Author: Kremlin Wickramasinghe

Supporting population-based approaches to preventing NCDs

For our latest post, we go to Oxford, UK with regular blogger Dr Kremlin Wickramasinghe who explains some exciting news in research on Global Health and NCDs.

This week, the British Heart Foundation Centre on Population Approaches for Non-Communicable Disease (NCD) Prevention in the Nuffield Department of Population Health, University of Oxford was officially designated as the WHO Collaborating Centre on Population Approaches for NCD Prevention.

Dr Shanthi Mendis, Senior Advisor, NCDs, World Health Organization Head Quarters, explained how this new collaborating centre would contribute to the Global action plan for the prevention and control of NCDs 2013-2020, which set a global target of reducing the premature mortality from NCDs by 25% by 2025. She indicated that the new centre will mainly contribute to the following two objectives of the Action Plan:

  • To reduce exposure to modifiable risk factors for NCDs through creation of health-promoting environments
  • To promote and support national capacity for high quality research and development for prevention and control of NCDs

She said that an interesting question to ask  is why  we need another collaborating centre in a developed country when we see more than 80% of NCD deaths occurring in low and middle income countries (LMICs)? In her answer she pointed out that we have large research and evidence gaps to support the implementation of the most cost effective interventions in high income countries and well as in LMICs and that collaboration with this new centre would enable the sharing of experience and the strengthening of the WHO’s response to the growing problem of NCDs.

Forum at the WHO CC launch. Photo:Prachi Bhatnagar

Forum at the WHO CC launch. Photo:Prachi Bhatnagar

Dr Gauden Galea, Director, Division of NCDs and Life Course in the WHO European office discussed current population based approaches in Europe. Although 50 countries in the region have ratified the WHO Framework Convention on Tobacco Control, the majority of those countries have struggled to implement important population based interventions fully. Only two countries have successfully introduced pictorial warning on cigarette packages and only three countries have completely banned advertising, promotions and sponsorships.  He demonstrated that similarly, in tackling alcohol and unhealthy diets, countries have shown a higher level of adoption of policies that raise public awareness or that provide information but smaller numbers of countries have implemented interventions such as taxes and other measures to affect food prices and the re-formulation of food products to reduce unhealthy nutrients. He demonstrated how the new centre would continue to work with the WHO on areas such as nutrient profiling, fiscal interventions, marketing of unhealthy food and the use of new data sources for NCD prevention.

Mr Simon Gillespie, Chief Executive, British Heart Foundation (BHF) welcomed this recognition for a research group they have funded for more than 20 years. As the leading funding body for cardiovascular disease research in the UK, he mentioned that the BHF would continue to support cardiovascular disease prevention research to make a greater impact nationally and internationally.

Dr Mike Rayner Director of the new collaborating centre emphasised the importance of population based NCD prevention approaches to create healthy societies rather than just healthy individuals. He argued that the aim of a population based approach should be to shift the distribution of risk factors for NCDs in the population rather than those at greatest risk and to focus on more the distal risk causes of  NCDs such as the price of goods and services. He concluded by saying that a population approach is complementary to an individual/high risk approach but that population based approaches have been neglected.

Picture, left to right: Dr Gauden Galea, Dr Shanthi Mendis, Dr Mike Rayner, Professor Rory Collins, Mr Simon Gillespie.

Picture, left to right: Dr Gauden Galea, Dr Shanthi Mendis, Dr Mike Rayner, Professor Rory Collins, Mr Simon Gillespie. Photo:Andrew Trehearne

This workshop also highlighted wider trends that NCD prevention community should focus on such as global warming, resource depletion and  rising food prices. It was mentioned that the post 2015 development agenda discussions should be used as an opportunity to link NCD prevention with the sustainability agenda. New areas such as the use of social media data and supermarket data for surveillance and prevention of NCDs were also mentioned by speakers during the panel discussion.

When a question was raised about the advice for the next generation it was mentioned that one important role would be to identify research gaps in areas where countries are struggling to implement cost effective interventions and try to improve our understanding on how to implement them. This would require stronger collaboration within and outside the population health disciplines such as economics, anthropology and politics.

The new collaborating centre will be working with the WHO, the BHF and other partners in capacity building by organising workshops and short courses, contributing to WHO’s work in the development of guidelines/manuals on population level NCD prevention, assisting WHO to develop methods for evaluating NCD prevention programmes and providing WHO with statistical analysis and systematic reviews related to population level NCD prevention.

This launch brought NCD prevention experts from leading academic research groups, the World Health Organization and a major non-governmental organisation concerned with NCDs  (the British Heart Foundation) to a single forum. Discussions ranged from generating evidence, using that evidence to developing guidelines, providing technical support to countries, funding actionable research and advocacy by these different organizations. It was evident that bringing these different organizations to the same forum allowed us to understand how these different roles would contribute to unpack the complexity around determinants of NCDs and the importance of working in collaboration, to develop sustainable solutions.

Connect with Kremlin on Twitter via @KremlinKW

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Public health vs business thinking: a case study from the Hult Prize Competition

This week, regular PLOS blogger and Oxford academic Dr Kremlin Wickramasinghe writes about the nexus of public health and business thinking – as well as some reflections on the global Hult Prize. Kremlin is currently doing a DPhil alongside his work as a researcher, quantifying the outcome of health policies addressing sustainable healthy diets.

Do public health academics and entrepreneurs think along the same lines? What would happen if we asked them to identify solutions to a problem that both groups care about? Would solutions be the same or drastically different? I had an opportunity to find some answers to these questions at the Hult Prize regional finals.

hultThe Hult Prize is funded by the Clinton Global Initiative to provide start-up funding (one million dollars) for the young social entrepreneurs who come up with the most compelling ideas to solve a problem faced by billions of the world’s population. This year the challenge was around solving the problem of rising non-communicable diseases (NCDs) such as cancers, diabetes and cardiovascular diseases amongst slum dwellers.  The judges for the prize largely come from a business background including top multi-nationals.

One of the doctoral students in my research group within the Nuffield Department of Population  Health at the University of Oxford took the initiative to form a team and enter this competition. The focus of my research group is also solutions to the problem of NCDs and we felt this would be a great opportunity to contribute to a global issue that we have a passion for. Our team comprised of three members with a background in public health and two engineers from the Healthcare Innovations Unit at the University. We were delighted to hear that we have been selected for the regional final which was held on 8th March in London from more than 10,000 entry level applications.  I am going to explain the thought process we (public health researchers) used to analyse our potential solutions and how the judges (who predominantly represented the business community) analysed them at the regional finals.

Before I go on, I need to make it clear that we did not win the regional final. But the judges gave our solution a “special mention” before announcing the winner. They said it was innovative and we should think about taking it forward. This is exactly what we heard earlier, that only one team would win, but that we should use this as an opportunity to find the energy to develop our idea into a successful social- enterprise.

One of the key criteria was that the winning solution should be able to reach 25 million people in five years.  We started brainstorming, produced a list of possible ideas and critically analysed them within the team.Through our research group, we had access to expertise in NCDs to inform our thinking.

Visiting slums in Sri Lanka One of the questions we considered was how to make screening for NCDs  more affordable and accessible in slums. However, when we shared our thoughts with public health experts they asked us what we would do when we identified people with the disease and whether we could provide the cost for treatment and further management.   The majority of slum dwellers do not have access to free healthcare and can’t afford to pay for treatment.  The public health community generally believes that it is “unethical” to screen people unless you can provide any necessary treatment. We struggled to come up with a sustainable business plan which could provide affordable treatment to patients identified through screening.

The post 2015 development goal  discussions have recognised “universal health coverage” as a major priority, but discussions with global health experts confirmed that it is unlikely to be achieved within 5 years.  Therefore we thought it would be impossible to win, if we only increased screening without assuring treatment.  We dropped that idea and decided to move ahead with a different idea that didn’t involve screening.

At the London regional finals, three out of the top four winning solutions were based on screening. It was interesting to see how judges with a business background approached their task. The winning team clearly showed how they were going to screen people for diabetes with bees!  Clearly innovative and excellent presentation by them.  They said they would send any patients they identified to the “local hospital”. They did not say how people would afford treatment. As the reason for their winning, the judges mentioned that they were able to “ focus” on one important aspect of the problem of NCDs amongst slum dwellers. This clearly shows the difference in how public health and business communities analysed the same solution.

Two teams, out of the top four, proposed to use animals for screening. When public health professionals consider novel methods of screening we think about false positives and false negatives.  So, for example, if we are going to screen people we should know how many actual cases are we going to miss (false negatives) and how many people we are going to take through for treatment even though they don’t have the disease (false positives). No screening test is 100% accurate but we need statistics on false positives and false negatives to decide the cost-effectiveness of a test before scaling up. We thought it would be impossible to win the prize without those statistics, which take time and money to produce. But judges didn’t ask about false positives and negative  nor did teams provided this information during the pitch. Judges just asked “can animals survive in slum conditions ?”. This shows that they had concerns beyond the financial model, but they were completely different to the concerns of the public health community.

Our inability to ensure that screened patients had access to treatment and the challenges of quantifying the sensitivity of potential innovative screening methods led us to conclude that it would be impossible to win if we presented a “screening solution”. However, the other teams managed to win without having solutions to these problems. As public health professionals we often attend conferences and meetings with likeminded people and take similar approaches to tackle NCDs. The Hult Prize, by contrast, brings people from different backgrounds to the same stage. It provided me with a unique opportunity to learn that the business and public health communities approach the same problem in completely different ways.

This difference in approaches might explain why most public health professionals are not successful entrepreneurs. My public health colleagues might say that this is why, despite millions of dollars in investments, we still haven’t tackled some of the biggest problems in the world. The problem is this: we invest in ideas that are attractive and “fancy”, but not necessarily tested with public health tools. If we changed the composition of the judges to a panel with 50% public health background and 50% business background, what would have been different? We will never know. This is a business plan competition and (obviously) organisers invited top business professionals to judge. They were very passionate about these issues and provided feedback and comments to teams. But I certainly gathered enough reasons to answer the first question I raised in this blog.  Public health academics and entrepreneurs do not think along the same lines.

Why does the public health opinion matter in this competition? The aim of the 2014 competition is to address one of the main public health problems in the world and the solution is supposed to reach 25 million people.  The wining solution should be implemented in many countries, which would require the approval from local and national level public health regulators around the world.

How can we move forward to align these two approaches to ensure success in our future endeavours? Clearly we cannot do this by working only within our own disciplines. Here are the important questions: Are public health professionals ready to think out of the box? Would business professionals value public health opinions at all when they make final decisions?  As the next generation, we will have to work harder to integrate these various ways of thinking if we really want to change the world.

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Reflections on the 8th Global Conference on Health Promotion (8GCHP), Helsinki – Part two

Last week I shared my key lessons and highlights of some sessions from the conference. This week’s blog aims to reflect upon some further interesting aspects of the conference.

Diversity of participants

A key feature of the conference was the diversity of backgrounds of the delegates and its interactive nature.  As an academic I am more familiar with academic conferences and the discussions at the 8GCHP were different in many ways.  Nearly a fifth of participants were from non health sectors. We did not spend much time on arguing on minor methodological issues or calculation of error bars in graphs. Instead discussions were around practicality, relevance and the challenges to implementing policies and programmes. Here is something I heard on the second day “The researchers’ goal of publishing papers is not important for politicians. Can we change this culture so we can have useful evaluations?”

Site visits rather than lectures

Thursday 13 June was the WHO Europe day.   It involved visits to various locations in Helsinki. WHO Europe shared their most important health promotion initiatives and other regions discussed how they could be relevant to them. There were several site visits including a visit to the Finnish House of Parliament. I participated in this visit and we were welcomed by MPs from the Social Affairs and Health Committee of the Parliament. The discussion showed how Finland can maintain its policies to promote public health through the values of its people. A good memory from this site visit is the statue of a mother with a baby who is saluting the MPs in the chamber for thinking about the future generation when forming policies. MPs said it is difficult for politicians to deviate from that approach, if in general, society believes in better outcomes for the next generations.

MPs of the Social Affairs and Health Committee

MPs of the Social Affairs and Health Committee

A life time achievement award for health promotion was given to Kemo Lepo who was cited as the father of health in all policies. Lepo et al’s book Health in All Policies – Seizing opportunities, implementing policies  was launched at the conference and it provides very good information on the topic.

Emerging voices in health promotion

Another highlight of the conference was the meeting of the group of energetic young professionals. Although there were no formal arrangements, due to the dedicated leadership of a few individuals, we met as a group on several occasions to compile our comments for the Helsinki declaration on health promotion. We were very pleased to see those comments were incorporated in the final draft of the conference statement .

A group of participants who appeared on the video of emerging voices at the 8GCHP

A group of participants who appeared on the video of emerging voices at the 8GCHP

Roopa Dhatt, President of the  International Federation of Medical Students’ Association’s addressed the delegation on behalf of emerging leaders and recommended global leaders should  get younger people involved in a meaningful, participatory way in every stage and every level (global, regional, national and local) in their multi-sectorial work. A video was screened to show the vision of emerging leaders and to highlight the need for opportunities to take part in global health promotion activities. Ilona Kickbusch Tweeted “Great young voices at final plenary – come on! take over from us dinosaurs!   Quickly! SOON!” Twitter was the other key feature of the conference.

Use of Twitter at the conference

Use of Twitter changed the environment completely during this week. The #healthinall was used to communicate and there was a big screen with the live Twitter feed. This allowed participants in the audience and watching the webcast to post questions and chairs picked interesting questions for speakers. Delegates used this opportunity to agree, disagree or to express their concerns during sessions.

A snap shot of the Twitter wall in the main conference hall

A snap shot of the Twitter wall in the main conference hall

The extent of the Twitter activity around the conference was demonstrated by a Twitter analysis disseminated by WHO- PAHO showing more than 1000 tweeters and more than 22,000,000 impressions. Dr Gauden Galea, WHO Europe conducted a network analysis of more than 3500 of those tweets and re-tweets which used #healthinall to show the largest connected group of nodes. We can use this information to plan better dissemination of future health messages.

The younger generation was very active in the Twitter conversation and I met many participants who opened their Twitter accounts during the conference as they didn’t want to miss any interesting Twitter interactions they saw on the big screen. It clearly kept more delegates involved during and after the sessions. Colleagues who didn’t attend the conference, but who followed the Twitter feed said they felt like being there with the live Twitter updates. This clearly convinced participants to expand the use of social media in future events and campaigns.

What’s next after Helsinki?

After an inspiring week in Helsinki most of us asked, “What changes can we expect in health promotion as a result of this conference?” Perhaps this is a difficult question to answer and we will only be able to find the answer in retrospect.

The framework for country action  provides countries with a practical means of enhancing health in all policies (HiAP) approach.  When we heard remarks from different WHO regions in the final plenary, Dr Temo Waqanivalu from the Pacific said we need to take actions before we develop “framework fatigue”. A response to that statement on Twitter said “May be. But we need to agree on a policy framework action to ensure implementation mechanisms are in place”.

With all the different opinions, I would like to pick capacity building through partnerships as the top priority. My choice could be biased by my current position in an academic institution. But I have several reasons to justify this choice. Capacity building could be started immediately at any country from any level depending on the available resources. It is unlikely to be challenged by all the other external forces which are against health promotion. If we build capacity for health promotion solely amongst healthcare workers, we will be going backwards in time. We need to have different professionals such as lawyers, economists, and development agents alongside public health professionals in the same room. The friendships and understanding they build during these events will result in innovative programmes for HiAP approach.

I would like to see the WHO and governments playing a key role to support and coordinate these capacity building activities through strong partnerships as stated by Zsuzsanna Jakab, WHO Regional Director for Europe. We will be able to reflect on those activities at the next global conference on health promotion and decide whether we have been successful or have just developed framework fatigue!

You can read further details about each day of the conference and reflections on  Professor Fran Baum’s BMJ blog.

Connect with Kremlin on Twitter via @KremlinKW

Kremlin Wickramasinghe is a researcher in the Department of Public Health, University of Oxford and also a DPhil Candidate. He works on the Cardiovascular Disease Epidemiology project in the British Heart Foundation Health Promotion Research Group. Kremlin graduated in 2006 with a medical degree (MBBS) from the Faculty of Medicine, University of Colombo, Sri Lanka. He completed his Masters in Global Health Science in 2009 from the University of Oxford. Kremlin started his DPhil in 2010 on environmentally sustainable healthy diets and he is the Course-Director of the “Short course on NCD prevention strategies” offered by the University of Oxford.

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Reflections on the 8th Global Conference on Health Promotion, Helsinki – Part one

Organizing committee members from the WHO and Finland

Organizing committee members from the WHO and Finland

After an inspiring week more than 900 delegates from all around the world left Helsinki  with greater enthusiasm and renewed hopes about health promotion. The 8th Global Conference on Health Promotion (8GCHP) was held in Helsinki from 10 to 14 June 2013. I had the opportunity to attend this conference with other delegates representing the UN, governments, academia and civil society organisations.

This conference was the latest in the WHO Global conference series which began in 1986 when the Ottawa Charter on Health Promotion was produced. At the opening ceremony a video was screened to show the health promotion journey from Ottawa to Helsinki.

Highlight of the conference

Undoubtedly the WHO Director General Dr Margaret Chan’s speech at the opening ceremony was the highlight of the conference,   It received a great response from the audience and also on social media. She said that “efforts to prevent noncommunicable diseases (NCDs) go against the business interests of powerful economic operators. It is not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda, and Big Alcohol. All of these industries fear regulation, and protect themselves by using the same tactics.” This set the perfect tone to a much debated and action oriented discussion during the week. Most of the delegates mentioned they didn’t expect to hear such a statement from a WHO DG during their careers and welcomed the leadership she demonstrated.

Working with different sectors

The conference theme was Health in All Policies; (HiAP) and there were several plenaries looking at how to work with  “friendly” and sometimes “ not so friendly” sectors to promote health. Enis Baris from the World Bank presented the bank’s strategy towards HiAP.  The audience’s response was mixed.  Few suggested that World Bank policies had pushed some countries into poverty worsening their health outcomes. Baris answered saying that they have learnt from those mistakes and now the Bank has a greater commitment to promote health. The World Bank Health responded to my question posted on Twitter saying that  approximately 14% of World Bank projects now measure health as an outcome. This may be a good start, but clearly it shows that there is much more work to be done within and between UN organisations to promote the HiAP approach.

Some participants wanted clear guidelines on how to deal with  private sector involvement after the WHO Director General’s  opening remarks. They questioned whether, if companies are required by law to maximise their profits for shareholders, we should expect them to collaborate for health promotion? There was no clear consensus about this and few delegates highlighted the need to work with the private sector to address certain issues.

Health promotion tools

The conference offered a wide range of parallel sessions and I tried to follow the theme of NCD prevention and health promotion throughout the week. Law and NCD preventions session from Professor Amandine Garde demonstrated that legal instruments have an important role in health promotion and the question is not whether to use them, but how to use them appropriately.  She stated that we should also talk about the constraints of law in the NCD prevention debate.

Franco Sassi (OECD) gave us an excellent summary of the research needed to understand the debate on fiscal measures in health promotion. He concluded that there is a strong case for the use of taxation to promote health. The argument is strong for tobacco products and alcoholic beverages, but less clear for foods. Out of all foods, sugar sweetened beverages are the most  likely to be the subject of taxes. Sinne Smed’s presentation shared some preliminary data on on Denmarks’s experience with a saturated fat tax .  This suggested there had been a decrease in fat and oil consumption at least in the short term. She concluded that if it was to be re considered it should come as a Joint European Initiative to tackle cross boarder trading.

NCDs in the health promotion agenda

Most of the plenaries and parallel sessions addressed different NCD prevention strategies. I noticed that several plenary speakers stated that “health promotion is not only NCD prevention”. This is a very interesting development. A few years ago the NCD community complained that NCDs didn’t get a fair share in the global health agenda compared to the disease burden and highlighted the need for bringing NCDs higher up in the agenda. I felt that it has reached a very satisfactory level in the global health promotion priority list and now we need to focus our energy to translate these discussions, strategies and frameworks in to actions in countries.

A plenary session in the Finlandia Hall

A plenary session in the Finlandia Hall

Take home message

Dr Oleg Chestnov, Assistant Director General, WHO said in his closing remarks “We will not wait. We will drive the change. We are seeing the birth of a social movement here in Helsinki.”A clear task was given to delegates to go back home and spread the message about this exciting event to drive health promotion forward.

I personally found it to be a very exciting event due to the interesting topics we discussed and also due to the dedicated dynamic group of global citizens who are committed to promote health. Congratulations to organisers and participants on a well organised and very successful conference which connected with a new  generation to take the health promotion agenda forward.

Next week I will blog about the key role played by emerging young leaders at the conference and the influence of Twitter.

Connect with Kremlin on Twitter via @KremlinKW


Kremlin joined the British Heart Foundation Health Promotion Research group at Oxford University’s Department of Public Health in 2009 – where he works on the epidemiology of cardiovascular disease (CVD) and associated risk factors. He is the course director of the Short course on prevention strategies for NCDs. Kremlin is currently doing a DPhil alongside his work as a researcher, quantifying the outcome of health policies addressing sustainable healthy diets. Kremlin graduated in 2006 with an MBBS from the Faculty of Medicine, University of Colombo, Sri Lanka. He completed his Masters in Global Health Science in 2009 from the University of Oxford and completed his internship at the World Health Organization Head Quarters in Geneva on the Social Determinants of Health project.

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