FeaturedWHO is the COHESION Project?

COHESION is the acronym of COmmunity HEalth System InnovatiON Project. It brings together institutions from Mozambique (Universidade Eduardo Mondlane), Nepal (B.P. Koirala Institute of Health Sciences), Peru (Cronicas Centre of Excellence in Chronic Disease at the Universidad Peruana Cayetano Heredia) and Switzerland (University of Geneva, Geneva University Hospitals, Graduate Institute and the Università della Svizzera italiana) with a focus on improving the management of Noncommunicable (NCD) and Neglected Tropical diseases (NTD) at Primary Health Care (PHC) for vulnerable populations.

Rather than focus on the “what” of the project: NCDs, NTDs and PHC; or the “how”: mixed methods, co-creation, innovative, adapted interventions at the community level and active communication with a variety of stakeholders, the first blog post of the COHESION Project will be on the “who”.

So who is the COHESION Project? The core team is comprised of leading academics in the fields of public health, epidemiology, clinical medicine, economics, sociology, gender, social marketing, communication, and anthropology. With many years of experience in different settings and across disease areas, the COHESION Team brings together a unique group of people. The sum of these individuals is an exceptional team with a unique set of skills and experience.

How did this team come together? This team is brought together by long-standing working relationships, joint projects, membership of similar networks, but most importantly a shared vision of:

  1. Mutual learning
  2. A focus on the most vulnerable
  3. Health systems strengthening
  4. Robust design and evaluation of complex interventions

The proposal and its approach were developed by the whole team building on the needs of the most vulnerable populations in the three countries as well as on the skills and expertise of the country groups and their members. Together we agreed on the proposal and its approach and in doing so became a cohesive team and highly motivated to make the COHESION Project a success.

3 GroupIndoorsColorFilter1_1100x665px

Co-creation Process in Nepal

The co-creation process was launched in Nepal in August and aimed at involving stakeholders at different levels in the selection of potential interventions. Two workshops were held in Itahari and Banyani districts. Participants included PHC staff and local health authorities, as well as community members comprising local leaders, representatives of local associations, female health worker volunteers and teachers.

During the workshops research findings were shared with participants. Afterwards they were divided into working groups, based on their seniority and gender, to collect their suggestions of potential activities that could be developed to address the gaps identified during the baseline research. Following the group discussions, participants presented their views in a plenary session.

In relation to NCDs, suggestions were numerous but mainly focused on Behavior Change Communication (BCC) interventions to promote healthy lifestyle and prevent these diseases, and on the need to improve access to diagnostic and treatment at PHC level. “Monthly lab camps” were also suggested as massive screening for NCDs. As for leprosy, the selected NTD for Nepal, active case finding door to door and health education targeting remote vulnerable populations were mentioned. For both NCDs and NTDs, stakeholders asked for better follow up and regular supply of drugs.

At the policy level, similar co-creation workshops were held in Kathmandu during the “National Conference of Nepalese Society of Community Medicine (CONCOM)” that took place on August 26th and at the “Nepal Health Research Council (NHRC)” which took place on September 1st. Approximately 100 participants from different sectors such as MoH representatives, faculty members, lectures and post-graduate residents of community medicine and public health professionals attended these workshops and contributed in identifying potential interventions. Some of the discussion topics included the need to improve the health insurance coverage and the global budget for health.

The suggestions provided by stakeholders from community, health system and policy levels are being studied by the Nepalese COHESION team, to prepare for a next round of consultation where the aim will be to prioritize interventions that could be developed during the next phase of the project.


Co-creation session in Baniyani.


Co-creation session at the Nepal Health Research Council (NHRC)


At the beginning of September 2017 in Bern the 4th International Conference on Research for Development (ICRD) was held. The aim of the conference was to present “visionary contributions that will enhance transformations towards sustainable development in countries of Africa, Asia, and Latin America.” (www.icrd.ch)

COHESION was of course present at this important event. COHESION co-organised two sessions on partnerships with the Council on Health Research for Development (www.cohred.org) and Commission for Research Partnerships with Developing Countries (www.kfpe.ch). Maria Amalia Pesantes from the COHESION Team in Peru was a panelist during a session on increasing equality in partnerships. These sessions on partnerships highlighted a variety of challenges in establishing partnerships, but also tools developed to help address these and the role funders can have in helping facilitate partnerships. One interesting aspect was thinking about the process of partnerships and how there are “Hard elements”, such as shared vision, setting the agenda together, fairness and sharing of process and capacity building. In parallel “Soft elements”, such as trust, respect, being open and cultural differences are equally important. Both hard and soft elements are essential to ensure success, but require different approaches to be established. It was interesting to reflect on these as COHESION as a project and a partnership evolves.

Silvana Perez Leon also from the Peru Team won a grant to present some of her work at the conference. During the session “Building transformative partnerships between health services and communities as a means to advancing the Agenda towards Sustainable Development: A pathway forward”, she presented her experience engaging with primary health care workers and community members in the COHESION project. She pointed out some of the enablers and challenges the Peru team had in building transformative partnership. Lessons from this session were that the WHO is preparing a community engagement framework that can be used for projects like COHESION. Recommendations were also that as a project we should systematically document our process of engagement which can later be used as evidence for other initiatives.

Besides COHESION’s direct contribution to the content of the conference, this was a unique opportunity to link the work being done in Mozambique, Nepal, Peru and Switzerland to the wider development agenda. A message that was mentioned frequently was the unfinished Millennium Development Goals (MDG) Agenda. Another element discussed widely was the link between economic development and health in parallel to progressing political processes and the role of communities and civil society in this.

These aspects are interesting in thinking about COHESION’s approach in dealing with diseases of poverty (NTDs) and diseases that are intimately linked to development (NCDs) by focusing attention on communities to develop interventions.

Being based in Switzerland it also emphasised the importance of Switzerland as a donor, funding such projects as the r4d scheme as well as that the Sustainable Development Goals (SDG) unlike the MDGs are for all countries and not just low income countries. This requires a change in approach from one of high income settings coming with solutions to MDG related problems to, as stated in SDG 17, partnership. The SDGs are integrated and inseparable in that many of the goals are interlinked.

The banner at the entrance of the conference had the following three words:
– Evidence
– Engagement
– Policies

Thinking about these three words and the SDGs, COHESION is increasing the evidence base in terms of burden of NCDs and NTDs at policy, health system and community level. To address these challenges, COHESION by engaging local stakeholders will develop innovative interventions to address these challenges. Based on the COHESION research to date the issue of policies is of concern in that although many aspects of NCDs and NTDs are being addressed in health systems through the delivery of care, but policies are lacking to help guide these responses and involve communities. From a COHESION perspective, a fourth element to the ICRD list would be implementation. In that evidence, engagement and policies without implementation are meaningless. As COHESION moves from formative research, engaging local stakeholders and understanding global and national policies, its next step will be to implement innovative interventions to contribute to the achievement of the SDGs.

Reframing non-communicable diseases as socially transmitted conditions: it is not about naming, but framing

Allen and Feigl1 fail to emphasize that non-communicable diseases (NCD) were framed and not named in global health discourse. NCDs from a global health perspective are currently thought of as four diseases and four associated risk factors.2 This framing does not include many NCDs, such as genetic defects, mental health and injuries, which by definition are included in the categorization as they are not transmitted from person to person. Within the 4 prioritized NCDs there are conflicts with what Allen and Feigl1 and others propose3,4. Some cancers are caused by a virus and are curable. Type 1 diabetes is of unknown etiology compared to type 2 diabetes which is mainly driven by changes in the environment.

Allen and Feigl5 state that the “global health community does not spend much time on branding”. We agree with this statement, but highlight that three communicable diseases which receive significant funding, namely HIV/AIDS, tuberculosis and malaria did not rename themselves. Two stuck to the causative pathogens and the third with its original name linked to the notion that it was caused by “bad air”. Advocates reframed these health issues, beyond a purely health based discourse and the specialist and academic spheres, as wider concerns impacting global security, economies and development.6,7

The inclusion of NCDs in the Sustainable Development Goals (SDG) is a unique opportunity. We suggest linking NCDs with each SDG in order to highlight that development cannot succeed without the inclusion of NCDs.8 One could call this the COHESION approach in that the focus of our work on NCDs and NTDs are the tools that allow us to address the SDGs versus a disease centric approach. For example SDG 1 and NCDs as caused and causes of poverty; SDG 2 and malnutrition as a risk factor for NCDs and that the double burden of malnutrition needs to be addressed; SDG 3 and how NCDs need to be included in Universal Health Coverage; Gender issues (SDG 5) as NCDs impact women and men in different ways; SDG 11 and in making cities safe this needs to include NCDs with regards to road traffic accidents and providing safe spaces for exercise and access to healthy food; and SDG 17 that national and global partnerships across sectors will be necessary to solve this challenge.

“What’s in a name? That which we call a rose; By any other name would smell as sweet. As stated by Romeo and Juliet names do not have an impact and the rose remains a rose no matter what we call it. NCDs will not be solved purely by being renamed, they need to be reframed politically.

1. Allen LN, Feigl AB. Reframing non-communicable diseases as socially transmitted conditions. The Lancet Global health 2017; 5(7): e644-e6.
2. WHO. Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva: World Health Organization, 2013.
3. Lincoln P. Renaming non-communicable diseases. The Lancet Global Health 2017; 5(7): e654.
4. Rigby M. Renaming non-communicable diseases. The Lancet Global health 2017; 5(7): e653.
5. Allen LN, Feigl AB. What’s in a name? A call to reframe non-communicable diseases. The Lancet Global health 2017; 5(2): e129-e30.
6. Stabinski L, Pelley K, Jacob ST, Long JM, Leaning J. Reframing HIV and AIDS. BMJ 2003; 327(7423): 1101-3.
7. de Waal A. Reframing governance, security and conflict in the light of HIV/AIDS: a synthesis of findings from the AIDS, Security and Conflict Initiative. Soc Sci Med 2010; 70(1): 114-20.
8. Beran D, Chappuis F, Cattacin S, et al. The need to focus on primary health care for chronic diseases. The lancet Diabetes & endocrinology 2016; 4(9): 731-2.

Co-creation with Communities in Peru

During the weekends of July 21st and 23rd 2017, the COHESION team in Peru visited the communities of Sicacate and Pingola to hold meetings with community members and begin the brainstorming process of future COHESION interventions. Thirty people participated in the Sicacate meeting (22 women, 8 men) and 34 in the meeting in Pingola (20 women, 14 men).

The experience from previous visits to the sites allowed our team members to use effective communication strategies to invite community members and secure participation. During the two weeks preceding the co-creation session, team members made phone calls to community leaders and visited the areas to disseminate information about our activities. This included placing posters in different community settings, broadcasting messages through the local radio station and community loudspeakers, as well as carrying out interpersonal communication activities where health personnel and school teachers invited community members to join our sessions.

Each meeting lasted around two hours and project team members collected suggestions for possible actions around each of the selected diseases. The sessions began with an explanation of the project, followed by information about the diseases. Then group discussions took place to collect suggestions of possible interventions.  The suggestions revolved around getting more information about the disease, making diagnostic tests available at the PHC, and providing examples of well-balanced meals and sanitation improvement.

The next meetings will take place in mid-October where the Lima team will return to discuss a subset of potential interventions, from which community members will then make a final selection and discuss the reasons behind their selection.

Co-creation session, Pingola.


Co-creation meeting dissemination, Sicacate.


Co-creation session, Sicacate.

Research Assistant from Peru awarded scholarship for ICRD

The fourth edition of the International Conference on Research for Development (ICRD), will be co-hosted by the Swiss Programme for Research on Global Issues for Development (r4d programme) and by the University of Bern’s Centre for Development and Environment (CDE). The event will take place 5-8 September 2017 in Bern, Switzerland, with the theme “Evidence. Engagement. Policies.”

The ICRD offered young researchers the opportunity to apply for financial support to participate in the conference. Silvana Pérez León, COHESION Research Assistant in Peru, applied and was awarded the scholarship.

“I thought this was a great opportunity to build a proposal and show some of the work the COHESION project has been doing in Peru. The session that captured my attention was ‘Building transformative partnerships between health services and communities as a means to advancing the agenda towards sustainable development: a pathway forward’; because one important objective of COHESION is to build interventions in primary health care services that include the participation of the community.” – Silvana Pérez León

Silvana’s proposal to the ICRD included information gathered during the engagement and formative studies with health workers and the communities. This process enabled the Peruvian team to understand and acknowledge the needs of different stakeholders and to start thinking about how COHESION could design interventions that build transformative partnerships between health services and communities.

Silvana will be a panelist at ICRD on September 6, showing some of the work the Peruvian team has been developing in the past months.

Silvana Pérez León presenting at the ICRD.


Silvana Pérez León collecting data that informed her presentation at ICRD.

Seminar in Peru: Health Policies and Systems Research

The CRONICAS Center of Excellence in Chronic Diseases is sharing knowledge, building capacity and mutual understanding of health Policy and Systems Research.

Given the growing emphasis on health systems research and the role of health policy in the health of populations, the Peruvian team of COHESION, CRONICAS recently held a seminar on the topic.

Here is an overview of what took place and what the main and most important messages were:

On July 03 2017, the Institute of National Health (INS) and CRONICAS Center of Excellence in Chronic Diseases with the support of The Alliance for Health Policy and System Research- WHO, held the seminar “Health Policies and Systems Research” at the headquarters of the INS.  The objective was to show and discuss a new area of research that can be used for the implementation of policies.

Dr. Hans Vasquez from the “General office of Research and Technology Transfer” opened the seminar and stressed the importance of moving forward from diagnostic research to doing research that can have a bigger impact on health. In countries like Peru there is little research on policies, health systems or implementation.

The first presentation was provided by Nhan Tran, manager of “The Alliance for Health Policy and Systems Research (AHPSR)”. He said that the current challenge is to ensure health interventions are effectively integrated into health systems and are designed to be scaled up in different contexts. He pointed out that one of the reasons why implementation is so difficult is because implementation is about change (asking organizations to behave differently, people to do things differently, etc.). That is why it is important to think implementation as a process of change. Finally, he emphasized three main important shifts on how to do implementation: 1) applying a more systems perspective, 2) thinking about research as part of the implementation research, and 3) having local investment in implementation.

(Left to right Dr. Hhan Tran and Dr. Hans Vásquez; picture from INS https://goo.gl/iwfkAt)

The next two presentations were from representatives of the public sector, Dr. Manuel Catacora Villasante from the “Institute of assessment in technologies in Health and Research” of the Social Security; and Bio Gisely Hijar Guerra from the “National Center of Public Health-INS”. They talked about the prioritized research subjects of their institutions, gave some examples of research being developed and pointed out some opportunities of funding.

The fourth presentation was given by Dr. Ludovic Reveiz from the Pan American Organization, where he explained how there is still too little information on how to do implementation research in policies. He showed the work the program iPIER is developing in Latin America and the Caribbean, which aims to facilitate improvements in program implementation through implementation research. An important part of this program is a workshop where the grant recipients receive a basic understanding of the research methodologies in implementation research.

The fifth presentation was from Dr. Fernando Llanos of the Universidad Peruana Cayetano Heredia. He talked about his research in health systems at primary care and universal coverage. He explained some conceptual frameworks, the methodology of the study and some final conclusions. He highlighted two important conclusions; first that before thinking in primary health care, there should be a clear definition of what is considered primary health care in Peru, and second, that talking about universal coverage meant to think of the system as a whole, because in the Peruvian context there are several subsystems.

Mg. Gerardo Seminario of “Salud sin Limites” gave the final presentation where he spoke about the process of making an agenda for public policies for the health of indigenous populations in Peru. He pointed out that a policy agenda is not necessarily a rational decision but derives from other factors like power roles, negotiations, institutional frames, etc. The making of an agenda consists on the concurrence of 4 factors: a problem, a possible solution, stakeholders and a window of opportunity. He concluded that the policies for the health of indigenous populations is still fragile, because the response for intercultural health is accepted but only on the surface, because the network of experts is not consolidated, because politicians change frequently as do their interests, because the vertical structure of the health system does not facilitate an intercultural health, and because the window of opportunities is narrowing.

(Picture from INS https://goo.gl/iwfkAt)

At the end of the seminar there were two panel discussions. One, about the priorities of research policies and health systems, included the participation of Dr. Maria del Carmen Calle Dávila (General Directorate of Strategic Interventions in Public Health) and Dr. Hans Vasquez (INS). The second panel was about funding opportunities for research in policies and health systems, and included Dr. Franco Romani (INS) and Dr. Alexander Tarev (General Directorate of Strategic Interventions in Public Health). The discussions brought to our attention the efforts of the public sector to do research, and though these efforts are few and recent, the road is being build. There is still the need that the research community meets the demands of the public sector. In that sense it is necessary that the public sector opens more opportunities where policy makers and researchers can encounter each other.

This seminar was a good opportunity for the dialog between the research community, policy makers and civil organizations. For the COHESION team, it was a good moment for engagement and to gain an update of the research being done in in health policies and systems.

CRONICAS and Health Systems Research:

At CRONICAS Center of Excellence in Chronic Diseases there have been past and ongoing research projects related to the assessment of health systems. Through 2012-2013 the project “Barriers” financed by the AHPSR, piloted for the first time in Peru a research implementation manual for the evaluation of healthcare systems’ responses to chronic non-communicable diseases. Currently the COHESION project has as objective to improving the health system response for attending the double burden of Noncommunicable and Neglected Tropical Diseases. Initiatives like these are in the path to look for solutions for the current health issues the health systems face.

Additional information:

Second Advisory Board Meeting in Peru

On the 15th of June 2017 the Peruvian team had their second Advisory Board meeting of the year. This meeting included the COHESION team in Peru and Advisory Board members Jeanine Anderson, Peter Busse, Cesar Náquira, Flor Calderon and Luz M. Moyano.

Maria Amalia Pesantes and Maria Kathia Cardenas presented preliminary results related to the qualitative study of “Local perceptions in the community” and to the “Health System Assessment”. Silvana Pérez León presented the process of co-creation the COHESION team will be developing in the following months.

As a result, the Peru Advisory Board suggested:

  • A possible intervention would be training health workers in the diagnostic of neurocysticercosis by secondary methods, for example through interviews, clinical history, or other practices.
  • To consider the different type of religions in the community as important for further interventions.
  • The school would be a suitable place to teach about sanitation. Changing attitudes in people’s lives takes time and starting with the children is a good option to see changes in the future.
  • It is important to know who the community are leaders. Work with a leader of the community that has legitimacy and that is effective in providing messages to the community
  • Some possible interventions could be providing education on the diseases of the project through game platforms for the children.
  • Good interventions for these localities would be related to education in sanitation, because working with children would be a better approach than working with adults.
  • To think the interventions in terms of the prevention of the diseases in addition to the damage of the diseases.
  • It is crucial to provide information of the diseases to the communities during the co-creation process.
  • It is important to try to change habits, to give the opportunity for the community to react in response of some of the information that will be provided by us, that they would like to change.

Finally, several of the members agreed that the co-creation process should be framed carefully, so the interventions proposed by the community would not generate expectations of interventions that are not possible for the COHESION project.

Engagement activity with stakeholders at the macro level of the health system in Lima- Peru

Summary: Engagement activity with stakeholders at the macro level of the health system in Lima- Peru

On May 3, the COHESION project in Peru held a meeting with stakeholders, where stakeholders related to the health sector and the diseases related to the project (diabetes, hypertension and neurocysticercosis) were invited. The purpose of the meeting was to present the project, create links with different institutions and receive inputs or recommendations for the project.

The meeting was attended by members of the COHESION project in Peru, part of the COHESION team from Switzerland, public officials from both the Ministry of Health and the Superintendence of Health, as well as some civil society organizations such as the Diabetes Association of Peru and the Peruvian Federation of rare diseases.

The meeting began with the words of welcome from Jaime Miranda, Director of “CRONICAS center of excellence in chronic diseases”. During his welcoming he remarked the intention of the meeting to carry out a co-creation process between the COHESION project and the assistants, to think together ways of improving the health system, especially in the attention given in the primary health care.

Following, David Beran principal investigator of the COHESION project made a presentation of the project COHESION (in Spanish). He explained the linkage between the project with the Millennium Development Goals and the Sustainable development objectives. He also pointed out important qualities of the project like being a multidisciplinary and multi-country team. Finally he explained the different stages that the project has carried out and the stages to come in the next years.

Subsequently, the words were given by María Kathia Cárdenas, coordinator and researcher of the COHESION project and at CRONICAS Center of Excellence in Chronic Diseases. During her presentation she explained the COHESION project in the Peruvian scenario. She specified the project is being carried out in the region of Piura, in the health posts of Sicacate and Pingola, located in the districts of Montero and Ayabaca respectively. During this presentation it was also specified two of the studies that the project is carrying on, the evaluation of policies and the health system assessment. She explained details of each study and the different levels of analysis. Furthermore, she also explained the methodology that is being implemented based on the manual “How to investigate access to care for chronic noncommunicable diseases in low and middle income countries” (2012) from the WHO, and she also explained the activities that were already performed at the community level such as interviews with patients, health workers, head of facilities, among others.

Next, María de los Ángeles Lazo, researcher of the COHESION project and at CRONICAS Center of Excellence in Chronic Diseases, detailed the steps that will follow the project in the next months to involve the stakeholders at the macro or national level. She explained to the participants the important need of their support and expressed the intention of the project to involve them actively in the process, as well as with other key stakeholders. It was also specified that in the short term the COHESION project will be contacting them to have personal interviews, to know their opinions on the health systems facilitators and barriers.

Finally the discussion was opened to the attendees so they could express their opinions, comment or question of the project. This final part was moderated by María Amalia Pesantes, coordinator and researcher of the COHESION project and at CRONICAS Center of Excellence in Chronic Diseases. Some of the most important arguments and recommendations are detailed below:

  • To include the perspective of caregivers. It is important the health system recognized their task, not only in a financial support, but also to be trained in the care of the patients and to consider the importance of psychological support for the caregivers, who were also called “acompañantes” (companions).
  • Developing engagement with key stakeholders such as public officials and political representatives is a long-term endeavor.
  • It is necessary to establish relations with the regional health directorate in Piura. This entity is the responsible of providing the health service, while the Ministry of Health is in charge of regulating and monitoring. It was also suggested to interview the head of the department of Planning and Budget and Human Resources, and to include the Regional Government, who has also responsibilities related to health, poverty, access to water and sanitation.
  • It was also highlighted the important role played by community agents in the health system.
  • It was acknowledged the low ability of the Ministry of Health to communicate strong messages. Furthermore, civil society lack of relevant information about diseases, especially the most neglected population.
  • Past experiences on training diabetes educators were shared and it was noticed that one of the main difficulties in the training of health workers was the high rotation to other health establishments, and this should be taken in to account for the project.


COHESION Team (Switzerland):

  • David Beran
  • Sarah Lachat
  • Suzanne Suggs
  • Nathaly Aya Pastrana

COHESION Team (Peru):

  • Jaime Miranda
  • Maria Kathia Cardenas
  • Maria Amalia Pesantes
  • Maria de los Angeles Lazo
  • Charlotte Darwis
  • Rosa Salirosa
  • Silvana Perez Leon


  • Jorge Calderón (President of the Diabetes Association in Peru)
  • Luciana Bellido Boza (Representative of Intendance of Research and Development – SUSALUD)
  • Jorge Ferrandiz (Executive Director of the Department of Prevention and Control of Noncommunicable, Rare and Orphaned Diseases)
  • Maria Lourdes Rodriguez (President of Hecho con Amor-asociation of multiple sclerosis in Peru and President of the Peruvian Federation of rare diseases)
  • Lilliam Lindley (Representative of Hecho con Amor-asociation of multiple sclerosis in Peru and President of the Peruvian Federation of rare diseases)


COHESION – a challenge to Frenk and Gómez-Dantés

In The Lancet, in February 2017 (http://dx.doi.org/10.1016/ S0140-6736(16)30181-7), two leading thinkers in global health, Julio Frenk and Octavio Gómez-Dantés, challenged the status quo of many of today’s public health and healthcare delivery processes through a detailed assessment of a variety of dichotomies that exist in global health. Frenk and Gómez-Dantés’ main message was the need for integration in global health across a wide range of challenges. This interesting piece led to a thought provoking discussion within the COHESION Team where we asked ourselves: are we operating within or beyond those scenarios of dichotomies?

The first dichotomy they describe is the prevention versus treatment debate. How does COHESION address this first dichotomy? For non-communicable diseases (NCD), even if all prevention measures are successful some people will still develop some of the conditions included in this overarching group. For Neglected Tropical Diseases (NTD) the “endgame” for many of these diseases is envisionable given the existence of medicines which provide a “magic bullet” to cure people and/or break the cycle of transmission. However, for both NCDs and NTDs people have already been exposed to some of the risk factors, have biological changes (e.g. high blood pressure; infected with Cysticercosis) and therefore require care. Yet, both NCDs and NTDs share fundamental root causes that determine its existence: poverty and exclusion. We cannot address treatment solely without the broader need for prevention.

The next “clash” described is the vertical versus horizontal debate. For NCDs and NTDs this debate is mute as the main driver of vertical programmes was funding. As was seen for HIV/AIDS funds were allocated to create complete vertical systems for distribution of medicines, training of health professionals, delivery of care, etc. For both groups of diseases that COHESION focuses on this funding is lacking thus vertical solutions are not implemented. That said NTDs are more at risk of becoming “verticalised” given the higher level of funding available in comparison to the burden, the “easier” solutions of mass drug administration (for some NTDs) and the defined populations that are impacted by some diseases. COHESION through its research and development of interventions will try to ensure a horizontal approach in order to benefit not only those with NCDs and NTDs, but any one requiring health care at primary level. We are allowing ourselves to redefine the interaction of an individual with the existing healthcare system where chronicity and continuity of care are fundamental.

Number three on Frenk and Octavio Gómez-Dantés’ list is primary versus specialized care. As mentioned above the main focus of COHESION is on primary health care. Given that our emphasis is on NCDs and NTDs which are both chronic in nature this will enable a strengthening of primary health care to guarantee continuity of care. Traditionally primary health care has been successful in maternal and child health, delivery of HIV/AIDS care (with significant funding) and acute care. However, with the burden of chronic disease a shift in the role of primary health care is needed. Through its formative research and interventions COHESION will focus its efforts on developing this level of the health system. We are not denying care, but aim integrate chronic care at primary health care as well as facilitate referral to specialized care when needed.

By design COHESION lays the fourth dichotomy to rest, the noncommunicable versus communicable disease prioritisaiton. By including NCDs and NTDs together within the core of its project COHESION wanted to focus on models of delivery of care versus mode of transmission. Leprosy and Type 2 diabetes from a delivery of care perspective share many similarities despite being communicable and noncommunicable. Need for proper diagnosis and initiation of treatment; patient education and empowerment; address issues of stigma; and prevention of complications.

Finally, the latest dichotomy posed the challenge between knowledge generation versus action. Again, COHESION is in a unique position thanks to the funding mechanism developed by the Swiss National Science Foundation and Swiss Agency for Development and Cooperation. The funding COHESION has received will not only enable the generation of new knowledge on NCDs and NTDs, at policy, health system and community level, but also to use this to co-create innovative interventions working closely with local partners through.

The title of Frenk and Octavio Gómez-Dantés’ comment includes the word “integrative”. COHESION in the design of its team and project has had this word as a guiding principle. Integration of different expertise from a variety of countries, institutions and individuals; different diseases and disease groups; different methodological approaches; local partners and stakeholders in the research and intervention development. As COHESION we would add another dichotomy to the list proposed by Frenk and Octavio Gómez-Dantés that is how solutions in global health are developed. Most solutions to date have had their roots in meetings at the World Health Organization, the minds of the best and brightest academics and in the offices of Ministries of Health. Our approach proposes a bottom up approach where interventions are informed by this, but designed by beneficiaries. To date although different normative documents exist on how to tackle the burden of NCDs and NTDs success is still far away. We hope through our innovative approach to find ways of addressing NCDs and NTDs as well as contributing to breaking down the dichotomies that Frenk and Octavio Gómez-Dantés highlight.


Written by David Beran and Jaime Miranda for COHESION








COHESION team meets in Nepal

Two members of the Swiss COHESION team (Sarah Lachat and Jorge Correia) traveled to Nepal
recently where they worked for 15 days with the local COHESION team (Nilambar Jha,
Suman Sing and Sanjib Sharma) at the B.P. Koirala Institute for Health Science.
The aim of the visit was to support the planning and implementation of the three
elements of the COHESION research project (policy analysis, health system assessment, community
perception study). In addition to working session at the BP Koirala, the selected sites of intervention
Itahari (urban) and Banyani (rural) were visited, including a visit of the two related Primary
Health Care centers and meetings with the local stakeholders (VCD committee members, staff from
the PHC centers, etc.). The current management of NCDs and leprosy was discussed, as well as perceptions regarding both types of diseases and related needs.
Another major aim of the visit was to perform a situational analysis of the management of patients affected by leprosy in Nepal, with a focus on therapeutic patient education, led by Dr.
Correia. This study was conducted in three sites, selected due to the number of leprosy patients that attend and the expertise of the institutions: B.P Koirala Institute of Health Sciences, Lalgadh Leprosy
Hospital and Services Center and the Anandaban Leprosy Hospital. More than 20 interviews were conducted with patients, caregivers, expert patients, health workers and program managers. Educational sessions were also observed.
Preliminary results show how stigma and social exclusion remain vivid, a source of distress for those who suffer from the disease. Many beliefs regarding the illness remain prevalent, still viewed by many patients as a curse or divine punishment despite the numerous education campaigns aimed at improving the understanding of the disease. Furthermore, treatment of leprosy and its reactions were discussed in-depth, and most importantly, the capital role of self-care to prevent disability. Different models of existing therapeutic education programs were analyzed. These were very well set up in the two specialized institutions visited, and limited in other health centers. Policy interviews with  program managers from three main NGOs involved in leprosy management were conducted jointly by the Swiss and Nepalese COHESION team members.
Before leaving the country, the joint team also paid a visit to the office of the Swiss Cooperation
Agency (SDC) and built a promising partnership with local officers. A brief policy interview on NCD
management was also performed with the WHO focal point of national Health Sector in Kathmandu.
A lot was done in little time. The main success was undeniably the opportunity to work together!