Action Plan for Prevention and Control of Noncommunicable Diseases in the South East Asia Region DRAFT

Transcription

1 Action Plan for Prevention and Control of Noncommunicable Diseases in the South East Asia Region DRAFT 7 June

2 Situational Analysis Health Burden of NCDs and Risk Factors 1. Noncommunicable diseases (NCDs) mostly cardiovascular diseases, chronic respiratory diseases, diabetes and cancer are top killers in South East Asia Region (SEAR), claiming an estimated 7.9 million lives each year. One third of these deaths are premature and occur before the age of 60 years, in economically productive individuals. In 2008, cardiovascular diseases for a quarter of all deaths, followed by chronic respiratory diseases (chronic obstructive pulmonary disease and asthma), cancers and diabetes which accounted for 9.6%, 7.8% and 2.1% of all deaths, respectively (Figure 1). Of the 7.9 million deaths due to NCDs in 2008, 3.6 million were due to cardiovascular diseases. The commonest cardiovascular diseases in the Region are ischaemic heart disease, stroke and hypertensive heart disease. Cancer claims 1.1 million lives each year and an estimated 1.65 million new cases occur each year. Among males, lung cancer is most common followed by oral cancer, while among females the incidence of breast and cervical cancers is the highest. Although majority of the chronic respiratory diseases are preventable, an estimated 1.4 million people died of these diseases in 2008; 80% of these deaths were due to chronic obstructive pulmonary disease (COPD). An estimated 81 million people are living with diabetes in the Region. The prevalence of diabetes is increasing in both urban and rural areas. Besides the four major NCDs, many other chronic conditions and diseases contribute significantly to the burden of noncommunicable disease in the Region, such as (renal, endocrine, neurological, haematological, gastroenterological, hepatic, musculoskeletal, skin and oral diseases, and genetic disorders). Figure 1. Percentage of deaths, by cause, South East Asia Region, 2008 Injuries 11% Cardiovascular diseases 25% Communicable diseases, maternal & perinatal conditions, nutritional deficiencies 35% Chronic respiratory diseases/asthma 10% Cancers 8% Other NCDs 10% Diabetes 2% 2

3 2. The four major NCDs are caused to a large exten by four modifiable behavioural risk factors, namely tobacco use, unhealthy diet, insufficient physical activity and harmful use of alcohol. In the Region, 6.8% of annual deaths (equals 1 million) are attributed to tobacco use. There are nearly 250 million smokers and an equal number of smokeless tobacco users in the Region. The prevalence of current use of any smoked tobacco ranges from 26% (India) to 61% (Indonesia) in males and from less than 1% (Sri Lanka) to 29% (Nepal) among females. In addition to smoking, use of smokeless tobacco is a major problem. Ninety percent of the world s tobacco users are in the South East Asia Region. The prevalence of smokeless tobacco product use among males ranges from 1.3% (Thailand) to 51.4% (Myanmar); in females prevalence of smokeless tobacco product use ranges from 4.6% (Nepal) to 27.9% (Bangladesh). The prevalence of smokeless tobacco use among young girls and women in the Region is on the rise. 3. There is a low intake of fruits and vegetables, high consumption of salt and widespread use of trans fats in the Region. The mean intake of salt per day varies from 8 to 13 gm per day, much higher than the recommended levels of <5 gm/day. Approximately 80% of the population does not eat sufficient quantities of fruits and vegetables and half a million deaths in the Region are attributed to low intake of fruits and vegetables. Annually, nearly deaths in the Region are attributed to inadequate physical activity. The prevalence of insufficient physical activity varies from 3% to 41% among males and from 6.6% to 64% among females. The prevalence of alcohol consumption varies from 2% to 44% among males and from 0.1% to 26% among females. An estimated people died in SEAR of alcohol related causes in The four behavioural risk factors described above lead to four major metabolic risk factors (overweight/obesity, high blood pressure, raised blood sugar and raised blood lipids) that are highly prevalent in the Region. High blood pressure, raised blood glucose and tobacco use together account for nearly 3.5 million deaths in the Region every year. Annually, deaths are attributed to overweight and obesity in the Region. The prevalence of overweight varied from 8% to 30% among males, and from 8% to 52% among females. Childhood obesity is an emerging issue. Approximately 30% of the adult population has high blood pressure, which accounts for nearly 1.5 million deaths annually. The prevalence of raised cholesterol is as high as 50% in some countries. Nearly 5% of the total annual deaths in the Region are attributed to raised cholesterol. 5. Apart from the four main behavioral risk factors, infectious and environmental factors also increase the risk of noncommunicable diseases. Household air pollution due to solid fuel combustion is an important risk factor for COPD. It is estimated that HAP caused 3.5 million premature deaths in 2010, globally. Further, emissions from solid fuel combustion lead to outdoor air pollution which may contribute to another 0.5 million deaths ( second hand cook fire smoke ). Exposure to environmental and occupational hazards, such as exposure to asbestos, diesel exhaust gases and ionizing and ultraviolet radiation in the living and working environment can increase the risk of cancer. Similarly, indiscriminate use of agrochemicals in agriculture and discharge of toxic products from unregulated chemical industries may cause cancer and other noncommunicable diseases such as kidney disease. 3

4 Social Determinants and Socioeconomic Impact 6. In addition to population ageing (a non modifiable determinant of NCDs) NCDs are driven by the negative effects of globalization (such as trade and irresponsible marketing of unhealthy products), rapid urbanization, inequity and illiteracy (Figure 2). Urbanization in SEAR is occurring at a rapid rate and increased from 26% in 1990 to 33% in It is expected that the projected percentage of population residing in urban areas will more than double by 2050 in most of the Member States. Several studies in the Region show that behavioural, anthropometric and biochemical risk factors of NCDs are more prevalent in urban than in rural areas. Globalization has brought processed foods and diets high in total energy, fats, salt and sugar into billions of homes in the Region. Nearly 30% of the Region s population remains non literate. Low levels of literacy affect health behaviours and lifestyle choices, so that people fall easy and early prey to NCDs. An inverse relationship between tobacco use and education has been observed. Studies in Bangladesh, India, Indonesia, Sri Lanka and Thailand have revealed that both smoking and smokeless tobacco use are more prevalent among the less educated. Poor level of awareness can also result in high consumption of salt, as well as use of saturated fats and trans fats and thus aggravate development of NCDs. There is a two way link between NCDs and household poverty. Poverty exposes populations to risk behaviours and poor health outcomes; NCDs in turn exacerbate poverty due to expenses incurred on unhealthy behaviours, expenses on health care and loss of wages. The macroeconomic burden is also enormous and includes health care costs, loss of productivity due to premature deaths and decreased gross domestic product. Figure 2. Determinants of noncommunicable diseases 4

5 Progress in Countries (needs to be revised based on the 2013 survey) 7. A public health response to NCDs has been initiated in all 11 Member States. Nine Member States have an integrated policy on NCDs. Cancer and diabetes are the most targeted diseases for control while chronic respiratory diseases are the least covered. Guidelines on dietary counseling are available in six countries, guidelines on tobacco dependence and physical activity are available in four countries and guidelines on alcohol dependence are available in five countries. Legislative support for tobacco is available in 10 countries; there is alcohol legislation in five countries. Two countries address diet and nutrition and only one country tackles physical inactivity through legislative measures. At least one NCD risk factor survey (national or subnational) has been completed in all 11 countries. Disease specific morbidity data are generally collected through the routine health information system in all 11 countries; mortality data are included in nine countries. Disease registries for NCDs have been most commonly established for cancers, followed by diabetes and stroke. Most mortality/morbidity data and disease specific registries are hospital based. All Member States provide at least one NCD related service at the primary care level in public health facilities. This includes primary prevention and health promotion (11 countries), early diagnosis of NCD risk factors (9 countries), and risk factor and disease management (10 countries). All Member States have an essential drugs list and many of the NCD related drugs are included in the national essential drugs list. Challenges 8. The major challenges that need to be overcome to effectively address NCDs include weak health systems, lack of strong national and private partnerships for multisectoral actions, weak surveillance systems, limited access to prevention, care and treatment services for NCDs, limited human resources and insufficient allocation of funds. Additionally, lack of effective partnerships among different development sectors at the national level is one of the main weaknesses in the Member States. Lack of availability of robust surveillance and research data on NCDs is also an important barrier to effective planning and implementation of NCD prevention and control programmes in the Region. There are many issues with current surveillance systems, such as NCD surveillance systems not being institutionalized and rarely being integrated into the national health information systems; lack of a comprehensive framework for surveillance and monitoring at the national and subnational levels; no reporting on reliable mortality statistics due to weak civil registration systems; inadequate population based causespecific morbidity and weak mortality data collection systems; and poorly funded surveillance and research for NCDs. Finally, there is a lack of access to basic prevention and treatment in the primary health care setting in Member States of the Region. The major investment on NCD prevention and control is for tertiary care services, which are available to a limited number of people living in urban areas, resulting in opportunities for early diagnosis being lost and NCDs being diagnosed at late stages as heart attacks, strokes and diabetes complications which require tertiary care. Community and homebased palliative care are almost nonexistent. Health systems in the Region have inadequate human resources capacity to address NCDs both in terms of number of 5

6 health workers and their training. Existing health professionals are concentrated in urban areas at the tertiary care level, resulting in an inadequate workforce capacity at the primary care level. Health workers particularly at the primary care level have limited training in addressing NCDs and their risk factors. Funds allocated for NCD programmes are disproportionately lower than the disease burden and contribute to ineffective access to prevention and control service facilities. Global Initiatives 9. Global initiatives to address NCDs started in the year 2000, with the adoption by the World Health Assembly of its resolution 53.17, in which the Assembly endorsed the global strategy for the prevention and control of such diseases, with a particular focus on developing countries. The strategy rests on three pillars: (i) surveillance; (ii) primary prevention; (iii) strengthened health care. 10. Since 2000, the World Health Assembly has adopted several resolutions in support of specific tools for the global strategy, including the WHO Framework Convention on Tobacco Control in 2003, the Global Strategy on Diet, Physical Activity and Health in 2004, and the Global Strategy to Reduce the Harmful Use of Alcohol in In 2008, the Assembly endorsed the Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases, with a particular focus on developing countries. The Action Plan has six objectives that include raising the priority accorded to such diseases in development work at the global and national levels. 11. To draw the attention of global leaders on the rising crisis of NCDs, the UN General Assembly convened a high level meeting in New York last year. It was only the second time in history that the General Assembly met with the participation of Heads of States and governments on a health issue. The main outcome of the high level meeting of the UN General Assembly was the adoption of the political declaration on NCDs, which acknowledges the rapidly growing magnitude of NCDs in developing countries and its increasingly devastating health and socioeconomic impact, and calls for concrete and comprehensive actions by Member States and the international community. 12. As a follow up to the Political Declaration of the UN High Level Meeting on NCDs, WHO led a consultative process of developing a Global NCD Action Plan ( ) and a comprehensive monitoring framework with indicators and global voluntary targets. The 66 th WHA in May 2013 endorsed the Global Action Plana including indicators and targets vide its resolution xx. The resolution urges Member States, to implement the global action plan and consider the development of national NCD monitoring frameworks, with targets and indicators based on national situations, taking into account the global ones and to establish and strengthen a national surveillance and reporting system to enable reporting against the 25 indicators and 9 global voluntary targets. 6

7 Regional Initiatives 13. Important recent regional initiatives for the prevention and control of NCDs are listed below: November 2005: Regional partnerships on NCD prevention and control strengthened and formalized through creation of South East Asian Network (SEANET NCD) at a regional meeting in Bondos, Maldives. October 2006: A regional meeting on implementing the global strategy on diet, physical activity and health in SEAR was organized in Yangon, Myanmar to facilitate regional country level implementation of the global strategy. September 2007: The sixtieth session of the WHO Regional Committee for South East Asia, vide its resolution on Scaling up Prevention and Control of NCDs in the South East Asia Region (SEA/RC60/R4) endorsed the Regional Framework for Prevention and Control of NCDs ( ). Key elements of the Regional Framework include: epidemiological assessment of NCDs and their determinants; awareness generation and high level advocacy; formulation and adoption of policy and strategic plan for integrated prevention and control of major NCDs; capacity building; resource mobilization; multisectoral and multilevel action to modify determinants. October 2007: The second meeting of SEANET NCD held in Phuket, Thailand discussed inputs for development of a regional and global plan of action for integrated prevention and control of NCDs. June 2009: The third meeting of SEANET NCD held in Chandigarh, India reviewed progress in scaling up of NCD prevention and control, particularly the role of SEA NET. The meeting also discussed and contributed to the global recommendations on marketing of food and non alcoholic beverages to children. September 2009: The thirty first session of SEA ACHR in Kathmandu, Nepal discussed research priorities in NCDs and called for intersectoral collaboration in carrying out research on NCDs. September 2010: The sixty third session of the WHO Regional Committee for South East Asia discussed progress in the prevention and control of NCDs in the Region. January 2011: A regional civil society meeting, with support from SEARO was organized by the Nepal Public Health Foundation in Kathmandu, Nepal. This meeting resulted in the Kathmandu Call for Action on NCDs. March 2011: A regional meeting on health and development challenges of NCDs was conducted in Jakarta, Indonesia with participation of all 11 Member States of the Region. The meeting culminated in the Jakarta Call for Action on prevention and control of NCDs and preparation of a report on key messages for UN HLM. September 2011: The twenty ninth meeting of Health Ministers of the South East Asia Region held in Jaipur India, passed a decision to include 10 key messages as input to the UN HLM on NCDs. April 2012: A regional consultation of Member States including partners, held in Yangon, Maynmar discussed inputs to the global action plan on NCDs as well as global targets and indicators June 2012: A regional workshop on surveillance was organized in Delhi, India to build a regional pool of experts in STEPS surveillance. 7

8 August 2012: A regional workshop on research in integrating NCDs into primary health care was organized in Kandy Sri Lanka to promote research and build capacity of Member States in operations research. September 2012: The sixty fifth session of the Regional Committee held in Yogyakarta Indonesia discussed NCDs including mental health as a technical subject and passed a resolution (RC/65/5). November 2012: A regional workshop was organized in Kathmandu Nepal to develop regional oral health strategy for SEAR. December 2012: An expert group meeting held in New Delhi, India discussed sodium reduction strategies and methods to monitor population sodium intake. February 2013: A regional consultation including 10 Member countries discussed the draft regional NCD action plan and the global monitoring framework, indicators and voluntary targets. Action Plan for Prevention and Control of NCDs for Member States of the South East Asia Region ( ) 14. The regional NCD action plan is consistent with the draft Global Action Plan ( ) and consolidates follow up actions of the outcomes of the high level meeting and recommendations of the various regional consultations with Member States. The regional monitoring framework, consistent with the global one (including indicators and a set of voluntary global targets for the prevention and control of NCDs), has been integrated into the regional action plan. Successful implementation of the plan would need high level political commitment, sustainable resources and concerted involvement of governments and whole of society. Purpose of the Regional Action Plan 15. This is a reference document to help Member States in developing and implementing national action plans for reducing the burden of NCDs within the existing socioeconomic, cultural, political and health system contexts of SEAR Member States. It is coherent with major global strategies for prevention and control of NCDs and aims at reducing the health and socioeconomic burden of NCDs, health inequities and improving the quality of life of people. The Regional Action Plan provides a framework to support and strengthen the implementation of existing regional resolutions, strategies and plans. Vision 16. All people of the South East Asia Region enjoy the highest attainable status of health, well being and productivity at every age, free of preventable NCDs, avoidable disability and premature death. 8

9 Goal 17. To reduce preventable morbidity, avoidable disability and premature mortality due to NCDs in the South East Asia Region. Guiding Principles 18. The Regional Action Plan relies on the following overarching principles and approaches: Recognition of the social determinants of health, including equity, education, gender, as well as economic, cultural, and environmental factors all of which contribute significantly to the presence of NCDs. Using a life course approach, which is key to prevention and control of NCDs, starting with maternal health, including preconception, antenatal and postnatal care and maternal nutrition; and continuing through proper infant feeding practices, including promotion of breastfeeding and health promotion for children, adolescents and youth; followed by promotion of a healthy working life, healthy ageing and care for people with NCDs in later life. An all of society approach for NCDs that promotes strategic alliances both within the health sector and with sectors outside of health, involving governments, civil society, academia, the private sector and international organizations. Public health approach with emphasis on health promotion, education and prevention as well as early detection, timely treatment and quality of care for persons who already have NCDs or who display warning signs in terms of the presence of risk factors. Reorientation of health systems, including providing training and capacity building and paying special attention to integrating NCD prevention and control into primary health care. Evidence based strategies: Application of the best available evidence, based on public health relevance and impact, using data from surveillance and research, in developing and formulating policies and programmes. 19. Based on the global indicators and targets, the proposed indicators and targets to be achieved by Member States by 2025 are as follows: 9

10 Proposed indicators and targets for the prevention and control of NCDs for SEAR Member States (definition of indicators and proposed data sources are provided in Annex) Mortality and morbidity Framework element Premature mortality from noncommunicable diseases Indicator (additional indicators included in Action plan) Mortality and morbidity 1.Unconditional probability of dying between ages of 30 and 70 from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases 2. Cancer incidence, by type of cancer, per population. Target (1) 25% relative reduction in overall mortality from cardiovascular diseases, cancer, diabetes and chronic respiratory diseases Risk Factors For NCDs (Behavioural) Risk factors Behavioural risk factors Harmful use of (3) Total (recorded and alcohol: 1 unrecorded) per capita (aged 15 years and older) alcohol consumption within a calendar year in litres of pure alcohol, as appropriate, within the national context Physical inactivity (4) Age standardized prevalence of heavy episodic drinking among adolescents and adults, as appropriate, within the national context (5) Alcohol related morbidity and mortality among adolescents and adults, as appropriate, within the national context (6) Prevalence of insufficiently physically active adolescents (defined as less than 60 minutes of moderate to vigorous intensity activity daily) (2) At least 10% relative reduction in harmful use of alcohol, as appropriate, within the national context 2 (3) 10% relative reduction in prevalence of insufficient physical activity 1 Countries will select indicator(s) of harmful use of alcohol as appropriate to national context and in line with WHO s global strategy to reduce the harmful use of alcohol and that may include prevalence of heavy episodic drinking, total per capita alcohol consumption, and alcohol related morbidity and mortality, among others. 2 In WHO s global strategy to reduce the harmful use of alcohol the concept of harmful use of alcohol encompasses drinking that causes detrimental health and social consequences for the drinker, the people around the drinker and society. 10

11 Unhealthy diet Salt/sodium intake (7) Age standardized prevalence of insufficiently physically active persons aged 18 years or older (defined as less than 150 minutes of moderate intensity activity per week or equivalent). (8) Mean population intake of salt (sodium chloride) per day in grams in persons aged 18 years and older (4) 30% relative reduction in mean population intake of salt/sodium intake 4 Risk Factors For NCDs (Behavioural) Low Fruits and vegetables Saturated fat intake Tobacco use (9) Age standardized prevalence of persons (aged 18 years and older) in population consuming less than five total servings (400 grams) of fruit and vegetables per day (10 3 ) Age standardized mean proportion of total energy intake from saturated fatty acids in persons aged 18 years and older. (11) Prevalence of current tobacco use among adolescents (12) Age standardized prevalence of current tobacco use among persons aged 18 years and older. (5) 30% relative reduction in prevalence of current tobacco use in persons aged 15 years and older Biological risk factors Raised blood pressure (13) Age standardized prevalence of raised blood pressure among persons aged 18 years and older (defined as systolic blood pressure 140 mmhg and/or diastolic blood pressure 90 mmhg) and mean systolic blood pressure. (6) 25% relative reduction in the prevalence of raised blood pressure or contain the prevalence of raised blood pressure, according to national circumstances 3 Individual fatty acids within the broad classification of saturated fatty acids have unique biological properties and health effects that can have relevance in developing dietary recommendations. 4 WHO s recommendation is less than five grams of salt (sodium chloride) or two grams of sodium per person per day. 11

12 Raised blood glucose / Diabetes 5 (14) Age standardized prevalence of raised blood glucose concentrations/diabetes among persons aged 18 years and older (defined as fasting plasma glucose concentration 7.0 mmol/l (126 mg/dl) or on medication for raised blood glucose concentration, respectively) (7) Halt the rise in diabetes and obesity Risk Factors For NCDs (Biological) Overweight & Obesity (15) Age standardized prevalence of overweight and obesity in adolescents (defined according to the WHO growth reference as: overweight one standard deviation body mass index for age and sex, and obese two standard deviations body mass index for age and sex) (16) Age standardized prevalence of overweight and obesity in persons aged 18 years and older (defined as body mass index greater than 25 kg/m² for overweight and 30 kg/m² for obesity). National systems Raised total cholesterol Drug therapy to prevent heart attacks and strokes (17) Age standardized prevalence of raised total cholesterol concentration among persons aged 18 years and older (defined as total cholesterol concentration 5.0 mmol/l or 190 mg/dl) and mean total cholesterol concentration National systems response (18) Proportion of eligible persons (defined as aged 40 years and older with a 10 year cardiovascular risk greater than or equal to 30%, including those (8) At least 50% of eligible people receive treatment with medicines and counselling (including control of glycaemia) to 5 Countries will select indicator(s) appropriate to national context. 12

13 Access to essential medicines and basic technologies to treat major noncommunicable diseases with existing cardiovascular disease) receiving treatment with medicines and counselling (including control of glycaemia) to prevent heart attacks and strokes. (19) Availability and affordability of quality, safe and efficacious essential medicines for noncommunicable diseases, including generics, and basic technologies in both public and private facilities. (20) Access to palliative care, as assessed by morphine equivalent consumption of strong opioid analgesics (excluding methadone) per death from cancer prevent heart attacks and strokes (9) 80% availability of affordable basic technologies and essential medicines, including generics, required to treat major noncommunicable diseases in both public and private facilities (21) Vaccination coverage against hepatitis B virus, monitored by number of third doses of hepatitis B vaccine administered to infants (22) Availability, as appropriate, if cost effective and affordable, of vaccines against human papillomavirus infection, according to national programmes and policies National policies (23) Proportion of women between the ages of 30 and 49 years screened for cervical cancer at least once, or more often, and for lower or higher age groups according to national programmes or policies. (24) Adoption of national policies that limit saturated fatty acids and virtually eliminate partially hydrogenated vegetable oils in the food supply, as appropriate within 13

14 the national context and national programmes (25) Policies to reduce the impact on children of marketing of foods and non alcoholic beverages high in saturated fats, trans fatty acids, free sugars, or salt. 14

15 Harmful use of alcohol 10% Regional Monitoring Framework Targets Premature mortality from NCDs 25% Physical Inactivity 10% reduction Essential medicines & technologies 80% Salt / Sodium intake 30% reduction Drug therapy & Counseling 50% Tobacco Use 30% reduction Diabetes/ obesity 0% Raised blood pressure 25% Additional targets to be discussed?screening for cervical cancer? Oral Cancer? Household Regional Monitoring Framework (+ indicators on?hap, oral cancer) Mortality & Morbidity Risk Factors National Systems Response Unconditional probability of dying between ages of 30 and 70 from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases Cancer incidence, by type of cancer, per population Harmful use of alcohol (3) Physical Inactivity (2) Salt/Sodium Intake Low Fruits & Vegetables Saturated Fat Intake (2) Tobacco Use (2) Raised blood pressure Raised blood glucose / diabetes Overweight & Obesity (2) Drug therapy & Counseling Essential NCD medicines & technologies Access to palliative care Hepatitis B Vaccine Human Papilloma Virus Vaccine Cervical cancer screening Policies to limit saturated fats & virtually eliminate trans fats Marketing to children 15

16 Priority Actions 20. To achieve the above targets, the priority actions for WHO and Member States are listed along four key strategic action areas 1 4. Area 1 Advocacy, partnerships, and leadership and management Area 2 Health promotion and risk reduction Area 3 Health systems strengthening for early diagnoses and management of NCDs and their risk factors Area 4 Surveillance, research, and monitoring and evaluation The tables below provide priority actions by WHO and Member States and indicators to monitor these actions. 16

17 Strategic Action Area 1: Advocacy, partnerships, and leadership and management 1.1 Advocacy Partners: Parliamentarians, All government agencies such as Ministries of Health, Finance, Trade, Education, Legal, Agriculture, Sports, Youth affairs, Information; UN agencies, Developmental Partners, Civil Society, NGOs, Media, Private sector Desired outcome Indicators Actions by WHO Recommendations for Actions by Member States Demonstrable Process indicators Strengthen advocacy to Heads of Integrate NCDs into health planning increase in political State, parliamentarians and policy processes and development plans with commitment for Percentage of government makers to give a high priority to special attention to social health issues expenditure on prevention NCDs determinants of health including NCDs and control of noncommunicable diseases NCDs included and prioritized in the national development plans and policies Offer technical support to integrate NCDs into national health planning processes, development agenda and poverty alleviation strategies Facilitate dialogue on regional & domestic resource mobilization and innovative financing Support United Nations Country Team, to integrate NCDs into the United Nations Development Assistance Framework (UNDAF) processes Generate and disseminate evidence on the relationship between NCDs and other development issues such as poverty alleviation, sustainable development, food security etc Raise public and political awareness and understanding about NCDs by social marketing, mass media and responsible media reporting Provide adequate and sustained resources for NCDs by increased domestic budgetary allocations, innovative financing and other means Mobilize the UN Country Teams and link NCDs into the UNDAF processes 17

18 1.2 Partnerships Partners: Parliamentarians, All government agencies such as Ministries of Health, Finance, Trade, Education, Legal, Agriculture, Sports, Youth affairs, Information; UN agencies, Developmental Partners, Civil Society, NGOs, Media, Private sector Desired outcome Indicators Actions by WHO Recommendations for Actions by Member States All stakeholders and partners engaged and have prioritized Process indicators Facilitate intercountry collaboration for exchange of best practices in the areas of health in Establish/ strengthen a national multisectoral NCD policy and plan with adequate budget NCDs in their policies all policies, whole of government and plans and whole of society approaches National and subnational mechanism/s for multisectoral involvement established and functioning Multisectoral national NCD policy, strategy or action plan which integrates several NCDs and shared risk factors developed and operational Provide guidance to countries in developing partnerships for multisectoral actions Coordinate activities related to NCDs of various UN Agencies, Funds, and Programmes Collate and publish regional best practices for effective public policy development and implementation in the Region Set up an effective national multisectoral mechanism commission, agency or task force reporting to the Head of State (or delegate), to plan, guide, monitor and evaluate the enactment of multisectoral national NCD policies and plans and to secure budgetary allocations Ensure policy coherence and accountability of different spheres of policy making for the implementation of health in all policies and whole of government and whole of society approaches for prevention and control of NCDs Mobilize a social movement engaging and empowering a broad range of actors to shape a systematic societywide national response to address NCDs, social environmental and economic determinants of health and health equity 18

19 1.3 Leadership and management Partners: Parliamentarians, All government agencies such as Ministries of Health, Finance, Trade, Education, Legal, Agriculture, Sports, Youth affairs, Information; UN agencies, Developmental Partners, Civil Society, NGOs, Media, Private sector Desired outcome Indicators Actions by WHO Recommendations for Actions by Member States Health Ministry Process indicators Examine the capacity of Member effectively leading States through capacity assessment and coordinating the NCD unit/department in the surveys to identify needs, and tailor national NCD Ministry of Health with the provision of technical support prevention and adequately skilled staff control programme established/strengthened Provide technical support to countries for health impact assessment of public policies for maximizing intersectoral synergies Develop appropriate training programmes to strengthen skills of national workforce in dealing with the complexity of issues needed for implementing NCD programmes Set up and/or strengthen a national unit on NCDs in the health ministry with suitable expertise and resources for: needs assessment, strategic planning, policy development, multisectoral coordination, programme implementation and evaluation Conduct periodic needs assessment of epidemiological and resource needs, including the health impact of policies in sectors beyond health Strengthen skills and capacity of workforce for implementing the national action plan and to deal with the complexity of issues relating to NCDs including multisectoral action, advertising, human behaviour, health economics, food and agricultural systems, law, business management, psychology, trade, commercial influence and urban planning, etc. 19

20 Strategic Action Area 2: Health promotion and risk reduction 2.1 Reduce tobacco use Partners: Ministries of Health, Finance, Trade, Education, Legal, Agriculture, Information; Media; Civil Society NGOs Desired outcome Indicators Actions by WHO Recommendations for Actions by Member States Tobacco use reduced Outcome indicators Age standardized prevalence of current tobacco use among persons aged 18 years and older Prevalence of current tobacco use among adolescents Process indicators Comprehensive national tobacco control legislations in line with the WHO FCTC adopted and enforced Provide technical support to countries in drafting tobacco control legislations /regulations/ directives, etc. Provide technical support to countries for enforcement of tobacco control legislation Develop and disseminate standard guidelines for tobacco cessation services Provide training for tobacco cessation to health professionals Provide technical support to countries to conduct tobacco surveillance Maintain a database of pictorial warnings to facilitate sharing between countries Ensure wide access to information on the tobacco industry Compile evidence of effectiveness of taxation policies to reduce tobacco use For Non Parties, accelerate process to accede to the WHO FCTC; for Parties, accelerate effective implementation of WHO FCTC and its Protocol to Eliminate Illicit Trade in Tobacco Products Strengthen tobacco surveillance system to monitor tobacco use and prevention policies and sponsorship Raise taxes and inflation adjusted prices on tobacco products in line with WHO FCTC (Article 6) Legislate for 100% tobacco smokefree environments in all indoor workplaces, public transport, indoor public places and, as appropriate, other public places (in line with WHO FCTC Article 8) Warn people about the dangers of tobacco, including through hardhitting mass media campaigns and large, clear, visible and legible health warnings (in line with WHO FCTC Articles 11, 12) Implement comprehensive bans on tobacco advertising, promotion and sponsorship (in line with WHO FCTC Articles 13) 20

21 Offer help to people who want to stop using tobacco (in line with WHO FCTC Article 14) Protect tobacco control policies from commercial and other vested interests of the tobacco industry in accordance with national law (in line with WHO FCTC Article 5.3) Regulate the contents and emissions of tobacco products, tobacco product disclosures and the methods by which they are tested and measured. (in line with WHO FCTC Article 9 & 10) Take measures to eliminate the illicit trade of tobacco products, including smuggling, illicit manufacturing and counterfeiting(in line with WHO FCTC Article 15) Prohibit sales of tobacco products to and by minors (in line with WHO FCTC Article 16) Consider taking action to deal with criminal and civil liability, including compensation where appropriate and to offer one another related legal assistance (in line with WHO FCTC Article 19) Establish or strengthen national surveillance programs, to initiate, cooperate, and promote tobacco control related research and the exchange of tobacco control related information. (in line with WHO FCTC Article 20) 21

22 2.2 Reduce harmful use of alcohol Partners: Ministries of Health, Finance, Trade, Education, Legal, Agriculture, information; Media; Civil Society NGOs Desired outcome Indicators Actions by WHO Recommendations for Actions by Member States Harmful use of alcohol Outcome indicators Provide leadership and technical Adopt and accelerate reduced Total (recorded and unrecorded) alcohol per capita (15+ years old) assistance to support the implementation of global strategy implementation of global strategy to reduce harmful use of alcohol consumption within a calendar year to reduce harmful use of alcohol Strengthen awareness of alcoholattributable in litres of pure alcohol as appropriate, within the national context Strengthen advocacy to all stakeholders for reducing harm from alcohol burden and leadership, political commitment to reduce harmful use of alcohol Age standardized prevalence of heavy episodic drinking among Promote networking & exchange of experiences among countries Regulate the commercial or public availability of alcohol adolescents and adults as appropriate, within the national Strengthen partnerships and resource mobilization through laws, policies and programmes. context Coordinate monitoring of alcohol Restrict or ban alcohol related harm and the progress advertising and promotions Process indicators that has been made Introduce pricing policies, such Comprehensive national alcohol as excise taxes on alcoholic policy and legislation in place for beverages reducing harmful use of alcohol enacted. Implement effective drink driving policies and countermeasures Reduce the public health impact of illicit alcohol and informally produced alcohol through identified measures Reduce the negative consequences of drinking and alcohol intoxication and providing consumer information Strengthen health services to provide prevention and treatment intervention to individuals and 22

23 families at risk of, or affected by alcohol use disorders and associated conditions Support and empower communities to use their local knowledge and expertise in adopting effective approaches to prevent and reduce harmful use of alcohol Strengthen surveillance systems to monitor the magnitude and trends of alcohol related harm, to strengthen advocacy, to formulate policies and to assess impact of interventions 23

24 2.3 Promote healthy diet high in fruits and vegetables and low in saturated fats/trans fats, free sugars and salt Partners: Ministries of Health, Education, Higher education, Finance, Trade, Legal, Food and agriculture, information & sports; Private: Food manufacturers, retailers; Media; Civil Society NGOs, consumer Desired outcome Indicators Actions by WHO Recommendations for Actions by Member States Reduced consumption Outcome indicators Develop and disseminate Advance the implementation of Global of unhealthy diet high in saturated fats/trans Prevalence of persons (aged 18+ years) consuming less than model policies, legislations and regulations (best practices) Strategy on Diet and Physical Activity for Health fat, free sugar and salt and increased intake of five total servings (400 grams) of fruit and vegetables per day Provide technical support to countries to develop and Implement WHO s set of recommendations on the marketing of fruits and vegetables Age standardized mean proportion of total energy intake from saturated fatty implement national policies and regulations foods and non alcoholic beverages to children, including mechanisms for monitoring acids in persons aged 18+ years and older Establish regulations and fiscal policies that promote consumption of fruits and vegetables and products low in sodium content, saturated and trans Process indicators National policies to reduce the impact on children of marketing of foods and nonalcoholic beverages high in saturated fats, trans fatty acids, free sugars or salt developed and enforced fatty acids, and free sugars Consider economic tools, including taxes and subsidies, to improve the affordability of healthier food products and to discourage the consumption of less healthy options Carry out public campaigns through mass media and social media to inform consumers about healthy diet Promote and support exclusive breastfeeding for the first six months of life, continued breast feeding until two years and beyond and timely complementary feeding 24

25 Population salt/sodium consumption reduced Outcome indicators Mean population intake of salt (sodium chloride) per person per day Process indicators Adoption of national policies to regulate private sector to reduce salt/sodium content of processed/packaged food Provide technical support to Member States to develop sodium reduction strategies Strengthen country capacity to conduct surveys on population sodium surveys Dialogue with the private sector and build pressure to reduce sodium content of processed food Implement the Codex Alimentarius international food standards for the labelling of pre packaged foods as well as the Codex Guidelines on Nutrition Labelling to provide accurate and balanced information for consumers and enable them to make wellinformed, healthy choices Develop and implement salt reduction strategies in line with WHO recommendations Increase collaboration between salt/sodium reduction programmes and salt iodization programmes for increased public health gains and higher efficiency. Carry out public campaigns to educate and motivate people to reduce salt consumption to recommended levels Regulate private industry to voluntarily reduce salt in packaged food and label food items and monitor compliance. Undertake representative surveys to measure population salt/sodium intake 25

26 Artificial trans fats eliminated and intake of saturated fats reduced Process indicators Adoption of national policies that limit saturated fatty acids and virtually eliminate partially hydrogenated vegetable oils in the food supply Develop and disseminate model policies, legislations and regulations to eliminate artificial trans fats Provide technical support to countries to develop national policies and regulations to eliminate saturated and trans fats in the food supply chain Establish policies and regulations to eliminate partially hydrogenated vegetable oils (PHVO) in the food supply and limit saturated fatty acids Monitor compliance of private sector with the regulations Carry out public campaigns to educate and motivate people to reduce saturated fat consumption 26

27 2.4 Promote physical activity Partners: Ministries of Health, Finance, Trade, Education, Sports, youth affairs, Legal, information, Local government, Infrastructure / Transport, planning & urban development; Media; Civil Society NGOs Desired outcome Indicators Actions by WHO Recommendations for Actions by Member States Physical inactivity reduced Develop and disseminate model legislation for supportive Adopt and implement national guidelines on physical activity for Outcome indicators 1. Prevalence of insufficiently active persons aged 18 years and older 2. Prevalence of insufficiently active adolescents (defined as less than 60 minutes of moderate to vigorous intensity activity daily) environments for physical activity Provide support for establishing collaboration with architects and town planners in countries to advocate urban planning to increase public spaces supportive of physical activity Develop and disseminate guidelines for physical activity Facilitate sharing of best practices and lessons learned among countries health Advocate to town planners for designing increased public spaces supportive of physical activity Establish legislation to ensure new housing developments include safe spaces for walking and cycling Carry out mass media and social marketing to raise awareness on benefits of physical activity Promote physical activity through activities of daily living including through active transport, recreation, leisure and sports. Encourage the evaluation of actions aimed at increasing physical activity, to contribute to the development of an evidence base of effective and cost effective actions 27

28 2.5 Promote healthy behaviours and reduce NCDs in key settings Partners: Ministries of Health, Education, Trade, Sports, youth affairs, information, Local government, Infrastructre/transport, planning/urban development; Corporate sector; Media; Civil Society NGOs Desired outcome Indicators Actions by WHO Recommendations for Actions by Member States Reduced risk of NCDs Process indicators Develop and disseminate model Appoint and train focal persons in among school children/ students at 1. National guidelines for health promoting schools/students at healthy schools/workplace policies and programmes MOH and Ministry of education for health promoting schools educational institutes, and workforce educational institutes developed and adopted 2. National guidelines for workplace wellness programmes developed and adopted Develop and disseminate model comprehensive workplace wellness policies and programmes to reduce the risk of NCDs Provide technical support to countries in developing and implementing school, workplace, policies and programmes Develop model NCD curricula for prevention and control of NCDs including counseling techniques as part of training of teachers Facilitate sharing of experiences and best practices among countries Establish health promoting schools with guidelines for implementation and mechanisms for monitoring and evaluation Conduct advocacy and training workshops to promote healthy behaviours in schools and workplaces Establish health promoting workplaces with guidelines for implementation and mechanisms for monitoring and evaluation Discontinue the excessive use of sugar and saturated fat containing foods offered by cafeteria and caterers at schools and workplaces 28

29 2.6 Reduce metabolic risk factors Partners: Ministries of Health, Education, Trade, Sports, youth affairs, information, Local government, Infrastructre/transport, planning/urban development; Corporate sector; Media; Civil Society NGOs Desired outcome Indicators Actions by WHO Recommendations for Actions by Member States Cardio metabolic risk reduced Outcome indicators Age standardized prevalence of overweight and obesity in adolescents (defined according to the WHO growth reference as: overweight one standard deviation body mass index for age and sex; and obese two standard deviations body mass index for age and sex) Age standardized prevalence of overweight and obesity in persons aged 18 years and older (defined as body mass index greater than 25 kg/m² for overweight and 30 kg/m² for obesity). Prevalence of raised total cholesterol among persons aged 18+ years and mean total cholesterol Age standardized prevalence of raised blood glucose concentrations/diabetes among persons aged 18 years and older (defined as fasting plasma glucose concentration 7.0 mmol/l (126 mg/dl) or on medication for raised blood glucose concentration, respectively) Raised blood pressure among persons aged 18+ years and mean systolic blood pressure Activities contributing to achievement of this indicator are included under 2.1, 2.2, 2.3, 2.4 and 2.5 Activities contributing to achievement of this indicator are included under 2.1, 2.2, 2.3, 2.4 and