CARMEN: CONJUCTO DE ACCIONES PARA LA REDUCIÓN MULTIFACTORIAL DE LAS ENFERMEDADES NO TRANSMISIBLES

In 1995 the Pan American Health Organization (PAHO) initiated Conjunto de Acciones para la Redución Multifactorial de las Enfermedades No Transmisibles (CARMEN) as a prac-tical tool for helping member nations meet the World Health Organization's chal-lenge of Health for All by the Year 2000. The project's main objective is to create national and local coalitions that can set policies and implement interventions designed to reduce risk factors for noncommunicable diseases (NCDs). CARMEN pro-jects focus on risk factors such as smoking, high blood pressure, overweight, diabetes, and excessive alcohol consumption; the specific risk factors addressed depend on the priorities of each participating nation. CARMEN takes an integrated approach that combines preventive health care services for individuals at high risk for NCDs with health promotion efforts directed at the general population. CARMEN projects reach their target audience through community, workplace, and school settings as well as through local health services.

CARMEN was developed in response to an increased awareness among PAHO member states that NCDs account for nearly two-thirds of deaths in the Americas, that these diseases often result from risk factors that can be modified, and that an increased emphasis on prevention could significantly improve the health status of individuals and populations. Although modeled after the Countrywide Integrated Noncommunicable Disease Intervention (CINDI) projects of Europe and Canada, CARMEN takes into account specific characteristics of Latin American and Caribbean nations. Interventions are implemented through the development of policy and practi-cal guidelines for more cost-effective management of risk factors; professional educa-tion to reorient health services toward prevention; marketing to rally political, corpo-rate, and social support for the project; and other measures. Countries interested in participating in CARMEN must submit an official request for membership, design an action plan for implementing interventions, and devise an evaluation plan that follows a CINDI protocol. In each participating country, CARMEN projects begin as demon-stration projects that apply existing prevention knowledge and services. Experience gained is then extended throughout the country. For example, a CARMEN project in Chile that began with a demonstration project in an area covered by the Health Service of Valparaíso will be expanded based on evaluation of the project's feasibility, performance, and impact.

Evaluations emphasize assessment of the efficacy and effectiveness of interventions in changing NCD morbidity and mortality, as well as the prevalence of NCD risk factors. The impact of program activities is determined based upon changes in essential indi-cators, such as risk factors in the population and mortality due to diseases of the circulatory system, diabetes, cancer, and other NCDs. Each participating country collects data on essential indicators every 3 to 5 years. However, relating the data to other pro-gram activities requires long-term observation given that significant health effects may require 15 or more years to develop. In the short term, process evaluations assess how interventions work, examine cost-effective approaches to their implementation, and document their intensity and scope. Impact and process evaluations are currently under way in several countries; results of a baseline impact evaluation are available for Chile.

Problems encountered in implementing CARMEN include lack of experience in inter-sectoral collaboration and coalition building, lack of economic incentives for physi-cians to contribute preventive health services, and resistance to the concept of inte-grated action. Solutions await a full assessment of these problems.

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