VOLUME 3: NO.

1 JANUARY 2006

SPECIAL TOPIC

Process, Rationale, and Interventions of

Pakistan’s National Action Plan on Chronic
Diseases
Sania Nishtar, PhD, FRCP, Khalif Mohamud Bile, PhD, Ashfaq Ahmed, MBBS, Azhar M.A. Faruqui, FRCP,
Zafar Mirza, MPH, Samad Shera, FRCP, Abdul Ghaffar, PhD, Fareed A. Minhas, FRCP, Aslam Khan, FRCP,
MRCP, Naeem A. Jaffery, FRCP, Majid Rajput, MPH, FCPS, Yasir A. Mirza, MSc, Mohammad Aslam, MSc,
FCPS, Ejaz Rahim, MA

Suggested citation for this article: Nishtar S, Bile KM, was released on May 12, 2004, and attempts to obviate the
Ahmed A, Faruqui AMA, Mirza Z, Shera S, et al. Process, challenges associated with addressing chronic diseases in
rationale, and interventions of Pakistan’s National Action countries with limited resources. By developing an
Plan on Chronic Diseases. Prev Chron Dis [serial online] integrated approach to chronic diseases at several levels,
2006 Jan [date cited]. Available from: URL: capitalizing on the strengths of partnerships, building on
http://www.cdc.gov/pcd/issues/2006/jan/05_0066.htm. existing efforts, and focusing primary health care on
chronic disease prevention, the NAP-NCD aims to mitigate
PEER REVIEWED the effects of national-level programs on local resources.

The impact of the NAP-NCD on population outcomes can

Abstract only be assessed over time. However, this article details
the plan’s process, its perceived merits, and its limitations
Most developing countries do not comprehensively in addition to discussing challenges with its implemen-
address chronic diseases as part of their health agendas tation, highlighting the value of such partnerships in
because of lack of resources, limited capacity within the facilitating the missions and mandates of participating
health system, and the threat that the institution of agencies, and suggesting options for generalizability.
national-level programs will weaken local health systems
and compete with other health issues. An integrated
partnership-based approach, however, could obviate Background
some of these obstacles.
Chronic noncommunicable diseases (NCDs) are estimat-
In Pakistan, a tripartite public–private partnership was ed to have caused 33.4 million deaths worldwide in 2002;
developed among the Ministry of Health, the nongovern- of these, 72% occurred in developing countries (1). In
mental organization (NGO) Heartfile, and World Health Pakistan, chronic diseases (cardiovascular disease, dia-
Organization. This was the first time an NGO participated betes, chronic lung diseases, and cancer) are among the top
in a national health program; NGOs typically assume a 10 causes of morbidity and mortality and account for
contractual role. The partnership developed a national approximately 25% of total deaths (2,3). Thirty-three per-
integrated plan for health promotion and the prevention cent of the adult population older than 45 years has high
and control of noncommunicable diseases (NCDs), which blood pressure; 10% of the adult population older than 18
as of January 2006 is in the first stage of implementation. years has diabetes, and more than 54% of men use tobac-
This plan, called the National Action Plan on NCD co. Data from an unselected autopsy series have shown
Prevention, Control, and Health Promotion (NAP-NCD), coronary artery involvement (of greater than 50% luminal

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
www.cdc.gov/pcd/issues/2006/jan/05_0066.htm • Centers for Disease Control and Prevention 1
 VOLUME 3: NO. 1
JANUARY 2006

diameter reduction) in more than 24% of those studied. a year of the agreement’s signing, and as of January 2006
Moreover, the coastal metropolis of Karachi, with a popu- is in its first phase of implementation (11,12).
lation of more than 15 million, reports one of the highest
incidences of breast cancer for any Asian population (4-9).
Over the years, Pakistan’s federal and provincial Developing the Plan
Ministries of Health have been heavily burdened with
reproductive-health and infectious-disease issues. Chronic diseases generally are linked by common risk
However, Pakistan is undergoing an epidemiological tran- factors and include cardiovascular disease (CVD), dia-
sition and, hence, is now also focusing on chronic diseases. betes, cancer, and chronic lung disease. However, the
NAP-NCD also includes injuries and mental illness in its
Pakistan has a population of 150 million and an annu- framework because of government requirements.
al gross national product (GNP) per capita of U.S. $700;
during the last 10 years, 0.6% to 0.8% of its GNP and A three-stage process was used to develop the NAP-
5.1% to 11.6% of its development budget has been spent NCD: 1) planning within the disease categories, 2) setting
on the health sector (2). Seventy percent of clinical serv- priorities, and 3) developing an integrated approach to pre-
ices are delivered by private-sector health care providers, venting NCDs (13).
and out-of-pocket payments are the major source of
health financing, despite the existence of an extensive Next, a situational analysis was conducted in which
public-sector–owned health care system. Preventive and data on current epidemiological evidence for NCDs were
educational services are delivered almost exclusively by gathered, existing strategies and policy measures were
the public sector. Lately, as part of certain preventive summarized, gaps in the system and opportunities that
programs (HIV and AIDS programs in particular), existed for integration with existing programs were out-
nongovernmental organizations (NGOs) have been deliv- lined, and the potential for program implementation was
ering preventive care, albeit in a contractual role in analyzed. Then, a broad-based consultative process was
which NGOs enter into contracts with the public sector. established, which included health professionals, NGOs,
professional societies, community representatives, donor
As in most other developing countries, NCDs had not and development agencies, corporations, and legislators,
featured prominently on Pakistan’s health agenda until and priority action areas were identified. In the absence
2003, when a national integrated plan for health promo- of local cost-effectiveness data, other priority-setting cri-
tion and the prevention and control of NCDs, known as teria were used, such as the extent to which an inter-
the National Action Plan on NCD Prevention, Control, vention was locally feasible, promoted community
and Health Promotion (NAP-NCD), was initiated. NAP- empowerment and participation, built on the strengths
NCD attempts to obviate the challenges associated with of partnerships, and contributed to capacity building and
addressing chronic diseases in countries with limited health systems strengthening. In addition, the capacity
resources. Initially, an agreement was developed between of the public health system and the ability of health care
the Ministry of Health and Heartfile, an Islamabad, leaders to implement the NAP-NCD were also identified
Pakistan-based nonprofit, NGO focused on chronic dis- as important criteria.
ease prevention and control and health promotion; a
month later, the World Health Organization (WHO) was Finally, a tool called the Integrated Framework for
asked to join the initiative. Heartfile’s role in the NAP- Action (IFA) was developed to identify action items that
NCD was to advocate for increased focus on chronic dis- could be applied to all NCDs (14). (The IFA is available
ease in the national health agenda. This was the first time from http://heartfile.org/pdf/IFAPDF.htm.) Additionally,
an NGO had participated in a national health program in the IFA included two sets of strategies — those that were
more than a contractual role. common to all NCDs (Table 1) and those specific to each
NCD (Table 2). The first set of strategies includes behav-
The partnership, developed on a national level, was ioral-change communication, focusing health services on
mandated with the task of developing and implementing a NCDs, development of institutional mechanisms, and
strategic plan to prevent and control the rates of NCDs monitoring and surveillance; the second set covers legisla-
(10). The NAP-NCD was released on May 12, 2004, within tive or regulatory matters and research. The IFA — which

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2006/jan/05_0066.htm
 VOLUME 3: NO. 1
JANUARY 2006

also provides guidance to administrators and health poli- model has been adapted for program evaluation, which
cy planners — helps set national goals at process, output, enables it to use indicators to track implementation process-
and outcome levels; defines integrated actions to meet es and facilitates an assessment of how interventions work
those goals; and allows for program assessment. and which components are the most successful. An initial
cross-sectional survey with a sample of sufficient size and
the power to detect population-level changes over time of the
Components and Configuration of the NAP- risk factors and NCDs has been conducted (18,19).
NCD
The integrated behavioral-change communication strat-
The NAP-NCD prioritizes a population-based approach egy consisted of two interventions. The first intervention
to chronic diseases that encompasses public education, included a media campaign targeting 90% of the country’s
behavioral-change communication, legislation, and regula- population. The second intervention introduced chronic
tion. These approaches have the greatest potential to disease prevention into the work plan of Lady Health
reduce NCD risk and uphold the principles of WHO’s Workers (LHWs) — Pakistan’s field force of more than
“Health-for-All Policy for the 21st Century” because the 83,000 grassroots health caregivers.
high-risk approach (i.e., targeting individuals at high risk
for chronic disease rather than populations as a whole) For the media campaign, 30-second spots and 5-minute
may be inaccessible to the majority of the country’s under- programs are being aired for 2 years during prime time
privileged population. Thirty-two percent of Pakistan’s on national television and radio and began in May and
population is below the poverty level of U.S. $1 a day (15). June 2005. One announcement focuses on creating
The NAP-NCD will be implemented in two phases. awareness about high blood pressure by advocating
opportunistic screening (i.e., using every clinical
First phase encounter “opportunity” to check the blood pressure of
every patient); the other emphasizes the principles of car-
The first phase of implementation, which spans 3 years diovascular disease prevention.
(May 2004 through July 2006), is jointly funded by the
Ministry of Health, Heartfile, and WHO. The implementa- Until recently, LHWs were involved in delivering
tion status is reviewed for accountability and program reproductive-health– and communicable-disease–related
evaluation every 3 months, and progress is posted online services to poor and underprivileged households in rural
(24); the process and output indicators stipulated in the areas covering 50% of Pakistan’s population. Heartfile
IFA are used for process evaluation. The first phase of the had previously pilot tested an approach in which CVD
NAP-NCD’s implementation focuses on the action items prevention was introduced into its work plan in the
summarized in Tables 1 and 2 and is organized into the fol- Lodhran district as part of a CVD prevention demonstra-
lowing three priority areas: an integrated and sustainable tion project. Seven hundred LHWs were involved in this
population-based NCD surveillance system, an integrated pilot project from 2001 through 2003 (20,21). Lessons
behavioral-change communication strategy, and legisla- learned from this experience have enabled the introduc-
tion in key areas. tion of the chronic disease perspective into the training
module in addition to an increased focus on chronic dis-
An integrated and sustainable population-based NCD ease in 17 other districts as part of the NAP-NCD.
surveillance system is a prerequisite for effective planning,
implementation, and evaluation of NCD prevention pro- Other priority areas for the first phase of implementa-
grams (with the exception of cancer, because a registry has tion include lobbying for key legislative actions, identifying
to be used for its surveillance) and is regarded as an entry research areas, building capacity within the health sys-
point for activities related to the prevention of NCDs — an tem, and focusing on institutional measures.
approach validated in several settings (16,17). The NAP-
NCD’s surveillance model includes population surveillance Second phase
of primary NCD risk factors (poor diet, physical inactivity,
and smoking) and combines modules on population surveil- The second phase of implementation will broaden the
lance of injuries, mental health, and stroke. In addition, the scope to include measures that focus health services on

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
www.cdc.gov/pcd/issues/2006/jan/05_0066.htm • Centers for Disease Control and Prevention 3
 VOLUME 3: NO. 1
JANUARY 2006

prevention; the launch of the second phase is planned for untapped. This model provides a mechanism for engaging
2006. The second phase will have implications for training NGOs in the national decision-making process and ensures
and capacity building of health professionals, improving their participation both in the formulation of health policy
basic infrastructure, and ensuring availability and access and implementation of national plans. Though an evalua-
to certain drugs at all levels of health care. tion mechanism, it also enables the assessment of each part-
ner’s contribution to achieving objectives. In this model,
Health care delivery in Pakistan is characterized by a WHO is gaining experience with a model in which WHO
variety of roles played by different categories of health care resources — which are otherwise allocated for the public sec-
providers, and all will be drawn into the loop. The NAP- tor — support the private sector in a national model. The
NCD makes recommendations to ensure physician training partnership is therefore integrated with national health pri-
as a permanent function of the health care system by estab- orities and complements state initiatives.
lishing links with provincial and district health depart-
ments; it also makes recommendations on how to form a This program is one of the few examples of a public–private
comprehensive continuing medical education program partnership for chronic disease prevention, an area that
structured around broad-based prevention-related goals has largely remained unexplored as part of global efforts to
and objectives to ensure ongoing training for both private- build public–private partnerships. This program’s imple-
sector and pubic-sector physicians. The second phase of the mentation is expected to yield important information
NAP-NCD will also include other legislative actions. about the performance of the health system by building
chronic disease partnerships in evidence-based models. As
for infectious disease partnerships, ethical, methodologi-
Merits and Limitations of the Approach cal, accountability, sustainability, and governance issues
must be considered (22-25).
The NAP-NCD presents one approach to developing a
national strategy for chronic diseases in countries with This initiative also created a mechanism for visible
limited resources. The strategy includes integration at six involvement and participation of many other stakeholders
distinct levels. By grouping chronic diseases and integrat- in the national consultation process in addition to avenues
ing actions, there is a shift from a national-level approach for their participation in the process of implementation.
to an approach based on diseases, which has significant This is important because many factors that affect NCDs
implications for maximizing health care resources. are outside of the health sector domain; these include
Horizontally integrating actions with existing initiatives trade, agriculture, finance, education, and communication.
strengthens the public health system; adopting integrated However, there is also the need to fit this strategy within
models on surveillance and behavioral-change communica- a more explicit policy framework — one that makes it
tion in addition to focusing health services on NCDs will obligatory to link relevant health ministries in a manner
yield important empirical evidence for emerging chronic that is mutually supportive of national NCD goals. The
disease programs. Additionally, integrating health promo- program needs to be supported by a clear, strong, and sus-
tion and prevention within the same program achieves two tained political commitment.
objectives for two populations with common activities.
The NAP-NCD can serve as both an empirical basis for
The evaluation mechanism of this model, which is struc- an integrated approach to NCDs and an experimental basis
tured within the accountability and progress charts of the of health sector reform in the area of public–private collab-
IFA, allows program assessment at a process-and-out- oration; most developing countries have limited experience
comes level and assessment of the level of contribution with each. It is also likely to yield useful lessons for min-
partners have made to achieve the NAP-NCD’s objectives. istries of health, NGOs, and multilateral agencies for estab-
lishing chronic disease programs in developing countries.
This program is of value to all partners. By leveraging the
strengths of the nonprofit private-sector technical partner Author Information
(Heartfile), the government included NCD prevention in its
policies. NGOs and the civil society can contribute to achiev- Corresponding Author: Sania Nishtar, FRCP, PhD,
ing national goals; however, this potential remains largely President, Heartfile, 1 Park Rd; Chak Shahzad,

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
4 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2006/jan/05_0066.htm
 VOLUME 3: NO. 1
JANUARY 2006

Islamabad, Pakistan. Telephone: +0092-51-224-3580. Medical Research Council; 2003.

E-mail: [email protected]. 8. Pakistan Medical Research Council. National Health
Survey of Pakistan 1990-94. Islamabad, Pakistan:
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Pakistan; Zafar Mirza, MPH, Network for Consumer 10. National Action Plan for Prevention and Control of
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Ghaffar, PhD, Global Forum for Health Research, Geneva, [Internet]. Islamabad, Pakistan: National Action Plan
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The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
www.cdc.gov/pcd/issues/2006/jan/05_0066.htm • Centers for Disease Control and Prevention 5
 VOLUME 3: NO. 1
JANUARY 2006

Behavioral Risk Factor Surveillance System (BRFSS) Tables

[Internet]. Atlanta (GA): Centers for Disease Control
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[cited 2004 Jun 22]. Available from: URL:
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The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
6 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2006/jan/05_0066.htm
 VOLUME 3: NO. 1
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Table 2. Action Items to Address Individual Noncommunicable Diseases (NCDs) in the National Action Plan on NCD
Prevention, Control, and Health Promotion (NAP-NCD), Pakistan

Priority Areas Action Items

Policies and legislation Effectively implement existing legislation on mental health — expanding its base to protect the interest of special
groups such as prisoners, refugees and displaced individuals, women, children, and individuals with disabilities

Revisit policy on diet and nutrition to expand its focus on undernutrition; establish policies and strategies to limit the
production of, and access to, ghee as a medium for cooking and agriculture; and establish fiscal policies that increase
the demand for healthy foods and make healthy food more accessible

Develop a physical activity policy

Institute legislation for occupational health and safety

Enforce seatbelt and helmet laws effectively

Upgrade existing highway ordinances

Enact and enforce legislation for locally manufactured vehicles

Regulate drivers’ training and licensing

Enforce legislation on building safety

Strive to improve trauma care to the extent that a credible, cost-effective analysis suggests

Enforce the National Environmental Quality Standards strictly and transparently

Institute proactive measures to contain potential risks to cancer in industrial settings; enforce labor laws more strictly

Regulate chemical handling stringently

Incorporate preventive health in the mandate of organizations providing health coverage for the labor workforce in order
to contain exposure to carcinogenic agents in the environment and in worksites

Develop a price policy for tobacco products

Subject tobacco to stringent regulations governing pharmaceutical products

Initiate fiscal measures to reduce dependence on revenues generated from tobacco

Initiate measures for agricultural diversification with respect to tobacco cultivation and assisting with crop diversification

Enforce legislation on smuggling tobacco, contrabands, and counterfeiting

Enforce more strict legislation to phase out all types of tobacco advertising

Regulate the import of areca nut

Research Identify causal associations specific to the population in NCDs to define precise targets for preventive interventions

Use clinical endpoint trails to define the best therapeutic strategies for prevention of NCDs, weighing cost against
economic feasibility

Research local policy and operations to examine tobacco tax policies in addition to marketing and advertising
strategies

Use existing data sources to assess cancer trends in industrial settings that may be exposing people to carcinogenic
agents

Conduct studies to bridge critical gaps in evidence of appropriate and cost-effective strategies for preventing common
cancers in Pakistan

Identify black spots on highways and on city roads; assessments guide interventions appropriate to reduce the
risk of highway crashes in these settings

Evaluate interventions to reduce all forms of violence in Pakistan

(Continued on next page)

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
www.cdc.gov/pcd/issues/2006/jan/05_0066.htm • Centers for Disease Control and Prevention 7
 VOLUME 3: NO. 1
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Table 2. (continued) Action Items to Address Individual Noncommunicable Diseases (NCDs) in the National Action Plan on
NCD Prevention, Control, and Health Promotion (NAP-NCD), Pakistan

Priority Areas Action Items

Research (continued) Examine trends in outdoor air pollution levels and their determinants to develop appropriate public health interventions;
address other priority areas such as include conducting research to quantify the magnitude and determinants of chron
ic lung diseases attributable to indoor air pollution both in rural and urban areas and developing appropriate public
health strategies to reduce risks in such settings

Institutional mechanisms Establish an Occupational Safety and Health Association

Establish a road safety committee

Establish a National Safety Commission

Develop product safety standards

Establish standards for household useables

Establish a National Cancer Control Council

Sustain institutional support of established cancer registries to facilitate surveillance

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
8 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2006/jan/05_0066.htm