NCDs: A priority for the Commonwealth - WHO · Non-communicable Diseases: A priority for the Commonwealth 2 The current magnitude of NCDs in the Commonwealth, their risk factors and

NCDs: A priority for the Commonwealth

Discussion Paper prepared by WHOon the occasion of the Commonwealth Health Ministers Meeting 2011 (Geneva, 15 May 2011)

Non-communicable Diseases: A priority for the Commonwealth

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The current magnitude of NCDs in the Commonwealth, their risk factors and social determinants The four types of non-communicable diseases (NCDs) -- cardiovascular diseases, cancers, chronic respiratory diseases and diabetes -- are the leading causes of death in the Member States of the Commonwealth Nations, and they strike hardest at the Commonwealth's low- and middle- income populations. These diseases have reached epidemic proportions, yet they could be significantly reduced, with millions of lives saved and untold suffering avoided, through reduction of their risk factors, early detection and timely treatments. Of the 19.5 million deaths in the Commonwealth in 2008, 9.3 million, or 47%, were due to NCDs (compared to 44% from communicable diseases, maternal, perinatal and nutritional conditions, and 9% from injuries, including road traffic fatalities), including 3.1 million deaths from NCDs which occurred before the age of 60 (please refer to Figure 1). Figure 1: Percentage of total deaths in Member States of the Commonwealth of Nations by broad cause group, 2008.

While popular belief presumes that NCDs afflict mostly high-income populations, the evidence tells a very different story: 97% of deaths from NCDs before the age of 60 in the Commonwealth occur in low- and middle-income countries (i.e. 3.0 million), and the majority of these NCD deaths occur in lower-middle-income countries of the Commonwealth (77%), followed by low-income countries of the Commonwealth (i.e. 17%, please refer to Figure 2).


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Figure 2: Deaths from NCDs before the age of 60 in Member States of the Commonwealth of Nations by World Bank income group, 2008. Mortality and morbidity data reveal the growing and disproportionate impact of the epidemic in lower-resource settings. NCDs also kill at a younger age in low- and middle-income countries. Premature death (before the age of 60) from NCDs among men ranges from 67% of all NCD deaths among men in Kiribati to 13% in Cyprus and the United Kingdom (please refer to Figure 3). Similarly, premature death from NCDs among women ranges from 58% in Sierra Leone to 8% in the UK (please refer to Figure 4). Figure 3: Deaths from NCDs among males before the age of 60 (as a percentage of all deaths from NCDs among men) in Member States of the Commonwealth of Nations, 2008.


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Figure 4: Deaths from NCDs among women before the age of 60 (as a percentage of all deaths from NCDs among women) in Member States of the Commonwealth of Nations, 2008. A large percentage of premature deaths from NCDs are preventable through the reduction of their four main behavioural risk factors: tobacco use, physical inactivity, harmful use of alcohol and unhealthy diet. The influences of these behavioural risk factors, and other underlying metabolic/physiological causes on the NCD epidemic in the Commonwealth, include: − Tobacco: The highest incidence of smoking among men is in lower-middle-income

Commonwealth countries, ranging from 74% in Kiribati to 8% in Belize. The incidence of smoking among men in low-income Commonwealth countries ranges from 42% in Bangladesh to 8% in Ghana, and from 40% in Malaysia to 7% in Dominica in upper-middle -income Commonwealth countries. In high-income Commonwealth countries, the incidence of smoking among men ranges from 27% in Malta to 9% in Barbados. Similar patterns can be observed among women. The highest incidence of smoking among women is in lower-middle-income Commonwealth countries, ranging from 62% in Kiribati to less than 1% in Sri Lanka. As a comprasion: The incidence of smoking among women in high-income Commonwealth countries ranges from 20% in the New Zealand to 1% in Barbados.

− Insufficient physical activity: Regular physical activity reduces the risk of

cardiovascular disease, including high blood pressure, diabetes, breast and colon cancer. Insufficient physical activity is highest in lower-middle-income Commonwealth countries, ranging from 69% the population (both sexes) being insufficiently active in


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Swaziland to 16% in India, but very high levels are now also seen in some upper middle-income Commonwealth countries (e.g. 61% in Malaysia), as well as low-income Commonwealth countries (e.g. 44% in Solomon Islands) and high-income countries (e.g. 72% in Malta).

− Harmful use of alcohol: Adult per capita consumption is highest in low-income

Commonwealth countries, ranging from 16 liters of pure alcohol in Uganda to less than 1 liter in Bangladesh), followed by high-income countries, ranging from 13 liters in the UK to 2 liters in Singapore.

− Unhealthy diet: Adequate consumption of fruit and vegetables reduces the risk for

cardiovascular diseases and colorectal cancer. Most populations consume much higher levels of salt than recommended by WHO for disease prevention; high salt consumption is an important determinant of high blood pressure and cardiovascular risk. High consumption of saturated fats and trans-fatty acids is linked to heart disease. Unhealthy diet is rising quickly in lower-resource settings. Available data suggest that fat intake has been rising rapidly in lower-middle-income countries since the 1980s.

The impact on development The NCD epidemic strikes disproportionally among people of lower social positions in Commonwealth countries of all levels of development. NCDs and poverty create a vicious cycle whereby poverty exposes people to behavioural risk factors for NCDs and, in turn, the resulting NCDs may become an important driver to the downward spiral that leads families towards poverty. The rapidly growing burden of NCDs in lower-income Commonwealth countries is accelerated by the negative effects of globalization, rapid unplanned urbanization and increasingly sedentary lives. People in lower-income countries are increasingly eating foods with higher levels of total energy and are being targeted by marketing for tobacco, alcohol and junk food, while availability of these products increases. Overwhelmed by the speed of growth, many governments are not keeping pace with ever-expanding needs for policies, legislation, services and infrastructure that could help protect their citizens from NCDs. People of lower social and economic positions fare far worse. Vulnerable and socially disadvantaged people get sicker and die sooner as a result of NCDs than people of higher social positions; the factors determining social positions are education, occupation, income, gender and ethnicity. There is strong evidence for the correlation between a host of social determinants, especially education and prevalent levels of NCDs and other risk factors (please refer to Figure 5). Since in poorer countries most health-care costs must be paid by patients out-of-pocket, the cost of health care for NCDs create significant strain on household budgets, particularly for lower income families. Treatment for diabetes, cancer, cardiovascular diseases and chronic respiratory diseases can be protracted and therefore extremely expensive. Such costs can force families into catastrophic spending and impoverishment.


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Figure 5: Causal links between underlying drivers for NCDs, behavioural risk factors, metabolic/physiological risk factors and NCDs.

Household spending on NCDs, and on the behavioural risk factors that cause them, translate into less money for necessities such as food and shelter, and for the basic requirement for escaping poverty – education. Each year, an estimated 100 million people are pushed into poverty because they have to pay directly for health services. The costs to health care systems from NCDs are high and projected to increase. Significant costs to individuals, families, businesses, governments and health systems add up to major macroeconomic impacts. Heart disease, stroke and diabetes cause billions of dollars in losses of national income each year in the most world’s most populous nations. Economic analysis suggests that each 10% rise in NCDs is associated with 0.5% lower rates of annual economic growth. The socioeconomic impacts of NCDs are affecting progress towards of UN Millennium Development Goals (MDGs). MDGs that target health and social determinants such as education and poverty are being thwarted by the growing epidemic of NCDs and their risk factors (please refer to Figure 6).


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Figure 6: Poverty contributes to NCDs and NCDs contribute to poverty.

NCDs as a development issue NCDs are a development issue because the social, economic and physical environments in lower-income countries afford their population much lower levels of protection from the risks and consequences of NCDs than in higher-income countries, where people tend to be protected by countermeasures. Programmes in many higher-income countries range from reducing the impact of marketing of tobacco, alcohol and unhealthy diets, to the early detection of breast and cervical cancers, diabetes and high blood pressure. These programmes have added years of life. They have also proven to be excellent economic investments: the low cost of these programmes has been a tiny fraction of what would have resulted in outrageous higher health care expenditures. Political leaders in the lower-income countries have committed themselves to establishing similar low-cost programmes. Their citizens, too, are demanding added years of life, and sustainable economic growth. Making this happen requires the active commitment of governments, international development agencies, civil society and the private sector. The capacity of countries to prevent and control NCDs In 2000 and 2010, WHO conducted surveys to assess national capacity for NCD prevention and control. The surveys found that some progress has been made in the past decade. But progress is uneven, with advancements far greater in higher income countries.


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Many advancements in developing countries appear to be on paper only – not fully operational -- or their capacity is still not at the level to achieve adequate interventions and surveillance. And many lower income countries still have no funding or programmes at all. Not surprisingly, lower income countries generally report the most severe gaps in capacity. Perhaps the greatest capacity shortfall in many countries is the lack of accurate data, which is vital to reverse the global rise in death and disability from NCDs. A substantial proportion of countries have little useable mortality data and weak surveillance systems. Data on NCDs are often not integrated into the national health information system. While many countries report NCD mortality as part of their national health information systems, only 21% report such morbidity data. And 16% of countries have no mortality or morbidity surveillance at all. High-income countries were 16 times more likely to have population-based NCD mortality data than low-income countries, and three times more likely to have morbidity data. Data on risk factors is even less likely to be included in a country’s national health information system, particularly in lower income countries, though surveillance regarding tobacco use has dramatically increased in many countries. Funding for NCD prevention and control is far more likely to exist in higher-income countries than in lower income countries. One third of low-income countries have no funding at all for NCD prevention and control, and this is a particular problem in the African region. Proportionately fewer low-income countries receive funding from government sources for NCDs. Around 65% of low-income countries receive government revenues for NCDs compared to about 90% of middle- and high-income countries; 12% of low-income countries receive funds from health insurance compared to 40–50% for other countries; and 7% of low-income countries receive earmarked taxes compared to about 20–25% for other countries. Also, a smaller percentage of low income countries receive donations compared to lower-middle income countries (59% compared with 83%). High-income countries were nearly four times more likely to have NCD services and treatments covered by health insurance than low-income countries. This leads to high out-of-pocket expenditures a greater likelihood of catastrophic spending by poorer families in the event of life-threatening NCDs. The availability of NCD treatments in low-income countries is one quarter that of high-income countries. Even in hospital settings in low-income countries, there is limited availability of basic technologies required for NCD care and rehabilitation. Lower income countries show poor availability of basic technologies and treatment, particularly for cancer and diabetes in primary care. There’s low availability of statins, oral morphine and steroid inhalers in primary care in low- and lower-middle-income countries. Public health systems in two thirds of countries in some regions have no access to basic management of end-stage renal disease, chemotherapy and radiotherapy for cancer, and photocoagulation services to prevent blindness.


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Gaps in the provision of essential services for NCDs in lower income countries often results in complications such as heart attacks, strokes, renal disease, blindness, and peripheral vascular diseases and the late presentation of cancers. An issue of critical need for many developing countries is the shortage of health practitioners in the workforce, particularly in rural and remote areas, and equipping the workforce to respond more effectively to NCDs. Fifty-seven countries, most of them in Africa and Asia, face severe health workforce shortages. WHO estimates that at least 2,360,000 health service providers and 1,890,000 management and support workers, or a total of 4,250,000 health workers, are needed to fill the gap. Evidence-based, affordable population-wide and individual health care interventions A combination of population-wide prevention and control interventions and individual health-care interventions for people at high risk of NCDs can save millions of lives, reduce human suffering and spare families and countries the enormous costs of NCDs. "Best buys", or interventions that address NCDs and also their key underlying risk factors - tobacco use, unhealthy diet, harmful use of alcohol and physical inactivity, while giving consideration to four key criteria: i) health impact; ii) cost-effectiveness; iii) cost of implementation; and iv) feasibility of scale-up, particularly in resource constrained settings, include (please refer to Table 1): Table 1: Best buys to prevent and control NCDs Risk factor / disease Interventions

Tobacco use

- Raise taxes on tobacco - Protect people from tobacco smoke - Warn about the dangers of tobacco - Enforce bans on tobacco advertising

Harmful use of alcohol - Raise taxes on alcohol - Restrict access to retailed alcohol - Enforce bans on alcohol advertising

Unhealthy diet and physical inactivity

- Reduce salt intake in food - Replace trans fat with polyunsaturated fat - Promote public awareness about diet and physical

activity (via mass media)


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Risk factor / disease Interventions

Cardiovascular disease (CVD) and diabetes

- Provide counselling and multi-drug therapy (including blood sugar control for diabetes mellitus) for people with medium-high risk of developing heart attacks and strokes (including those who have established CVD)

- Treat heart attacks ( myocardial infarction) with aspirin

Cancer

- Hepatitis B immunization beginning at birth to prevent liver cancer

- Screening* and treatment of pre-cancerous lesions to prevent cervical cancer

Lessons learned and the way forward Review of international experience and examination of the existing knowledge and evidence base provide important lessons and critical messages to policy-makers to guide policy development and programmatic decision-making on NCDs. The following lesson summaries are based on a review that was first conducted in 1999 in preparation for the development of the Global Strategy, and that was subsequently updated following a global consultation organized by WHO in 2010. Multisectoral action and health-in-all-policies

Experience has shown that community-based NCD programmes both inform and support national action towards appropriate policy formulation, as well as legislative and institutional changes. Effective community-based NCD interventions require a number of combined elements at the national level: meaningful community participation and engagement, supportive policy prioritization and setting, multisectoral collaboration and active partnerships among national authorities, nongovernmental organizations, academia and the private sector. Decisions made outside the health sector often have a major bearing on factors that influence NCD-related risk. More prevention gains may be achieved by influencing public policies in domains such as trade, food and pharmaceutical production, agriculture, urban development, pricing, advertising, information and communication technology and taxation policies, than by changes that are restricted to health policy and health care alone. Many approaches to implementing intersectoral action on health exist and deciding on the scale of intersectoral action and the most appropriate method depends on the context. However, two overall strategies for intersectoral action can be identified: - One general strategy is to aim to integrate a systematic consideration of health

concerns into all other sectors’ routine policy processes, and identify approaches and opportunities to promote better quality of life. This approach has been disseminated by


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the Finnish government as “Health in All Policies” based on its well-documented experience.

- An alternative approach to the ambitious goal of formally including health in all national policies is a more issue-centred and narrower strategy. Here the goal is to integrate a specific health concern into other relevant sectors’ policies, programmes and activities. Widespread adoption of the WHO Framework Convention of Tobacco Control has made tobacco control an excellent example of this strategy.

Regardless of the approach, all strategies to implement intersectoral action should consider three cross-cutting issues fundamental to any public policy. - First, intersectoral action depends highly on the context – political, economic, and

cultural – and it is also affected by the characteristics of the targeted issue. - Second, political will and commitment from all levels of government and all sectors is

required to allow a shared policy framework for concrete actions and policies to be established and applied.

- Third, the establishment and reinforcement of accountability mechanisms which can be used to evaluate the overall health-related performance of the sector policy.

There are a series of steps that can be taken to initiate and succeed with intersectoral action on health. The ten steps described below (please refer to Table 2) are relevant to both an issue-centred approach to implementing intersectoral action on health and to a general strategy of achieving health in all policies. The steps should not be seen as linear, but form part of a continuous cycle of learning for improvement, and need to be adapted to every different context. Table 2: Ten steps for policy-makers to implement intersectoral action on health Step Objective Self-assessment Assess the health sector’s capabilities, readiness,

existing relationships with relevant sectors and participation in relevant intergovernmental bodies.

Assessment and engagement of other sectors

Achieve a better understanding of other sectors, their policies, goals, language, values, and priorities, and establish links and means of communication with them and assess their relevance to the established health priorities.

Analyse the area of concern Define the area of concern and the intervention needed in terms of determinants of health and a cross-sectoral approach, and analyse the context with regards to available mechanisms, opportunities, interests, and politics

Select an engagement approach Gauge the intensity of engagement with other sectors in terms of health impact, health priorities, overall public policy priorities, common interests, and the


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Step Objective strategic relevance of the relationship with the sector.

Develop an engagement strategy and policy

Develop a strategy to involve the relevant sectors

Use a framework to foster common understanding between sectors

to identify a common understanding of the key issues and required actions to address them

Strengthen governance structures, political will and accountability mechanisms

Assess the political route required to adopt the policy.

Enhance community participation

Enhance community participation throughout the policy development and implementation process

Choose other good practices to foster intersectoral action

Join other sectors in establishing common policies/programmes/initiatives with joint reporting on implementation

Monitor and evaluate Follow closely the implementation of intersectoral action through monitoring and evaluation processes to determine the progress in achieving planned outcomes.

Surveillance and monitoring

Monitoring and evaluation of NCDs is essential to policy and programme development. Three key areas require monitoring: exposures (risk factors and determinants), outcomes (morbidity and cause-specific mortality), and assessment of health system capacity and response. Measurable core indicators for each have to be adopted and used to monitor trends and progress. For a surveillance system to be effective it should be integrated into the national health information system, and supported by long-term funding. High-quality risk factor surveillance is possible even in resource-limited settings and countries. Risk factor surveillance is a priority within a more comprehensive NCD surveillance framework, as it provides both the impetus for current action and predicts future burden trends. Table 3 provides a framework for a national NCD surveillance scheme. Three major components of NCD surveillance are: a) monitoring exposures (risk factors); b) monitoring outcomes (morbidity and disease-specific mortality; and c) health system responses, which also includes national capacity to prevent NCDs (in terms of policies and plans, infrastructure, human resources and access to essential health care including medicines). Reduced risk factors Multisectoral action tackle NCD risk factors through population-wide interventions that are affordable, cost effective and can even be revenue generating for governments. These interventions for tobacco use, unhealthy diet, lack of physical activity and harmful alcohol


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have proven to be successful in countries and populations of all income levels and have shown quick results in lives saved and disease burden alleviated. Health systems

The long-term needs of people with NCDs can only be addressed by reorienting existing organizational and financial arrangements surrounding health care. Initiatives aimed at improving health systems performance and reform should additionally include specific NCD-related endpoints in universal coverage goals. Broad-based attempts to achieve equity in financing are vital protections against the risk of catastrophic health expenditures, which are mainly related to NCD-related healthcare costs. Financial risk and inequity can be minimized through both conventional and innovative financing mechanisms. Innovative financing refers to a range of non-traditional mechanisms to raise additional funds for development and aid through “innovative” projects such as micro-contributions, taxes, public-private partnerships and market-based financial transactions. Supplementing traditional public sector funding and, in some countries, development assistance (ODA) with innovative and/or non-state sector financing can potentially bridge considerable funding gaps which constitute the biggest stumbling block to strengthen NCD interventions in primary health care. There are examples of countries that have successfully used revenues from raised taxation on tobacco and alcohol to finance health promotion and promote coverage in primary health care. As mentioned above, the World Health Report 2010 provides numerous examples of innovative financing systems that can be considered to complement National health budgets. Table 3: Framework for national NCD surveillance Exposures: - Behavioural risk factors: tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diet. - Physiological and metabolic risk factors: raised blood pressure, overweight/obesity, raised blood glucose,

and raised cholesterol. - Social determinants: educational level, household income, access to health care. Outcomes: - Mortality: NCD-specific mortality. - Morbidity: Cancer incidence and type. Health system response: - Interventions and health system capacity: infrastructure, policies and plans, access to key health-care

interventions and treatments, partnerships.


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Following the 2009 recommendations of the High-Level Task Force on Innovative Financing, one of the new concepts to assess and develop was a global levy on tobacco products. A Solidarity Tobacco Levy ("STL") is being considered as a possibility for raising funds that could support NCD prevention and control in low-income countries. Essential medicines Cost-effective medicines to treat NCDs are available and in mostly low cost generic forms, although they remain inaccessible and unaffordable to many who need them, especially in low- and middle-income countries. Scaling up access to NCD medicines is critical to global efforts to ameliorate the burden of NCDs and also in achieving the MDGs. Challenges to scaling up access to NCD medicines reflect each country’s situation and need to be addressed in a country-specific way to achieve sustainable and equitable accessibility. This can be achieved by a combination of policies and programmatic options suited to countries’ situation. Concerted global efforts are important for improving access to NCD medicines and the emergence of a NCD global health initiative (GHI) could be a viable platform. Governments, in collaboration with the private sector, should give greater priority to improving the accessibility of NCD medicines. Important mechanisms for providing sustainable access to NCDs include efficient procurement and distribution of these medicines in countries, establishment or the provision of viable financing options, generic promotion policies and the development and use of evidence based guidelines for the treatment of NCDs. Preparations for the High-level Meeting on NCDs in September 2011 Strategic vision and long-term roadmap In May 2000, the World Health Assembly reaffirmed that the Global Strategy for the Prevention and Control of NCDs is directed at reducing premature mortality and improving quality of life (resolution WHA53.17), and requested the WHO Director-General to continue giving priority to the prevention and control of such diseases. The strategy rests on three pillars: surveillance, primary prevention and strengthened health systems. Since 2000, several resolutions have been adopted in support of specific tools for the global strategy: the Framework Convention on Tobacco Control (WHA56.1); the Global Strategy on Diet, Physical Activity and Health (WHA57.17); and the Global Strategy to Reduce the Harmful Use of Alcohol (WHA63.13). In 2008, the World Health Assembly endorsed the Action Plan for the Global Strategy for the Prevention and Control of NCDs (WHA61.14). The Action Plan has six objectives, with a particular focus on low- and middle-income countries and vulnerable populations. It comprises a set of actions that, when performed collectively by Member States, international partners and the WHO Secretariat, will tackle the growing public-health burden imposed by NCDs.


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The first objective in the Action Plan focuses on raising the priority of NCDs in development work at global and national levels and on integrating prevention and control of such diseases into policies across all government departments. The implementation of the actions set for WHO under objective one of the action plan has received high priority since the endorsement of the Action Plan in May 2008. These actions, which include the discussion of the development challenges of NCDs during the ECOSOC High-level Segment in 2009 and the Commonwealth Heads of Government Meeting in 2009, have contributed to the priority recently given by Member States in the priority given to the prevention and control of NCDs on the agenda of the United Nations General Assembly in 2010. As a result, the United Nations General Assembly decided in May 2010 to convene a High-level Meeting on the Prevention and Control of NCDs during 2011, with the participation of Heads of State and Government. The General Assembly resolutions have created an opportunity for Heads of State and Government in developed and developing countries to consider stronger, more coordinated actions in response to NCD diseases. The preparatory process leading to the high-level meeting of the United Nations General Assembly includes the initiatives described in Figure 7. WHO has been active in response to this development and has taken a key role in the preparatory process leading to the High-level Meeting. Figure 7: The preparatory process leading towards the High-level Meeting on NCDs (New York, 19-20 September 2011)

The High-level Meeting on NCDs (New York, 19-20 September 2011)


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In consecutive sessions, in May and December 2010, the United Nations General Assembly adopted resolution 64/265 (Prevention and control of NCDs) and resolution 65/238 (Scope, modalities, format and organization of the High-level Meeting on NCDs). The resolutions related, respectively, to the convening of, and detailed organizational arrangements for, a High-level Meeting of the United Nations General Assembly on the Prevention and Control of NCDs. Further support for the High-level Meeting was provided by the General Assembly in resolutions 65/1 (Keeping the promise: united to achieve the MDGs) and 65/95 (global Health and Foreign Policy). Activities mandated by resolutions 64/265 and 65/238 In May 2010, the United Nations General Assembly adopted resolution 64/265, in which it decided to convene a High-level Meeting on NCDs in September 2011, with the participation of Heads of State and Government. In support of the implementation of resolution 64/265, a side event, was organized on 20 September 2010 by WHO, jointly with Member States, on the High-level Meeting and the links between the Millennium Development Goals and NCDs. An intensive process of consultations, led by the President of the General Assembly and facilitated by two Member States (Jamaica and Luxembourg), resulted in the adoption of resolution 65/238 on 13 December 2010. This resolution includes the organizational arrangements of the High-level Meeting and the round tables, including formal plenary meetings to be chaired by the President of the General Assembly. In the same resolution 65/238, the General Assembly also decided that the High-level Meeting would result in a concise action-oriented Outcome Document, and requested the President of the General Assembly to produce a draft text (commonly referred to as a 'Zero Draft Outcome Document') in consultation with Member States based on their inputs, as well as inputs from the preparatory process, and to convene informal consultations (envisaged to take place from July 2011 to September 2011) in order to enable sufficient consideration and agreement by Member States prior to the High-level Meeting on the final text of the Outcome Document.. The Outcome Document is intended to generate global momentum and commitment both to implementing the Global Strategy for the Prevention and Control of NCDs ((WHA53.17) and its Action Plan (WHA61.14) and to the "inclusion of the prevention and control of NCDs as an integral part of the global development agenda and related investment decisions" (quoted from proposed action 17.a included in the Action Plan), building on the 2010 commitment from Heads of State and Government to "undertake concerted action and a coordinated response in order to adequately address the developmental challenges posed by NCDs" (quoted from operative paragraph 76.i of the MDG Outcome Document included in resolution 65/1 which was adopted by the General Assembly on 22 September 2010). United Nations General Assembly resolutions 65/1 and 65/95 In September 2010, the General Assembly also adopted resolution 65/1, which includes the Outcome Document of 2010 MDG Summit. In the Document, Heads of State and Government committed themselves to achieving the MDGs by, inter alia, strengthening


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the effectiveness of health systems and proven interventions to address evolving health challenges such as NCDs; and undertaking concerted action and a coordinated response at the national, regional and global levels in order to adequately address the developmental and other challenges posed by NCDs. In United Nations General Assembly resolution 65/95, the General Assembly welcomed plans to hold the First Global Ministerial Conference on Healthy Lifestyles and NCD Control (Moscow, 28-29 April 2011). Regional consultations In resolution 65/238, WHO was invited to hold regional consultations which would serve to provide inputs to the preparations for the High-level Meeting, as well as to the Meeting itself. In response to the invitation, the following regional meetings were hosted by interested Member States for the countries of their regions during the last quarter of 2010 and the first half of 2011, with support from WHO: - Islamic Republic of Iran for Member States in the Eastern Mediterranean Region

(Tehran, 24-25 October 2010) - Norway for Member States in the European Region (Oslo, 24 and 25 November 2010) - Fiji for Member States in the Pacific islands subregion of the Western Pacific Region

(Nadi, 3–5 February 2011) - Mexico for Member States in the Region of the Americas (Mexico City, 23–25

February 2011) - Indonesia for Member States in the South-East Asia Region (Jakarta, 1–4 March 2011) - Republic of Korea for Member States in the Western Asian subregion of the Western

Pacific Region (Seoul, 17 and 18 March 2011). - The WHO Regional Office for Africa hosted a regional consultation for Member

States of the African Region (Brazzaville, 4–6 April 2011). The respective reports summarizing the outcomes of each regional consultation are available on WHO's website at www.who.int/ncd. A summary of the main shared outcomes of the regional consultations is available in the chapter below (Recommendations). WHO Informal Dialogues WHO has organized informal consultations with representatives of NGOsand civil society organizations and the private sector on 1 and 2 November 2010, respectively. A summary of the informal dialogues has been prepared as a contribution to the High-level Meeting. Copies of the reports are available on WHO's website at www.who.int/ncd.


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Reports Note by the Secretary-General (23 November 2010) The United Nations General Assembly met on 23 November 2010 to discuss the 'Note by the Secretary-General transmitting the report by the Director-General of the World Health Organization on the global status of NCDs, with a particular focus on the development challenges faced by developing countries'. Member States underlined that NCDs present significant socio-economic challenges, particularly in developing countries, as outlined in the report. A number of Member States supported an idea tabled by the Caribbean Community (CARICOM) to develop global goals, targets and indicators to monitor how Member States address the issue. A copy of the note is available on WHO's website at www.who.int/ncd. First WHO Global Status Report on NCDs (27 April 2011) In accordance with the Action Plan, WHO has developed the WHO Global Status Report on NCDs, which was launched on 27 April 2011 at the occasion of the First Global Ministerial Conference on Healthy Lifestyles and NCD Control (Moscow, 28-29 April 2011). It is the first report on the global burden of NCDs, their risk factors and determinants. It is written for policy makers in health and development, health officials, and the various stakeholders and it covers surveillance, population-based prevention, health care, and the capacity of countries to respond to the epidemic. It includes up-to-date evidence about ways to map NCDs, reduce their leading risks and strengthen health care for people who already suffer from these diseases. A copy of the report is available at www.who.int/nmh/publications/ncd_report2010. UN Secretary-General's Report on NCDs (May 2011) It its resolutions 64/265 and 65/238, the General Assembly requested the Secretary-General to submit a report to the General Assembly on the global status of NCDs, with a particular focus on the developmental challenges faced by developing countries. The report (currently under formulation in collaboration with WHO and relevant UN funds, programmes and specialized agencies) will be submitted to the General Assembly in May 2011 and will serve as an input to the preparatory process for the High-level Meeting. Global consultations The Russian Federation and WHO jointly organized the First Global Ministerial Conference on Healthy Lifestyles and NCD Control, which was hosted by the Ministry of Health of the Russian Federation in Moscow on 28 and 29 April 2011. The aim of the Global Ministerial Conference was to support Member States in developing and strengthening policies and programmes that promote healthy lifestyles and prevent NCD diseases. The Conference, which was attended by 150 Member States, including 90 Ministers of Health, resulted in the Moscow Declaration on NCDs, which includes a call to action to strengthen international support for the full and effective implementation of the


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Action Plan for the Global Strategy for the Prevention and Control of NCDs, and supporting WHO in developing a comprehensive global monitoring framework on NCDs. A copy of the Moscow Declaration is available at: www.who.int/nmh/events/moscow_ncds_2011/conference_documents Informal interactive hearing with civil society, NGOs and the private sector (New York, 16 June 2011) The President of the General Assembly was requested by the General Assembly to organize and preside over an informal interactive hearing with NGOs, civil society organizations, the private sector and academia in order to provide an input into the preparatory process for the High-level Meeting. The hearing is scheduled to take place on 16 June 2011 in New York. The President of the General Assembly will prepare a summary of the hearing, to be issued as a document of the General Assembly prior to the High-level Meeting. A Civil Society Task Force has been appointed by the President of the General Assembly to advice him on the conduct of the informal interactive hearing in June 2011 and on civil society participation in the High-level Meeting in September 2011. WHO is supporting the work of the Civil Society Task Force, which had its first face-to-face meeting on 26 April 2011 in Moscow, on the occasion of the WHO Global Forum (Moscow, 27 April 2011) and the First Global Ministerial Conference on Healthy Lifestyles and NCD Control (Moscow, 28-29 April 2011). World Health Assembly (16-24 May 2011) The theme of the general discussion in the plenary of the 64th Session of the World Health Assembly (16-24 May 2011) is "The prevention and control of NCDs worldwide". In their interventions, Ministers are invited to highlight the challenges that their countries face in addressing NCDs and implementing the recommended interventions of the Action Plan, opportunities to address these challenges, and proposals for the way forward. A WHA lunchtime technical briefing session on NCDs will take place on 18 May 2011 and will cover the following topics: - Update on process to prepare for the High-level Meeting - Key outcome from the regional consultations - Country preparations for the High-level Meeting - Expectations of outcomes of the High-level Meeting - Country example of how Ministries of Health had success in communication and

advocacy of NCD and development issues with Heads of State in relationship to the High-level Meeting

- Discussion, including questions from the audience


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Recommendations Addressing the NCD epidemic is a priority for Member States and the international community. Action is urgently needed at all levels. The following represent actions recommended for Member States, the international community and other stakeholders which have surfaced from the regional consultations: Recommended actions for Member States: − Implement the cost-effective best buys and good buys in population-wide interventions

for NCD risk factors for immediate reduction in mortality, morbidity and economic losses that result from the NCD epidemic.

− Demonstrate leadership by including prevention and control of NCDs among top priorities in national health strategies and plans. Generate momentum by accelerating implementation of the Action Plan for the Global Strategy for the Prevention and Control of NCDs.

− Strengthen national information systems by implementing a surveillance framework that monitors exposures (key risk factors and determinants), outcomes (morbidity and mortality), and health systems capacity.

− Set standardized national targets and indicators to assess progress made in addressing noncommunicable diseases.

− Promote multisectoral and health-in-all policies approaches to address the social determinants and risk factors of NCDs.

− Engage non-health sectors and key stakeholders, including the private sector and civil society, in collaborative partnerships to promote health and reduce NCD risk factors.

− Implement international agreements and strategies to reduce risk factors, including the WHO Framework Convention on Tobacco Control (FCTC), the Global Strategy on Diet, Physical Activity and Health and the Global Strategy to Reduce the Harmful Use of Alcohol.

− Develop and implement standards for marketing of food and non-alcoholic beverages based on recommendations endorsed by the World Health Assembly. Improve transport systems and urban designs that are not conducive to walking or biking. Revitalize primary health care and promote access to cost-effective interventions for NCDs, including access to essential medicines and technologies.

− Build upon health care models for chronic HIV disease management, especially in high burden, low resource settings, to expand to NCD management.

− Mobilize additional resources and support innovative approaches to financing essential NCD health care interventions within primary health care.

− Invest in a prioritized NCD research agenda to bridge the major gap between what is known and what is implemented.


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Recommended actions for international and regional organizations, intergovernmental agencies and heads of state and government − Acknowledge the increasingly serious threat of the NCD epidemic on human and

economic development and the links with poverty. − Raise the priority accorded to noncommunicable diseases in development work at all

levels. − Integrate cost-effective preventive interventions into the development agenda and

related investment programmes in low- and middle-income countries. − Scale up technical support and strengthen capacity of low- and middle-income

countries to tackle noncommunicable diseases as part of the official development assistance (ODA) programmes and global poverty reduction initiatives.

− Develop and adopt a set of targets and indicators for surveillance and establish a framework to monitor the trends of noncommunicable diseases, their determinants and risk factors, and assess the action taken by countries through regular reporting on progress.

− Agree on mechanisms to ensure the effective involvement in health and NCD polices of public and private sectors outside of the health sector.

− Ensure active engagement of United Nations Agencies and Programmes in global and regional initiatives to address the health and socioeconomic impact of NCDs.

Recommended actions for other international and national stakeholders Industry: − Promote healthy behaviours among workers including occupational safety through

good corporate practices, workplace wellness programmes, and insurance schemes. − Contribute to improved access and affordability to ensure that quality NCD essential

medicines and technologies − Ensure responsible and accountable marketing and advertising, especially to children − Assess the health impact of manufactured products and reformulate to healthier

options Civil Society: − Mobilise political and community awareness and commitments in support of NCD

prevention and control − Fill in gaps in the provision of NCD prevention and treatment services, particularly for

marginalized populations and crisis situations − Build community capacity in promoting healthy lifestyles − Support the implementation of NCD population-wide interventions to reduce tobacco

use and harmful alcohol use and improve healthy diet and physical activity − Promote collaborative partnerships among key multisectoral stakeholders in public and

private sector


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− Mobilise additional resources and support innovative approaches to financing NCD prevention and control

ooo000ooo


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Acknowledgements This discussion paper does not represent an official position of the World Health Organization. It is a tool to explore the views of interested parties on the subject matter. References to international partners are suggestions only and do not constitute or imply any endorsement whatsoever of this discussion paper. The World Health Organization does not warrant that the information contained in this discussion paper is complete and correct and shall not be liable for any damages incurred as a result of its use. The designations employed and the presentation of the material in this discussion paper do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this discussion paper. However, this discussion paper is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the presentation lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Unless specified otherwise, the data contained in this discussion paper is based on the 2008 update on the 'Global burden of disease'. Additional information is available at www.who.int/research. © World Health Organization, 2011. All rights reserved. The following copy right notice applies: www.who.int/about/copyright


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NCDs: A priority for the Commonwealth - WHO · Non-communicable Diseases: A priority for the Commonwealth 2 The current magnitude of NCDs in the Commonwealth, their risk factors and

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