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Author: Lubomir Ivanov

Editor's Note: This monograph — and its second edition some twenty years later — was published as rebound mechanism to the unreferenced CINDI study for Bulgaria, called shortly CINDI - 1. After discontinuation for 17 years, the programme was re-initiated on demonstration basis at year 2000. As of further 7 years it has transferred to the Health Care Systems in Transition (HiT) profile for Bulgaria and is under control from European Observatory, WHO Regional Office for Europe. The inconsistencies, however, of Bulgarian health policy are far from being resolved and continue on intermittent basis.


Bulgaria has participated as member of CINDI from year 1984. CINDI comes from Countrywide Integrated Non-communicable Diseases Intervention Programme, a subsidiary of WHO. This complex program for prophylaxis of non-communicable diseases was established in one region of the country - comprising, 4 /four/ districts with population 1 200 000 and it was decided that new preventive methods, technologies and organizational forms should be approbated.

One of the first tasks in that direction was a mass screening program for the population aged from 7 to 65 years - aiming, to establish the distribution of main risk factors for the health of the people /i.e., nutrition, physical activity, behavioral traits, etc./. Information for known risk factors as hypertension, body mass index and others was also gathered. In the early phase of the screening - which, took part in 1986 - a total population of 711 000 persons was examined.

Data analysis at first hand found the following results — baseline, increased body mass index in 47.7% of the screening subjects; hypertension in 13.6% of the screening subjects /with specifications for mean values of blood pressure for different population groups/; salt consumption was excessive in 8.5% of the screening subjects; decreased physical activity was established in 61.5% of the screening subjects and distress was found in 8% of the study. Further analysis is expected and including computerized search of the data base.

This demonstration project was shared with health education and prophylactic work on a countrywide level. Prevention of non-communicable diseases was emphasized for a future employment in the field.

Full report of the screening data /i.e., from year 1986/ was published in a separate monograph given in our booklist - cf., "Ch. Merdjanov. One Compromised Leadership. Sofia: Izdatelstvo "Sv. Kliment Ochridski", 1995, 574 pp."



First Addendum: According to recent projections of the global burden of disease, by the year 2020, NCD will be the predominant cause of ill-health both in the developed and the developing countries. The impending burden of NCD was recognized by WHO already in the mid-seventies.

During the period 1978-1981, WHO undertook a pioneering initiative to develop an integrated approach to NCD prevention and control. At the WHO meeting on an integrated programme for the prevention and control of NCD convened by WHO Headquarters and the Regional Office for Europe in Kaunas, Lithuania, in 1981, the concept of the integrated approach to the prevention and control of NCD was formulated and principles of international collaboration for the implementation of the approach were proposed. The definition of the integrated approach is based on the evidence that major non-communicable diseases share several risk factors and implies that common action against them should be taken. This pioneering idea was followed up and in 1983 the Countrywide Integrated Noncommunicable Intervention (CINDI) programme was established by the WHO Regional Office for Europe to support Member States in their efforts to address the issues of NCD prevention and control at national level in a practical manner. Based on the CINDI protocol and guidelines, in 1995 the WHO Regional Office for the Americas initiated a similar programme: Conjunto de Acciones para la Reducción Multifactorial de Enfermedades No Transmisibles (CARMEN).

The CINDI and CARMEN programmes are first and foremost action programmes. The preventive intervention paradigm of the programmes is based on promoting international collaboration on the application of health promotion and disease prevention experience gained through effective interventions in high-risk groups and entire populations. The participating countries implement and evaluate national programmes with the overall aim of improving the health of populations by reducing mortality and morbidity from major NCD through integrated preventive intervention. The countries participating in the CINDI and CARMEN are committed to the prevention and control of NCD through the integrated approach, which entails: combining health promotion and disease prevention efforts; developing intersectoral collaboration and community involvement; enhancing the role of health professionals in health promotion and disease prevention; establishing adequate health information systems for monitoring and making better use of existing resources.

A second study of the comparative analysis of NCD policy development and implementation processes examines the results of previous efforts. It is the sequel to the comparative analysis of NCD policy development and implementation processes in CINDI, carried out in 1994. The results of this first study were presented at the European Health Policy Conference held in Copenhagen in 1994. Both studies were commissioned by the Council of CINDI Programme Directors. The CARMEN programme was involved in the second study from the outset.

Because the vast majority of countries included in the study belong to the CINDI programme, the aggregate results and the conclusions apply mainly to CINDI. The inclusion of CARMEN enriches the study by providing information on programmes from health systems other than those of Europe and North America. However, the lessons learned from the study will be of benefit to both the CINDI and the CARMEN programmes alike.

Study Methodology Design

The second study was designed by the Ad Hoc Working Group on Policy Development in close collaboration with the WHO Collaborating Centre for Policy Development in the Prevention of Non-communicable Diseases, Health Canada. The working group included participation from both the CINDI and the CARMEN networks and the Centers for Disease Control and Prevention, Atlanta, USA and was supported by the WHO Regional Offices for Europe and the Americas. The study was built on the experience gained in organizing and carrying out the first study in 1994. The design of the study began at a meeting of the Working Group held in Canada in November 1998 to define the objectives. It was agreed that the second study would create an opportunity for new participating countries to provide information on the origins (processes, factors and resources) of their programmes, on processes of policy development and strategic planning, on marketing and resource mobilization and on strategies used for the implementation of the integrated approach. It was also agreed that increased emphasis should be put on learning how the national CINDI and CARMEN programmes collaborate and what strategic issues they face. How can the experience gained in the programmes be disseminated beyond the demonstration areas? How are the CINDI and CARMEN programmes positioned with respect to primary health care and public health services? Special emphasis was placed on finding out what changes had occurred regarding programme organization, resources and partnerships since the first study.

It was decided that the study instrument would be a semi-structured questionnaire for the collection of mostly qualitative data. The questionnaire used for the first study was modified to accommodate the new questions. Out of a pool of over 100 possible questions, 74 were selected and arranged in the following 12 sections: origins of the programme; programme organization and resources; partnerships; programme scope and current areas of emphasis and main projects; processes of policy development and strategic planning; marketing and resource mobilization of the programme; interaction with WHO initiatives and other countries programmes; programme evaluation; programme success and sustainability; health systems; dissemination and deployment; programme strategic issues for the future.


Second Addendum: The CINDI and CARMEN programmes are the outcome of a process that started on an international scale with the preparation of the report on the WHO meeting held in Kaunas in 1981. This report was ahead of its time. The initiative described pioneered seminal ideas of integration, including the integration of NCD activities with primary health care, the importance of multisectoral action, the application of practical health promotion to the prevention of NCD in entire populations, and the evaluation of interventions through process and outcome indicators. The report provided precise guidelines on the type of data that should be collected, including the cost-effectiveness of programme development and delivery. Over a twenty-year period, two WHO Regional Offices (for Europe and for the Americas) have developed an extensive network of country programmes based on the theoretical framework for organizing an effective intervention programme, formulated at the Kaunas meeting.

A score-card

It is tempting to regard the ideas and principles from the Kaunas meeting as a backdrop that, when combined with the results of this second study, can produce a score-card twenty years later. Such a score-card would be, for the most part, a positive one. Thirty CINDI and CARMEN country programmes existed at the time of this study and all programmes participated in it. Seven new countries have joined the networks since the study took place. All of these programmes value the concept of integration and strive to put it into practice using modern principles of health promotion, including multisectoral action. They are engaged in primary health care activities and have built considerable capacity in professional education and monitoring and evaluation (though there is scope to increase the use of data in monitoring policy and programme development). Demonstration appears to have taken hold in the CINDI and CARMEN programmes as an effective strategy for translating policy into practice. These developments occurred in all geographical areas during an unprecedented period of political, social and economic upheaval. This suggests that the philosophy for NCD prevention that originated in Kaunas is sound; it also speaks for the quality of the human resources responsible for the organization of the programmes at different levels. It would be hard to argue that the CINDI and CARMEN programmes have not been good investments for WHO.

Moving towards the population approach

The study has documented a number of points for reflection. One of the most important is that a good number of CINDI and CARMEN programmes have been putting population strategies into practice and attempting to balance them with efforts targeted to high-risk groups. To strengthen this, the following is required: a supportive health promotion framework at the national level; close collaboration with the ministry of health; a balance between the numbers of partners from the health sector and those from the non-health and private sectors, reinforced by continued marketing to the health sector; and increased marketing of the programmes outside the health sector.

Programmes expressed the need to improve capacity in community mobilization, public education and social marketing as intervention strategies. There is an increased awareness of the value of policy development and a desire to enhance capacity in this area. International collaboration is highly valued as a means of accessing expertise in health promotion and of learning how to mobilize resources from sectors other than the health system. All these factors enable population approaches to NCD prevention.

Marketing remains a challenge

Marketing of the value of prevention to the population at large and marketing of the CINDI and CARMEN programmes are essential if we are to build a solid political and policy base and to establish the programmes as significant players in the health systems of their countries. Marketing provides the opportunity to expand partnerships, mobilize resources, strengthen the population approach (including public education) and makes the CINDI and CARMEN programmes countrywide in scope. The programmes have important assets to market: the integrated NCD prevention model; the technical capacity to carry out epidemiological and health systems research; the capacity for professional education; and the potential, through health system reforms, to extend activities within the new public health services, e.g., incorporating health promotion approaches into the traditional public health services that used to deal mainly with communicable diseases. Yet, progress has been inconsistent, for the most part opportunistic and not strategically targeted. The barriers to marketing in a strategic sense should not be difficult to overcome and strategies to improve marketing should be explored. It is recommended that capacity building in marketing be given priority.

The “C” in CINDI

Two major challenges for CINDI and CARMEN in the future are to make the programmes more countrywide and to move from demonstration, as the mainstay of intervention, to dissemination. Clearly these challenges are related. Readers of this report, still holding as a backdrop for our score-card the principles of the intergrated NCD prevention and control programme formulated at the Kaunas meeting, should be aware that, at the meeting, neither of the two concepts, “countrywide” and “dissemination”, were discussed. It would have been unusual to address issues of dissemination at that time. Twenty years ago, the time was ripe to concentrate efforts on proving the effectiveness of community interventions and on building local capacity through demonstration projects. Undoubtedly, the demonstration strategy has served the programmes well.

While lending political attractiveness to the programme, the “C” (countrywide) in CINDI poses a great challenge. As this study progressed, two points became increasingly clear. Firstly, most countries were operating at the demonstration area level when they started. Secondly, being countrywide might be regarded more appropriately as a continuous variable (with countries at various stages of this continuum) than as a dichotomous variable. The study shows that most of the CINDI and CARMEN programmes were moving towards expanding collaborative activities with national organizations, establishing partnerships at the national and international levels, and becoming involved in national processes of policy development, which will eventually render them more countrywide in scope.

The “C” in CINDI is prominent. It would be appropriate for all CINDI and CARMEN programmes, as well as for WHO, to reflect on the barriers (political, policy, capacity, managerial, governance) that programmes face in becoming progressively countrywide. It would be worthwhile to develop an index of how to measure the extent to which programmes are countrywide.

Becoming countrywide at different rates

CINDI and CARMEN programmes are moving at different speeds towards the countrywide goal. This is to be expected since the programmes are at different stages of development. Operating at the demonstration area level may be appropriate for countries that joined CINDI and CARMEN in recent years and are trying to develop capacity in monitoring and evaluation, to establish sustainable management structures and financing arrangements, and to build a basic network of partnerships. Another consideration is that the concept of demonstration may differ from country to country and that the programme started at different points in time in the countries.

Second-generation demonstration programmes

Demonstrations programmes, such as the Stanford Five-City project and the North Karelia project (CINDI-Finland), set out to illustrate the feasibility of effective intervention to prevent cardiovascular disease and NCD at the community level. A second generation of programmes, CINDI-Canada being one of them, used demonstration areas to develop implementation capacity and to adapt disease prevention and health promotion methods that had been proven effective elsewhere. In spite of the difficulty of characterizing programmes as being in the demonstration mode or not, there is still concern that, for a variety of reasons, not all programmes are exploiting their potential to become national in scope.

Dissemination research or lack of it

Another place to start would be in discovering practical ways to disseminate capacity and the interventions that CINDI and CARMEN programmes have found effective. In contrast to demonstration, relatively little research and few resources have been devoted to studying the processes of dissemination. The First Dissemination Research Conference, held in Vancouver in 1995, defined research on dissemination as the process of identifying and acting upon variables that facilitate or hinder the uptake of capacity and interventions by jurisdictions, organizations and communities. The CINDI and CARMEN programmes are well positioned to document processes of dissemination and to develop databases of case studies and experience in this area. It should be emphasized that, in contrast to demonstration, dissemination requires increased political support. To be practical, dissemination processes need to occur through the increased utilization of existing public health and primary health care infrastructures and through intersectoral collaboration within and outside government.

The increased involvement of the CINDI and CARMEN programmes in policy development affords the opportunity to sell the idea of dissemination to government at policy level, including the need for NCD prevention programmes to deliver the preventive dose (doing the right thing, to the right number of people, with the right duration and intensity of interventions). The CINDI and CARMEN programmes can build a platform to make dissemination possible, contribute to the science of NCD prevention and, possibly, speed up progress to full-scale implementation.

Research observatories

CINDI and CARMEN are powerful networks and constitute real observatories for research in health systems policy; they are reservoirs of information on the successes and failures of implementation. This research capacity has yet to be systematically exploited. A CINDI / CARMEN observatory may be the precursor of a global observatory for policy development and implementation in NCD prevention.

Networks and linking agents

Besides implementing activities in NCD prevention, CINDI and CARMEN are unique international networks whose members share common goals, resources and approaches. They are already fostering mutual support and collaboration. This is true not only of the WHO Regional Offices but also of the participating countries in the WHO Regions for Europe and the Americas (e.g. sharing protocols, site visits, participation in CINDI / CARMEN Working Groups). The coordinating, political and policy support that the WHO Regional Offices provide to CINDI and CARMEN programmes is essential to their governance and to their capacity to carry out practical prevention work.

The functionalities of CINDI and CARMEN as networks have yet to be fully tapped. These programmes are poised to play a key role in global health agendas; in promoting good practices and evidence-based policy development, in securing priority for health promotion and disease prevention within the legislative frameworks of health care reform; in finding common ground for health promotion and disease prevention in major global and local initiatives, and in contributing capacity and insight in areas such as monitoring, evaluation, professional education and dissemination. For example, by virtue of the fact that CINDI and CARMEN are involved in both public health (population) and clinical (high risk) interventions, these programmes can contribute to the debate on how health systems can best utilize health resources available. They can help to reduce the existing disproportion between the allocations for health promotion and disease prevention and those for curative care.

The CINDI and CARMEN networks can play an effective role in dissemination by linking with other initiatives and networks and by sharing experience accrued over the years on the implementation of interventions through the health systems (public health services, primary health care). Cases in point are the WHO Mega Country Health Promotion Network, WHO initiatives in NCD community programmes, and innovative health promotion community initiatives that have been proposed for implementation on a global scale. There are compelling reasons for the CINDI and CARMEN networks to engage in other networks and initiatives. By enriching the capacity of others, CINDI and CARMEN programmes can enrich their own capacity.

Good reason for optimism

Taken as a whole, our score-card for CINDI and CARMEN gives rise to optimism. The fact that in carrying out this study two WHO Regional Offices pooled implementation experience augurs well for future international collaboration. This is a strategy in which WHO and other social and economic development agencies, such as the World Bank, could and should play a central role by facilitating the transfer of new NCD prevention and control technology across countries, indeed on a global scale. All CINDI and CARMEN programmes have the capacity to exercise leadership, introduce innovation and serve as linking agents among organizations that share similar goals in health promotion and disease prevention.

Dissemination - one step at a time

If there is one single key conclusion to be taken from the study, it is that dissemination should be seen as a new phase for CINDI and CARMEN. This would be the key to innovating these programmes and rendering them highly relevant to health systems, many of which are in transition and seeking answers on how to improve the health of their populations with respect to NCD within a generation span. And the environment is right. The international meeting to celebrate 20 years after Alma Ata reflects the general conviction that all segments of society need to be involved in the promotion of health and the prevention of disease. A gradual, step-by-step approach is necessary to tackle dissemination. Political and policy support, building partnerships, developing information databases and resource mobilization will be key issues in this process. Strengthened international collaboration and the optimal use of information technology might be important facilitators in taking the first steps towards dissemination. Increasing capacity in resource mobilization, partnership and marketing will be prerequisites for success.

At the same time, CINDI and CARMEN programmes should continue to keep the score. For, in the words of Machado, a 20th Century Spanish poet: “There is no road ahead of us, we must make our own road”.



Copyright © 2005, 2008 by the author.