Chronic diseases and health promotion

Part Four - Taking action: essential steps for success

Chapter One: Providing a unifying framework - the role of government

Itroduction to the stepwise framework

The stepwise framework offers a flexible and practical approach to assist ministries of health in balancing diverse needs and priorities while implementing evidence-based interventions.


The stepwise framework includes three main planning steps and three main implementation steps, which will be described in detail later in this chapter. The first planning step is to assess the current risk factor profile of the population. This is followed by making the case for action. The second planning step is to formulate and adopt chronic disease policy. The third planning step is to identify the most effective means of implementing this policy. The chosen combination of interventions can be considered as levers for putting policy into practice with maximum effect.

Planning is followed by a series of implementation steps: core, expanded and desirable. The chosen combination of interventions for core implementation forms the starting point and the foundation for further action. This chapter suggests specific milestones for different stages of implementation. These are not prescriptive, because each country must consider a range of factors in deciding the package of interventions that constitute the first, core implementation step, including the capacity for implementation, acceptability and political support.

The reality of planning

While the stepwise framework has the benefits of offering a rational process and rallying multiple disciplines around an acceptable course of action, it does not automatically resolve the difficulties encountered in planning chronic disease prevention and control programmes. The reality is that public health action is incremental and opportunistic, reversing and changing directions constantly. The different planning and implementation steps might in fact overlap with one another depending on the unique situation.

The priority accorded to different health programmes is partly a result of the broader political climate. It is important to identify, and ideally predict, the national or sub-national political climate and to capitalize on opportunities. The priorities of individual political leaders can be dramatically shaped by private experiences. There are many examples of leaders who, after being personally touched by disease, have subsequently made that disease a new national priority for action. These people can be important allies for change.

The stepwise framework