in Phnom Penh, Cambodia. A key recommendation of the first intercountry training was for the World Health Organization (WHO) to continue supporting Cambodia, the Lao People’s Democratic Republic and Viet Nam, as requested, to implement their prioritized activities. It was therefore proposed to conduct regular meetings to provide updates on and share experiences of the implementation of action plans, and to strengthen these plans according to recent developments in best practice. The second intercountry training workshop was conducted in Ho Chi Minh City, Viet Nam from 20 to 23 February 2017, with the following objectives: 1) to share experiences of and updates to the implementation of subnational plans for CVD prevention, control and management; 2) to provide training on recently developed global and regional tools related to cardiovascular risk management and salt intake reduction; and 3) to develop monitoring and evaluation frameworks for implementation of prioritized CVD initiatives, including the WHO Package of Essential Noncommunicable Disease Interventions (PEN). It was attended by 12 representatives responsible for the implementation of CVD prevention, control and management interventions, including salt reduction initiatives, in Cambodia, the Lao People’s Democratic Republic and Viet Nam. Other participants included one resource person from the WHO Collaborating Centre for Population Salt Reduction (Australia) and nine staff members from the WHO Regional Office for the Western Pacific and country offices. The workshop provided an opportunity for participants to share their experiences in implementing their subnational plans for CVD prevention, control and management and salt reduction. Updates on recent global and regional developments, including the Global HEARTS Initiative (which is composed of three technical packages: HEARTS1, SHAKE2 and MPOWER3) and HeartCare (desktop computer- and Android-based software for CVD risk calculation and clinical decision support).
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HEARTS = Healthy lifestyle, Evidence-based treatment protocols, Access to essential medicines and technology, Riskbased management, Team care and task-sharing, and Systems for monitoring 2 SHAKE = Surveillance, Harness industry, Adopt standards for labelling and marketing, Knowledge, and Environment 3 MPOWER = Monitor tobacco use and prevention policies, Protect people from tobacco smoke, Offer help to quit tobacco use, Warn about the dangers of tobacco, Enforce bans on tobacco advertising, promotion and sponsorship, Raise taxes on tobacco
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Following the workshop, Member States are encouraged to do the following: 1) to recall the commitments made by Member States on the nine global voluntary targets included in the WHO Global Action Plan for the Prevention and Control of NCDs and the ten progress indicators agreed during the 2014 United Nations General Assembly second highlevel meeting on NCDs, especially about CVD, salt reduction and national response to NCDs; 2) to complete national submissions for the NCD Country Capacity Survey (CCS) 2017 to monitor progress and achievement in expanding capacities for NCD prevention and control; 3) to encourage and facilitate cross-sectoral collaboration between ministries and other relevant stakeholders for developing strategy/action plans and scaling up ongoing initiatives on CVD and salt reduction; 4) to establish consortiums among Member States for specific themes, as needed, and conduct regular meetings to provide updates and share experiences of the implementation of action plans; and 5) to explore the feasibility of adapting the intercountry training workshop model and curriculum at national and subnational levels to build capacity, catalyse support for CVD and salt reduction, and to mobilize country stakeholders in its operationalization. WHO is requested to do the following: 1) to widely disseminate the Noncommunicable Disease Progress Monitor 2015 report and global/regional NCD CCS reports for countries and areas to monitor their progress on the nine voluntary targets and four time-bound commitments; 2) to support Member States as they implement the Global HEARTS package and its tools, including the design and use of mechanisms to monitor and report progress, whenever requested; and 3) to provide Member States with technical assistance in fulfilling prioritized follow-up activities for CVD prevention and control and salt reduction, whenever requested.
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1. INTRODUCTION 1.1 Background Noncommunicable diseases (NCDs) account for 50% of premature mortality in the Western Pacific Region. The probability of dying prematurely from one of the four major NCDs (cardiovascular disease, diabetes, cancer or chronic respiratory disease) is 18% in Cambodia, 24% in the Lao People’s Democratic Republic and 17% in Viet Nam. The majority of deaths from NCDs in these countries are due to cardiovascular disease (CVD). This NCD burden reflects a high prevalence of risk factors, in particular raised blood pressure (approximately 20% of males and females 18 years and older in each of these countries) and low coverage of clinical interventions for CVD risk reduction. In 2015, the first intercountry training workshop on subnational initiatives for CVD prevention and control was held in Phnom Penh, Cambodia. A key recommendation of the first intercountry training was for the World Health Organization (WHO) to continue supporting Cambodia, the Lao People’s Democratic Republic and Viet Nam, as requested, to implement their prioritized activities. It was therefore proposed to conduct regular meetings to provide updates on and share experiences of the implementation of action plans, and to strengthen these plans according to recent developments in best practice. 1.2 Objectives The second intercountry training workshop was conducted in Ho Chi Minh City, Viet Nam from 20 to 23 February 2017 with the following objectives: 1) to share experiences of and updates to the implementation of subnational plans for CVD prevention, control and management; 2) to provide training on recently developed global and regional tools related to cardiovascular risk management and salt intake reduction; and 3) to develop monitoring and evaluation frameworks for implementation of prioritized CVD initiatives, including the WHO Package of Essential Noncommunicable Disease Interventions (PEN). 1.3 Participants The workshop was attended by 12 representatives responsible for the implementation of CVD prevention, control and management interventions, including salt reduction initiatives, in Cambodia, the Lao People’s Democratic Republic and Viet Nam. Other participants included one resource person from the WHO Collaborating Centre for Population Salt Reduction (Australia) and nine staff members from the WHO Regional Office for the Western Pacific and country offices. A list of participants, resource persons and secretariat members is given in Annex 1. 1.4 Organization The workshop comprised five sections in addition to the opening session. The sections were designed to address different aspects of CVD intervention implementation: (1) progress reports and updates in CVD prevention, control and management; (2) global/regional CVD initiatives and updates including
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the HEARTS4 technical package; (3) SHAKE5 technical package training; (4) field visit on WHO PEN implementation and salt reduction; and (5) action planning for CVD prevention and control. A full outline of the programme is provided in Annex 2. A workbook was also developed to support the sessions and to guide the group work and skill-building activities (Annex 3). 2. PROCEEDINGS 2.1 Opening session Dr Truong Dinh Bac, Deputy General Director of General Preventive Medicine, Ministry of Health, Viet Nam welcomed all participants. In Viet Nam, NCDs account for 73% of all deaths and 43% of premature deaths before the age of 70. CVDs (stroke and heart disease) cause over a third of all deaths. Salt consumption is twice that of WHO recommended levels and this has contributed to increasing levels of hypertension. Dr Bac acknowledged that with the support of WHO there has been progress in escalating the profile of NCD prevention and control to an inter-ministerial level. Discussion to establish a National Healthy Movement is in progress in order to generate health promotion actions at the community level in all provinces. Dr Hai-Rim Shin, Coordinator, NCD and Health Promotion, WHO Regional Office for the Western Pacific, gave opening remarks on behalf of Dr Shin Young-soo, WHO Regional Director for the Western Pacific. Following the first intercountry training workshop, significant progress has been made in the three participating countries. Yet, common challenges still exist in strengthening health systems at all levels to deliver essential NCD services. Dr Shin encouraged the participants to take this opportunity in learning from other countries and from recent global and regional developments. Dr Shin finally expressed her appreciation to the Ministry of Health of Viet Nam for hosting the workshop. Dr Warrick Junsuk Kim, Medical Officer, NCD and Health Promotion, WHO Regional Office for the Western Pacific, reviewed the programme of activities for the 3.5-day workshop. 2.2 Progress reports and updates in CVD prevention, control and management Since the first intercountry training workshop in December 2015, the three participating countries have moved forward in implementing and expanding subnational initiatives on CVD. Participants had been requested in advance to provide progress reports on the implementation of WHO PEN and salt reduction in their respective countries. The following are key points from the progress reports: Cambodia: WHO PEN demonstration sites are operating in six districts in four provinces that cover about 19 000 people aged over 40 years. CVD risk screening is provided to these residents, but further support for drug supplies and data management is needed. A subnational survey in Khmuonh commune showed that the average daily intake of salt in the population was 7.7 grams. A draft national action plan for salt reduction is to be developed in 2017 after publication of the recently conducted STEPwise approach to surveillance (STEPS) survey that includes national data on salt intake. Lao People’s Democratic Republic: WHO PEN demonstration sites have been functioning in Champasak province since 2014 with support from WHO and are being expanded to the capital Vientiane with allocated budget from the Government of the Lao People’s Democratic
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HEARTS = Healthy lifestyle, Evidence-based treatment protocols, Access to essential medicines and technology, Riskbased management, Team care and task-sharing, and Systems for monitoring 5 SHAKE = Surveillance, Harness industry, Adopt standards for labelling and marketing, Knowledge, and Environment
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Republic to cover a total population of 768 743 in nine districts. A study in 2013 found that the average daily salt intake in the country is 6.4 grams. Education and advocacy through mass media campaigns are needed to raise awareness of the harm of excessive salt intake and solutions to reduce the amount of salt consumed. Viet Nam: A community-level integrated NCD and mental health service delivery model has been established in Ha Nam province, aiming to provide management for hypertension and diabetes at commune health centres. Training and supervision of the health workforce at commune health centres remain a challenge. Average daily salt intake in Viet Nam is 9.4 grams. Low public awareness and low commitment from the food industry are challenges.
2.3 Global/Regional CVD initiatives and updates Dr Shin presented an overview of NCD prevention and control in the Western Pacific Region. She noted that NCDs are a vital element in the development agenda. The economic impact of NCDs is significant, and poverty and NCDs are intimately linked. The cost of inaction is unacceptably high and significantly more than the total investment to control NCDs. The United Nations General Assembly high-level meeting on NCDs in 2011 acknowledged the critical role of NCDs as a development issue; the resulting Political Declaration on NCDs outlined government commitments to NCD prevention and control, including health systems strengthening for NCD management. Dr Kim introduced the global and regional initiatives currently existing for NCD prevention and control in the primary care setting. The Global HEARTS Initiative was launched by WHO and the United States Centers for Disease Control and Prevention (US CDC) in 2016 to combat the global threat of CVDs. The new initiative is comprised of three technical packages: HEARTS technical package to strengthen management of CVD in primary health care following the WHO PEN approach, the SHAKE package for salt reduction and the MPOWER package for tobacco control. The NCD unit in the WHO Regional Office has developed three user-friendly tools to facilitate the translation of the WHO PEN and HEARTS technical guidelines into practice at the primary health care level: 1) HeartCare: a desktop computer- and Android-based software that helps primary health care workers evaluate and keep track of patients’ 10-year risk of developing heart attack or stroke. 2) NCD education manual: a packaged publication that complements the WHO PEN guidelines by providing an easy-to-use patient counselling flip-chart guide. These are comprised of 15 modules: 7 modules for hypertension, 7 modules for diabetes and 1 module for tobacco cessation. 3) Action for Healthier Families (AHF): a toolkit that recognizes the important role of the family in shaping the health and well-being of its members. It helps families identify and understand their health issues, risk factors that contribute to these, and the interventions that address these and improve health. 2.4 Salt reduction (SHAKE) technical package training Ms Clare Farrand, Senior Project Manager, WHO Collaborating Centre for Population Salt Reduction, George Institute for Global Health, Australia presented on the (1) evidence base for reducing salt, (2) introduction to the SHAKE package, and (3) outline of different interventions and information on how to monitor and evaluate programs.
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Ms Farrand gave an overview of the history of salt including its use in food preservation and the current situation in terms of global salt intakes relative to the WHO recommended maximum daily salt intake of less than 5 grams. She presented the clear evidence linking salt and raised blood pressure as well as the negative impacts on health, highlighting the importance of reducing salt intakes. Salt reduction was highlighted as a very cost-effective intervention for CVD prevention and control on account of its feasibility, effectiveness and low cost for implementation, particularly stressing that it costs only 1–2% of a clinical hypertension programme. The WHO SHAKE technical package includes five key action areas including: surveillance, harnessing the food industry, adopting standards for labelling and marketing, knowledge and environment. Ms Farrand outlined the importance of: leadership and governance; advocacy such as making the case, targeting the message, identifying the audience, and using communication strategies and tools; and planning with clear objectives and strategies and resource development. Each action area has a set of interventions that are cost-effective and feasible. A SHAKE technical toolkit is currently being developed to complement the technical package, providing actual and practical examples of interventions that have been implemented around the world. Ms Farrand stressed the importance of tracking progress through regular monitoring and evaluation of salt reduction programmes towards meeting their objective and to inform the effectiveness of each element. It was reiterated that a clear monitoring and evaluation scheme should be developed at the beginning of any salt reduction programme. 2.5 Field visit on salt reduction The Viet Nam Ministry of Health and WHO country office also organized a field visit to a commune health centre at Commune 5 in District 8 of Ho Chi Minh City and the Ho Chi Minh Nutrition Center. At the commune health centre, participants were shown how early detection, counselling and referral of patients with raised blood pressure are done at the community level. Clinic staff provided an overview of the services that patients receive, including blood pressure checks and information about a healthy diet. The visit to the Ho Chi Minh Nutrition Center was an opportunity to learn how the Government works with the food industry to reduce the salt content of processed foods including reformulation of foods marketed to children to contain less salt. These foods included instant noodles, canned foods, sausage, porridge, vermicelli noodles and lean pork paste. It was recognized that there is a need for further support to scale up this project to the national level and include nutrition labelling to inform consumers of sodium levels in processed foods. There was an informal discussion on establishing a network among Cambodia, the Lao People’s Democratic Republic and Viet Nam to share experiences and enhance capacities for salt reduction programmes. 2.6 Action planning for CVD prevention and control Country participants used a workbook entitled “ProHEARTS: Promoting Heart Health in the Western Pacific” (Annex 3) to brainstorm challenges to CVD prevention and control, prioritize elements of the HEARTS package for implementation, analyse stakeholders, and formulate an action plan for 2017 including estimated costs and proposed funding sources.
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Throughout the 3.5-day workshop, Dr Warrick Kim and Dr Albert Francis Domingo, Consultant, NCD and Health Promotion, WHO Regional Office for the Western Pacific facilitated a series of participatory group work using the workbook. Participants were guided through a rapid assessment and prioritization of the HEARTS elements, followed by country-level stakeholder analysis for two priority HEARTS elements, fishbone analysis of the priority challenges, and identification of countermeasures and practical methods. A final group work on action planning for CVD prevention and control was facilitated to identify areas of highest priority to progress the development and implementation of country CVD and salt reduction strategies. Actions that were identified by national participants are the following: Cambodia: There is ongoing discussion to conduct a United Nations Interagency Task Force mission on NCD in Cambodia this year, with preparation on track for August or September 2017. Updated data from the recently conducted STEPS survey will provide an overall view of the current burden of NCDs in Cambodia. Development of staff mobility regulations is also being planned to ensure that appropriate numbers of health workers are allocated in underserved areas. Lao People’s Democratic Republic: There is a strong demand to develop a national salt reduction strategy to comply with the WHO recommendation of maximum 5 grams of salt per day. Additional efforts focusing on tobacco control, including regulations to impose penalties to prevent conflict of interest and further instructions from the Prime Minister to strengthen the Tobacco Control Law, are priorities in 2017. WHO PEN demonstration sites are expanding from Champasak to Vientiane in 2017. Viet Nam: A need to develop policies and mechanisms for hypertension and diabetes management at commune health centres is a top priority. Essential medicines and basic technologies should be provided at commune health centres to be paid by the national health insurance programme. At the same time, capacity-building of staff in commune health centres is needed considering that NCDs are a relatively recent concept for most staff at the community level. Guideline development and campaigns for healthy canteens are planned for 2018. Immediate actions to be taken are advocacy in national and local governments and raising public awareness through social media.
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2.7 Workshop evaluation Participants completed a post-workshop confidence and knowledge assessment, and results were compared to the pre-workshop assessment. A written evaluation of the workshop was conducted using a structured questionnaire to gauge participants’ impressions and success of the workshop (Annex 4). Participants valued the information, skills and new tools acquired in the various sessions, the sharing of experiences from other countries, and the observations and insights generated by the field visits. 3. CONCLUSIONS AND RECOMMENDATIONS 3.1 Conclusions The workshop provided an opportunity for participants from the ministries of health of Cambodia, the Lao People’s Democratic Republic and Viet Nam to share their experiences in implementing their subnational plans for CVD prevention, control and management and salt reduction. Updates on recent global and regional developments, including the Global HEARTS Initiative (which is composed of
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HEARTS, SHAKE and MPOWER 6 ) and HeartCare. Through facilitated group work, participants were able to identify barriers and opportunities for implementation of CVD initiatives and also prioritized actions needed in the following year for their country or area. It was agreed that another regional meeting should be planned for 2018 in the Lao People’s Democratic Republic to update progress on these issues. There was an informal discussion on establishing a network among Cambodia, the Lao People’s Democratic Republic and Viet Nam to share experiences and enhance capacities for salt reduction programmes. 3.2 Recommendations 3.2.1 Recommendations for Member States Member States are encouraged to do the following: 1) to recall the commitments made by Member States on the nine global voluntary targets included in the WHO Global Action Plan for the Prevention and Control of NCDs and the ten progress indicators agreed during the 2014 United Nations General Assembly second highlevel meeting on NCDs, especially about CVD, salt reduction and national response to NCDs; 2) to complete national submissions for the NCD Country Capacity Survey (CCS) 2017 to monitor progress and achievement in expanding capacities for NCD prevention and control; 3) to encourage and facilitate cross-sectoral collaboration between ministries and other relevant stakeholders for developing strategy/action plans and scaling up ongoing initiatives on CVD and salt reduction; 4) to establish consortiums among Member States for specific themes, as needed, and conduct regular meetings to provide updates and share experiences of the implementation of action plans; and 5) to explore the feasibility of adapting the intercountry training workshop model and curriculum at national and subnational levels to build capacity, catalyse support for CVD and salt reduction, and to mobilize country stakeholders in its operationalization. 3.2.2 Recommendations for WHO WHO is requested to do the following: 1) to widely disseminate the Noncommunicable Disease Progress Monitor 2015 report and global/regional NCD CCS reports for countries and areas to monitor their progress on the nine voluntary targets and four time-bound commitments; 2) to support Member States as they implement the Global HEARTS package and its tools, including the design and use of mechanisms to monitor and report progress, whenever requested; and 3) to provide Member States with technical assistance in fulfilling prioritized follow-up activities for CVD prevention and control and salt reduction, whenever requested.
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MPOWER = Monitor tobacco use and prevention policies, Protect people from tobacco smoke, Offer help to quit tobacco use, Warn about the dangers of tobacco, Enforce bans on tobacco advertising, promotion and sponsorship, Raise taxes on tobacco
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ANNEX 1 LIST OF PARTICIPANTS, RESOURCE PERSON AND SECRETARIAT
1. PARTICIPANTS Dr Loun CHHUN, Chief of Noncommunicable Disease Office, Preventive Medicine Department Ministry of Health, No 80, Samdech Penn Nouth Blvd (289), Sankat Boeungkak 2, Toul Kork District Phnom Penh, Cambodia, Telephone: (855) 11953124, Email: chhunloun@yahoo.com Dr CHEA Mery, Deputy Manager of National Nutrition Programme, National Maternal and Child Health Center, #13A, 47 France Street, Sra Chork, Daun Penh, Phnom Penh, Cambodia Telephone: + (855) 12892266, E-mail: chea.mary50@gmail.com Dr LUN Thanvuth, Chief of Health Education, Health Promotion Unit, National Center for Health Promotion, #3, Street 6ª, Kean Khlang, Preak Leap, Russey Keo, Phnom Penh, Cambodia Telephone: + (855) 92212118, E-mail: tvuthlun@gmail.com Dr SIN Eap, Chief of Planning and National Policy, Department of Mental Health and Substance Abuse, Ministry of Health, #80, Pen Nuth Blvd., Phnom Penh, Cambodia, Tel No.: +(855) 77326464 E-mail: sineap_khmer@yahoo.com Professor VANG Chu, Director of the Lao-Luxembourg Heart Centre, Mahasot Hospital, Vientiane Lao, PDR, Telephone: (856) 2054303999, E-mail: profdrvangchu@gmail.com Dr PHOUTSAVATH Phisith, Deputy Director of Health Care, Department of Health Care Ministry of Health, Dondeng Village Chanthabouly District, Vientiane, Lao PDR Telephone: +(856) 2099966198, E-mail: psavath@gmail.com Dr Bounthom PHENGDY, Director of Nutrition Center, Nutrition Center, Bane Kaonhot, Ministry of Health, Vientiane, Lao PDR, Telephone: +(856) 2055618246, E-mail: bphengdy@yahoo.com Associate Professor Dr Pany KESONE, Deputy Director of the Lao-Luxembourg Heart Centre Mahasot Hospital, Vientiane, Telephone: +(856) 2055417881, E-mail: kesone3@hotmail.com Dr DO Thi Phuong Ha, Principle Researcher, Chief of the Department of Community Nutrition National Institute of Nutrition, 48-B Tang Bat Ho str., Hanoi, Viet Nam, Telephone: +(84)(4) 3 9715127, E-mail: dothiphuongha@dinhduong.org.vn Dr HA Huy Toan, Deputy Head Division of NCD and School Health, General Department of Preventive Medicine and Environment, 135/1 Nui Truc Alley, Ba Dinh District, Hanoi Viet Nam, Telephone: +84 438464415, E-mail: toanytdpvn@gmail.com Ms DINH Hai Linh, Officer – Division of Noncommunicable Diseases and School Health General Department of Preventive Medicine, Ministry of Health, 138A-Giang Vo – Ba Dinh Hanoi, Viet Nam, Telephone: +84 437367184, E-mail: dinhhailinh86@gmail.com Dr VU Quynh Hoa, Deputy Head of General Planning Department, Nutrition Center of Ho Chi Minh City, 180 – Le Van Sy Str., Ward 10, Phu Nhuan District, Ho Chi Minh City Viet Nam, Telephone: +84 839915370, E-mail: vuquynhhoa75@yahoo.com Dr TRUONG LE VAN Ngoc, Medical Expert – Coordinator for Prevention and Control of Noncommunicable Diseases, Department of Medical Service Administration Ministry of Health, 138 A-Giang Vo – Ba Dinh, Hanoi, Telephone: +84 462732445 E-mail: ngoctruongmoh@gmail.com
Dr PHAM Tran Linh, Member of Committee of Cardiovascular Prevention and Risk Factors, Bachmai General Hospital, Ministry of Health, 78 – Giai Phong – Dong Da, Hanoi Telephone: +84 913363101, E-mail: ptlinhmd@gmail.com Dr BUI Van Dung, National Geriatric Hospital, 1ª-Phuong Mai – Gong Da, Hanoi, Viet Nam Telephone: +84 979099246, E-mail: dungtmvlk@gmail.com 2. RESOURCE PERSON Ms Clare FARRAND, Senior Project Manager, Salt Reduction Strategies, The George Institute for Global Health, WHO Collaborating Centre on Population Salt Reduction, Level 10, King George V Building, 83117 Missenden Rd., Camperdown, New South Wales, 2050 Australia Tel. No.: +61 402545094, E-mail: cfarrand@georgeinstitute.org.au 3. SECRETARIAT Dr Hai-Rim SHIN (Responsible Officer), Coordinator, Noncommunicable Diseases and Health Promotion, Division of NCD and Health through the Life-Course (DNH), World Health Organization Regional Office for the Western Pacific, United Nations Avenue, Ermita , Manila, Philippines Telephone: (632) 528 9860, Facsimile: (632) 526 0279, Email: shinh@wpro.who.int Dr Warrick Junsuk KIM, Medical Officer, Noncommunicable Diseases and Health Promotion Division of NCD and Health through the Life-Course (DNH), World Health Organization Regional Office for the Western Pacific (WPRO), United Nations Avenue, Ermita, Manila, Philippines Telephone: (632) 528 9860, Facsimile: (632) 526 0279, Email: kimw@wpro.who.int Dr Katrin ENGELHARDT, Technical Lead for Nutrition, Division of NCD and Health Through the LifeCourse, WHO Regional Office for the Western Pacific, United Nations Avenue corner Taft Avenue, Manila 1000, Philippines, Telephone: +632 528 9093, Facsimile: +632 526 1036 E-mail: engelhardtk@who.int Ms Mina KASHIWABARA, Technical Officer,Tobacco-free Initiative, Division of NCD and Health Through the Life-Course, WHO Regional Office for the Western Pacific, United Nations Avenue corner Taft Avenue, Manila 1000, Philippines, Telephone: +632 528 8001, Facsimile: +632 526 1036 E-mail: kashiwabaram@who.int Dr Jason LIGOT, Consultant, Mental Health and Substance Abuse, Division of NCD and Health Through the Life-Course, WHO Regional Office for the Western Pacific, United Nations Avenue corner Taft Avenue, Manila 1000, Philippines, Telephone: +632 528 8001, Facsimile: +632 526 1036 E-mail: ligotj@who.int Dr Albert DOMINGO, Consultant, Noncommunicable Diseases and Health Promotion, Division of NCD and Health Through the Life-Course, WHO Regional Office for the Western Pacific United Nations Avenue corner Taft Avenue, Manila 1000, Philippines, Telephone:+632 528 8001 Facsimile: +632 526 1036, E-mail: dominga@who.int Mr James RARICK, Technical Officer (NCD), World Health Organization, Office of the WHO Representative in Cambodia, 1st Floor No. 61-64, Preah Norodom Blvd., (corner St. 306), Sangkat Boeung Keng Kang I, Khan Chamkamorn, Phnom Penh, Cambodia, Telephone: +855 23 216610 Facsimile.: +855 23 216211, E-mail: rarickj@who.int Mr Yel DARAVUTH, National Professional Officer, World Health Organization – Cambodia, No. 61-64 Norodom Blvd Corner Street 306, Sangkat Boeung Keng Kang 1, Khan Chamkamorn Phnom Penh, Cambodia, Telephone: (85 5) 2321-6610, Facsimile: (85 5) 2321-6211 E-mail: daravuthy@who.int
Dr CHOU Vivath, Technical Officer, Disability and Rehabilitation, World Health Organization – Cambodia, No. 61-64 Norodom Blvd Corner Street 306, Sangkat Boeung Keng Kang 1 Khan Chamkamorn, Phnom Penh, Cambodia, Telephone: (85 5) 2321-6610, Facsimile: (85 5) 2321-6211, E-mail: chouv@who.int Dr Sam Ath KHIM, National Professional Officer, World Health Organization – Cambodia No. 61-64 Norodom Blvd Corner Street 306, Sangkat Boeung Keng Kang 1, Khan Chamkamorn Phnom Penh, Cambodia, Telephone: (85 5) 2321-6610, Facsimile: (85 5) 2321-6211 E-mail: khims@who.int Mr Douangkeo THOCHONGLIACHI, National Professional Officer (TFI), World Health Organization Office of the WHO Representative in Lao PDR, 125 Saphanthong Road, Unit 5, Ban Saphangthongtai Sisattanak District, Vientiane, Lao PDR, Telephone: (856) 21 353-902, Facsimile: (856) 21 353-905 E-mail: thochongliached@who.int Dr Lam NGUYEN TUAN, Technical Officer, World Health Organization – Viet Nam 63 Tran Hung Dao Street, Hoan Kiem District, Hanoi, Telephone +84 4 38500294 Facsimile: +844 39433740, E-mail: nguyentuanl@who.int Mr LAI Duc Truong, Technical Officer, World Health Organization, Office of the WHO Representative in Viet Nam, 304 Kim Ma Street, Ha Noi, Viet Nam, Tel. No.: +84 (0) 4 38 500 100, Facsimile: +84 (0) 4 37 265 519, E-mail: laid@wpro.who.int Dr NGA Pham Thi Quynh, Technical Officer, World Health Organization – Viet Nam 63 Tran Hung Dao Street, Hoan Kiem District, Hanoi, Viet Nam, Telephone +84 4 38500294 Facsimile: +844 39433740, E-mail: ngap@who.int Dr NGUYEN Phuong Nam, Technical Officer, World Health Organization – Viet Nam 63 Tran Hung Dao Street, Hoan Kiem District, Hanoi, Viet Nam, Telephone +84 4 38500294 Facsimile: +844 39433740, E-mail: nguyenp@who.int
ANNEX 2 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
PROGRAMME OF ACTIVITIES
Monday, 20 February 2017 08:30-09:00 Registration
(1) Opening ceremony
09:00-09:20 Welcome address
Dr Truong Dinh Bac Deputy General Director of General Preventive Medicine Ministry of Health Viet Nam Dr Hai-Rim Shin Coordinator Noncommunicable Diseases and Health Promotion WHO Regional Office for the Western Pacific Dr Warrick Junsuk Kim Medical Officer Noncommunicable Diseases and Health Promotion WHO Regional Office for the Western Pacific
Opening remarks
09:20-10:00 Introduction of participants Overview of the workshop
Group photo
10:00-10:30 Mobility break
(2) Progress reports and updates in CVD prevention, control and management 10:30-11:30 Progress reports on PEN implementation and salt reduction in Cambodia, Lao PDR and Viet Nam Country participants Moderator: Mr James Rarick Team Leader NCDs and Health through the LifeCourse WHO Cambodia 11:30-12:00 Groupwork 1: Brainstorming on challenges to CVD prevention and control 12:00-13:30 Lunch break (3) Global/Regional CVD initiatives and updates 13:30-14:30 Introduction to the Global/Regional CVD initiatives and updates Dr Hai-Rim Shin 14:30-15:00 Mobility break 15:00-15:30 Groupwork 2: Rapid assessment and prioritization of the HEARTS elements for CVD risk management Facilitator: Dr Albert Francis Domingo Consultant Noncommunicable Diseases and Health Promotion WHO Regional Office for the Western Pacific Facilitator: Dr Warrick Junsuk Kim Mr James Rarick
15:30-16:30 Groupwork 3: Country-level stakeholder analysis for two priority HEARTS elements 17:00-19:00 Welcome reception
Tuesday, 21 February 2017 08:45-09:00 Recap of Day 1 09:00-10:00 Regional HEARTS: Tools 10:00-10:30- Mobility break 10:30-11:30 Introduction to the SHAKE technical package and tools Ms Clare Farrand Senior Project Manager – Salt Reduction Strategies, Food Policy Division The George Institute for Global Health WHO Collaborating Center on Population Salt Reduction WHO country office staff Dr Warrick Junsuk Kim
11:30-12:00 Open forum on HEARTS and SHAKE 12:00-13:30 Lunch break
Dr Hai-Rim Shin
13:30-14:30 Groupwork 4: Fishbone analysis of the priority challenges
Facilitator: Dr Albert Francis Domingo
14:30-15:00 Mobility break 15:00-16:30 Groupwork 5: Countermeasures and practical methods Facilitator: Dr Warrick Junsuk Kim
Wednesday, 22 February 2017
(4) Salt reduction (SHAKE) technical package training
08:45-09:00 Recap of Day 2 09:00-10:00 SHAKE the salt habit training: Interventions - Harnessing industry, Adopt labelling, Knowledge, Environment 10:00-10:30 Mobility break 10:30-12:00 Case studies on salt reduction using the SHAKE toolkit 12:00-13:30 Lunch break
WHO country office staff Ms Clare Farrand
Ms Clare Farrand
(5) Field visit on salt reduction 13:30-16:30 Field visit on salt reduction WHO Viet Nam (Nutrition Center of Ho Chi Minh City and public health centre)
Thursday, 23 February 2017 08:45-09:00 Recap of Day 3 09:00-10:00 SHAKE the salt habit training: Monitoring and Evaluation 10:00-10:30 Mobility break WHO country office staff Ms Clare Farrand
(6) Action planning for CVD prevention and control
10:30-11:30 Groupwork 6: Action planning for CVD prevention and control
Facilitators: Dr Hai-Rim Shin Dr Warrick Junsuk Kim
(7) Closing ceremony 11:30-12:00 Plenary presentation of action plans 12:00-13:30 Lunch break All participants
ANNEX 3
Promoting Heart Health In The Western Pacific
PRO HEARTS 2 nd Intercountry Training Workshop on Subnational Initiatives for Cardiovascular Disease Prevention, Control and Management in the Mekong Countries
Ho Chi Minh, Viet Nam | 20-23 February 2017
PRO HEARTS
Promoting Heart Health In The Western Pacific Ho Chi Minh, Viet Nam | 20-23 February 2017
2 nd Intercountry Training Workshop on Subnational Initiatives for Cardiovascular Disease Prevention, Control and Management in the Mekong Countries
This workbook was developed by the Noncommunicable Diseases and Health Promotion Unit of the WHO Regional Office for the Western Pacific for use at the 2nd Intercountry Training Workshop on Subnational Initiatives for Cardiovascular Disease Prevention, Control and Management in the Mekong Countries (2nd Workshop on CVDs in the Mekong Countries). It is not a formal publication at this time and is not for sale or use for commercial purposes. Comments and suggestions to improve this document are welcome and may be sent to wproncd@who.int.
Contents Introduction …………………………………………………………………………………………………………………………………. 1 Participant’s Notes ………………………………………………………………………………………………………………………… 3 Welcome to Mekong Land! ……………………………………………………………………………………………………………… GROUPWORK 1 GROUPWORK 2 GROUPWORK 3 7 Brainstorming on challenges to CVD prevention and control …..…………………………………… 8 Rapid assessment and prioritization of the HEARTS elements for CVD risk management …. 11 Country-level stakeholder analysis for two priority HEARTS elements ………………………….. 15
GROUPWORK 4A Brainstorming and multi-voting on HEARTS implementation problems ….……………….…… 19 GROUPWORK 4B Fishbone analysis of the priority challenges ……………………………………..………………….…… 22 GROUPWORK 5 GROUPWORK 6 Countermeasures and practical methods ………………………………………………………………….. 25 Action planning for CVD prevention and control ……………………………….………………………… 28
2nd Workshop on CVDs in the Mekong Countries ProHEARTS: Promoting Heart Health in the Western Pacific
Introduction BACKGROUND In the Western Pacific Region, noncommunicable diseases (NCDs) account for 50% of premature mortality. The probability of dying prematurely from one of the four major NCDs (cardiovascular disease, diabetes, cancer or chronic respiratory disease) is 18% in Cambodia, 24% in Lao PDR, and 17% in Viet Nam. The majority of deaths from NCDs in these countries are due to cardiovascular disease (CVD). This NCD burden reflects a) a high prevalence of risk factors, in particular raised blood pressure (approximately 20% of males and females 18 years and older in each of these countries) and tobacco smoking (over 45% of males 15 years and older in Cambodia and Viet Nam) and b) low coverage of clinical interventions for CVD risk reduction. The global and Western Pacific regional action plans for the prevention and control of NCDs present an array of policy options and costeffective interventions to reduce the burden of NCDs. The WHO Regional Office for the Western Pacific (WPRO) supports the Mekong countries to implement these actions through strengthening national capacity, leadership, governance, multisectoral action and partnerships, and through provision of technical advice on strengthening and reorienting health systems. Last 2015, the first intercountry training on subnational initiatives for cardiovascular disease prevention and control was held in Phnom Penh, Cambodia. This training was valuable as it provided the Mekong countries with an opportunity to share their achievements, challenges and ideas for reducing CVD burden. Each country developed a strategy/action plan to further strengthen CVD prevention control and management. They included salt reduction and the WHO Package of Essential Noncommunicable Disease Interventions (PEN) as priorities.
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A key recommendation of the first intercountry training was for WHO to continue supporting Cambodia, Lao PDR, and Viet Nam, as requested, to implement their prioritized activities. It was therefore proposed to conduct regular meetings with the participating countries to provide updates on and share experiences of the implementation of action plans, and to revise and strengthen these plans according to recent developments in best practice. OBJECTIVES At the end of this training workshop, participants will have: • shared experiences of and updates to the implementation of subnational plans for CVD prevention, control and management in their respective countries; • received training on recently developed global and regional tools related to cardiovascular risk management and salt intake reduction; and • developed action plans with monitoring and evaluation frameworks for the implementation of prioritised CVD initiatives, including the Package of Essential Noncommunicable Disease Interventions.
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Participants Notes | Day 1 Participants are encouraged to note down highlights or key messages from the presentations. ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________
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Participants Notes | Day 2 Participants are encouraged to note down highlights or key messages from the presentations. ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________
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Participants Notes | Day 3 Participants are encouraged to note down highlights or key messages from the presentations. ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________
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Participants Notes | Day 4 Participants are encouraged to note down highlights or key messages from the presentations. ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________
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Welcome To Mekong Land! Mekong Land is a country in Southeast Asia with an estimated population of 10,000,000 as of 2015. Average life expectancy at birth is estimated at 67 years for men and 72 years for women. As of 2014, the probability of dying between ages 30 and 70 years from the four main NCDs is 20%. NCDs are estimated to account for 58% of total deaths. The World Bank classifies the country as lower middle income (GDP per capita of 5,000 international dollars/PPP). Total expenditure on health as a percentage of GDP was 5.0% in 2014. A majority of the Mekong Land citizens are Buddhist, with substantial Christian and Muslim minorities. The country is governed by a unitary parliament, with an executive branch headed by the Prime Minister. Health and social services are delivered through district- and communitylevel health centres that are linked to provincial hospitals. Mekong Land has a predominantly agricultural economy. It is known for its delicious and flavourful cuisine, often accompanied by rice noodles and served with a variety of dips and sauces on the side. Mekong Land elected a new government earlier this year and the Prime Minister has just appointed a new Senior Health Programme Manager for NCDs. The Prime Minister’s spouse is the Chair of a hypertension patients’ society. She got involved in the association due to her interest in NCDs as a result of her father’s premature death from a heart attack many years ago. Unfortunately, NCD services are not widely available in primary care health centers. Only a few physicians/general practitioners are aware of the WHO PEN. WHO has started work with the Ministry of Health to demonstrate the WHO Package of Essential NCD interventions (PEN) in two districts. The new Senior Health Programme Manager is keen to advance NCD prevention and control, particularly for carviovascular diseases (CVD), in Mekong Land. She attended the launch of the Global HEARTS initiative last September 2016 in New York which consists of three packages: MPOWER for tobacco control, SHAKE package for salt reduction and HEARTS for CVD risk management, and would like to implement it (particularly SHAKE and HEARTS) in her country. Over the next few groupworks, learn about progress in implementing CVD prevention and control in Mekong Land while planning for your own country’s context.
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Groupwork 1 Time needed 30 minutes Materials
Brainstorming on challenges to CVD prevention and control Objective • To highlight country progress in implementing CVD prevention and control programmes, plans or policies.
Poster worksheet for country achievements, markers
Instructions 1. 2. Proceed to your small groups (by country) in the breakout areas. Within your small groups, discuss progress in CVD prevention and control in your respective countries guided by the following questions:
• What strategies have helped advance CVD prevention and control in your country? • Which key stakeholders did you engage and what roles did they play? • What challenges did you encounter in advancing CVD prevention and control? 3. 4. You may refer to the template for country progress reports sent by the Secretariat in advance, if available. After the small group discussion, identify 3 main achievements and 3 main challenges in advancing CVD prevention and control in your country and indicate them in worksheet 1.
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Example
Mekong Land Top 3 achievements and good practices in CVD prevention and control in your country: Brief description: Coalition of civil society organizations, NGO, youth groups and concerned citizens established to raise awareness and advocate for salt reduction School-based adolescent risk factor survey with questions on dietary salt carried out in randomly selected public secondary schools Demonstration site to develop NCD referral networks started in an urban area
1. Salt reduction coalition established
2. School survey on adolescent risk factors carried out 3. Demonstration site started to strengthen NCD referral networks between primary and higher levels of care
Top 3 challenges in advancing CVD prevention and control:
1. Low capacity among primary health workers to conduct screening and risk assessment following WHO PEN
2. Limited financial resources available to support initiatives
3. Local food has a lot of salt
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Worksheet 1 | Brainstorming on challenges to CVD prevention and control
Country Top 3 achievements and good practices in CVD prevention and control in your country: 1 2 1 2 Brief description:
3
3 Top 3 challenges in advancing CVD prevention and control:
1
2
3
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Groupwork 2 Time needed 30 minutes
Rapid assessment and prioritization of the HEARTS elements for CVD risk management
Materials Workbook, worksheet of HEARTS elements, markers, stickers
Objective • To assess importance and feasibility of the six HEARTS elements for CVD risk management. • To identify priority HEARTS elements for implementation in 2017.
The HEARTS package has six elements for CVD risk management:
H Healthy lifestyle
E Evidence-based treatment protocols
A Access to essential medicines and technology
R Risk-based management
T Team care and task-sharing
S Systems for monitoring
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Instructions 1. 2. Within your country group, review the six HEARTS elements. Using the worksheets provided, assess the importance of each HEARTS element according to your country context. Please place a red square on the corresponding number in the heart diagram provided. 10 minutes 0 – Not important 1 – Slightly important 2 – Moderately important 3 – Important 4 – Very important 3. Using the same worksheet, now assess the feasibility of each HEARTS element according to your country context. Please place a green triangle on the corresponding number in the same heart diagram. This assessment is based on the availability of resources (e.g. materials, money, people and time) to implement the HEARTS element. 10 minutes 0 – Not important 1 – Slightly important 2 – Moderately important 3 – Important 4 – Very important 4. Review your assessment of all the six HEARTS elements. Based on your country context and keeping in mind their importance and feasibility, select two priority HEARTS elements. Write down the priority HEARTS elements and their scores on importance and feasibility on the table. 10 minutes
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Example Importance Feasibility
High priority
Evidence-based treatment protocols 4 3 4 3 2 1 2 1 1 2 3 4
Healthy lifestyle
Access to essential medicines and technology
1 2 3 4 2 3 4 1
1 2 3 4
Systems for monitoring
Risk-based management
Team care and task-sharing
High priority
HEARTS Element Evidence-based treatment protocols Team care and task-sharing
Importance 4 3
Feasibility 4 3
Level of Priority 4 x 4 = 16 3x3=9
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Worksheet 2 | Rapid assessment and prioritization of the HEARTS elements Importance Feasibility
Evidence-based treatment protocols 4 3 4 3 2 1 2 1 1 2 3 4
Healthy lifestyle
Access to essential medicines and technology
1 2 3 4 2 3 4 1
1 2 3 4
Systems for monitoring
Risk-based management
Team care and task-sharing HEARTS Element Importance Feasibility Level of Priority
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Groupwork 3 Time needed 60 minutes Instructions 1.
Country-level stakeholder analysis for two priority HEARTS elements Objective • To identify champions and develop a single overarching communication outcome (SOCO).
Materials Workbook, worksheet, sticky notes, markers
Within your country groups, reflect on the outcomes of the earlier activities. Recall the two HEARTS elements you will prioritize for 2017. Identify all the stakeholders you need to reach to achieve meaningful change for each of the priority HEARTS elements you have chosen. Write out each stakeholder on a sticky note.
2. Situate each stakeholder on the influence-interest grids below. Use one grid for each priority HEARTS element. The grids enable you to gauge each stakeholder’s standing with regard to their ability to influence the process of change as well as their interest in the particular HEARTS elements which you would like to implement. 3. Draw arrows between your champions indicating the direction of influence between them (e.g. who influences who). The arrow should point from the one who influences towards the one who is influenced. 20 minutes Categories of champions to consider:
Program side Donors, Government leaders, Program managers, Health workers, Media professionals, Primary care providers, Private practitioners, Civil society leaders, Hospital administrators
Client or audience side Families, Men, Women, Children, Senior citizens, Youth, Business owners, Workers, Educators, Students
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4.
Within your country groups, discuss the map and select/encircle ONE champion who will you seek to influence. 10 minutes High
HEARTS Element: Evidence-based treatment protocols
Example
INFLUENCE
Mr Mitch Alampay Prime Minister
Mrs Xiao Kim Wife of the Prime Minister
Ms Katrin Khow TV Celebrity Mr Todd Kashiwabara CEO of ML Inc Low
Dr Jonathon Barrett Senior Cardiologist
High
INTEREST Dr Minjoo Sobel Hospital Chief Ms Joy Ligot Labor Union Leader Ms Thea Zepeda Student Union President
Low
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Worksheet 3A | Country-level stakeholder analysis
HEARTS Element: High
INFLUENCE
Low
High
INTEREST
Low
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Worksheet 3B | Country-level stakeholder analysis
HEARTS Element: High
INFLUENCE
Low
High
INTEREST
Low
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Groupwork 4A Time needed 30 minutes Materials
Brainstorming and multi-voting on HEARTS implementation problems
Objective • To brainstorm and identify problems that block implementation of the high priority HEARTS elements • To prioritize these implementation problems
Workbook, worksheet, markers
Instructions 1. Looking at the highest priority HEARTS element for your country, discuss with your group what could be problems that will block implementation. Write these implementation problems into first column of the table below. 15 minutes • Implementation problems should be written in a specific and measurable manner. 2. Using a multi-voting system, select the implementation problems that you want to address first. • • • • • Multi-voting is done by counting the number of challenges in the list and voting for just over half the number. Here where we listed five, on the first round of voting each group member should choose only three. The top three will then be subject to a second round of voting where each group member should choose only two. Finally on the third round of voting each group member should choose only one. The challenge that remains at the end of the multi-voting process is the highest priority. 15 minutes
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Example
High priority HEARTS Element: Evidence-based treatment protocols
Implementation problems Existing guidelines are for specialists No practical guidance for primary health care workers for hypertension and diabetes No self-care guidelines for patients with diabetes Unclear protocols for tobacco cessation counselling Guidelines for hypertension and diabetes have overlaps and are not integrated
Voting round 1
Voting round 2
Voting round 3
III IIII-II \ II IIII II
II IIII-I \ IIII
IIII
II
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Worksheet 4A | Brainstorming and multi-voting on priority implementation problems
High priority HEARTS Element:
Implementation problems
Voting round 1
Voting round 2
Voting round 3
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Groupwork 4B Time needed 60 minutes Materials
Fishbone analysis of the priority challenges Objective • To identify the underlying causes of the selected implementation problem that can be modified or acted upon
Workbook, worksheet, metacards, markers
Instructions 1. 2. Write the challenge statements from worksheet 1 at the head of a fishbone diagram (use one diagram per challenge). Draw arrows toward the head of the fish and write down underlying causes for the implementation challenge. • Ask yourself “why?” each time you draw an arrow. Keep on drawing arrows for underlying causes until you get to an underlying cause that you can modify or act upon. Draw a cloud around these underlying causes.
3.
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Example
HEARTS Element: Evidence-based treatment protocols Other country guidelines are being used instead of WHO guidelines
There are disagreements among practitioners on blood pressure and blood sugar targets
Senior policymakers are not interested in cardiovascular disease prevention and control
Key stakeholders have no time to convene into an expert panel There are limited resources available for an expert panel.
No practical guidance for primary health care workers for hypertension and diabetes There is no expert panel to work on guidance documents
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Worksheet 4B | Fishbone analysis
HEARTS Element:
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Groupwork 5 Time needed 90 minutes Materials
Countermeasures and practical methods Objective • To develop countermeasures and practical methods that are feasible and effective to overcome the underlying causes of the implementation challenges
Workbook, worksheets, and markers
Instructions 1. Using the matrix provided for this activity, write down the priority implementation challenge in the box towards the left of the matrix. Write the underlying causes that were encircled with clouds in the column on “causes”. Discuss with your fellow participants specific solutions or countermeasures needed to address the causes. Write these countermeasures down in the “countermeasures” column. In the following column, write down practical methods of implementing the countermeasures.
2. 3.
4.
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Example Implementation Problem Causes Countermeasures Practical methods Coordinate with WHO country office to obtain WHO guidelines Other country guidelines are being used instead of WHO No practical guidance for primary health care workers for hypertension and Senior diabetes policymakers are not interested in cardiovascular disease prevention and control Use WHO guidelines Convene medical practitioners to arrive at consensus on WHO guidelines Disseminate published WHO guidelines to reach primary care physicians Meet with the wife of the Prime Minister to raise importance Prepare policy briefs for decisionmakers Invite high-level officials to global meeting on CVD Feasibility (1 to 5) 5 Impact (1 to 5) 5 Priority Score 25
3
5
15
4
5
20
Advocate for development of evidence-based protocols and guidelines
2 4 3
4 4 3
8 16 9
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Worksheet 5 | Countermeasures and practical methods Implementation Problem Causes Countermeasures Practical methods Feasibility (1 to 5) Impact (1 to 5) Priority Score
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Groupwork 6 Time needed 60 minutes (followed by 30 minutes of plenary discussion) Instructions 1. 2. Materials
Countermeasures and practical methods Objective • To prepare an action plan with indicators, due dates, expected outcomes, estimation of costs and sources of funds.
Workbook, worksheets, and markers
Using the action plan template below, write down the countermeasures and the highest priority practical methods from the previous activity. Add in specific progress monitoring indicators and targets (preferably at the level of outputs), due dates within 2017, expected outcomes, estimated costs (in your own country’s currency) and source of funds. • Examples of output indicators: ‣ Proportion of primary health care facilities offering cardiovascular risk stratification for the management of patients at high risk for heart attack and stroke - Target: Fifty percent (50%) ‣ Proportion of primary health care facilities of the public sector with all of the following drugs generally available: insulin, aspirin (100 mg), metformin, thiazide diuretics, ACE inhibitors, CC blockers, statins and sulphonylureas - Target: Fifty percent (50%) • Examples of outcomes: ‣ Primary health care patients availing of cardiovascular risk stratification ‣ Patients assessed to have a high risk for heart attack and stroke availing of drugs and medicines at primary health care facilities of the public sector ‣ Salt consumption level reduced
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Example Country team: Mekong Land Implementation problem: No practical guidance for primary health care workers for hypertension and diabetes Countermeasures Practical methods Output indicators Dates due and targets Use WHO guidelines Coordinate with WHO country office to obtain WHO guidelines Latest WHO PEN April 2017 guidelines obtained from WHO and adapted to country context Expected outcomes Estimated cost Source of funds WHO
WHO PEN USD 1,500 guidelines adapted/endorsed by MOH and published locally
Advocate for development of evidence-based protocols and guidelines
Prepare policy Two evidenceMay 2017 briefs for decision- informed policy makers notes prepared and disseminated on the benefits of CVD prevention and control
Senior policymakers able to understand the benefits of CVD prevention and control
USD 2,000
Line-item budget – work and financial plan of MOH
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Worksheet 6 | Action planning for CVD prevention and control Country team: Implementation challenge: Countermeasures Practical methods Output indicators Dates due and targets Expected outcomes Estimated cost Source of funds
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ANNEX 4
Second Intercountry Training on Subnational Initiatives for Cardiovascular Disease Prevention, Control and Management Ho Chi Minh, Viet Nam, 20 to 23 February 2017
Workshop evaluation The workshop was attended by twelve (12) participants responsible for the implementation of CVD prevention, control and management interventions, including salt reduction initiatives, in Cambodia, the Lao and Viet Nam. Three (3) WHO Regional Office for the Western Pacific staff, six (6) WHO country office staff and one temporary advisor served as secretariat for the workshop. The three-and-a-half day programme was evaluated using a questionnaire where participants gave scores on a scale of 1-10 (10 being the highest, 1 being the lowest) for operational arrangements and for the technical sessions. Participants also assessed their knowledge and confidence levels on a scale of 1-5 (5 being the highest, 1 being the lowest) before and after the workshop (knowledge assessment results not disclosed). The distribution of the scores is provided below.
Questionnaire 1 - Overall impression The participation in this meeting was The facilitation in this meeting was The leadership in this meeting was Travel arrangements for the meeting was Facilities of this meeting were Accommodation for this meeting was Meals provided during this meeting were The overall impression of this meeting was Questionnaire 2 - What have you achieved? 10 9 8 7 9% 18% 17% 17% 17% 25% 33% 25% 17% 17% 6 0% 0% 0% 0% 0% 0% 0% 8% 0% 0% Session 2: Progress reports and updates in CVD prevention, control and management 9% 55% 27% a. to understand the objectives of the session 0% 55% 27% b. to exchange views and information in the discussions Session 3: Global/Regional CVD initiatives and updates a. to understand the objectives of the session b. to exchange views and information in the discussions Session 4: Salt reduction (SHAKE) technical package training a. to understand the objectives of the session b. to exchange views and information in the discussions Session 5: Field visit on salt reduction a. to understand the objectives of the session b. to exchange views and information in the discussions Session 6: Action planning for CVD prevention and control a. to understand the objectives of the session b. to exchange views and information in the discussions 17% 8% 17% 0% 8% 0% 17% 8% 42% 42% 58% 67% 33% 25% 42% 33% 25% 33% 8% 8% 25% 42% 25% 42% 10 17% 17% 17% 17% 8% 17% 17% 17% 9 33% 58% 75% 58% 50% 17% 58% 75% 8 42% 17% 0% 17% 25% 50% 17% 0% 7 8% 8% 8% 8% 17% 17% 8% 8% 6 0% 0% 0% 0% 0% 0% 0% 0%
Questionnaire 3 - Groupworks and Activities Brainstorming on challenges to CVD prevention and control Rapid assessment and prioritization of the HEARTS elements Country-level stakeholder analysis for two priority HEARTS elements analysis of the priority challenge Fishbone Countermeasures and practical methods Action planning for CVD prevention and control 10 0% 0% 0% 0% 0% 0% 9 50% 50% 50% 50% 50% 60% 8 30% 30% 30% 30% 30% 20% 7 20% 20% 20% 20% 20% 20% 6 0% 0% 0% 0% 0% 0%
Pre- and post-workshop assessment (average score) Knowledge assessment Assessing the current status of cardiovascular diseases and salt reduction in my country Identifying and monitoring the priority problem areas for cardiovascular diseases and salt reduction Defining the actionable root causes of priority problems Drafting an action plan to address these actionable root causes Delineating priority actions along the service delivery level, the programme level, and at the level of policy Pre 2.92 2.83 2.75 2.83 2.75 Post 3.83 3.83 3.83 3.75 3.75 Improvement + 0.91 + 1.00 + 1.08 + 0.92 + 1.00
www.wpro.who.int