The Global Alliance against Respiratory Diseases (GARD) Country Report

Dear Sirs,

The Global Alliance against Respiratory Diseases (GARD) is a network within the World Health Organization (WHO), comprising representatives of national and international organisations, institutions and agencies, all of whom are working towards the common goal of improving global lung health.^1–3 GARD aims to increase worldwide recognition of the importance of Chronic Respiratory Diseases (CRDs) as one of the most important health problems globally, and also aims to establish cooperation between countries and GARD member organisations in improving programmes for the prevention and management of CRDs.^2,3

GARD was formed almost a decade ago, and since then there have been many successes, particularly at country level (see Table 1). There has indeed been increased recognition of the importance of chronic diseases, as demonstrated by the United Nations Summit on Chronic Diseases held in 2012, during which CRDs — along with cardiovascular diseases, diabetes and cancers — were recognised as major priorities.

Table 1. GARD Country Plans.

However, in many countries there has been reluctance to engage with local GARD champions in establishing local initiatives. One reason for this is a preference for national health services to devise strategies that include other chronic diseases, and in many countries there appears to be a lack of political will to commit to effective CRD prevention and control measures. Nevertheless, local GARD champions — many of whom are national and international leaders in respiratory and allergic disease professional medical societies — continue to be key activists for the formation of effective programmes.

Current projects vary in different countries according to country-specific needs and the level of engagement of government health departments. Where government involvement is strong, as in Turkey, Italy and Portugal,^4–6 progress has been considerable. In Italy, Portugal, Kyrgyzstan, Russia and Turkey, GARD has played a significant role in assisting the development of national CRD control programmes. However, in other countries the GARD-supported programmes are more limited, being either disease-specific or restricted to certain geographical regions. In 2012, GARD played an important role in helping to establish the Portuguese National Programme on Respiratory Diseases.⁶ The Dutch GARD leadership succeeded in convincing the government to develop a SMART-formulated collaborative National Action Programme on CRDs.⁷ In the Czech Republic, GARD leaders launched CARO (Czech Alliance against Chronic Respiratory Diseases), leading to the formation of a National Programme by the Ministry of Health in 2008. GARD Brazil has made significant strides in including a guideline for prevention and management of asthma, rhinitis and COPD in primary health care programmes, and has implemented a pilot project utilising the Practical Approach to Lung Health (PAL); in addition, access to free inhalers for patients with asthma has increased throughout the country.⁸

GARD has four strategic objectives: advocacy; partnership; national plans; and surveillance. For each objective, expected outcomes, indicators, milestones and core activities have been established.

Advocacy

The majority of countries have focal points within their governmental health departments, usually the officer in the health ministry responsible for NCDs. Obtaining and maintaining ongoing ministerial endorsement is a problem in some countries since governments can change frequently and rapidly, causing changes in health policy and national priorities.

Partnership

GARD's policy is to develop and maintain a network of collaborative partnerships with different parties, which then helps with both human and financial resources. The number of collaborating parties in different countries varies, and is highest in Turkey (58 parties), Italy (42), the Netherlands (34), Czech Republic (21), Portugal (18), Iran (13) and Krygyzstan (12). Funding models also vary. In Turkey and Italy, GARD projects are funded by the Ministry of Health, and in the Netherlands there is substantial government funding. In most other countries, GARD activities are funded by a variety of sources including non-governmental organisations (NGOs), pharmaceutical companies and the private sector.

National plans

The expected outcome for national plans is a strengthening of existing initiatives for CRDs and the adoption of multisector national policies which conform to the WHO Action Plan for NCDs (see Table 1). GARD Turkey is a good example of this integration.⁹ In Turkey's national plans, not only were CRDs included in the NCD plans, but the GARD-affiliated CRD experts led the development of an NCD network that established the national plan. In Italy, planning innovation required confrontation of issues that threaten public health.⁴ In the Netherlands, their national programme aims to reduce hospitalisation days, productivity loss, adolescent smoking, and mortality due to asthma and COPD.⁷ South Africa's plan included development of an integrated care clinical practice guideline for asthma, COPD, TB and pneumonia, as well as a training programme for primary care nurses and doctors; initially called Practical Approach to Lung Health South Africa (PALSA PLUS), the South African programme is now called PC101 and has been adopted by the Ministry of Health for national roll-out.¹⁰ Integrated Care Pathways for Airway Diseases (AIRWAYS-ICPs) is a GARD demonstration project approved by the European innovation Partnership on Active and Healthy Ageing (DG Sanco and CNECT, European Union).

Surveillance

Expected outcomes are the development of a WHO framework for evaluating CRDs, collection of epidemiological information, identification of knowledge gaps, and the development of cost-effective interventions.² A further outcome is the proportion of participating countries whose information on CRDs is reported to WHO and subsequently published. Using national ministry of health data, information and analysis from two countries, Turkey^5,9 and Italy⁴, has already been published.

To date, GARD's major achievements have been the launch of national GARD-led initiatives and a variety of projects in partnership with government health departments, as exemplified by GARD's role in Turkey, Portugal and Italy. Arguably, GARD's greatest achievement has been its ability to forge collaborative partnerships and develop a shared vision with a large number of parties including professional medical societies, patient organisations, medical and pharmaceutical companies, NGOs, governments, and WHO, in order to address chronic respiratory diseases and allergy worldwide. Preventing and controlling CRDs, and keeping them on the global health agenda, will require the ongoing energies of all involved in GARD.