PRIMARY HEALTH CARE FOR ADDRESSING OBESITY AND PREVENTING NONCOMMUNICABLE DISEASES IN WORLD BANK PROJECTS DISCUSSION PAPER NOVEMBER 2023 Simone Wahnschafft Jaime Bayona Garcia Manuela Villar Uribe PRIMARY HEALTH CARE FOR ADDRESSING OBESITY AND PREVENTING NONCOMMUNICABLE DISEASES IN WORLD BANK PROJECTS Lessons from a Review of Completed World Bank Health, Nutrition, and Population (HNP) Projects Simone Wahnschafft, Jaime Bayona Garcia, Manuela Villar Uribe November 2023 Health, Nutrition, and Population (HNP) Discussion Paper This series is produced by the Health, Nutrition, and Population Global Practice of the World Bank. The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account this provisional character. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. For information regarding the HNP Discussion Paper Series, please contact the Editor, Jung-Hwan Choi at jchoi@worldbank.org or Erika Yanick at eyanick@worldbank.org. RIGHTS AND PERMISSIONS The material in this work is subject to copyright. Because the World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, the World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. © 2023 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved. ii Health, Nutrition, and Population (HNP) Discussion Paper PRIMARY HEALTH CARE FOR ADDRESSING OBESITY AND PREVENTING NONCOMMUNICABLE DISEASES Lessons from a Review of Completed World Bank Health Sector Lending Projects Simone Wahnschafft,a Jaime Bayona Garcia,a Manuela Villar Uribea a Primary Health Care Performance Initiative, the World Bank Group, Washington DC, USA Paper prepared for Dissemination The World Bank Group, Washington DC, USA, May 2022 Abstract: A whole-of-society approach encompassing integrated health services, empowered people and communities, and multisectoral policy and action, primary health care (PHC) is an essential building block of universal health coverage (UHC). As the burden of obesity and noncommunicable diseases (NCDs) rises rapidly in low- and middle-income countries (LMICs), a robust health sector response must leverage a strong focus on PHC. The World Bank Health, Nutrition, and Population (HNP) Global Practice has a key role to play in catalyzing a PHC approach to tackle obesity. However, a World Bank report published in early 2020 highlighted a lack of health sector stewardship in supporting client countries to address obesity. As such, there is little systematized understanding of best practices for realizing a PHC approach to address obesity in World Bank health sector investments. This paper aims to bridge this knowledge gap by conducting an in-depth review of completed World Bank health sector investments that sought to address obesity and prevent NCDs in LMICs. Utilizing Primary Health Care Performance Initiative (PHCPI) tools, this evaluation systematically identifies and maps relevant project objectives, activities, indicators, and successful approaches to critical components of strong PHC systems. Successful projects are further investigated through in-depth document review and Task Team Leader interviews to synthesize successful strategies for PHC improvement and lessons learned. This investigation found that, while limited, completed projects demonstrated an important precedent of HNP stewardship to address obesity. Completed HNP projects were characterized by key successes, particularly in building national capacities for addressing the challenges of obesity and NCDs, implementing community-based health promotion policies and programs, and improving primary care services for NCD early detection and management. That said, completed projects also highlighted critical gaps in health sector stewardship, particularly in supporting multisectoral action to realize a “Health in All Policies” approach. As HNP scales up support to client countries to address obesity and prevent NCDs, project successes and persisting gaps identified in completed HNP projects offer crucial lessons for the future. Keywords: Primary health care (PHC), obesity, noncommunicable disease (NCDs), PHC improvement strategies iii Disclaimer: The findings, interpretations, and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. Correspondence Details: Primary Health Care Performance Initiative (Washington, DC) https://improvingphc.org/. iv Table of Contents RIGHTS AND PERMISSIONS ...................................................................................... II ACKNOWLEDGMENTS ........................................................................................... VIII ACRONYM LIST ............................................................................................................. 9 INTRODUCTION........................................................................................................... 11 OBESITY: A HEALTH AND ECONOMIC THREAT .............................................................. 11 PRIMARY HEALTH CARE FOR ADDRESSING OBESITY AND NCDS .................................. 11 PRIMARY HEALTH CARE AND OBESITY IN THE WORLD BANK: A KNOWLEDGE GAP ..... 12 METHODOLOGY ......................................................................................................... 13 OBJECTIVES.................................................................................................................... 13 CONCEPTUAL FRAMEWORK............................................................................................ 13 OVERVIEW: ANALYTICAL APPROACHES ........................................................................ 14 STEP 1. IDENTIFYING COMPLETED HNP PROJECTS WITH OBESITY/NCD OBJECTIVES ... 14 Inclusion/Exclusion Criteria ................................................................................... 14 Classification of Obesity/NCD Objectives ........................................................... 15 Document Search Strategy ................................................................................... 16 STEP 2. SUMMARIZING BASIC PROJECT CHARACTERISTICS ............................................ 16 STEP 3. MAPPING PROJECT ACTIVITIES TO THE PHCPI CONCEPTUAL FRAMEWORK ...... 17 STEP 4. MAPPING PERFORMANCE INDICATORS TO THE PHCPI CONCEPTUAL FRAMEWORK .................................................................................................................. 17 STEP 5. SCORING PERFORMANCE INDICATORS AND ASSESSING PROJECT SUCCESSES .... 18 STEP 6. SYNTHESIZING PHC IMPROVEMENT STRATEGIES AND LESSONS LEARNED ....... 18 RESULTS ........................................................................................................................ 19 BASIC PROJECT CHARACTERISTICS ................................................................................ 19 Overview................................................................................................................... 19 Source: Authors’ own contribution. ...................................................................... 19 Geographic Trends ................................................................................................. 19 Projects by Region .............................................................................................. 19 Projects by Income Bracket ............................................................................... 20 Temporal Trends ..................................................................................................... 20 Projects by Fiscal Year Approval and Duration .............................................. 20 Temporal Trends ................................................................................................. 22 Financing Trends .................................................................................................... 23 Financing Instrument .......................................................................................... 23 Total Loan Amount .............................................................................................. 24 Project Costs Allocated to Obesity and NCD Activities................................. 24 Thematic Trends ..................................................................................................... 24 Project Theme Codes ......................................................................................... 24 Epidemiological Trends.......................................................................................... 25 Obesity Morbidity................................................................................................. 25 Obesity Mortality .................................................................................................. 26 v Epidemiological Trends ...................................................................................... 27 PROJECT OBJECTIVES FOR ADDRESSING OBESITY AND PREVENTING NCDS .................. 29 Overview................................................................................................................... 29 Objective Trends by Category .............................................................................. 29 Integrated Health Services ................................................................................ 29 Empowered People and Communities ............................................................ 29 Multisectoral Policy and Action ......................................................................... 30 General NCD Prevention and Management ................................................... 30 SOURCE: AUTHORS’ OWN CONTRIBUTION. ...................................................................... 31 PROJECT ACTIVITIES FOR ADDRESSING OBESITY AND PREVENTING NCDS ................... 31 Overview................................................................................................................... 31 Activities by PHC Domain: Systems .................................................................... 32 Governance and Leadership ............................................................................. 32 Health Financing.................................................................................................. 33 Adjustment to Population Health Needs.......................................................... 33 Activities by PHC Domain: Inputs......................................................................... 34 Activities by PHC Domain: Service Delivery....................................................... 35 Population Health Management ....................................................................... 35 SOURCE: AUTHORS’ OWN CONTRIBUTION. ...................................................................... 36 PROJECT MEASUREMENT FOR ADDRESSING OBESITY AND PREVENTING NCDS ............ 37 Overview................................................................................................................... 37 Measurement by PHC Domain: Systems ........................................................... 38 Governance and Leadership ............................................................................. 38 Health Financing.................................................................................................. 38 Adjustment to Population Health Needs.......................................................... 38 Measurement by PHC Domain: Inputs ................................................................ 39 Measurement by PHC Domain: Service Delivery .............................................. 39 Population Health Management ....................................................................... 39 High-Quality Primary Health Care .................................................................... 39 Measurement by PHC Domain: Outputs ............................................................. 39 Measurement by PHC Domain: Outcomes ........................................................ 40 PROJECT SUCCESSES FOR ADDRESSING OBESITY AND PREVENTING NCDS ................... 40 Overview................................................................................................................... 40 Project Successes by PHC Domain .................................................................... 41 Systems ................................................................................................................ 41 Inputs..................................................................................................................... 42 Service Delivery................................................................................................... 42 Outputs.................................................................................................................. 42 Outcomes ............................................................................................................. 42 Total Project Success ......................................................................................... 42 PHC IMPROVEMENT STRATEGIES AND LESSONS LEARNED FOR ADDRESSING OBESITY AND PREVENTING NCDS ................................................................................................ 44 Case Studies—Successful Projects .................................................................... 44 Brazil Second Disease Surveillance and Control Project ............................. 44 Uruguay Noncommunicable Diseases Prevention Project ........................... 47 Bosnia and Herzegovina Health Sector Enhancement Program Project ... 50 vi Croatia Health System Project .......................................................................... 52 India Tamil Nadu Health System Project......................................................... 53 China Rural Health Project ................................................................................ 56 Summary .................................................................................................................. 57 DISCUSSION .................................................................................................................. 58 Limitations ............................................................................................................ 58 Key Takeaways ................................................................................................... 59 Policy Implications and Recommendations .................................................... 66 CONCLUSION ............................................................................................................... 67 ANNEXES ....................................................................................................................... 68 ANNEX 1 – PHCPI FRAMEWORK DOMAIN GLOSSARY ................................................... 68 ANNEX 2 – OBESITY SEARCH TERMS ............................................................................. 71 ANNEX 3 – INDICATOR SCORING METHODOLOGY .......................................................... 71 ANNEX 4 – DOCUMENT SEARCH STRATEGY RESULTS.................................................... 74 ANNEX 5 – SUMMARY OF BASIC PROJECT CHARACTERISTICS ........................................ 75 ANNEX 6 – SUMMARY OF OBJECTIVES FOR ADDRESSING OBESITY AND PREVENTING NCDS ............................................................................................................................. 75 ANNEX 7 – SUMMARY OF PROJECT ACTIVITIES FOR ADDRESSING OBESITY AND PREVENTING NCDS ....................................................................................................... 78 ANNEX 8 – SUMMARY OF PROJECT INDICATORS FOR MONITORING AND EVALUATION ON ACTIVITIES FOR ADDRESSING OBESITY AND PREVENTING NCDS .................................. 83 ANNEX 9 – ADDITIONAL RESOURCES FOR PHC IMPROVEMENT ..................................... 86 REFERENCES................................................................................................................ 88 vii ACKNOWLEDGMENTS The authors of this report are extremely grateful for the support from the greater World Bank Primary Health Care Performance Initiative (PHCPI) Team: Federica Secci, Mary Ndege, Marwa Ramadan, HuiHui Wang, Neesha Harnam, Renzo Efren Sotomayor, Gianluca Cafagna, and Tonny Brian Mungai Muthee. The authors are also grateful for the support, continuous collaboration, and exchange of ideas from Latifat Okara, Cameron Feil, and Jasmine Vicencio. Simone Wahnschafft would like to acknowledge and thank her co-authors Manuela Villar Uribe and Jaime Nicolas Bayona Garcia for their instrumental guidance, support, and mentorship throughout the authoring of this report—without which, it would not have been possible. The authors are grateful to the World Bank for publishing this report as an HNP Discussion Paper. viii ACRONYM LIST APL Adaptable Program Loan BCC Behavior Change Communication BiH Bosnia and Herzegovina BMI Body Mass Index CRVS Civil Registration and Vital Statistics CVD Cardiovascular Disease DLI Disbursement Linked Indicator DPF Development Policy Financing EAP East Asia and the Pacific ECA Europe and Central Asia EPHF Essential Public Health Functions EMR Electronic Medical Record FM Family Medicine FY Fiscal Year FUNCOMIN Fund for Indigenous Community Initiatives HiAP Health in All Policies HNP Health, Nutrition, and Population HICs High-Income Countries HLC Health Lifestyle Center HPS Health Promoting School ICR Implementation Completion and Results Report IEC Information, Education, and Communication ICRR Implementation Completion and Results Review Report IEG Independent Evaluation Group IO Intermediate Outcome IPF Investment Project Financing LAC Latin America and the Caribbean LICs Low-income countries LMICs Low- and middle-income countries MENA Middle East and North Africa NCD Noncommunicable disease NHA National Health Account NPHW Nonphysician Health Worker PAD Project Appraisal Document PDO Project Development Objective PforR Program for Results PHC Primary Health Care PHCPI Primary Health Care Performance Initiative PPAR Project Performance Assessment Report PPENT Noncommunicable Diseases Prevention Project PPHP Priority Public Health Functions RS Republika Srpska SA South Asia SIL Specific Investment Loan 9 SIM Sector Investment and Maintenance SSA Sub-Saharan Africa SVS Secretariat for Health Surveillance TTL Task Team Leader UMICs Upper-Middle Income Countries 10 INTRODUCTION OBESITY: A HEALTH AND ECONOMIC THREAT Noncommunicable disease (NCD) morbidity, and mortality constitutes one of the major global development challenges of the 21st century. In 2016 alone, NCDs accounted for approximately 70 percent of global mortality, with approximately three of every four deaths occurring in low- and middle-income countries (LMICs) (WHO 2016). The burden of NCDs in LMICs is characterized by a high burden of premature NCD mortality compared to high- income countries (HICs). For example, on average, 50 percent of all cardiovascular disease (CVD) deaths in LMICs occur in adults ages 30–70 years compared to 20 percent in HICs (Frieden and Bloomberg 2018). The majority of premature NCD deaths in ages 30–70 years on a global scale are the result of four major NCDs: cardiovascular disease (CVD), cancer, diabetes, and chronic respiratory disease (WHO 2014). Obesity is a major culprit in the unprecedented rise of NCDs in LMICs. The result of an imbalance between energy consumed and energy expended, obesity is associated with increased risk for all four of the major NCDs (Banjare and Bhalerao 2016). As it stands, the principal behavioral risk factors of obesity—unhealthy diets and physical inactivity— are the top preventable causes of NCD morbidity and mortality on a global scale (Banjare and Bhalerao 2016). Dietary and physical activity behaviors are embedded in the very fabric of the social and built environments in which people are born, grow, live, work, and age. Thus, dramatic population shifts underway in many LMICs, such as rising life expectancy, rapid urbanization, economic growth, and changing lifestyles, have shaped an epidemiological transition toward a greater burden of obesity and associated NCDs (Ford, Patel, and Narayan 2017). The growing epidemic of obesity in LMICs presents a formidable threat to the realization of the World Bank’s goals of ending extreme poverty and boosting shared prosperity, contributing to rising health care costs and household economic burden, reduced labor force productivity, and deepening health inequities (Miranda et al. 2019). The Health, Nutrition, and Population (HNP) Global Practice’s most recent strategy (2007) recognizes obesity as a significant emerging challenge to improving the health and well-being of millions of the world’s poorest people (World Bank Group 2007). However, despite this and a robust body of evidence on the catastrophic health and economic impacts of obesity, as well as growing attention to obesity and NCDs in the global development agenda, a recently published World Bank report found that World Bank investment to address this pervasive issue has been scant (Shekar and Popkin 2020). In addition, the report noted that attention that has been paid to obesity through the World Bank has been concentrated in the transportation sector, while the health sector has provided relatively little stewardship (Shekar and Popkin 2020). While leadership from outside of the health sector is necessary to address this pervasive threat, the health sector has a vital role to play in catalyzing action for addressing obesity and preventing NCDs. PRIMARY HEALTH CARE FOR ADDRESSING OBESITY AND NCDS For many LMICs, effectively responding to population health needs in the face of epidemiological transition requires health system transformation. Namely, systems that have historically been built for predominantly “curative” functions must be reoriented to promote health and prevent disease across a range of settings, as well as be equipped to 11 meet the demands of diseases that require chronic management across the life course. As a whole-of-society approach encompassing not only primary care service delivery, but integrated essential public health functions, an emphasis on empowered people and communities, and a focus on multisectoral policy and action, Primary Health Care (PHC) has a strategic role to play in catalyzing this transformation. When strengthened, PHC can meet approximately 80 percent of population health needs (Pettigrew et al. 2015). Several studies have sought to systematically investigate and consolidate the role of PHC in improving outcomes for NCD prevention and management. One salient resource, which has underpinned health system reform for NCDs in many countries since its inception, is the Chronic Care Model. An organizational model for high-quality NCD management in PHC, the Chronic Care Model emphasizes six key areas of action at the primary care level: decision supports, clinical information systems, self-management support for patients, delivery system design, and community resources and policies (Bodenheimer, Wagner, and Grumbach 2002). More recently, Demaio et al. (2014) put forth key principles of a PHC approach as they aligned to meet the challenges of NCDs in LMICs, such as the integration of public health functions into health services and emphasis on equity, community participation, and multisectoral action (Demaio et al. 2014). Finally, a growing area of research has sought to investigate the role of PHC in tackling the social determinants of NCDs, identifying key areas of action at the national, community, and individual levels for PHC practitioners and policy makers (Allen et al. 2019). PRIMARY HEALTH CARE AND OBESITY IN THE WORLD BANK: A KNOWLEDGE GAP Though health sector stewardship within the World Bank for addressing obesity and associated NCDs has historically been limited, there is evidence of growing investment. Namely, a search of obesity-related terms (“obesity,” “overweight,” and “obese”) in the World Bank Operations Portal yields 50 lending projects led by the HNP Global Practice since the mid-1990s, approximately half of which (48 percent) have been approved in just the past five years alone (Fiscal year [FY] 2015 onward). As HNP scales up support to countries to address obesity and prevent NCDs, it is important to learn from what has already been done. While conceptual elements of an effective PHC approach for tackling obesity and NCDs have been investigated in existing frameworks and literature, there has been little analytical work conducted to understand how a PHC approach has been bridged into practice within the context of World Bank operations. This constitutes a key gap in institutionalized knowledge of best practices and improvement strategies for World Bank investments for effectively addressing the health and economic threat of obesity and associated NCDs in client countries. Completed HNP projects that have supported client countries to address obesity and prevent NCDs demonstrate HNP stewardship in action and applied knowledge in fostering a PHC approach to tackle this critical health issue. Thus, the objective of this analysis is to investigate trends in project objectives, activities, and measurements to address obesity and prevent NCDs through a PHC approach; identify key successes; and synthesize “PHC improvement strategies” from completed HNP projects that may inform current and future practice. 12 METHODOLOGY OBJECTIVES This assessment, which focuses on completed HNP projects that include objectives to address obesity and prevent NCDs through a PHC approach, is underpinned by three primary objectives: 1. To understand key trends in PHC activities and measurement for achieving project objectives aimed at addressing obesity and preventing NCDs. 2. To evaluate the success of projects in strengthening critical components of PHC systems to address obesity and prevent NCDs. 3. To synthesize PHC improvement strategies and lessons learned from successful projects for addressing obesity and preventing NCDs for dissemination to relevant stakeholders, including World Bank Task Team Leaders (TTLs) of active/pipeline HNP operations with a focus on obesity and/or NCDs. CONCEPTUAL FRAMEWORK To achieve these objectives, this analysis uses conceptualizations of a PHC approach developed through extensive literature review and expert consultation by the Primary Health Care Performance Initiative (PHCPI), a partnership dedicated to catalyzing improvements in PHC through comprehensive measurement and evidence-based improvement strategies in LMICs. The use of PHCPI tools in this analysis is twofold. First, the definition of PHC put forth by PHCPI (see Box 1) is used to develop a classification system of project objectives to address obesity and prevent NCDs that reflect three core values of a PHC approach: (1) integrated health services, (2) multisectoral policy and action, and (3) empowered people and communities. Primary Health Care is a whole-of-society approach to health that aims to maximize the level and distribution of health and well-being through three components: (a) primary care and essential public health functions as the core of integrated health services, (b) multisectoral policy and action, and (c) empowered people and communities. Second, the PHCPI Conceptual Framework (see Figure 1), which identifies essential domains of effective PHC across a continuum of systems, inputs, service delivery, outputs and outcomes, is used to delineate key project activity and measurement trends as they pertain to distinct components of a PHC approach. The PHCPI Conceptual Framework also underpins the evaluation of project successes and identification of improvement strategies to discern specific entry points in PHC for addressing obesity and preventing NCDs. For a full glossary of PHC domain definitions encompassed in the PHCPI Conceptual Framework, see Annex 1. 13 Figure 1. PHCPI Conceptual Framework Source: PHCPI. Notes: PHC = Primary health care; RMNCH = Reproductive, Maternal, Newborn, and Child Health; NCDs = Noncommunicable diseases. OVERVIEW: ANALYTICAL APPROACHES This analysis is broken down into six key steps: (1) Identifying completed HNP projects with objectives for addressing obesity and preventing NCDs, (2) Summarizing basic project characteristics, (3) Mapping project activities to address obesity and prevent NCDs to domains of the PHCPI Conceptual Framework, (4) Mapping project performance indicators to address obesity and prevent NCDs to domains of the PHCPI Conceptual Framework, (5) Scoring the achievement of performance indicators for each project across PHC domains and quantifying overall project “success” in achieving objective(s) for addressing obesity and preventing NCDs, and (6) Synthesizing PHC improvement strategies and lessons learned. STEP 1. IDENTIFYING COMPLETED HNP PROJECTS WITH OBESITY/NCD OBJECTIVES Inclusion/Exclusion Criteria The first step of this analysis was to identify completed HNP projects with objective(s) aimed at addressing obesity and preventing NCDs. To accomplish this, a set of inclusion criteria was created and applied in a review of the World Bank Operations Portal. To be included in the analysis, projects had to meet the following conditions: (1) Have a “completed” status, with an available Project Appraisal Document (PAD) and Implementation Completion and Results Report Review (ICRR), at the time of this analysis (cutoff at June 2020); (2) Be led by the HNP Global Practice; and (3) Include at least one objective aimed at addressing obesity and/or preventing NCDs in the PAD. 14 Classification of Obesity/NCD Objectives Objectives to addressing obesity and preventing NCDs refer to relevant project goals outlined in either the Project Development Objective (PDO) or project component section of the PAD. While focusing solely on projects with a PDO related to obesity/NCDs would have been ideal, this approach was ultimately limited by a dearth of completed projects meeting such conditions. Consequently, those projects that were found to have relevant objective(s) embedded in the project components and/or subcomponents of project PADs were also included in this analysis. To identify relevant objectives for addressing obesity and preventing NCDs that were characterized by a PHC approach, a classification system was devised to organize thematic elements of objectives that coincided with core values of PHC. The classification system devised includes four overarching categories of objectives: (1) Integrated Health Services, (2) Empowered People and Communities, (3) Multisectoral Policy and Action, and (4) General NCD Prevention and Management. The first three categories form three essential pillars of the PHC approach, while the fourth category encompasses objectives that carry a broader focus on supporting countries to address the burden of NCDs. To qualify for inclusion, objectives had to encompass an explicit focus on preventing obesity, its risk factors, and/or NCDs, as well as align with one of the four categories. Projects that sought to address undernutrition alone, while relevant to obesity prevention, were excluded to maintain the focus on projects aiming to address obesity and prevent NCDs. The definition of each of these categories, as well as rationale for inclusion or exclusion for the purpose of this analysis, can be found in Table 1. Table 1. Inclusion and Exclusion Criteria for Objectives to Address Obesity and Prevent NCDs in Completed HNP Projects Category Included Definition Rationale or excluded Integrated Included Encompasses objectives that Essential public health functions and primary health aim to strengthen health system care service delivery form the core of integrated services functions for chronic disease health services and are critical to a PHC primary prevention and approach. As such, projects that aim to address management, particularly obesity and/or prevent NCDs through through strengthening primary strengthening these health system functions are care service delivery and/or highly relevant to PHC. essential public health functions. Objectives with a focus on strengthening secondary or tertiary care without any focus on PHC were excluded. Empowered Included Refers to objectives aiming to Health promotion policies and programs aim to people and promote health at the national empower individuals and communities to communities and/or community level to engage in healthy behaviors and reduce the risk address the modifiable risk of chronic disease. Promoting healthy lifestyles, factors of obesity and associated such as diet and physical activity, is integral to NCDs, such as unhealthy diet obesity prevention. Empowering people and and physical inactivity. communities through health promotion activities is a key dimension of the PHC approach to 15 realizing more person-centered care and addressing the social determinants of health. Multisectoral Included Pertains to objectives that aim to Not only is multisectoral policy and action policy and foster policy action for fundamental to a PHC approach, it is also action addressing obesity and other essential to address the multifaceted NCD risk factors that cross determinants of obesity. Solutions to the across sectors, both in the scope challenges of obesity require stewardship from of policies/actions themselves sectors such as agriculture, urban planning, and/or collaboration with education, and labor, to name a few. stakeholders across sectors. General NCD Included Encompasses objectives with an These objectives were included because prevention overarching focus on reducing initiatives to prevent and control NCDs, and morbidity and/or mortality from including CVD, diabetes, and cancer, may hold management NCDs. valuable lessons for obesity prevention in addressing the modifiable risk factors, such as unhealthy diet and physical inactivity, that underpin these chronic diseases. Early Excluded Refers to goals that aim to While addressing undernutrition in childhood is childhood improve nutrition, particularly an important approach to obesity prevention, undernutrition among mothers and children, this analysis focuses on projects with expressed with an explicit focus on goals to address obesity, its risk factors, and/or mitigating undernutrition. downstream NCD health outcomes. Source: Authors’ own contribution. Notes: NCDs = Noncommunicable diseases; PHC = Primary health care; CVD = Cardiovascular disease. Document Search Strategy Once the inclusion criteria were defined, they were applied to a review of project PADs. To narrow down the search of HNP PADs to review, a list of obesity-related search terms was developed and applied in the World Bank Operations Portal to isolate projects with a focus on obesity/NCD prevention. The development of search terms for obesity was informed by a review of the literature on obesity-related terminology. Terms were organized into 11 categories: (1) overweight/obesity, (2) health promotion, (3) NCD risk factors, (4) behavioral risk factor surveillance, (5) NCD prevention, (6) physical activity, (7) school health, (8) food systems/environment, (9) obesity policy, (10) diet quality, and (11) mobility infrastructure (see Annex 2 for the full list of terms by category). Projects that were identified through this initial search were then further refined to include only those projects that were completed. Finally, the PDO and project components sections of the remaining PADs were read closely to identify objectives that fit within the scope of the classification system devised, leading to the finalized subset of completed HNP projects with at least one objective to addressing obesity and preventing NCDs. STEP 2. SUMMARIZING BASIC PROJECT CHARACTERISTICS The second step of this analysis was to assess basic project characteristics and identify salient contextual considerations for lessons identified from completed HNP projects. First, geographic characteristics were analyzed to assess HNP investment in addressing obesity and NCDs by region and World Bank income bracket. Second, the range of fiscal years (FYs) in which projects were approved, average project duration, and relative focus 16 within the HNP portfolio over time were assessed to understand HNP investment in addressing obesity and NCDs over time. Key dimensions of project financing, including financing instrument used, total loan amount, and percentage of project costs allocated to obesity and NCD activities were identified to understand financial commitments made to addressing obesity and preventing NCDs among completed projects. Project costs allocated to obesity and NCDs were estimated by calculating the projected cost of components/subcomponents with objectives to address obesity and prevent NCDs out of the total project cost at appraisal. Project costs allocated to obesity and NCDs were compared to project theme codes across projects, which are utilized to designate project focus on strategic World Bank priorities, to deepen the understanding of project commitment to addressing obesity and preventing NCDs. Finally, epidemiological trends, namely adult obesity morbidity and mortality at the time of project approval, were identified to contextualize the public health burden of obesity and associated NCDs that countries faced at the time of each project. Apart from epidemiological trends identified, data for these trends were extracted from project PADs and Implementation Completion and Results Reports (ICRs). STEP 3. MAPPING PROJECT ACTIVITIES TO THE PHCPI CONCEPTUAL FRAMEWORK To develop an understanding of key trends in project activities to address obesity and prevent NCDs, project outputs that were completed to achieve objectives aimed at addressing obesity and preventing NCDs were identified from project ICRs and mapped to corresponding domains of systems, inputs, and service delivery of the PHCPI Conceptual Framework. Project activities that were planned at project appraisal but were ultimately not completed by the culmination of the project were not included in the mapping exercise. The mapping of project activities to the PHCPI Conceptual Framework was based on an in-depth review of PHCPI domain definitions, as detailed in Annex 1. STEP 4. MAPPING PERFORMANCE INDICATORS TO THE PHCPI CONCEPTUAL FRAMEWORK Project performance indicators used in the project Results Framework to monitor and evaluate progress on objectives to address obesity and prevent NCDs were isolated from project ICRs and mapped on a one-to-one basis to their corresponding domain of PHCPI Conceptual Framework to facilitate the identification of overarching trends in measurement pertaining to obesity/NCDs in completed projects. The mapping of project indicators was based on in-depth review of PHCPI domain definitions and metrics, as well as iterative consultations with PHCPI experts. As objectives included in this analysis sometimes encompassed a broader focus on NCD prevention, certain indicators identified were not ostensibly related to obesity (e.g., substance use indicators, cancer screening, etc.). These indicators were excluded for the purposes of this mapping exercise. Indicators that pertained to the prevention and management of NCDs with significantly increased risk due to obesity and characterized by common modifiable risk factors, such as unhealthy diet and physical inactivity, were included. This included selected indictors pertaining to cardiovascular disease (CVD) and diabetes prevention and management. Only indicators that were ultimately measured at project completion (i.e., not dropped over the duration of the project) were included in this analysis. 17 STEP 5. SCORING PERFORMANCE INDICATORS AND ASSESSING PROJECT SUCCESSES Once mapped, performance indicators were scored based on the extent to which they were achieved. The scoring of indicators was limited to projects with a minimum threshold of 5 or more obesity/NCD-related performance indicators. For each project, the scoring of indicators was ultimately used to quantify project success for (a) each specific PHC domain reflected in project measurement; and (b) overall achievement of objective(s) to address obesity and prevent NCDs. Indicators were divided into two categories, PDO indicators and Intermediate Outcome (IO) indicators. The achievement of PDO indicators was weighted twice that of the achievement of IO indicators in the determination of the final project success score (K). This weighting system, which was informed by input from World Bank Task Team Leaders, emphasizes the achievement of the overarching project objective as fundamental to project success. For full details on the methodology used to score performance indicators and quantify project success, see Annex 3. STEP 6. SYNTHESIZING PHC IMPROVEMENT STRATEGIES AND LESSONS LEARNED The final step of this analysis was to synthesize the successes and lessons learned from completed successful HNP projects into PHC Improvement Strategies and lessons learned for addressing obesity and preventing NCDs, particularly within the context of HNP investment. This qualitative analysis was carried out through in-depth review of project completion documents, including project ICRs, Implementation Completion and Results Reports Review (ICRRs), and, where available, Project Performance Assessment Reports (PPARs). Where possible, semi-structured interviews were conducted with project TTLs. Interview questions probed further into successful project activities, challenges encountered, perceived risks to sustainability of project outcomes, and lessons learned. Insights from document review and TTL interviews were complemented by additional literature review on evidence-based interventions for addressing obesity and preventing NCDs through a PHC approach. The data for this paper were collected in June-July 2020. 18 RESULTS BASIC PROJECT CHARACTERISTICS Overview As of mid-2020, a total of 17 completed projects were found to contain at least one objective to address obesity and prevent NCDs in the PDO and/or project component(s) and thus met the full criteria to be included in the analysis (see Table 2). For full details on the results of the document search strategy in the World Bank Operational Portal, see Annex 4. Table 2. Completed HNP Projects with Objective(s) to Address Obesity and Prevent NCDs Region Country Project name Project ID number Latin Argentina Essential Public Health Functions Programs II P110599 America and Project the Brazil Second Disease Surveillance Project – P083013 Caribbean VIGISUS II (LAC) Uruguay Non-communicable Disease Prevention P050716 Project Bosnia and Health Sector Enhancement Project P088663 Herzegovina (BiH 1) Bosnia and Reducing Health Risk Factors Project P160512 Herzegovina (BiH 2) Europe and Croatia Health System Project P051273 Central Asia Estonia Health Project P008402 (ECA) Hungary Health Services and Management Project P008484 Latvia Health Reform Project P058520 Turkey Project in Support of Restructuring the Health P102172 Sector Bangladesh Health, Nutrition, and Population Sector P074841 South Asia Project (SA) India Tamil Nadu Health Systems Project P075058 Sri Lanka 1 Health Services Project P010526 Sri Lanka 2 Second Health Sector Development Project P118806 China Rural Health Project P084437 East Asia Samoa Health Sector Management Program Support P086313 and the Project and Additional Financing Pacific Tonga Health Sector Support Project P075230 (EAP) Source: Authors’ own contribution. Geographic Trends Projects by Region Completed projects were implemented primarily in Europe and Central Asia (ECA) (N = 7), followed by South Asia (SA) (N = 4), Latin America and the Caribbean (LAC) (N = 3), and East Asia and the Pacific (EAP) (N = 3). No completed projects were identified in the Middle East and North Africa or sub-Saharan Africa regions. For most countries, only one 19 completed project was identified, apart from Bosnia and Herzegovina (BiH) and Sri Lanka, which each were the site of two completed projects with objectives to address obesity and prevent NCDs. Projects by Income Bracket Completed projects were conducted primarily in upper-middle income countries (UMICs), with eight projects in total. Five projects were carried out in high-income countries (HICs), and four were carried out in low- and middle-income countries (LMICs), all of which were in the South Asia region. No completed projects were identified in low-income countries (LICs) (see Figure 2). Figure 2. Map of Countries with Completed HNP Project(s) with Objective(s) to Address Obesity and Prevent NCDs by World Bank Income Bracket Source: Authors’ own contribution. Notes: WB = World Bank. Samoa and Tonga not pictured. Temporal Trends Projects by Fiscal Year Approval and Duration Fiscal year of approval for completed projects exhibited a range of over two decades, with the earliest project approved in 1993 and the latest in 2017. Duration of project implementation, from FY of project approval to FY of project completion, ranged from a minimum of 2 years to a maximum of 11 years, with an average of 6.5 years. In total, completed projects spanned 26 years, capturing over two decades of HNP operations related to addressing obesity and preventing NCDs. Apart from the Health Services Project in Sri Lanka, the projects carried out in the mid/late 1990s were concentrated in Europe and Central Asia (ECA). Projects conducted within the past decade spanned across all four regions (see Figure 3). 20 Figure 3. Time Line of Completed HNP Projects with Objective(s) to Address Obesity and Prevent NCDs Implementation by Region Source: Authors’ own contribution. Notes: HNP = Health, Nutrition, and Population; BiH = Bosnia and Herzegovina. Results in Context: The World Bank HNP Portfolio on Obesity and NCD Prevention Overview This analysis takes a deep dive into the portfolio of completed HNP projects that aim to address obesity and prevent NCDs; however, these 17 projects only encompass little over a third of all HNP projects addressing obesity and/or NCDs. Specifically, at the time of this analysis, a total of 50 projects were identified that included objectives to address obesity and/or NCDs, of which 29 (58 percent) were still active, 17 (34 percent) were completed, and 4 (8 percent) were dropped. Geographic Trends Of the total HNP projects related to obesity, the majority have been completed or are currently being implemented in Latin America and the Caribbean (LAC) and in Europe and Central Asia (ECA), followed by South Asia (SA) and East Asia and Pacific (EAP). 21 Figure 4. Regional Distribution of all HNP Projects with Objective(s) to Address Obesity and Prevent NCDs (1986–2020) Source: Authors’ own contribution. The regional focus of the HNP financing portfolio with obesity prevention and management goals has shifted over the past several decades. Specifically, while projects in the 1990s were concentrated primarily in the ECA Region, those projects approved within the past decades are more evenly distributed across World Bank regions. Obesity prevention and management in MENA and SSA is a relatively new focus across the HNP portfolio, with only two projects across the entire portfolio, all of which were approved in FY2015 or later. Table 3. HNP Obesity/NCD Projects—Fiscal Year Approval by Decade and World Bank Region (Percent) ECA LAC SA EAP MENA SSA Total N (%) 1980–1989 0% 0% 0% 0% 0% 0% 0 (0%) 1990–1999 4 (80%) 0% 1 (20%) 0% 0% 0% 5 (10%) 2000–2009 2 (22%) 2 2 (22%) 3 (34%) 0% 0% 9 (18%) (22%) 2010–2020 12 10 5 (12%) 5 (15%) 2 (6%) 2 (6%) 36 (33%) (28%) (72%) Total N 18 12 8 (16%) 8 (16%) 2 (4%) 2 (4%) 50 (%) (36%) (24%) (100%) Source: Authors’ own contribution. Notes: LAC = Latin America and the Caribbean; SA = South Asia; EAP = East Asia and the Pacific; MENA = Middle East and North Africa; SSA = Sub-Saharan Africa. Temporal Trends For the most part, completed HNP projects identified reflect an early and limited focus on obesity and NCDs within the HNP portfolio (see Figure 4). Just two completed projects were approved within the past decade. On average, completed HNP projects addressing obesity and NCDs made up less than 3 percent of all HNP projects approved each year from 1993 to 2017. On the other hand, projects with objective(s) to address obesity and prevent NCDs have comprised an average of 7.5 percent of HNP projects approved annually since 2013. However, most of these more recently approved projects 22 are still in varying phases of implementation and thus were not eligible for inclusion in this analysis. Figure 5. HNP Completed Projects with Objectives for Addressing Obesity and Preventing NCDs relative to (a) Ongoing Projects with Objective(s) to Address Obesity and Prevent NCDs (Orange), and (b) Total Number of Projects (Gray), by FY Approval Source: Authors’ own contribution. Notes: HNP = Health, Nutrition, and Population; NCD = Noncommunicable disease; FY = Fiscal year. Vertical axis limit is 70 projects or more. The number of total HNP projects approved was higher than 70 only in 2020 due to COVID-19 (N = 144). Financing Trends Financing Instrument The most common financing instrument across projects were Specific Investment Loans (SIL), which were used in 10 of the 17 projects. Investment Project Financing (IPF) 1 and Adaptable Program Loans (APL) were both used in three projects, while only one project used a Sector Investment and Maintenance (SIM) Loan. None of the completed projects used Program-for-Results (PforR). 2 This is attributable in part to the recent emergence of 1 Investment Project Financing provides financing to governments for activities that create the physical/social infrastructure necessary to reduce poverty and create sustainable development. 2 Program-for-Results links disbursement of World Bank funds directly to the delivery of defined results, helping countries improve the design and implementation of their own development programs and achieve lasting results by strengthening institutions, enhancing systems, and building capacity. 23 PforR in 2012, which would leave a relatively short window for PforR projects to have been approved and completed by the time of this analysis. Total Loan Amount Total loan amount ranged widely across completed projects, from US$1.4 million to US$874.9 million. For the most part, smaller loans were more common, with just over half of the project loan amounts under the amount of US$50 million. Project Costs Allocated to Obesity and NCD Activities For most projects (N = 10), the percentage of the total project cost at appraisal dedicated to achieving obesity/NCD-related objectives was less than 25 percent. Only 3 of the total 17 projects dedicated over half of estimated project costs to achieving objectives aimed at addressing obesity and preventing NCDs. It must be noted that, for many of the projects, cost breakdowns were only available by component, rather than by subcomponent. Thus, for projects with obesity/NCD objectives embedded in subcomponents, percentages calculated are likely an overestimation of funds allocated to obesity/NCD-related activities. A summary of financing trends can be found in Table 4. Table 4. Financing Trends across Completed HNP Financing Projects with Objectives to Address Obesity and Prevent NCDs Financing instrument N % SIL 10 58.9 IPF 3 17.6 APL 3 17.6 SIM 1 5.9 Total loan amount* <$50M 9 53.0 $50–$99M 3 17.6 $100–$149M 2 11.8 $150–$199M 0 0 >$200M 3 17.6 % Cost at appraisal allocated to obesity goals** 0–24.99% 10 62.5 25–49.99% 3 18.8 50–74.99% 0 0 75–100% 3 18.8 Source: Authors’ own contribution. Notes: HNP = Health, Nutrition, and Population; NCDs = Noncommunicable diseases. *As stated on front page of the Project Appraisal Document (PAD) as Total Loan Amount. **Calculated from costs of obesity components/subcomponents out of total project cost at project appraisal from PAD and/or Implementation Completion and Results Report (ICR). No data available for P074841. Thematic Trends Project Theme Codes Project theme codes reflect multifaceted focus of completed projects with objectives to address obesity and prevent NCDs. While NCDs were a common theme code found across projects (N = 9), they captured an average of 30 percent of project thematic focus across completed projects. Instead, a broader focus on health system performance/health system strengthening was predominant. Several projects with objectives to address 24 obesity and prevent NCDs also sought to address other issues relevant to PHC, such as communicable diseases, Indigenous health, child health and nutrition, and food security, to name a few. A full summary of project themes and average relative focus is included in Table 5. Table 5. Number of Projects with and Percentage Focus on Theme Codes across Completed HNP Projects with Objectives to Address Obesity and Prevent NCDs Investment theme # of Average % project projects focus on theme code Health system performance | Health system 12 49.0 strengthening NCDs | Injuries & NCDs 9 30.0 Other communicable diseases 4 15.3 Indigenous peoples 3 17.3 Child health 3 14.0 Nutrition and food security 2 18.5 Population and reproductive health 2 21.0 Rural services and infrastructure 1 33.0 Other accountability and anti-corruption 1 25.0 HIV/AIDs 1 6.0 Tuberculosis (TB) 1 4.0 Public expenditure, financial management and 1 3.0 procurement Conflict prevention & post conflict reconstruction 1 n.a. Law reform 1 n.a. Source: Authors’ own contribution. Notes: HNP = Health, Nutrition, and Population; NCDs = Noncommunicable diseases; HIV/AIDS = Human Immunodeficiency virus/Acquired immune deficiency syndrome; n.a. = Not Available Epidemiological Trends Obesity Morbidity At the time of each respective project approval, adult obesity (body mass index [BMI ≥ 30) prevalence varied significantly across project countries (see Figure 6). Obesity prevalence was highest among the two Pacific Island countries of Samoa and Tonga, at 42.2 percent and 39.1 percent, respectively. Conversely, several countries in South Asia (SA) with projects approved in the same decade faced a much lower relative burden of obesity, with 1.8 percent and 2.0 percent prevalence in Bangladesh and India, respectively. It should be noted, however, that obesity prevalence at a cutoff of BMI ≥ 30 may not adequately reflect the health risks of obesity in Asia-Pacific countries, as the proportion of people with a high risk for obesity-associated NCDs, including type II diabetes and cardiovascular disease, has been found to be substantial at lower BMI in Asian countries than observed among European populations (WHO Expert Consultation 2004). Obesity prevalence among countries in LAC ranged from 16.4 percent in Brazil to 25.3 percent in Argentina, with a similar range across project countries in ECA. By income bracket, average obesity prevalence was significantly higher in HICs (18.8 percent) and UMICs (24.1 percent) at the time of project approval than in LMICs (2.5 percent). 25 Figure 6. Prevalence of Adult Obesity (Age-Standardized, 18+ Years, Percent) at FY Approval for Countries with Completed HNP Financing Projects Addressing Obesity Source: WHO, Global Health Observatory. Notes: FY = Fiscal year; HNP = Health, Nutrition, and Population. Obesity Mortality The burden of mortality from obesity at project approval followed a similar trend as overall prevalence (see Figure 7), with Tonga and Samoa having the highest share of deaths— 16.6 percent and 17.7 percent, respectively. Across the countries in ECA, the share of mortality attributable to obesity ranged only slightly, from 12.9 percent to 15.1 percent, with an average of 14.1 percent. For the countries in Latin America and the Caribbean, average obesity-related mortality was slightly lower, at 10.7 percent. Again, obesity mortality was significantly higher among HICs (13.4 percent) and UMICs (13.1 percent) compared to LMICs (2.0 percent) at project approval. Figure 7. Share of Overall Mortality (Percent) Attributable to Obesity at FY Approval for Countries with Completed HNP Financing Projects Addressing Obesity Source: IHME, Global Burden of Disease. Notes: FY = Fiscal year; HNP = Health, Nutrition, and Population 26 Results in Context: Epidemiological Trends and the World Bank HNP Portfolio on Obesity and NCD Prevention Epidemiological Trends Turning to the regional level and consideration of the entire HNP portfolio on NCDs, the first trend of note is that, over the period of this analysis in which HNP projects addressing obesity and/or preventing NCDs were identified (i.e., 1986–2020), obesity became a more salient challenge across all World Bank regions. Such a trend can be observed in the regional trends of average body mass index (BMI), a measure of weight and height used by the WHO to define cutoffs for overweight (e.g., BMI > 25) and obesity (e.g., BMI > 30). As shown in Table 6, average BMI for both males and females increased for all regions over the three decades considered, with particularly concerning increases observed in LAC and MENA, as well as among females in SSA and SA and males in EAP. Table 6. Epidemiological Trends in Mean Body Mass Index by Gender and Region, 1986–2016 SSA LAC EAP SA ECA MENA Avg BMI (Males) 22.3 26.2 23.2 21.6 26.5 26.2 Avg BMI (Females) 23.6 26.9 23.3 21.7 27.0 27.9 BMI Rate of Change (Males) (%) 6.53 9.24 8.60 7.27 6.41 8.97 BMI Rate of Change (Females) 1986-2016 (%) 9.34 10.36 6.93 8.97 2.66 10.20 Source: NCD-RisC, https://ourworldindata.org/obesity. Notes: SSA = Sub-Saharan Africa; LAC = Latin America and the Caribbean; EAP = East Asia and the Pacific. While the burden of overweight and obesity increased across all four regions, response to address this issue through HNP projects has been uneven at the regional level. This trend can be observed in Figure 8, which summarizes the regional trends in average BMI alongside the number of HNP projects that aimed to address obesity and/or prevent NCDs by region over the same time period (Note: data for mean BMI was only available through 2016). Most notable from this figure is the dearth of projects in MENA relative to other regions with similar absolute and relative epidemiological trends in the burden of overweight and obesity, such as LAC and ECA, over the same time period. There is also a notably low number of projects identified in SSA, despite concerning rises in overweight and obesity over the time period considered, particularly among females. 27 Figure 8. Regional Trends in Average Body Mass Index and Number of HNP Obesity/NCD Prevention Projects by World Bank Region, 1986– 2020. Source: NCD-RisC, https://ourworldindata.org/obesity. Notes: BMI = Body Mass Index; HNP = Health, Nutrition, and Population; NCD = Noncommunicable disease. Regional average BMI data only available until 2016; BMI cutoff for overweight is >25 kilograms/square meters (kg/m2) for all regions except East Asia and the Pacific and South Asia, where it is 23 kg/m2 (WHO Expert Consultation 2004). 28 PROJECT OBJECTIVES FOR ADDRESSING OBESITY AND PREVENTING NCDS Overview Objectives aimed at tackling obesity and NCDs across completed projects aligned with key dimensions of a PHC approach. Namely, of the 17 total projects, 13 included objectives to establish or improve systems of integrated care, 9 included objectives to empower people and communities, 4 included objectives to promote multisectoral policy and action for NCD prevention, and 3 included objectives to improve overall morbidity or mortality associated with NCDs. Several projects included objectives that spanned across more than one pillar of a PHC approach. Namely, objectives focused on strengthening integrated health services and empowering people and communities through health promotion were most often identified in tandem, as eight projects carried a focus on reorienting the health sector and/or health care service delivery to carry a greater focus on health promotion. Ten projects encompassed obesity objectives in the PDO, while the remaining seven projects included objectives to address obesity and prevent NCDs in the project component(s) section of the project PAD. Project PDOs that pertained to obesity and NCDs focused first and foremost on integrated health services and overall objectives to improve morbidity and mortality outcomes pertaining to NCDs. Meanwhile, objectives identified in project components carried a greater emphasis on empowering people and communities to address NCD risk factors and on improving multisectoral policy and action for NCDs. For a full summary of objectives to address obesity and prevent NCDs and their classification for each of the 17 projects, see Annex 6. Objective Trends by Category Integrated Health Services Objectives in this category focused on two PHC dimensions for addressing obesity and associated NCDs: (1) essential public health functions, and (2) primary care service delivery. Objectives focused on improving essential public health functions sought primarily to build capacity at the national Ministry of Health to design and implement NCD prevention programs, such as population-based screening, and to improve national surveillance and information system management for NCDs and their associated risk factors. Objectives focused on primary care service delivery centered around two types of services for NCD prevention and control: (1) early detection and management of NCDs and risk factors in primary care practice, and (2) healthy lifestyle counseling/behavior change promotion services. Only two projects encompassed PHC objectives that aimed to strengthen both public health functions and primary care service delivery: The Noncommunicable Disease Prevention Project in Uruguay and the Tamil Nadu Health Systems Project in India. Empowered People and Communities Empowering people and communities through national and community-based health promotion initiatives was another common goal across projects. One of the primary themes that emerged across goals within this category was the centrality of community- 29 based policies and programs. Almost half of project objectives identified within this category explicitly mentioned a focus on community-level/community-driven health promotion. That said, these objectives were generally not the principle focus of projects, as they were more often embedded in project components and/or subcomponents rather than project PDOs. Multisectoral Policy and Action Several objectives sought to develop national policies and/or strategies to address modifiable risk factors of NCDs. However, this was a small focus across project objectives and the extent to which multiple sectors were involved in the activities undertaken to achieve these goals was not identified as an explicit focus in project objectives. In addition, none of these objectives were reflected in project PDOs. General NCD Prevention and Management Only a handful of projects contained objectives focused on improving overall outcomes related to NCD morbidity and mortality or supporting the country partner governments to address new challenges related to the epidemiological transition. These objectives were generally proposed as PDO objectives that were then expanded upon in project components and/or subcomponents. For examples of objectives encompassed under each category and alignment with core values of PHC, see Table 7. Table 7. Classification of Objectives to Address Obesity and Prevent NCDs from Completed HNP Financing Projects and Alignment to Core Tenets of PHC Objectives to Address Obesity and Prevent NCDs in Completed HNP Projects through a PHC Approach Integrated health services (N = 13) Essential public health functions • Strengthen the capacity of Uruguay’s public health system in the screening and control of prevalent NCDs and their risk factors—that is, hypertension, cardiovascular disease, obesity, overweight, diabetes, and selected preventable cancers. • Upgrade the standards of performance of the public health system and enable it to better respond to the challenges of malnutrition and noncommunicable diseases. • Reengineer the MSN to improve management of NCDs and priority public health programs (PPHPs). • Contribute to improving the health status of the Hungarian population by supporting public health programs aimed at reducing risk factors contributing to the high prevalence of noncommunicable diseases. • Strengthen the nascent noncommunicable disease and risk factor surveillance system. • Develop information management for NCD prevention and control. • Develop capacity for surveillance of noncommunicable diseases and related risk factors. • Pilot new interventions to address emerging health challenges (such as NCDs and associated behavioral risk factors). Primary care service delivery • Expand accessibility and quality of primary health care services related to selected noncommunicable diseases early detection and medical care. • Reorient health services to promote healthy lifestyles emphasizing health promotion and disease-prevention programs. • Scale up the family medicine program and support the MoH in implementing preventive health care services for the control of communicable and noncommunicable diseases. 30 • Restructure primary health care to address sectoral inefficiencies and ready the sector to deal in a cost-effective manner with core health issues, such as the growing burden of NCDs. • Support the prevention of noncommunicable diseases through behavior change promotion and screening. Empowered people and communities (N = 9) • Promote community-driven local development in health through grants provided to Indigenous communities. • Promote innovation in health promotion to reduce risk factors through two pilots in Misiones and Tucuman Provinces and various small subprojects related to health promotion. • Reduce selected noncommunicable disease risk factors by promoting tobacco and alcohol control, and diet and physical activity in selected beneficiaries (preschool children, school children, teachers, health workers, and local government employees) in four selected local communities. • Support annual funding of health promotion programs in support of local initiatives. • Improve health status through a series of targeted investments in health promotion and disease prevention activities. • Develop and implement health promotion strategies including, inter alia, provision of subgrants to support the implementation of health promotion activities consistent with priorities set out in the program. Multisectoral policy and action (N = 4) • Promote innovations in health promotion to reduce risk factors through prevention and research to be implemented by selected NGOs, academic institutions, and/or municipalities. • Develop an NCD Strategy for Sri Lanka, compile an NCD database, and develop recommendations on food and tobacco policy. • Develop effective ways to reduce NCDs and road traffic accidents, undertake pilots, and evaluate their impact to inform state policy and future NCD programs. • Support the development of policies and strategies for emerging challenges, with a focus on prevention and control of major NCDs. General NCD prevention and management (N = 3) • Address new challenges raised by the epidemiological transition and the increasing importance of noncommunicable diseases of adults. • Improve overall results for noncommunicable diseases, as measured by proxy indicators. • Reduce mortality and morbidity from communicable and noncommunicable disease and exposure to risk factors associated with ill health. Source: Authors’ own contribution. Notes: NCDs = Noncommunicable diseases; HNP = Health, Nutrition, and Population; PHC = Primary health care; MSN = Ministerio de Salud Provincial (Provincial Ministry of Health); MOH = Ministry of Health. PROJECT ACTIVITIES FOR ADDRESSING OBESITY AND PREVENTING NCDS Overview To achieve the objectives detailed in the previous section, projects invested first and foremost in three overarching domains for PHC system improvement: (1) governance and leadership; (2) adjustment to population health needs; and (3) population health management. Regarding the first domain of governance and leadership, 13 project activities included improving policy frameworks and institutional capacity for tackling NCDs, establishing infrastructure for improving quality management of health services for NCDs, and/or strengthening citizen engagement and multisectoral collaboration for action on NCDs. The second-most common area of activities aimed at improving the capacity of 31 the health system to meet the growing burden of NCDs, included 11 projects investing in NCD surveillance capabilities, use of data in decision-making processes, and/or the implementation and evaluation of innovative pilot programs for the delivery of health promotion and preventive services at the primary care level. Finally, 10 projects included activities to improve population health management of NCDs, including through improvements in community-based health promotion activities for enhanced outreach, community engagement opportunities, and priority setting for NCD activities among subnational health jurisdictions. The following sections provide greater detail on activities completed across projects for addressing obesity and preventing NCDs by investing in PHC systems, inputs, and service delivery. Activities by PHC Domain: Systems Governance and Leadership Project support to PHC governance and leadership can be further categorized into three domains of activities: (1) PHC policies, (2) Quality management infrastructure, and (3) Social accountability. • PHC policies (11 projects). Investment in PHC policies encompassed four general areas of activities: (1) adoption of national plans/strategies for NCDs, (2) enactment of public health policies for NCD prevention, (3) institutional capacity building for health promotion, and (4) national communication campaigns for health promotion. Completed projects in Bangladesh, Brazil, and Uruguay supported the development of national action plans to coordinate action for NCD prevention and management. Three projects introduced regulatory policies for mitigating NCD risk factor prevalence in particular settings, including a sodium reduction law in Argentina, trans fat regulation in Uruguay, and policies for healthy food consumption in schools in both Turkey and Uruguay. In addition, project funds were used in Hungary to support the development of a voluntary front-of-package nutrition label—the Heart Healthy logo—as well as to work with food manufacturers to promote the adoption of the label. Other activities encompassed under this domain pertain to building institutional capacity to carry out policies for NCD prevention. Namely, two projects sought to improve national capacity for health promotion, including the development of a national health promotion unit at the Ministry of Health in Croatia and the development of a national health promotion program in Samoa. Finally, support to national media campaigns to improve knowledge and awareness on NCD risk factors were common across projects, and were identified in six projects overall. • Quality management infrastructure (6 projects). Activities in this domain sought primarily to improve the quality of clinical services for NCD early detection and management. For example, projects in Argentina, India, and Uruguay supported the development of quality standards and certification/accreditation programs for NCD service delivery in primary care centers. In the case of Samoa, the project supported the development of clinical guidelines and protocols for NCD management in primary care. Additional activities for quality management sought to encourage accountability for high-quality health promotion activities, such as 32 through the introduction of criteria for certification as a “health responsible municipality” in Argentina. • Social accountability (7 projects). Project activities in this domain include those aimed at promoting both higher citizen engagement and cross-sectoral collaboration for NCD prevention. To encourage higher citizen engagement, projects in Brazil, Hungary, Bosnia and Herzegovina, and Uruguay established health promotion networks to strengthen linkages and knowledge sharing between community-based civil society organizations. Several projects also supported the development of more formal multisectoral partnerships, namely between the Ministries of health, education, and labor, to implement school- and workplace- based health promotion programs. Health Financing Project activities aimed at improving health financing for obesity and NCD prevention focused on two domains: (1) Payment systems, and (2) Spending on PHC. • Payment systems (3 projects). Projects in Bosnia and Herzegovina (BiH), China, and Uruguay introduced novel provider payment systems, namely performance- based/results-based financing models, to align PHC provider payment with the delivery of NCD preventive services. For both BiH and Uruguay, this system was introduced as a subnational pilot, which was subsequently scaled up nationwide in the case of Uruguay. • Spending on PHC (2 projects). Two projects supported increased spending in PHC relevant to addressing obesity and preventing NCDs, including increases in earmarked funds for health promotion in Hungary and the strengthening of National Health Accounts (NHAs) in Tonga to both analyze and subsequently increase budget allocation to PHC preventive services for NCDs. Adjustment to Population Health Needs Activities that support the capacity of PHC systems to adjust to population health needs fall into three domains: (1) Surveillance, (2) Priority setting, and (3) Innovation and learning. • Surveillance (9 projects). Activities in this domain focused first and foremost on the completion of national and/or subnational NCD risk factor surveys to assess the prevalence of behavioral and metabolic risk factors for NCDs. Three projects encompassed more comprehensive activities in this domain, including the introduction of national NCD risk factor surveillance systems in Brazil and Uruguay and the establishment of a childhood obesity surveillance system in Turkey. • Priority setting (3 projects). Three projects encompassed activities to strengthen the use of data in decision-making and setting of priorities for NCD policies and program planning. For instance, national NCD risk factor surveillance systems developed in both Brazil and Uruguay were integrated into the development of national and subnational plans to reduce NCD risk factor prevalence. In the case of Latvia, NCD risk factor surveys and capacity-building of routine statistics 33 pertaining to NCD service delivery were integrated into the design of health promotion interventions at the national level. • Innovation and Learning (7 projects). Projects supported two general types of activities to improve innovation and learning capacity: (1) Introduction of knowledge sharing platforms on NCDs, and (2) Implementation and evaluation of innovative NCD pilot activities. In both China and Hungary, knowledge-sharing platforms were developed across local jurisdictions implementing health promotion activities to share best practices and lessons learned, as well as encourage increased adoption of evidence-based interventions at local levels. Additionally, in Brazil, a national program was implemented to conduct implementation research on the effectiveness of local physical activity interventions and to share results across local jurisdictions. Projects in Argentina, BiH, India, and Uruguay introduced and evaluated pilot programs to improve key functions for NCD prevention and management, such as financing, delivery of community-based health promotion, and/or strengthening of NCD preventive services. In the case of both India and Uruguay, evaluations of NCD pilots were leveraged in the scaling up of project pilots to the state and national levels. Activities by PHC Domain: Inputs Project activities to improve PHC system inputs can be categorized into four overarching domains: (1) Drugs and supplies, (2) Facility infrastructure, (3) Workforce, and (4) Information systems. • Drugs and supplies (3 projects). While not a predominant focus, projects in India, Sri Lanka, and Uruguay encompassed activities to improve the availability of essential NCD drugs and equipment to improve screening and case management of NCDs in PHC facilities. • Facility infrastructure (4 projects). Three projects invested in physical facility infrastructure to establish counseling centers for NCD prevention and management in primary care centers, including “Healthy Lifestyle Centers (HLCs)” in India and Sri Lanka and obesity counseling units in Turkey. • Workforce (7 projects). Investments in PHC workforce primarily pertained to the establishment and delivery of PHC provider training programs on effective NCD service delivery. For projects in India, BiH, Sri Lanka, Tonga, and Turkey, workforce training focused specifically on expanding qualifications for NCD service delivery among the nonphysician health care workforce (NPHW), including nurses and community health workers. Training topics identified across projects include NCD screening, counseling, and case management. • Information systems (4 projects). Projects in both Brazil and Turkey included activities to strengthen the Civil Registration and Vital Statistics (CRVS) system to improve available information on causes of mortality. In addition, projects in BiH and Uruguay encompassed key activities to establish a unified Electronic Medical Record (EMR) to improve the collection and utilization of patient clinical information. 34 Activities by PHC Domain: Service Delivery Population Health Management Project activities for improving NCD service delivery focused on three domains of population health management: (1) Proactive population outreach, (2) Community engagement, and (3) Local priority setting. • Proactive population outreach (8 projects). These project activities aimed to improve the prevention and management of NCDs outside of health care settings, such as through the implementation of health promotion programs in schools and workplaces for improving diets and physical activity (BiH, Hungary, India, Uruguay); expansion of population-based NCD screening and counseling programs in community settings (Samoa, Tonga); and implementation of community-based health education groups and workshops for NCD prevention (Argentina, China, India). Activities for health communication encompassed under outreach differ from those discussed under PHC policies due to an explicit focus on implementation at the community level and/or in partnership with local civil society organizations and community members. • Community engagement (4 projects). These activities fall into two categories: (1) Establishment of platforms for community member participation and decision making, and (2) Financial support for community-led health promotion initiatives. The former pertains to the establishment of intersectoral community working groups on NCDs in Argentina, while the latter refers to the introduction of community grants to fund community-led health promotion interventions in BiH, Brazil, and Estonia. • Local priority setting (3 projects). Activities to promote local priority setting pertain to the establishment of “healthy settings” approaches, namely the Healthy Municipalities, Cities and Communities (HMCCs) model in Argentina and Uruguay and the “Healthy Village” approach in China. These movements promote the role of local government in promoting health through activities such as improvements to the built environment, adoption of local public health policies for NCD prevention, and strengthening of community health services. In the case of both Argentina and Uruguay, projects activities supported the creation of agreements between national and subnational health departments to enact actions for local health promotion. For a summary of project activities by PHCPI domain identified, see Table 8. For a full breakdown of project activities for each project by PHCPI domain, see Annex 7. 35 Table 8. Summary of Project Activities for Addressing Obesity and Preventing NCDs PHCPI domain # of Summary of project activities by PHC domain projects Systems Governance and leadership (N = 13) PHC policies 11 • Adoption of national plans and strategies for addressing NCD risk factors. • Enactment of public health regulatory policies for NCD prevention. • National capacity building for health promotion and preventive service delivery. • National communication campaigns on NCD risk factors. Quality 6 • Creation of accreditation/certification programs for NCD service delivery in PHC Management and/or health promotion activities. Infrastructure • Development of guidelines for NCD services in PHC. Social 7 • Development of cross-sectoral committees, partnerships, and programs for NCD Accountability action. • Strengthening of national networks for health promotion advocacy. Health financing (N = 5) Payment 3 • Introduction/expansion of financing models (performance/results-based) to improve Systems the delivery of NCD services in PHC. Spending on 2 • Earmarking of insurance funds for health promotion PHC • Budget monitoring and improving allocation for primary prevention Adjustment to population health needs (N = 11) Surveillance 9 • Establishment of national NCD surveillance systems • National surveys on NCD risk factor prevalence Priority setting 3 • Strengthening the use of data for decision making on NCD policy and programming Innovation and 7 • Establishment of knowledge sharing platforms for local health promotion activities learning • Implementation, evaluation, and scaling up of pilot programs for improving health promotion and preventive service delivery Inputs (N = 8) Drugs and 3 • Provision of necessary drugs and equipment for NCD service delivery in PHC supplies Facility 4 • Establishment of facility infrastructure for NCD early detection, counseling, and infrastructure referral Workforce 7 • Establishment and delivery of training opportunities for PHC providers on NCD prevention • Building capacity of nonphysician health workers (NPHWs) to deliver NCD services in PHC Information 4 • Investments in Civil Registration and Vital Statistics (CRVS) systems • Consolidation of health information system reporting capabilities to national level, including on NCD service delivery • Introduction of electronic medical records Service delivery Population health management (N = 10) Proactive 8 • Community-based behavior change communication campaigns conducted population • Establishment of community, school, and workplace-based health promotion outreach programs • Population-based NCD screening Community 4 • Establishment of community working groups for local action on NCDs engagement • Community grants for community-led health promotion projects Local priority 3 • Engagement of subnational health ministries on health promotion and NCD setting prevention activities through introduction of ‘healthy settings’ approach • Enactment of institutional agreements between national and subnational governments for health promotion • Enactment of local health promotion policies and interventions Source: Authors’ own contribution. Notes: PHCPI = Primary Health Care Performance Initiative; NCD = Noncommunicable disease. 36 PROJECT MEASUREMENT FOR ADDRESSING OBESITY AND PREVENTING NCDS Overview To assess the achievement of project objectives and implementation of project activities, a total of 112 indicators (N = 110) were utilized across the 17 projects to measure improvements in PHC performance. On average, completed projects included ~6.5 indicators to monitor progress on objectives aimed at addressing obesity and preventing NCDs, with as few as 1 indicator (Argentina, Bangladesh, Tonga) and up to 26 indicators (Bosnia and Herzegovina). For all but five projects, measurement of progress on achieving objectives for addressing obesity and preventing NCDs spanned across more than one domain of the PHCPI Conceptual Framework continuum of systems, inputs, service delivery, outputs, and outcomes (see Table 9). That said, only one project—the Noncommunicable Disease Prevention Project in Uruguay—included indicators that spanned across all five domains of the framework to comprehensively assess improvements in PHC performance. Measurement focused first and foremost on improvements to PHC system capabilities for addressing obesity and preventing NCDs, as these indicators were identified in 13 of the 17 projects. This focus was followed by inclusion of indicators measuring progress on investments in PHC inputs and service delivery for addressing obesity and preventing NCDs, which were included in eight and nine projects, respectively. Comparatively, few projects measured improvements in PHC outputs, with just six projects including any measurement of coverage for health promotion, early detection, and/or NCD management services. Finally, three projects included indicators to measure improvements in PHC outcomes, namely improvements in population health pertaining to NCD risk factors. Following the structure of project activities in the section above, the following sections provide greater detail on project measurement trends to monitor progress on addressing obesity and preventing NCDs in completed HNP projects across the continuum of PHC systems, inputs, service delivery, outputs, and outcomes. Table 9. Obesity and NCD Indicators from Completed HNP Projects across the PHCPI Conceptual Framework Domains Region Project PHCPI domain Total Systems Inputs Service Outputs Outcomes delivery Argentina — — 1 — — 1 LAC Brazil 2 3 1 — — 6 Uruguay 4 3 7 3 1 18 BiH 1 8 13 3 2 — 26 BiH 2 — 1 1 3 — 5 Croatia 7 1 — — — 8 ECA Estonia 2 — — — 3 5 Hungary 2 — 1 1 — 4 Latvia 2 — — — — 2 37 Turkey 2 — 4 — — 6 Bangladesh 1 — — — — 1 SA India 3 — 2 2 — 7 Sri Lanka 1 8 1 — — — 9 Sri Lanka 2 — 1 1 1 — 3 China 3 2 — — — 5 EAP Samoa — — — — 3 3 Tonga 1 — — — — 1 Total # of indicators 45 25 21 12 7 110 Total # of projects 13 8 9 6 3 17 Source: Authors’ own contributions. Notes: PHCPI = Primary Health Care Performance Initiative; LAC = Latin America and the Caribbean; ECA = Europe and Central Asia; SA = South Asia; EAP = East Asia and the Pacific; BiH = Bosnia and Herzegovina. Measurement by PHC Domain: Systems Thirteen projects measured improvements in PHC system capabilities for addressing obesity and preventing NCDs, spanning across domains of governance and leadership, health financing, and adjustments to population health needs. Governance and Leadership Nine projects measured improvements in PHC policies and/or national capacity for NCD prevention, four projects measured the implementation of infrastructure to promote high- quality NCD services, and two measured improvements in social accountability for NCDs. Measurement of PHC policies focused on monitoring the adoption of national action plans/strategies, as well as the establishment of national infrastructure for health promotion. Measurement of quality management infrastructure included indicators focused on either the development and dissemination of clinical guidelines for NCD services or monitoring of the number of facilities/teams accredited for the delivery of NCD services at the level of primary care. Finally, indicators focused on the improvement of social accountability monitored the establishment of a health promotion advocacy group and the availability of consumer information on disease prevention and treatment compliance. Health Financing Indicators in this domain measured the implementation of novel provider payment systems and spending on PHC to improve the focus on health promotion detailed in the project activities section. Namely, projects included indicators on the number of performance- based contracts signed with PHC providers and monitored expenditure on health promotion/NCD prevention. Adjustment to Population Health Needs Five projects monitored improvements in NCD surveillance, including the creation and expansion of NCD surveillance systems in the case of Brazil and Uruguay and the implementation of regular NCD risk factor surveys. Only one project monitored the use of data for decision making at the national level, as the Second Disease Surveillance Project in Brazil included an indicator on the use of surveillance data to enact local plans for reducing NCD prevalence. Finally, four projects included indicators to measure innovation and learning capacity, such as those measuring the implementation, evaluation, and scaling up of innovative pilots for NCD service delivery and/or health promotion in PHC. 38 Measurement by PHC Domain: Inputs Eight projects measured improvements in PHC inputs for addressing obesity and preventing NCDs, focusing on improvements in drugs and supplies, physical facility infrastructure, workforce capacity, and information systems. In terms of inputs, projects measured the implementation of workforce training programs along with the quality and coverage of vital statistics. Other salient indicators include measurement of NCD drug availability in primary health care facilities and the construction of facilities for healthy lifestyle counseling. Measurement by PHC Domain: Service Delivery Nine projects measured the delivery of PHC services for addressing obesity and preventing NCDs, which was accomplished either through monitoring the implementation of population health management activities or assessing improvements in the quality of care at the primary care level. Population Health Management Indicators in this domain measured the implementation of population health management activities detailed in the activities section, including the implementation, quality, and coverage of school health promotion programs, funding opportunities for community- based health promotion, and “healthy settings” approaches to improving social and built environments in local jurisdictions. High-Quality Primary Health Care The second category of service delivery indicators included in projects pertains to measurement of service quality for NCD prevention in primary care settings. Namely, six projects sought to measure improvements in the comprehensiveness, continuity, and accessibility or person-centeredness of services for NCD prevention and control. Those indicators related to continuity were primarily concerned with improving follow-up pharmacological treatment and/or lifestyle counseling for those deemed at-risk for the development of NCDs, such as those screened and identified as overweight/obese, hypertensive, and/or diabetic. Several indicators measured whether progress was made on the comprehensiveness of services available to manage NCDs in primary care, such as screening to identify at-risk patients and lifestyle counseling services. In these activities, there was a particular emphasis on the management of obesity comorbidities, while focus on obesity prevention and management in clinical settings was relatively scant. One project in Bosnia and Herzegovina included several indicators to measure the accessibility of PHC as the first contact of care, including “per capita annual visits to family medicine physicians’ and share of family medicine visits out of total health care visits.” Finally, two projects included indicators to measure the perceived quality of NCD services through metrics of patient satisfaction. Measurement by PHC Domain: Outputs Six projects measured improvements in effective service coverage for the early detection and management of NCDs and health promotion. Measurement of NCD service coverage emphasized the management of obesity comorbidities, namely hypertension and diabetes control, and included indicators to assess progress in population screened and treated for these conditions. Measurement of health promotion coverage focused on assessing changes in knowledge, attitudes, and behaviors for NCD risk factors, including physical activity and nutrition. 39 Measurement by PHC Domain: Outcomes Finally, though not common across completed projects, a handful of projects aimed to measure progress on improving overall health outcomes related to obesity and associated NCDs. Only one project monitored and evaluated the change in overweight and obesity prevalence over the course of the project. Other relevant outcomes measured included dimensions of dietary intake, physical activity, and CVD and diabetes mortality. For a full summary of the results of indicator mapping across the PHCPI Conceptual Framework, including indicators utilized to measure progress for each critical component of PHC in completed projects, see Annex 8. PROJECT SUCCESSES FOR ADDRESSING OBESITY AND PREVENTING NCDS Overview Ten projects contained at least five indicators to monitor progress on objectives to address obesity and prevent NCDs and were included in the scoring exercise to evaluate project success both across PHC domains and for the overall project. Projects were most successful in achieving objectives related to improving PHC systems capabilities to address obesity and prevent NCDs, followed by PHC service delivery and PHC inputs (see Figure 9). Comparatively, successful improvements in PHC outputs (effective service coverage) and outcomes (improvements in health status) were less consistent. The following section details project successes along the continuum of systems, inputs, service delivery, outputs, and outcomes. 40 Figure 9. Percentage of Projects with Successful, Partially Successful, and Unsuccessful Objectives to Address Obesity and Prevent NCDs by PHC Domain Source: Authors’ own contribution. Notes: NCDs = Noncommunicable diseases; PHC = Primary health care. Project Successes by PHC Domain Systems Eight projects that were scored invested in improving PHC systems. For seven of those projects, activities were predominantly successful. Successful activities improved national capacity for both essential public health functions and primary care service delivery and pertained to critical components of PHC governance and leadership, health financing, and adjustments to population health needs. Key successes in PHC governance and leadership include the adoption of national action plans for NCD prevention and health promotion (N = 2), establishment of a public health institution/unit responsible for health promotion activities (N = 2), creation of nutrition guidelines (N = 1), and creation/dissemination of guidelines and protocols for NCD service delivery in primary care (N = 2). Successful health financing activities include increasing the number of PHC providers under performance-based financing contracts (N = 2) and increased spending for health promotion activities (N = 1). Finally, successful activities for adjusting to population health needs include improvements to monitoring and surveillance systems of NCD risk factors (N = 2), implementation and evaluation of a pilot clinic-based NCD prevention program (N = 2), and scale-up of pilot programs (N = 2). Certain activities were not consistently successful across all projects. Namely, the implementation of national policies for NCD prevention and management, dissemination of clinical guidelines, improvement of NCD surveillance, and implementation and scale-up of pilot NCD programs were also found to be partially or completely unsuccessful. These unsuccessful 41 activities were primarily drawn from one project: the Sri Lanka Health Services Project (P010526). Inputs Successful activities for improving PHC inputs across five projects include community health center renovation (N = 1), improvements to vital statistics coverage and accuracy (N = 1), and training for NCD service delivery in primary care (N = 2). Service Delivery Eight projects sought to improve PHC service delivery for addressing obesity and preventing NCDs, with a particular focus on population health management. Activities in this domain were predominantly successful for five projects, partially successful in one project, and unsuccessful in two projects. Successful activities for population health management include increasing the percentage of the population empaneled (N = 2), increasing the number of subnational jurisdictions implementing “healthy municipality/healthy village” strategies (N = 2), and implementing health promotion activities in schools (N = 2). Projects also sought to improve the quality of care and were successful in increasing the availability of NCD preventive services (N = 1), improving patient follow-up among those diagnosed with NCD risk factors in primary care (N = 2), and increasing patient satisfaction with the quality of services delivered (N = 2). Outputs Four projects sought to improve and measure changes in effective service coverage for obesity and associated NCDs. Ultimately, two were successful, one was partially successful, and one was unsuccessful based on achievement of project performance indicators. Project success included improving overall coverage of team-based care (N = 1) and improving screening for NCD risk factors (N = 2). Improving the percentage of patients screened that receive treatment was partially successful in India, while improving awareness of NCD risk factors among both health and education workers in Bosnia and Herzegovina was ultimately unsuccessful. Outcomes Only two projects, one in Uruguay and one in Estonia, sought to realize improvements in overall outcomes for obesity and NCD prevention, with varied results. While both projects sought to improve overall mortality outcomes for cardiovascular disease, the project in Uruguay achieved this goal while the one in Estonia did not. However, both projects noted that observed changes in overall CVD mortality could not be attributed to project activities alone. Other outcomes assessed included improving population daily salt and fat intake in Estonia, which were not achieved. Total Project Success Project success scores across PHC domains were used to calculate an overall success score (0 < K < 3) for each of the 10 projects. Ultimately, six projects were found to be successful (K > 2), three were partially successful (1 < K < 2), and one was unsuccessful (K < 1) in achieving objectives to address obesity and prevent NCDs. The following section delves specifically into the six successful projects to identify key lessons and “PHC improvement strategies” for addressing obesity and preventing NCDs. For a full summary of success scores across PHC domains and overall, for each project assessed, see Table 10. 42 Table 10. Success Scores for Each PHCPI Domain and for the Overall Project for Ten Projects with Five+ Indicators to Address Obesity and Prevent NCDs in the Project Results Framework PHCPI domain PHCPI subdomains Overall Project name (# of indicators) represented and success project ratings success score L Surveillance A Brazil Second Systems (2) Priority setting Success C Disease Inputs (3) Information systems (K = 2.5) Surveillance Service delivery (1) Community engagement Project – VIGISUS II PHC policies Systems (4) Quality management Infrastructure Social accountability Uruguay Payment systems Noncommunicabl Information systems Success e (NCD) Disease Inputs (3) Workforce (K = 2.4) Prevention Local priority setting Project Service delivery (7) Empanelment Proactive population outreach Continuity Outputs (3) Effective coverage: NCDs and mental health Outcomes (1) Health status E PHC policies C Systems (7) Quality management A infrastructure Bosnia and Payment systems Herzegovina Innovation and learning Health Sector Facility infrastructure Success Enhancement Inputs (13) Information systems (K = 2.5) Project Workforce Service delivery (4) Empanelment Comprehensiveness Outputs (1) Effective service coverage: Disease prevention Inputs (1) Workforce Bosnia and Partial Herzegovina Service delivery (1) Proactive population outreach Success Reducing Health (K = 1.2) Risk Factors Outputs (3) Effective coverage: Health Project promotion PHC policies Quality management Croatia Health Systems (6) infrastructure System Project Social accountability Success Surveillance (K = 3) 43 Inputs (1) Workforce Service delivery (1) Person-centered Systems (2) PHC policies Estonia Health Spending on PHC Partial Project Outcomes (3) Health status Success (K = 1.8) Turkey Project in Systems (2) PHC policies Support of First contact accessibility Partial Restructuring the Service delivery (4) Success Health Sector Person-centered (K = 1.5) S Systems (3) Innovation and learning A India Tamil Nadu Proactive population outreach Health Systems Service delivery (2) Person-centered Success Project Outputs (2) Effective service coverage: (K = 3.0) NCDs and mental health PHC policies Sri Lanka Health Quality management Services Project Systems (8) infrastructure Unsuccessful Surveillance (K = 0.22) Innovation and learning Service delivery (1) Empanelment E China Rural Systems (3) Innovation and learning Success A Health Project Service delivery (3) Local priority setting (K = 3.0) P Continuity Source: Authors’ own contribution. Notes: PHCPI = Primary Health Care Performance Initiative; NCDs = Noncommunicable diseases. PHC IMPROVEMENT STRATEGIES AND LESSONS LEARNED FOR ADDRESSING OBESITY AND PREVENTING NCDS Case Studies—Successful Projects Brazil Second Disease Surveillance and Control Project The VIGISUS II project was the second in a three-phase, US$600 million Adaptable Program Loan (APL) with two primary objectives: (1) Strengthening public health surveillance, and (2) Supporting disease prevention and control for Indigenous populations in Brazil. The first phase—VIGISUS I—focused on national disease surveillance for communicable diseases and successfully contributed to a national reduction in the incidence of malaria, rabies, vaccine-preventable diseases, leprosy, and cholera. VIGISUS II sought to build on this success by expanding the surveillance system to include NCDs, and environmental and behavioral risk factors of disease, injuries, and maternal/child health. Government commitment to the project objectives were very strong, driven in part by the evidence of improved health outcomes for infectious diseases that were realized from previous investments in the surveillance system. VIGISUS II expanded national surveillance activities to monitor NCD behavioral risk factors (health knowledge, attitudes, and behaviors); health outcomes (cause-specific mortality); and health system capacity and response. This NCD surveillance system, accompanied by significant improvements in the coverage and quality of vital statistics, was crucial for building national capacity to conduct health situation analyses, an important 44 component for strategic planning and adjustment to population health needs at the national level. VIGISUS II also successfully supported the decentralization of health surveillance financial resources, introducing performance-based incentives and targets (agreed upon between federal, state, and municipal governments) for the implementation of health surveillance activities by municipal health secretariats. By project completion, the decentralization of health surveillance was reported to have increased the flexibility of municipal health secretariats to monitor local health needs and introduce measures for promotion and health risk reduction accordingly. In addition, VIGISUS II strengthened the respective roles and responsibilities for health surveillance across federal, state, and municipal levels. Specifically, while municipal governments carried out health surveillance activities, states coordinated and supervised and the federal government integrated data into strategic policy and planning decisions. Finally, the creation and expansion of the Secretariat for Health Surveillance (SVS), an entity that integrated surveillance and health information systems with programs necessary to prevent and control diseases at the Ministry of Health, represented a key success of VIGISUS II. By project completion, SVS, in partnership with state and municipal managers, gathered data on NCDs, analyzed the health situation, and disseminated the results to relevant stakeholders. SVS also developed key capacities for national health promotion, including the financing of over 500 federal entities through the Healthy Cities network, the consolidation of a National Network for Health Promotion, oversight of a national school-based health promotion program, and multiple health education campaigns on NCD risk factor prevention. In the project ICR, the creation of SVS was highlighted as a predominant success of the VIGISUS II project and as a key dimension for ensuring project sustainability, as it has now been institutionalized into Brazil’s Ministry of Health. PHC Improvement Strategy for Addressing Obesity and Preventing NCDs— Surveillance Integrating Surveillance, Health Information Systems, and Health Promotion Policies and Programs NCD surveillance—the ongoing systematic collection of information on a country’s NCD burden—is vital to achieving strategic policy and program development and building overall country capacity to prevent NCDs. Despite growing NCD disease burden, NCD surveillance has historically been underprioritized in LMIC contexts. The results from the most recent WHO global Country Capacity Survey indicate that over 40 percent of low- income and lower-middle-income countries monitored fewer than half of NCD risk factors (0–4 out of 9 total) between 2012–2017 (WHO 2018a). Furthermore, surveillance mechanisms on NCDs and associated risk factors are often not integrated into national health information systems, limiting the sustainability of data collection. Sustainable NCD surveillance systems must be integrated into national health information systems and supported by adequate financial resources to ensure sustainability. NCD surveillance must incorporate three key dimensions: (1) exposure to risk factors of NCDs, such as diet and physical inactivity; (2) prevalence and distribution of morbidity and disease-specific mortality outcomes; and (3) assessment of health system capacity and response for NCD prevention (WHO 2012). Finally, data collected 45 from national and subnational surveillance systems must be utilized to conduct health situation analyses and be integrated into policy design and implementation. Learning from the case of the VIGISUS II project in Brazil, surveillance activities were expanded to monitor NCD behavioral risk factors (health knowledge, attitudes, and behaviors); health outcomes (cause-specific mortality); and health system capacity and response, a multipronged approach that is aligned with the WHO’s framework for national NCD surveillance. In addition, the creation of the SVS was a key successful approach to bridging data and decision making. The SVS integrated NCD surveillance, health information systems, and health promotion programming under a single entity, which was institutionalized and backed by strong government commitment. Apart from strengthening information systems and surveillance capacity, VIGISUS II focused on improving the health of vulnerable communities, with a focus on Indigenous health. Specifically, the project supported community-driven health promotion projects through the Fund for Indigenous Community Initiatives (FUNCOMIN). Grants were provided to Indigenous communities and used to support a range of community-based health promotion activities, including community kitchens, promotion of traditional health practices, fruit tree groves, vegetable gardens, and women’s support and mutual help groups. This grant program was found to be successful based on community feedback, as 85 percent of grant beneficiaries reported meeting their health promotion objectives, and 100 percent reported that the health promotion projects contributed to improvements in community health. PHC Improvement Strategy for Addressing Obesity and Preventing NCDs— Community Engagement Fostering Sustainability of Community-Based Health Promotion Programs Community-based programs for health promotion and obesity prevention are designed to reach people outside of traditional health care settings. They can encompass a range of activities to promote health, from education to improve risk behaviors to local policy change, and are often delivered across a range of settings (schools, workplaces, community-wide initiatives, etc.). Historically, evidence of the effectiveness of community-based health promotion programs has been mixed, as several evaluations of large-scale, community-based programs have found only modest changes to population behavior (Merzel and D’Afflitti 2003). Program sustainability is a key concern, as significant improvements in obesity prevalence can only be realized with long-term investments in behavior change. Recent literature has identified two critical components for sustainability of community- based health promotion programs. The first emphasizes that policy and environment interventions, such as changes to recreational infrastructure, school wellness policies, and changes to the food environment, are more sustainable than program interventions, such as health education classes or physical activity programs (Ochtera, Siemer, and Levine 2018). The second highlights the central importance of formal community engagement mechanisms, including coalitions, formal committees, funded community coordinators, and diverse community partnerships, for realizing sustainable improvements. 46 The FUNCOMIN experience in the VIGISUS II project drew attention to the association observed between community empowerment in program design and implementation and the sustainability of health promotion programs; however, once the VIGISUS II project ended, funding for health promotion ceased. Future projects must be more proactive to incorporate sustainability considerations into the design and delivery of community- based health promotion activities to adequately realize their potential. Specifically, community engagement mechanisms should be formalized, and interventions aimed at altering policy, and/or environmental factors should be prioritized over health education programs. Uruguay Noncommunicable Diseases Prevention Project The Noncommunicable Diseases Prevention Project (PPENT), approved in 2007 and extended twice through to 2015, was a US$25.3 million Specific Investment Loan (SIL) that encompassed two primary objectives: (1) to expand accessibility and quality of primary health care services related to selected noncommunicable diseases early detection and medical care; and (2) to avoid and reduce exposure to selected NCD risk factors as well as their health effects. The PPENT was the first World Bank lending operation that focused exclusively on NCD prevention, as well as the first to introduce results-based financing to Uruguay, and thus was highly innovative in design. The innovative and comprehensive nature of the project contributed to both project success and critical challenges that offer key lessons for future projects. PPENT was highly successful in advancing Uruguay’s health policy framework to address NCDs. Key actions included implementing the Strategic Plan for Health Promotion, updating National Food Regulation, supporting the Strategic Plan for Prevention and Control of NCDs (2015–2025), and developing a multisectoral health promotion network at the national and departmental levels. In addition, the project introduced key quality management infrastructure to improve the quality of care for NCDs at the primary care level, including the development and implementation of NCD quality standards for the accreditation of PHC facilities. PPENT also culminated in the creation and dissemination of clinical guidelines and protocols for treatment of patients with hypertension, diabetes, and obesity; however, the level of adoption of such materials at the primary care level is not known. This project also supported key dimensions of surveillance and strengthening information systems to address NCDs, including the development of a national surveillance system on NCDs, and initial progress on building an integrated health information system, though these dimensions of the project were not as successful. Finally, PPENT introduced a shift in the incentive structure for the delivery of NCD preventive services in PHC through the introduction of results-based capitation payments. Originally introduced in the form of a pilot, the Previniendo program sought to enhance risk factor prevention and control in three Uruguayan departments for hypertension, diabetes, overweight/obesity, and colon cancer, and was quickly scaled to all 19 departments nationwide. PHC Improvement Strategy for Addressing Obesity and Preventing NCDs— Payment Systems The Previniendo Pilot Experience—Results-Based Financing 47 The Previniendo pilot program, which was scaled nationwide over the course of the project, aimed to improve access to and coverage of NCD risk factor prevention through primary care. Specifically, primary care providers offered a base package of preventive interventions and activities to high-risk populations, which were incentivized financially based on screening outcomes. Services incentivized through Previnendo targeted NCDs with high prevalence in Uruguay, including hypertension, diabetes, obesity, and colon cancer. By project completion, significant improvements in performance, as monitored through changes in the percentage of NCD cases diagnosed and under follow-up by primary care teams, were observed. Namely, cases diagnosed and under follow-up increased by 7.9 percent and 13.7 percent for hypertension and diabetes, respectively, between 2006 and 2014. Even greater improvements were observed for management of obesity in primary care, with an increase of 21.3 percent over the same time period. The Previniendo pilot model was identified as a success in that it supported the provision of training and equipment to providers while aligning financial incentives that supported the implementation of training on NCD prevention into practice. Apart from improving PHC systems capabilities at the national level, PPENT also financed activities to expand health promotion at the community level, including the implementation of the “Healthy Municipalities” approach. PHC Improvement Strategy for Addressing Obesity and Preventing NCDs—Local Priority Setting Healthy Municipalities, Cities and Communities Movement Model The Healthy Municipalities, Cities and Communities (HMCC) movement is a strategy that has been widely adopted across Latin America to promote participatory health promotion at the local level. The HMCC movement emphasizes the role of local jurisdictions in establishing healthy public policies, promoting active community participation, supporting the development of healthy built environments, and reorienting health services toward prevention and promoting healthy lifestyles (Rice et al. 2007). In the case of Uruguay, the Healthy Municipalities project culminated in 63 agreements signed between the National Ministry of Health and local departments to deliver health promotion policies and programs. Activities include the implementation of healthy school strategies, introduction of subnational salt reduction policies, expansion of walking and bike paths, and introduction of “healthy stations” and “outdoor gyms” for people to use free of charge. As HMCC approaches are increasingly adopted across countries with varying political, cultural, and economic contexts, the following best practices have been synthesized as critical elements of an effective approach: (1) Build on existing local initiatives, (2) Garner strong political support to ensure sustainability, (3) Implement a coordinating structure for multisectoral collaboration, (4) Facilitate active community participation through partnerships with nongovernmental organizations (NGOs) and community-based organizations, (5) Ensure leadership continuity, (6) Partner with international agencies for support, (7) Focus on short-term achievements in addition to long-term goals, and (8) Implement monitoring and evaluation metrics to assess progress (Takano, Baum, and Ogawa 2000). The Pan American Health Organization (PAHO) has developed a 48 comprehensive toolkit, drawing on previous implementation experience, that can be used to guide effective design, implementation, and evaluation of HMCC initiatives (Cerqueira and Rice 2001). Ultimately, the feasibility, design, and implementation of an HMCC approach will vary widely across different health system contexts. However, the rapid adoption of this approach and evidence of success, such as those demonstrated in Uruguay, evince the potential for bolstering the role of local governments in addressing the multifaceted social and built environment factors that contribute to the growing burden of obesity. Though PPENT was highly innovative in design and characterized by several successes, challenges encountered in project design and implementation offer key lessons that are applicable across contexts. Project Design and Implementation—Lessons Learned for Addressing Obesity and Preventing NCDs 1. Preventing NCDs requires a multidimensional approach beyond strengthening the role of public health and health services. The PPENT approach for NCD prevention centered primarily on preventive health service delivery. Strategies to foster healthy lifestyles were implemented in schools and at the community level; however, their emphasis and scale were limited. In addition, their sustainability following the project relied primarily on the interest of individuals or municipalities to continue. 2. The extent to which the Ministry of Health can work with other ministries and civil society stakeholders should be an explicit goal of projects aiming to address NCD risk factors. PPENT was characterized by little discussion on synergies with activities led by other relevant stakeholders in addressing NCDs or active focus on multisectoral collaboration. Stakeholders such as the Ministry of Education, the Ministry of Social Development, the Honorary Commission for Cancer and Cardiovascular Diseases, and civil society efforts, such as the NCD Alliance and Diabetes Association, all had a role to play in strengthening community and municipal-level health promotion activities and primary care service delivery; however, the project did not foster connections across these stakeholders. 3. Projects with a strong focus on capacity-building and behavior change need to be more realistic about what can be feasibly achieved within the project lifetime. The project sought to tackle several capacity-building functions for improving quality of care for NCDs, including the creation and dissemination of clinical guidelines and protocols and introduction of results-based financing. The project underestimated the time and resources it would take to bridge these interventions into practice through training providers and monitoring provider performance. In particular, the project underestimated the learning process involved in refining and adjusting measures used to monitor provider performance at the primary care level. Successful behavior change, which is integral to effective NCD 49 prevention, is time- and resource-intensive and must be taken into consideration as such in project design and implementation. 4. Innovative projects such as the PPENT should devote more attention to capturing learning from project implementation. The novel results-based financing structure for the delivery of NCD preventive services in primary care was initially introduced in three municipal health departments in Uruguay and scaled to all 19 departments before the project could show results or systematize the learning from the pilot. This lack of systematized learning representing a missed opportunity to crystallize lessons from project implementation for other contexts. Bosnia and Herzegovina Health Sector Enhancement Program Project The BiH Health Sector Enhancement Project (HESP), approved in 2005 and extended twice with additional financing through to 2014, sought to improve overall results for NCDs across the two entities of Bosnia: the Federation of Bosnia and Herzegovina (FBiH) and Republika Srpska (RS). First and foremost, the project sought to improve the delivery of preventive services for NCDs at the primary care level, primarily by shifting the entire model of primary care from a specialist-based model to a team-based family medicine (FM) model. Key activities included investments in family medicine training programs and health management educational opportunities, improvements to primary care facility infrastructure, a pay-for-performance pilot for NCD preventive services, and introduction of innovative grants for health promotion and primary prevention programs. HESP piloted performance targets in primary care, accompanied by incentives, for the delivery of NCD preventive services among community health care centers of four subnational (cantonal) health systems in FBiH. Indicators were utilized to monitor dimensions of care processes, such as screening, delivery of lifestyle counseling, and pharmacological treatment, and outcomes related to hypertension and diabetes control. A key success of the pilot was the adoption of the reporting system developed by the four pilots as the standard reporting system in FBiH and acceptance of new software among FM teams for analyzing their own performance. In addition, the ICR notes that a final report of pilot implementation indicated significantly greater performance among FM teams receiving payment incentives, though these results were not available among project completion documents. PHC Improvement Strategy for Addressing Obesity and Preventing NCDs—Quality Management Infrastructure Performance Indicators for NCD Prevention and Management Utilized to assess progress across a range of PHC health issues, performance indicators collected in primary care can be leveraged to promote improvements in quality of services delivered through a variety of approaches, including facility-level monitoring, benchmarking across facilities and/or regions, accreditation/certification programs, and alignment of payment incentives for providers linked to performance indicators. As the prevalence of NCDs continues to grow, certain countries have shifted the use of performance indicators in primary care to monitor key dimensions of NCD service 50 delivery. These are primarily used to monitor quality of care for managing obesity comorbidities, including hypertension, diabetes, and dyslipidemia. In the case of Bosnia and Herzegovina, four pilot cantons introduced payments linked to the delivery of core NCD services in performance indicators. This pilot successfully culminated in the systemic implementation of core NCD preventive services in primary care among pilot cantons; however, payment incentives were inconsistently adopted by cantonal health insurance funds, limiting the long-term sustainability of this pilot. In Bosnia, performance indicators have been used first and foremost in the implementation and expansion of a rigorous PHC accreditation program in both entities. Relevant indicators that are regularly monitored at the primary care level include the following: • Patients with documented record of smoking cessation counseling in previous 12 months (%) • Hypertensive patients with documented record of blood pressure BP measured in previous 12 months (%) • Hypertensive patients with documented record of body mass index (BMI) in previous 12 months (%) • Diabetic patients with documented record of body mass index (BMI) in previous 12 months (%) • Diabetic patients with record of retinal screening in previous 15 months (%) • Diabetic patients with record of neuropathy testing in previous 15 months (%) • Patients with myocardial infarction who, in the preceding 12 months, have a record of dietary and exercise advice (%) • Patients with hypertension under control (BP < 140/90 mm Hg) (%) • Patients with diabetes under control (HbA1c < 7.0 percent) (%) As in the case of BiH, indicators monitored should emphasize the quality and outcomes of services delivered, such as disease control achieved, rather than capacity functions or care processes alone (Davies et al. 2020). To improve obesity prevention and management in primary care, the American Medical Group Association developed and piloted a set of seven measures, including prevalence of obesity and obesity comorbidities, obesity diagnosis, prescription practices, changes in weight over time, and patient-centered care outcomes (Ciemins et al. 2020). Initiatives have also sought to improve evaluation of population approaches to national and community-level obesity prevention efforts by way of performance indicators. For instance, the US National Academy of Medicine developed a framework and set of indicators for measuring progress on six strategic obesity goals: (1) Improve collective impact of obesity prevention efforts, (2) Improve the physical activity environment, (3) Improve the food and beverage environment, (4) Improve the messaging environment, (5) Improve health care and worksites, and (6) Improve school and childcare environments (IOM 2013). Another key dimension of project success was the implementation of innovative grants for educational programs to improve public awareness on NCD risk factor prevention and acceptance of family medicine (FM) as a system of primary prevention. Grants were 51 competitively awarded to nongovernmental organizations (NGOs) and local service delivery providers. The primary success of the grants program was the development of cooperation between the health care sector, other social sectors, and the nongovernmental sector. Another noted success of projects financed by innovation grants was the exposure of existing weaknesses of the health system for NCD prevention among vulnerable groups and increased awareness of weaknesses among local authorities. Croatia Health System Project The Croatia Health System Project, which was carried out from 2000 to 2005, was the second HNP project completed in the country. While the primary focus of the project was on CVD prevention and management rather than obesity, several project activities were relevant for addressing obesity and its risk factors. First, one of the project components focused specifically on improving national health system capacity for health promotion. Key successful activities included the creation of a unit at the National Institute of Public Health (NIPH) specializing in health promotion, training for delivery of health promotion activities, and development of a national health promotion advocacy campaign. PHC Improvement Strategy for Addressing Obesity and Preventing NCDs— Governance and Leadership Health Promotion Capacity-Building According to the WHO definition, capacity-building refers to the development of knowledge, skills, commitment, structures, systems, and leadership to enable effective health promotion (Smith, Tang, and Nutbeam 2006). Capacity-building encompasses three primary activities: (1) Building institutional infrastructure to deliver health promotion programs, (2) Fostering partnerships and organizational environments so that programs are sustained, and (3) Building problem-solving capacity (Hawe et al. 2000). The Croatia Health System Project made key strides in capacity-building for health promotion through the introduction of a dedicated unit for health promotion and implementation of a health promotion advocacy campaign. However, the project also noted that, at the culmination of the project, financial commitment to health promotion activities was not absorbed by the national government, limiting the overall sustainability of health promotion capacity advancements. In addition, health promotion activities focused minimally on fostering partnerships for health promotion practice. To echo the insights drawn from the Brazil VIGISUS II project on community-based health promotion, future projects must incorporate key elements to improve the institutionalization, and therefore sustainability, of health promotion capacity-building efforts. Key requirements for effective health promotion, as identified by the WHO Capacity Mapping for Health Promotion project, include the following: (1) Introduction of integrated policies and plans for health promotion; (2) Collaboration between national government ministries and across national and subnational actors; (3) Use of multipronged intervention strategies (e.g., health communication, improving built and social environments for healthy lives, introducing food and tobacco policies, health advocacy and reorientation of service delivery); (4) Partnerships with NGOs and the private sector for joint health promotion activities; (5) Support for health promotion training; (6) Robust information systems to track and report on behavioral, social, and environmental risk factors and health promotion activities; and (7) Dedicated health promotion financing (WHO 2010). 52 Apart from a focus on national health promotion, the Health System Project also focused on improving primary, secondary, and tertiary prevention of disease through the creation of a National Program for Prevention of Cardiovascular Diseases. Primary prevention activities included the development of CVD guidelines and protocols for primary health care and training on effective CVD management in PHC for providers. India Tamil Nadu Health System Project Implemented from 2004 to 2015 in the seventh-most populous Indian state of Tamil Nadu, this project sought first and foremost to improve the overall effectiveness of the public and private health system, with a focus on addressing the health challenges posed by the growing burden of NCDs and improving health service access and utilization among disadvantaged and tribal groups. Activities relevant to addressing obesity and preventing NCDs were organized under the umbrella of one project component: “developing effective models to combat noncommunicable diseases.” Activities within this component included health promotion in communities, schools, and workplaces; implementation of lifestyle counseling centers; and introduction of two primary care pilot programs for NCD screening and management focused on hypertension and cervical cancer. The project received additional financing in 2010, at which point the NCD pilots were scaled up to the remainder of primary and secondary facilities across the entire state. Health promotion activities were multifaceted and included the implementation of a community-based behavior change communication campaign on healthy diets and exercise, support for community-based women’s self-help groups for NCD prevention through the Tamil Nadu Corporation for Development for Women (TNCDW), and collaboration with the state Department of Education and Department of Labor to develop health-related local policies (tobacco-free schools, safe water and sanitation, healthier cafeteria meals) and foster healthier lifestyles for employees (tobacco cessation programs, workplace exercise, and nutrition education). PHC Improvement Strategy for Addressing Obesity and Preventing NCDs— Proactive Population Outreach School and Workplace Health Promotion Schools and worksites are key settings for promoting healthy behaviors, including physical activity, healthy eating, and substance use. School-based policies and programs can be grouped into two categories: (1) those targeting individual knowledge, skills, and health behaviors, such as health education curriculum and training of educators; and (2) those targeting social/built environmental determinants, such as school policies for healthier food environments, changes to facility infrastructure, and partnerships between schools and communities. Evidence from a review of school- based interventions in developing countries suggest that a comprehensive approach that targets both individual and environmental determinants of health is more effective for achieving behavior change and health outcomes (Mukamana and Johri 2016). Additionally, strong policy support, multistakeholder engagement, integration with existing curriculum and student participation have been identified as critical factors for successful school-based interventions (Xu et al. 2020). To guide the implementation of effective school-based health promotion interventions, the WHO has developed the Health Promoting School (HPS) framework, which includes global standards, indicators, and implementation guidance for early action on NCD risk factors (Raniti et al. 2020). 53 Though evidence on effectiveness in LMIC contexts is still emerging, systematic reviews in high-income countries demonstrate small, yet significant, improvements in body mass index (BMI), physical activity, fruit and vegetable intake, and tobacco use across trials in HPS schools (Langford et al. 2015). Worksite interventions for health promotion can be similarly grouped into behavior change and environmental strategies to influence diet and physical activity. Interventions include information and education, behavioral counseling, behavior change incentives, improvements to workplace food environments, health club memberships, and other health promoting workplace policies. Worksite programs intending to improve diet and/or physical activity behaviors are backed by strong evidence for effectiveness in reducing weight among employees and are recommended by the US Community Preventive Services Task Force (Anderson et al. 2009). Emerging evidence from LMIC contexts indicates that worksite programs have been effective in reducing health risks across a range of industries and resource settings (Pham et al. 2020). Factors influencing health promotion program success in LMICs include the length of the intervention implementation, active intervention strategies, commitment from workplace leaders, support from authorities, and proactive involvement of workers (Pham et al. 2020). Learning from the case of Tamil Nadu, approaches to school and workplace interventions were characterized by early and comprehensive multistakeholder engagement, community-based partnerships with NGOs, and multicomponent approaches to behavior and environmental change. School and workplace interventions continue to be a pillar in Tamil Nadu, which has become an international model for public health and good health outcomes achieved at low cost (Balabanova et al. 2013). Health promotion activities were also implemented in clinic-based settings. Namely, the project introduced lifestyle counseling centers through public-private partnerships with NGOs to provide advice, particularly to poor and disadvantaged patients, for lifestyle modification in public hospitals and tribal health centers. This program complemented the NCD pilots for hypertension and cervical cancer screening and management, as positively screened patients were referred for lifestyle modification counseling. Dietary counseling services were delivered by nurses and doctors at the PHC level, and, at project culmination, a high proportion of patients were found to receive such services. Lifestyle counseling, along with increasing demand for services through community-based behavior change communication (BCC) and information, education, and communication (IEC) activities was deemed an important intervention to mitigate the identified trend of failure to follow-up for those screened for NCDs in project pilots. Strengthening the role of NCD staff nurses was a particularly important approach for improving continuity of care in project pilots, as nurses delivered counseling on accessing screening and complying with lifestyle advice and medication, and focused on improving patient follow-up. PHC Improvement Strategy for Addressing Obesity and Preventing NCDs—Team- Based Care Organization Task Shifting for Health Promotion and Preventive Service Delivery In LMIC contexts where PHC physician capacity is often limited, shifting certain tasks for the prevention and management of NCD risk factors to nonphysician health workers 54 (NPHWs), such as nurses and community health workers, can be an effective strategy for improved NCD management (Joshi et al. 2014). Literature on task shifting for NCDs pertains primarily to management of cardiovascular disease risk factors, including hypertension, diabetes, and the behavioral risk factors of diet, physical activity, and substance use. NPHWs can support several functions along the continuum of care for NCD management, including screening, delivery of lifestyle counseling, patient follow- up, and proactive population outreach (WHO 2018c). Increasing the role of NPHWs in CVD prevention is an important approach in both primary care and community settings. Community health worker (CHW) interventions implemented in LMICs have been found to improve screening for CVD risk factors, decrease systolic blood pressure, increase quit rates of smoking, decrease weight, and improve diet and physical activity (Khetan et al. 2017). Several factors have been identified as important enablers for effective task shifting in CVD prevention interventions, including qualitative research and feasibility studies prior to program implementation to identify and address barriers, introduction of workflows specifying clinical roles in care pathways, and remuneration for the delivery of assigned tasks by NPHWs (Joshi et al. 2018). In the case of the Tamil Nadu Health System project, over 2,000 NCD staff nurses were recruited and trained to support several functions of the NCD pilot programs, including counseling patients on accessing screening, providing lifestyle counseling, and following up with patients. A critical component of project success for the role of nurses pertained to government financial support to nurses, as NCD staff nurses were absorbed into the overall nursing workforce and their salaries were paid through the domestic budget of the government of Tamil Nadu. Distinct from activities carried out, this project was characterized by key considerations in project design and implementation that influenced its success. Project Design and Implementation—Lessons Learned for Addressing Obesity and Preventing NCDs 1. Project design maximized the use of limited resources for the NCD program through assessments of cost-effectiveness and evaluation of well-focused pilots to test feasibility of NCD interventions. The government of Tamil Nadu initially wanted to address all NCDs; however, iterative discussions on resource constraints, cost-effective interventions, and consultations with leading experts focused the scope on hypertension, diabetes, and cervical cancer. The project implemented these programs as pilots and built a rigorous evaluation of pilots into the intervention design. This approach allowed decision makers to make strategic decisions on the feasibility and effectiveness of NCD pilot programs that were leveraged to effectively scale services across Tamil Nadu. 2. The project pursued a “phased approach” for most project activities, which allowed project stakeholders to learn and adapt before scaling up to all districts in the state. This project emphasized the need to improve demand for services, particularly among underserved groups. This was pursued primarily through the implementation of behavior change interventions. Noting that complex “software” 55 investments in training, behavior change, and quality procedures and processes may be less prioritized among implementers than “hardware” investments in buildings and equipment, the project team used a phased approach that began with both “hardware” and “software” investments but required the “software” investments to be completed before the next phase of investment could begin. The use of this phased approach served as an effective incentive for successful and timely implementation of activities. 3. Project design was highly participatory in nature, empowering multisectoral collaborations that facilitated project success. Project preparation included extensive consultation with NGOs and private entities providing services in tribal health areas. Project ownership was enhanced early in project design through high participation in the Social Assessment among NGOs, community organizations, local authorities, the private sector, and academic institutions. The high attention to stakeholder participation was reflected in project activities, which were conducted in partnership with NGOs, the Department of Education, and the Department of Labor, to name a few. 4. The project was fully integrated within government structures at all levels. By project culmination, the financing for all activities was absorbed into the state health budget or national health programs, which significantly improved the sustainability of project activities. China Rural Health Project The Rural Health Project, carried out from 2008 to 2014, sought to improve three health system functions: (1) Equitable access to quality health services, (2) Financial protection, and (3) Effective management of public health threats in pilot provinces and counties. Project activities relevant to addressing obesity and preventing NCDs fall primarily within the scope of the third category. This project implemented the “healthy village” approach, a set of standards to be implemented by local jurisdictions to empower healthy lives. While this approach focused primarily on improving community sanitation and rural health services, it also emphasized the promotion of healthy diets and physical activity. By the end of the project, 35 out of 40 project counties launched the “healthy village” approach and 277 villages met “healthy village” standards. A key element of success in implementing the “healthy village” program across project counties was proactive knowledge transfer, which fostered a culture of evidence-based decision making. PHC Improvement Strategy for Addressing Obesity and Preventing NCDs— Innovation and Learning Knowledge Sharing for NCD Prevention and Management Programs Innovation and learning capabilities refer to cultural and operational elements that allow for health system flexibility and adaptation to modify behavior, practice, priorities, and policies to reflect new knowledge and insights (PHCPI 2019). While there is no one- size-fits-all approach to fostering a culture of innovation and learning, the continuous 56 cycle of evidence collection, knowledge transfer, and operationalization of insights into the design and scaling of innovations are essential facets of an effective approach. In the case of the implementation of the “healthy village” model in China, knowledge generation took the form of a strong focus on operational research, with 11 operational research studies conducted over the course of the project. To facilitate knowledge transfer, a learning network of project counties was created, and dissemination workshops were held biannually through the network to share lessons learned and best practices from provinces implementing healthy village standards. The focus on knowledge transfer also made up an explicit focus of the project Results Framework, as indicators assessed whether lessons from project counties were documented and disseminated, as well as whether project experiences were adopted in nonproject counties. Other relevant project activities include the establishment of the National Cooperative Medical Scheme (NCMS) to increase reimbursement for chronic disease management through performance-based financing; training on chronic disease management in PHC; improving follow-up of patients screened for NCDs; and introducing a multisector management platform for NCD prevention and control. Summary From a review of six completed HNP projects that were successful in achieving objectives to address obesity and prevent NCDs set at project approval, several entry points for PHC improvement were identified. These entry points pertained to PHC systems and service delivery capabilities. For a full summary of PHC domains with identified improvement strategies, see Figure 10. Additional resources identified to support the design, implementation, and evaluation of PHC improvement strategies outlined can be accessed in Annex 9. 57 Figure 10. PHCPI Conceptual Framework with Entry Points for PHC Improvement Identified from Successful Projects Source: PHCPI. Notes: PHC = Primary health care; RMNCH = Reproductive, Maternal, Newborn, and Child Health; NCDs = Noncommunicable diseases. Entry points for PHC improvement boxed in black. DISCUSSION This analysis took a deep dive into a small set of completed HNP projects to identify trends in activities and measurement to address obesity and prevent NCDs through a PHC approach, evaluate project success, and synthesize “PHC improvement strategies” for addressing obesity and preventing NCDs from successful projects. In addition, key characteristics of projects were identified to contextualize lessons drawn from projects. From this exercise, several key takeaways and recommendations for improvement emerge. However, a few limitations of this analysis must first be recognized. Limitations The most salient limitation of this analysis pertains to the reliance on project indicators at face value as the basis for evaluating project success. This analysis evaluated projects on the extent to which they achieved the targets they had set out to achieve, as reflected by the performance indicators in the Results Framework; however, this analysis did not evaluate the quality of the targets set out in project performance indicators themselves and whether they were appropriate metrics of project success. Thus, differences observed in project success may not reflect just the relative success of project activities themselves, but also project differences in utilizing appropriate indicators to realistically set and monitor progress. Despite this limitation, the focus of this analysis on completed projects offered 58 a singular opportunity to consolidate knowledge on what projects were ultimately able to achieve in practice in the evaluation of project success, and reliance on performance indicators enhanced comparability across projects. In addition, the quantitative evaluation of project success through indicators was also accompanied by in-depth review of project documents and Task Team Leader (TTL) interviews to provide a more holistic understanding of project success, which was explored in-depth in the identification of PHC improvement strategies and lessons learned for addressing obesity and preventing NCDs. Another limitation of this analysis is the sole focus on completed projects pertaining to obesity and NCDs. While this focus was advantageous from the perspective of identifying successful strategies based on what projects had achieved in practice, it focused the analysis on predominantly older projects that most likely do not reflect the full gamut of activities the World Bank has since invested in recent years to address obesity and prevent NCDs. To address this limitation, methods should be explored to expand and modify the analysis to include projects that aim to address obesity and prevent NCDs that are currently active. Despite these limitations, six key takeaways emerge from this analysis of completed HNP projects with objectives to address obesity and prevent NCDs through a PHC approach. Key Takeaways Key Takeaway 1: The World Bank HNP Global Practice can and must play a critical role in supporting countries to address the growing epidemic of obesity and associated NCDs. This exercise highlights a precedent for HNP stewardship in addressing obesity and preventing NCDs and a small foundation of successful experiences to build upon. As the recently published World Bank report on obesity highlighted, health sector stewardship to address obesity within the World Bank is limited. That said, it is not without precedent. This exercise highlights a small body of projects that, in one way or another, achieved important milestones in supporting client countries to address the challenges of obesity and NCDs more effectively. HNP focus on addressing obesity has grown since most projects included in this analysis were completed, though obesity remains overall underprioritized in HNP projects relative to the shifting disease burden in World Bank client countries. As of 2013, the average number and relative focus on projects with objectives to address obesity and prevent NCDs in the HNP portfolio has increased significantly, coinciding with key milestones for scaling up efforts to address the growing burden of obesity and associated NCDs. In 2013, the WHO introduced the Global Action Plan for the Prevention and Control of Noncommunicable Diseases (2013–2020) and Global Monitoring Framework, which together introduced critical actions, targets, and indicators for monitoring and evaluating country progress on tackling NCDs. However, while increasing, HNP support to obesity remains relatively limited when compared to the entire HNP portfolio, comprising an average of 7.5 percent of projects approved each year since 2013. These findings echo those of a 2018 evaluation of the World Bank’s roles and contributions to supporting health services conducted by the Independent Evaluation Group (IEG), which found NCDs to be underprioritized compared with relative disease burden for 82.3 percent of client countries (World Bank 2018). Thus, there is a critical need for HNP to ramp up efforts to close this gap, drawing upon lessons learned from previous projects and international evidence-based best practices. Obesity and associated NCDs constitutes a massive health and economic 59 threat to the realization of the World Bank’s goals of ending extreme poverty and boosting shared prosperity. The critical role and opportunity of development partners like the World Bank to support client countries to address obesity was emphasized in the recently published World Bank report on the health and economic consequences of obesity. This analysis builds on that report by demonstrating the potential for the HNP Global Practice to intervene at the individual, community, and national levels to address the pervasive threat of obesity and NCDs in client countries. Key Takeaway 2: Fostering a PHC approach to health sector stewardship for addressing the burden of obesity is vital and must be strengthened in HNP project objectives. Sustainable improvements for addressing the threat of obesity and preventing NCDs can be mobilized through a PHC approach. The principal determinants of obesity and associated NCDs are embedded in the very fabric of the social and built environments in which people are born, grow, live, work, and age. A robust health sector response to address obesity and prevent NCDs must not only strengthen primary care services to prevent and manage NCDs across the life course but tackle the societal underpinnings that systematically and inequitably culminate in a catastrophic preventable burden of chronic disease. To achieve this fundamental shift, a PHC approach that emphasizes primary care and essential public health functions at the heart of integrated services, empowered people and communities, and multisectoral policy and action is key. These core values, which have been committed to by states and governments around the world most recently in the Declaration of Astana, have been recognized as the primary approach for achieving the global vision of universal health coverage (UHC) (WHO 2018b). This analysis demonstrates how these core PHC values have been pursued in project objectives across completed HNP projects to address the challenges of obesity. HNP project objectives aimed to strengthen essential public health functions and primary care service delivery for obesity. Projects sought first and foremost to improve PHC for addressing obesity and preventing NCDs through improving essential public health functions and primary care service delivery. Objectives for essential public health functions aimed to improve national capacity for NCD prevention, such as health promotion and screening, and strengthen NCD surveillance and information management. Objectives focused on primary care service delivery sought to integrate services for early detection and management of NCDs and lifestyle counseling for high-risk patients into primary care settings. Two projects, both of which were ultimately successful in achieving project goals, encompassed objectives that sought to improve both essential public health functions and primary care service delivery for addressing obesity and associated NCDs. HNP projects set a small yet vital precedent of aiming to empower people and communities to lead healthy lives through health promotion policies and programs; however, this focus must be strengthened. The majority of completed projects that sought to address obesity and prevent NCDs encompassed a focus on health promotion to empower individuals and communities to lead healthier lives in project objectives. Approaches to achieve such objectives spanned integrating health promotion into primary care services, fostering health promotion in community settings, and building capacity for health promotion at the national level through strategic action plans and institutional infrastructure. Community-level/community-driven health promotion initiatives were common across projects, though generally small in scope and characterized by limited commitment. Ultimately, completed projects recognized the potential of community empowerment to promote healthier lives but failed to truly capitalize on the potential to form sustainable partnerships with communities to realize sustainable changes in health 60 behavior. HNP commitment to health promotion through a PHC lens must be a more central focus in project objectives to realize long-term improvements in obesity-related health outcomes. Multisectoral policy and action is limited across completed HNP project objectives. A handful of completed projects emphasized the development of policies for addressing NCDs and their risk factors; however, explicit focus on fostering multisectoral policy and action in project objectives was limited. Addressing the social and built environments that shape the burden of obesity will necessitate a “Health in All Polices” approach, with concerted action across multiple sectors. Thus, the lack of explicit focus on this core PHC value among project objectives constitutes a key gap in HNP priorities for effectively addressing obesity through health sector stewardship. Key Takeaway 3: Successful activities for addressing obesity and preventing NCDs in completed HNP projects focused first and foremost on improving PHC systems capacities, followed by service delivery in communities and primary care settings, as defined by the PHCPI Conceptual Framework. Successful project activities focused on improving national capacity for NCD prevention and control through improvements to PHC governance and leadership, health financing, and adjustment to population health needs, as defined by the PHCPI Conceptual Framework. To effectively address and respond to the growing burden of NCDs, countries must build essential capacities at the national level. These capacities are outlined and assessed every two years by the WHO through the NCD Country Capacity Survey and encompass the following: health system infrastructure; funding; policies, plans, and strategies; surveillance; primary health care; and partnerships and multilateral collaboration (WHO 2020). Completed HNP projects successfully contributed to building these capacities in client countries. Key successful activities conducted in more than one project include the development of national action plans for NCD prevention and health promotion, improvements to NCD unit infrastructure, development and implementation of clinical guidelines for NCD services in primary care, implementation of performance-based financing for NCD services, improvements to NCD surveillance capacity, and the implementation and evaluation of pilot programs for NCD service delivery. Though less common, successful project activities also sought to address obesity in communities and primary care settings through population health management and improvements to quality of primary care services delivered. Activities geared toward improving NCD prevention and management in community and clinical settings were also common. Successful community-based activities conducted in more than one project include implementing Healthy Municipalities, Cities and Communities (HMCC) approaches among local governments and school-based health promotion activities. Clinic-based activities aimed to improve the continuity, comprehensiveness, and person- centeredness of services for early detection and management of NCDs, such as screening, pharmacological treatment, and lifestyle counseling. These activities emphasized the management of obesity comorbid conditions, such as hypertension and diabetes, while focus on the clinical management of obesity itself was mentioned in only one project. Key Takeaway 4: HNP projects demonstrate a nascent potential to support multisectoral collaboration for critical action to address obesity and prevent NCDs that must be realized in future projects. 61 Successful action for addressing obesity and preventing NCDs necessitates concerted action across sectors. The World Bank report on obesity identified six key actions to prevent obesity: (1) Fiscal policies, such as taxation and subsidies; (2) Regulatory policies on marketing and advertising; (3) Agriculture/food system approaches, including through food service; (4) Education sector policies such as school cafeterias and physical activity in schools; (5) Transport and urban design interventions such as mass transit and city and building design; and (6) Early childhood nutrition programs that focus on improving breastfeeding rates and reducing stunting. The challenges addressed by these actions are complex in nature and require coordinated action across sectors such as education, transport, agriculture, macrofiscal, and urban planning. That said, the health sector can certainly play a role in fostering multisectoral collaboration to further actions with significant health implications. While an explicit focus on multisectoral action in project objectives was limited, certain key actions were identified in the review of project activities. To further understand the extent to which completed HNP projects have supported multisectoral best practices for obesity prevention, project activities are compared to the typology of actions introduced in the World Bank obesity report in Table 11. Table 11. Alignment of Activities in Completed HNP Projects with Multisectoral Actions for Obesity Prevention Typology of actions for obesity prevention Action Activities in completed HNP projects Fiscal policies • None identified. Regulatory policies • Voluntary “Heart Healthy” logo developed and implemented in Hungary. on marketing and advertising Agriculture/Food • Local sodium reduction policies for bread sold in bakeries in Argentina systems approaches and Uruguay through “Healthy Municipalities” approach. Education sector • Education program for healthy lifestyles implemented in schools and approaches workplaces in four communities in Bosnia and Herzegovina. • School canteen regulations for healthy food consumptions in primary and secondary schools in Turkey. • School health promotion program in partnership with Department of Education to establish health-related school policies; provide safe water and sanitation; and skills-based approach to hygiene, nutrition, and healthier school meals in Indian state of Tamil Nadu. • School-based health promotion program implemented in Uruguay. Active transport and • Healthy spaces implemented at municipal level in Uruguay (open-air building/city design gyms, community bikes). • Community development grants support education and changes to the community-built environment, such as community kitchens, fruit tree groves, vegetable gardens, and women’s support and mutual help groups. Early childhood • Not assessed. Projects with a focus on early childhood nutrition were nutrition programs excluded from analysis. Source: Authors’ own contribution. Note: HNP = Health, Nutrition, and Population. 62 Completed HNP projects encompassed some support to key multisectoral actions for obesity prevention, primarily in conjunction with the education sector. Support to multisectoral actions for obesity prevention in completed projects consisted primarily of school-based health promotion policies and programs implemented in partnership with the education sector. In comparison, policy and food system approaches to reducing unhealthy diets were scant and included the development of one voluntary front-of- package nutrition labeling policy in Hungary and the implementation of local salt reduction initiatives aimed at bakeries in Argentina and Uruguay. Finally, support to multisectoral actions for active transport and urban development were limited, though two projects included small-scale actions to introduce changes, such as community bikes, open-air gyms, community kitchens, and vegetable gardens. Support to early childhood nutrition programs was not assessed, as many HNP projects with relevant activities were excluded from this analysis. However, support to multisectoral actions for obesity prevention is ultimately limited across completed HNP projects, representing an unrealized opportunity for health sector stewardship for a whole-of-society approach. Support to multisectoral activities to address the underlying determinants of obesity has historically been carried out primarily in partnership with the education sector and has supported education activities over policies and improvements to the built environment. Noticeably absent policies include sugar-sweetened beverage taxes, food and beverage marking restrictions, trans-fat regulation, and fruit and vegetable subsidies, to name a few. Improvements to the built environment to promote the availability and accessibility of healthy diet and infrastructure for physical activity are also limited. These actions are not the sole responsibility of the health sector by any means and will require leadership from multiple sectors; however, as demonstrated through emerging experience from completed projects, HNP can foster a “Health in All Policies” approach and steward multisectoral collaboration for whole-of-society actions that carry pervasive health implications. Key Takeaway 5: Completed projects are characterized by regional, temporal, financing, and epidemiological trends that do not capture the full potential of HNP to support countries to address obesity and prevent NCDs. Completed projects primarily reflect HNP’s early focus on addressing obesity and preventing NCDs, with only two completed projects approved in the past decade. Completed projects analyzed were carried out over the course of two decades, from the early 1990s to the late 2010s. HNP focus on projects with objective(s) to address obesity and prevent NCDs has increased significantly within the past decade; however, most of those projects were not included in this analysis because they are not yet completed. One potential implication of the relatively early time line of completed projects is that they may not exemplify the full gamut of strategies pursued by HNP projects to address obesity through a PHC approach. The challenge of obesity and NCDs has risen significantly on the global development agenda within the past decade, accompanied by key milestones such as the development of WHO Global Action Plan and Monitoring Framework, the UN Decade of Action on Nutrition (2016–2025), and WHO NCD “Best Buys,” to name a few. These international milestones have encompassed strategies and tools to support countries in preventing NCDs that can be bridged into practice. Thus, HNP projects with objective(s) to address obesity and prevent NCDs approved within the past decade may encompass key objectives, interventions, and successes of PHC approaches to addressing obesity that are not represented in this analysis. 63 Completed projects were characterized by limited financing tools and commitments to addressing obesity. The recently published World Bank report on obesity outlined important World Bank lending instruments to support countries for obesity prevention, including Development Policy Financing (DPF), 3 Investment Project Financing (IPF), and Program for Results (PforR) with Disbursement Linked Indicators (DLI). Apart from a handful of projects financed through IPF, the majority of completed projects did not utilize these recommended World Bank services, thereby limiting the opportunity to learn from these tools in practice. In addition, completed projects were characterized by limited financial commitment to obesity, both in total loan amount and in the allocation of total project costs to objectives for addressing obesity and preventing NCDs. This limited commitment was echoed in project thematic focus on NCDs, which averaged less than a third across completed projects. Future research must further inform the lessons identified in completed projects by expanding the analysis to the entire HNP portfolio dedicated to addressing obesity and preventing NCDs. While completed projects were characterized by key successes and lessons learned, they very well may not reflect the full extent of HNP strengths and weaknesses in supporting client countries to address obesity. They also do not reflect the full extent to which HNP has supported countries to address obesity across varying regional, economic, and epidemiological contexts. An important future direction would be to expand this assessment across the entire gamut of HNP projects with objectives to address obesity and prevent NCDs, as well as subsets of projects such as the COVID-19 portfolio or projects focused on child and adolescent health, to determine how these trends have since shifted and identify promising practices and persisting gaps in HNP support for addressing obesity and preventing NCDs in client countries. Key Takeaway 6: There are many entry points for PHC improvement to address obesity in HNP projects; however, four common lessons for effective project design and implementation emerge. Projects dedicated to fostering a PHC approach to address obesity and associated NCDs must be realistic about what can be accomplished during the project lifetime and plan accordingly. Supporting country health systems to address obesity and prevent NCDs requires paradigmatic change. As discussed, a PHC approach that emphasizes integrated essential public health functions and primary care service delivery, empowered people and communities, and multisectoral policy and action is vital. Such change requires long-term investment in capacity-building and behavior change across a range of stakeholders. Completed projects with objective(s) to address obesity and prevent NCDs were variable in duration, financial commitment to achieving objectives aimed at addressing obesity and preventing NCDs, and scope of expectations over the project lifetime. Problems arose when projects sought to realize swift improvements over short periods of time, did not account for time and resources necessary for cultural change, and did not ensure adequate mechanisms for learning from project implementation along the way. Implementing and scaling innovative interventions to address obesity and NCDs can build government commitment and make more effective use of evidence and limited resources through implementation of “phased” and “pilot” approaches. 3 Development Policy Financing provides budget support to governments or a political subdivision for a program of policy and institutional actions to help achieve sustainable, shared growth and poverty reduction. 64 Recognizing the challenges of fostering paradigmatic shift to address obesity and NCDs, several projects successfully pursued project activities in phases and pilots, allowing the opportunity to rigorously evaluate and share knowledge, accommodate the learning process in early stages, and adapt accordingly prior to scaling up time- and resource- intensive activities. For instance, several projects sought to integrate NCD service delivery, such as screening and lifestyle counseling, into primary care. To do so, interventions were piloted across a select number of communities and rigorously evaluated. For more than one project, initial results from pilot activities were pivotal in government decisions to scale activities to regional or national levels. The pilot approach was also instrumental across the various Healthy Municipalities, Cities and Communities (HMCC) programs implemented in projects. Namely, best practices from trailblazing HMCC activities in local settings were synthesized and shared proactively through learning networks, which facilitated their adoption across different local settings. A final successful approach identified was the use of a phased approach to project implementation, primarily to improve government commitment to long-term investments in behavior change activities. Ultimately, these approaches, while variable across projects, sought to break up long-term change into manageable steps and promote evidence-based decision making for effective use of limited resources in addressing obesity and NCDs. Early and comprehensive stakeholder dialogue, along with formal multisectoral participation in project design and implementation, are critical for successful multisectoral action for obesity prevention. Several completed projects sought to reduce unhealthy diets and physical inactivity through multisectoral action in school and workplace health promotion, with variable success. One critical element identified in a successful approach was an explicit focus on multisectoral participation in project design and implementation, such as the creation of formal partnerships and long-term dialogue between the Ministries of Health, Education, and Labor. Early and comprehensive engagement with community-based NGOs and civil society also proved to be critical in effectively introducing community-based health promotion programs and ensuring that efforts to address NCDs complemented existing initiatives. Certain mechanisms, such as engaging stakeholders in project design through a series of consultations, proved to be crucial in enhancing community ownership of project activities and leveraging partner strengths for effective implementation. Future HNP projects must expand support to client countries to pursue multisectoral action for obesity, as outlined above. To successfully accomplish this, HNP projects must foster multisectoral stakeholder participation through all stages of project design and implementation. Health promotion activities must ensure mechanisms to maximize impact and sustainability following project completion. Significant improvements in obesity can only be realized with long-term investments in behavior change. While health promotion objectives and activities were common across projects, considerations of impact on health behaviors and sustainability were variable. Health promotion activities varied from national and community-based health education programs to changes in the built environment at the community level. In terms of impact and sustainability, the latter is more effective in promoting long-term changes in behavior and health outcomes. Thus, health promotion activities should prioritize interventions that improve the social and built environments in which people are born, grow, live, work, and age over those that target individual knowledge and attitudes. Sustainable health promotion programs must also be institutionalized by country governments. For more than one completed project, health promotion funding ceased when the project ended, and health promotion activities were left up to the interest of local governments and community members to continue. Finally, 65 completed projects recognized the importance of community empowerment in realizing successful community-based health promotion activities; however, community member engagement was rarely pursued through formal engagement mechanisms. To maximize community ownership in health promotion activities, formal mechanisms, such as coalitions, committees, dedicated community coordinators, and community partnerships, are essential. Future projects seeking to shift health sector focus toward health promotion must integrate considerations of impact and sustainability early on in project design and implementation. Policy Implications and Recommendations Drawing from the key takeaways of this analysis, the following actions are recommended for the HNP Global Practice for addressing obesity and preventing NCDs in future World Bank health sector projects: • Leverage the relative strength of diverse World Bank analytical and operational expertise to steward multisectoral interventions to address obesity and prevent NCDs. Obesity and associated NCDs cannot be addressed by the health sector alone, but rather necessitate concerted multisectoral action. The World Bank consists of 18 global practices, spanning agricultural, education, energy, finance, transport, and social protection sectors, to name a few; however, there is still much unrealized potential within the World Bank to draw on expertise and resources across sectors to develop innovative multisectoral interventions to address the epidemic of obesity and associated NCDs. • Hone HNP stewardship for addressing obesity and preventing NCDs by increasing resources and technical support in World Bank client countries. Action on obesity and NCDs is growing in HNP projects but remains underprioritized relative to their epidemiological burden in World Bank client countries. Consolidating support for action on NCDs within the World Bank, such as through the establishment of a Trust Fund focused on NCDs or a cross-sectoral program to provide focused technical support for key obesity and NCD actions, has significant potential to build momentum for action in HNP projects. A salient example of this potential has been demonstrated by the World Bank Global Tobacco Control Program, a multisectoral program led by HNP that, since 2013, has conducted assessments on tobacco tax systems and provided support for the enactment of tobacco tax policy reforms in over 40 countries (World Bank Group 2019). Apart from directing additional resources toward addressing obesity and preventing NCDs, existing resources, such as trust funds with relevant missions, should also be mobilized to support analytics for evidence-based obesity prevention policies and programs in client countries. • Elevate the inclusion of objectives related to community-based health promotion and multisectoral policy and action into HNP projects and Results Frameworks to foster accountability for action. These areas of action, while key to improving outcomes for addressing obesity and preventing NCDs, were limited in project objectives and unsustainable in execution. Future projects should be designed to provide greater emphasis on these fundamental elements of a PHC 66 approach, which could be enabled by explicit inclusion of obesity and NCD prevention in project PDOs and components, clear budgetary allocation to said activities, and integration of relevant performance indicators in project Results Frameworks to foster accountability and effectively monitor progress. • Explore opportunities to align incentives and milestones in the HNP project planning process to enable the integration of project design and implementation lessons identified in this analysis, including encompassing formal multisectoral partnerships for the implementation of NCD activities into the project structure and integrating considerations of sustainability of health promotion programs into project design. • Utilize analytical tools to identify strategic areas for improvement to guide focused investments in PHC strengthening for addressing obesity and preventing NCDs. To address the challenges of allocating limited resources to achieve realistic improvements in PHC for addressing obesity and preventing NCDs, certain analytical tools can be drawn upon to guide the identification of areas for investment in HNP projects. For instance, the NCD Country Capacity Survey, completed by 189 countries most recently in 2019, can be drawn upon to identify key gaps in health systems capacity for future investment. Additionally, the Primary Health Care Performance Initiative (PHCPI) has developed tools to measure PHC performance and provide targeted recommendations for improvement. This analysis can be conducted before or during the project planning process to inform investments in PHC strengthening to better meet population health needs, including NCDs. CONCLUSION As highlighted in the World Bank report on the health and economic consequences of obesity, health sector stewardship to address obesity and prevent NCDs is limited. However, as this exercise demonstrates, it is not without precedent. Completed HNP projects encompass crucial examples of project objectives, activities, and successes in addressing obesity and preventing NCDs. These projects invest in various dimensions of a PHC approach, including improvements to essential public health functions and primary care service delivery for NCDs and empowering people and communities through health promotion policies and programs. Projects are also characterized by key successes, particularly in building national capacity for addressing the challenges of NCDs, implementing community-based health promotion policies and programs, and improving primary care services for NCD early detection and management. That said, completed projects also highlight critical gaps in health sector stewardship, particularly in supporting multisectoral action to realize a “Health in All Policies” approach and implementing six key actions for obesity prevention. As HNP continues to scale up support to client countries to address obesity and prevent NCDs, project successes and persisting gaps identified in completed projects outline important elements for a roadmap to the future. 67 ANNEXES ANNEX 1 – PHCPI FRAMEWORK DOMAIN GLOSSARY Community engagement. The inclusion of local health system users and community resources in all aspects of design, planning, governance, and delivery of health care services. Comprehensiveness. Refers to the provision of holistic and appropriate care across a broad spectrum of health problems, age ranges, and treatment modalities. Comprehensive care should address a wide range of preventive, promotive, chronic, behavioral, and rehabilitative services and include an assessment of a patient’s risks, needs, and preferences at the primary care level. Continuity. Refers to a long-term healing relationship between a person and his or her primary care provider or care team over time. Coordination. Involves managing and integrating care across levels of the system and across time to ensure patient information is communicated at the right time and to the right people to facilitate the delivery of safe, appropriate, and effective care. Drugs and supplies. This measures the availability of essential medicines, vaccines, and commodities. It also includes measures of essential equipment, such as scales and thermometers. Empanelment. A continuous, iterative set of processes that identify and assign populations to facilities, care teams, or providers who have a responsibility to know their assigned population and to proactively deliver coordinated primary health care toward achieving universal health coverage. Facility infrastructure. Captures the actual availability of facilities, including numbers of facilities, the mix of facilities (health posts and health centers), and the distribution of facilities, both public and private, throughout the country. Facility management capability and leadership. Refers to the capabilities of managers and leaders within a facility. Financial access. Means that there are no or few cost barriers to receipt of care, including prohibitive user fees, out-of-pocket (OOP) payments, or other costs associated with care seeking such as transportation or childcare costs. First contact accessibility. Refers to the capacity of a primary care system to serve as the first point of contact, or a patient’s entry point to the health system and main coordinator of care, for the majority of a person’s health needs. Funds. Pertains to the availability of funds at the facility level, looking at the ability to address recurrent and fixed costs incurred at the facility level. Geographic access. The absence of barriers including distance, transportation, and other physical challenges in accessing care when needed. 68 Health financing. Addresses the efficacy of health systems to (1) mobilize adequate funds for health to ensure access to PHC in a financially sustainable manner; (2) provide protection from catastrophic financial expenditure on health leading to impoverishment; and (3) ensure equitable and efficient use of resources. Information systems. An overarching term that refers to the systems used for collecting, processing, storing, and transferring data and information that is used for planning, managing, and delivering high-quality health services. Information systems use. The effective utilization of existing information systems and the data they produce at the facility level to coordinate care, monitor performance, and drive management. Innovation and learning. A characteristic of a health system that enables flexibility and iteration to continuously improve services and ultimately drive improved health outcomes. The goal of innovation and learning is to stimulate and make use of new and existing evidence, research, and data and to adapt and incorporate these learnings into changes at scale. Local priority setting. The process of identifying health priorities specific to the local community and developing action plans informed by community needs as well as national or regional priorities. Patient-provider respect and trust. Refers to a relationship between patients and providers that is mutually respectful and trusting. Performance measurement and management. Encompasses systems for monitoring performance and managing through implementing improvement strategies within facilities. Person-centered care. Involves engaging with people as equal partners in promoting and maintaining their health and assessing their experiences throughout the health system, including communication, trust, respect, and preferences. Population health management. An approach to primary health care (PHC) provision that integrates active outreach and engagement with the community in care delivery. Primary health care (PHC) policies. Decisions and plans undertaken by governments with input from other stakeholders to achieve specific health care goals. PHC policies promote, support, and establish system orientation, financing, inputs, and service delivery mechanisms to ensure quality and improve and develop PHC functions and outcomes. Priority setting. The process of making decisions about how best to allocate limited resources to improve population health. Effective priority setting addresses differing interests and motivations through a clear process focused on the use of evidence, transparency, and participation to identify the most appropriate programs and interventions to address population health needs. Proactive population outreach. The active provision of care in homes or communities rather than exclusively in facilities. 69 Provider availability. The presence of a trained provider at a facility or in the community when expected and providing the services as defined by his or her job description. Provider competence. Entails having and demonstrating the “knowledge, skills, abilities, and traits” to successfully and effectively delivery high-quality services. Provider motivation. Captures intrinsic and extrinsic characteristics that affect the behavior and performance of providers in a health system. Intrinsic motivation is the feeling of accomplishment driven by organizational goals and the impact of one’s work on patients and communities. Alternatively, extrinsic motivation is driven by monetary or nonmonetary individual or environmental incentives. Safety. Refers to safe practices being routinely followed in the delivery of care as well as in facilities more broadly. Social accountability. A measure of whether a country is held accountable to existing and emerging social concerns and priorities based on need. Surveillance. The ongoing and systematic collection, analysis, and interpretation of health-related data essential to the planning, implementation, and evaluation of service delivery and public health. Team-based care organization. Refers to groups of providers with diverse education and capabilities. Timeliness. Includes two elements. First, patients should be able to physically access care with acceptable and reasonable waiting times. Second, hours and days of facility operation should be such that patients can find a time to visit facilities without sacrificing other obligations and duties such as work or childcare and can access care for emergent needs, including on nights and weekends. Quality management infrastructure. Comprises the planning, control activities, and improvement work that ensure populations receive high-quality health services: the right care, at the right time, responding to the service users’ needs and preferences, while minimizing harm and resource waste. Workforce. The term PHC workforce refers to all occupations of health professionals responsible for organizing and delivering PHC. This subdomain reflects the need to have a trained workforce, sufficient numbers of health personnel, and the right mix of staff that is well distributed geographically to promote equitable access for the population. 70 ANNEX 2 – OBESITY SEARCH TERMS Key search terms – Obesity Prevention & Literature Search Strategy (as entered in Management Operations Portal search) Obesity-related terms: “obesity” OR “obese” OR “overweight” OR “body Obesity / obese / overweight / body mass index / mass index” OR “BMI” OR “weight change” OR BMI / weight change / weight control / metabolic “weight control” OR “metabolic syndrome” syndrome Lifestyle interventions terms: “promote healthy lifestyle” OR “healthy lifestyle” (promote) Health(y) lifestyle (or lifestyle or OR “healthy lifestyle" OR “promote healthy lifestyle) / Lifestyle counseling / obesity lifestyle" OR “healthy lifestyle” counseling NCD risk factor activities: “NCD risk factor” OR “Risk factors associated to NCD Risk Factor(s) / Risk factors associated to NCDs” OR “Reduce risk factors” OR “risk factors NCDs / Reduce risk factors (if related to NCDs) / of the NCDs” OR “NCDs and related risk factors” Risk factors of the NCDs / NCDs and related risk factors NCD and risk factors surveillance terms: “NCD surveillance” OR “Risk factor surveillance” NCD Surveillance / Risk factor surveillance / OR “nutritional surveillance” OR “NCD survey” Nutritional surveillance / NCD survey / NCD risk OR “NCD Risk factor survey” OR “health factor survey / Health behavior(al) survey / behavior survey” OR “surveillance of NCDs” OR surveillance of NCDs and related risk factors / “obesity surveillance” obesity surveillance NCD prevention activities terms: “NCD prevention” OR “NCD control” OR “NCD NCD(s) Prevention and/or control / NCD preventive program” OR “Cardiovascular disease preventive program / Cardiovascular disease prevention” OR “CVD prevention” OR “Chronic (CVD) prevention / Chronic disease prevention / disease prevention” OR “prevention of NCDs” disease prevention (if evident it’s referring to OR “diabetes prevention” NCDs) / prevention of NCDs / diabetes prevention Physical activity-related terms: “Physical activity” OR “Sedentary lifestyle” OR Physical Activity / Sedentary lifestyle / activity “activity promotion” OR “physical education” promotion / physical education / exercise School-based interventions terms: “School Health” OR “School-based activities” OR School health / School-based activities / schools “Schools for Health Promotion” OR “Healthy for health promotion / healthy school strategies / School Strategies” OR "school nutrition" school canteen Food system/environment terms: “Garden” OR “Food environment” OR Garden / food environment / healthy environment “Community Kitchen” OR “Healthy Corner” OR / community kitchen / healthy corners / grocery “Grocery Store” OR “Healthy Spaces” OR stores / healthy spaces / supermarket "supermarket" Source: Authors’ own contribution. ANNEX 3 – INDICATOR SCORING METHODOLOGY STEP 1: Identification of Indicators to be Analyzed. 1. Identify indicators in the project Results Framework that are used to measure progress on identified objectives to address obesity and prevent NCDs 2. Highlight all indicators mapped to relevant PDO(s)/component goals in the mapping exercise. 3. Eliminate indicators that were dropped/not measured by project completion. 4. Eliminate indicators with clear divergence from obesity (e.g., smoking prevalence, contraception) 5. Include the remaining indicators as indicators to be mapped and scored. 71 STEP 2: Score each individual performance indicator. 1. Score indicators based on extent of achievement relative to target set at project onset or, if applicable, the most recent project target set based on a scale of 0–5, according to the following thresholds: Achievement Point level Definition s Surpassed x >125% 5 Achieved 100% or "Achieved" designation 4 Almost achieved 99% > x > 75% 3 Partially 75% > x > 50% or "partially achieved" designation (if not achieved able to calculate percentage) 2 Partially unachieved 50% > x >25% 1 Not achieved <50% target or "not achieved" designation 0 STEP 3: Calculate success scores for PHC-specific subdomains 1. For a given PHCPI-specific subdomain, identify the number of performance indicators that correspond to that dimension of PHC. 2. Determine the average score across the indicators, separating PDO indicators from IO indicators. a. X (PDO Indicator score) = S (PDO achievement scores) / S (5 * # of PDO indicators) b. Y (IO indicator score) = S (IO achievement scores) / S (5 * # of IO indicators) 3. Calculate a weighted average of the PDO and IO indicator scores to determine the PHCPI-specific subdomain score (0 < Z < 1). a. Z (PHCPI domain/subdomain success score) = (X * 0.6) + (Y * 0.4) 72 4. Determine an overall “success” score for each PHCPI-specific subdomain according to the following thresholds: PHCPI-specific subdomain success score Definition Success Z > 0.75 0.75 > Z > Partial success (Upper) 0.50 0.50 > Z > Partial success (Lower) 0.25 Failure Z < 0.25 STEP 4: Calculate overall project success score 1. For each PHCPI-specific subdomain scored in a project, determine the equivalent “K” success score on a scale of 0 to 3. PHCPI-specific subdomain Equivalent “K” success score score Success K=3 Partial success (Upper) K=2 Partial success (Lower) K=1 Failure K=0 2. Weight each PHCPI-specific subdomain score of a project according to the relative number of indicators within each specific subdomain: a. Weighted “K” score = (# of indicators in specific subdomain / # of performance indicators mapped in the project) * PHCPI-specific subdomain “K” score 3. Take the total sum of weighted “K” scores across the PHCPI specific subdomains to determine the overall project score “K” according to the following thresholds: Success Definition Success K>2 Partial success 190% death certifications coverage, <11% of deaths are ill- defined. 84 • BPS, RUCAF, ASSE, and FNR beneficiary databases and internal MSP databases are integrated into the National Health Information System. • Percentage of population registered with FM teams. • Development of NCD data registry • Percentage of ASSE beneficiaries registered in electronic medical records. Service delivery Population health management (N = 7 projects) Proactive population 4 • Number of toolkits for tobacco and alcohol control, and diet and physical outreach activity developed according to target group. • 2,500 students take courses on healthy lifestyles in elementary schools by 2000. • Health promotion for prevention of CVD among school children carried out. • Proportion of public schools implementing "healthy school" strategies. Community 1 • Beneficiaries in 80% of Indigenous communities receiving grants have engagement met stated objectives, and 50% consider that the subprojects have contributed to the improvement of previously defined health problems. Local priority setting 3 • At least 200 out of 700 participating municipalities certified as Health Responsible Municipalities. • Number of administrative villages that have initiated the implementation of “healthy village.” • Number of Health Departments that carry out "Healthy Municipality" strategy, including (a) health promotion subprojects related to NCDs, and (b) development of healthy spaces. High-quality primary health care (N = 6 projects) First contact 1 • Per capita annual visits to family medicine physicians. accessibility • Share of family medicine visits in total visits. Comprehensiveness 2 • Systemic implementation of selected preventive services (e.g., hypertension, breast cancer, prostate enlargement, smoking, etc.) in at least 2 major FBiH cantons. • Provision of preventive services increased by providers. • % of Medical Office of Health areas with at least two healthy lifestyle centers. Continuity 2 • % of individuals over 35 with hypertension who have been followed-up in the last three months. • Percentage of hypertension cases diagnosed and under follow-up by primary care teams. • Percentage of diabetes cases diagnosed and under follow-up by primary care teams. • Percentage of overweight/obesity cases diagnosed and under follow-up by primary care teams. • Percentage of ASSE beneficiaries with risks for NCDs detected that are receiving follow-up under Previniendo guidelines. Person-centered 2 • Increased satisfaction and perceived quality of care in counseling centers. • Client satisfaction with health services. Outputs NCDs and mental 3 • Increasing percentage of hypertensive patients (measured quarterly) health correctly receiving treatment at facilities enrolled in the pilot. • Cardiovascular disease (CVD) prevention and control as measured by number screened and treated (equipment, training provided) 2014: 85 Percentage of eligible persons (both men and women) in age group >30 years screened for hypertension. • Percentage of persons (over 40 years) screened for selected NCDs (diabetes, hypertension, cancer) at healthy lifestyle centers. • Percentage of population 45–64 years of age covered by the National Integrated Health System and screened for NCD risk factors. • Percentage of population between 45–64 years with ASSE coverage screened for NCDs risk factor. Health promotion 3 • Percentage increase in awareness of linkage between habits and behaviors, and NCD risks (such as cardiovascular disease, cancer, diabetes, stroke) among public education and health care employees. • Percentage of health workers aware of links between physical activity and health. • Percentage of educational workers aware of link between physical activity and health. • The recognition of the Heart Healthy logo will be at least 15% among the adult population by 2000. Disease prevention 1 • Coverage of population through family medicine (FM) teams. • Utilization rates for preventive services increased. Outcomes Health status 3 • Age-standardized ischemic heart disease death rate. • Daily salt intake. • Daily fat intake. • Prevalence of diabetes. • Percentage of people with high levels of physical activity. • People aged 18 years and over overweight or obese. • Crude mortality rate from Diseases of the Circulatory Systems in population under 70 years. Source: Authors’ own contribution. Notes: RFW = Results Framework; NCD = Noncommunicable disease; PHC = Primary health care; CVD = Cardiovascular disease; RS = Republika Srpska; MOH = Ministry of Health; PCPs = Primary Care Physicians; PHCPI = Primary Health Care Performance Initiative; FBiH = Federation of Bosnia and Herzegovina; FM = Family medicine; IT = Information technology; PAT = ; GP = General practitioner; MSP = Ministerio de Salud Provincial (Provincial Ministry of Health). ANNEX 9 – ADDITIONAL RESOURCES FOR PHC IMPROVEMENT Resource Description Governance and leadership WHO Capacity Mapping for This World Health Organization report includes comprehensive tools to assess Health Promotion capacity in health promotion planning, program implementation, financing, and cross-sector collaboration. Application of assessment tools can be utilized to identify gaps to be addressed in future planning efforts. Quality management infrastructure Obesity Care Model Playbook Created by the American Medical Group Association, this playbook incorporates strategies and performance indicators for obesity prevention and management for four critical actors: (1) Community, (2) Health care organizations, (3) Primary care teams, and (4) Patient and family-centered programs. Indicators for Measuring This set of indicators, developed as part of the report “Evaluating Obesity Progress in Obesity Prevention Prevention Efforts: A Plan for Measuring Progress” encompasses indicators that can be utilized by national and community-based stakeholders to monitor the achievement of six population based and high-risk approaches to obesity prevention and management. Local priority setting 86 Healthy Municipalities and Developed by the Pan American Health Organization (PAHO), this kit is geared Communities: Mayor’s Guide for toward mayors and local authorities to guide the design and implementation of Promoting Quality of Life the HMCC approach for good health governance at the local level. The kit encompasses practical strategies that can be adapted across various economic, cultural, and geographic contexts. Proactive population outreach WHO Health Promoting Schools The WHO HPS framework outlines critical components that must be (HPS) Framework implemented to achieve effective health promotion in schools. Most recently, a list of global standards and indicators, along with an implementation guide for HPS schools, have been developed and will be formally published soon. Source: Authors’ own contribution. Note: HMCC = Healthy Municipalities, Cities and Communities. 87 REFERENCES Allen, L. N., R. W. Smith, F. Simmons-Jones, N. Roberts, R. 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The World Bank Health, Nutrition, and Population (HNP) Global Practice has a key role to play in catalyzing a PHC approach to tackle obesity. However, a World Bank report published in early 2020 highlighted a lack of health sector stewardship in supporting client countries to address obesity. As such, there is little systematized understanding of best practices for realizing a PHC approach to address obesity in World Bank health sector investments. This paper aims to bridge this knowledge gap by conducting an in-depth review of completed World Bank health sector investments that sought to address obesity and prevent NCDs in LMICs. Utilizing Primary Health Care Performance Initiative (PHCPI) tools, this evaluation systematically identifies and maps relevant project objectives, activities, indicators, and successful approaches to critical components of strong PHC systems. Successful projects are further investigated through in-depth document review and Task Team Leader interviews to synthesize successful strategies for PHC improvement and lessons learned. This investigation found that, while limited, completed projects demonstrated an important precedent of HNP stewardship to address obesity. Completed HNP projects were characterized by key successes, particularly in building national capacities for addressing the challenges of obesity and NCDs, implementing community-based health promotion policies and programs, and improving primary care services for NCD early detection and management. That said, completed projects also highlighted critical gaps in health sector stewardship, particularly in supporting multisectoral action to realize a “Health in All Policies” approach. As HNP scales up support to client countries to address obesity and prevent NCDs, project successes and persisting gaps identified in completed HNP projects offer crucial lessons for the future. ABOUT THIS SERIES: This series is produced by the Health, Nutrition, and Population Global Practice of the World Bank. The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account this provisional character. For free copies of papers in this series please contact the individual author/s whose name appears on the paper. Enquiries about the series and submissions should be made directly to the Editor Jung-Hwan Choi (jchoi@ worldbank.org) or HNP Advisory Service (healthpop@worldbank.org, tel 202 473-2256). For more information, see also www.worldbank.org/hnppublications. 1818 H Street, NW Washington, DC USA 20433 Telephone: 202 473 1000 Facsimile: 202 477 6391 Internet: www.worldbank.org E-mail: feedback@worldbank.org