Noncommunicable diseases

Regional framework for action

Focus continued to be placed on scaling up the implementation of the Political Declaration of the High-Level Meeting of the United Nations General Assembly on the Prevention and Control of Non-Communicable diseases, based on the regional framework for action. Since its endorsement by the Regional Committee, in 2012, the framework has been updated annually and a set of process indicators, intended to guide Member States in measuring progress in implementing the strategic interventions, has been developed.

This region has been very engaged, and has taken important initiatives, in the follow-up to the global strategy and the 2011 Political Declaration. In 2014, the second annual regional meeting provided an opportunity for Member States not only to review the progress made in implementing the regional framework for action but also to provide an important contribution to the Member States’ discussions in New York to prepare the outcome document of the high-level meeting of the General Assembly on the comprehensive review and assessment of the progress achieved in the prevention and control of noncommunicable diseases. Most of the recommendations made by Member States of the Region to the facilitators and Member States in New York were reflected in the final outcome document endorsed by the high-level meeting in July 2014. The only exception was the recommendation requesting the establishment of a monitoring mechanism, based on a specified set of indicators, to assess the progress made by countries between 2014 and the next review meeting of the General Assembly in 2018.

The critical importance of establishing such a monitoring mechanism was subsequently raised again by Member States during the 61st Session of the Regional Committee in October. A resolution was passed inviting the WHO Executive Board to request the Director-General to publish a technical note, before the 68th World Health Assembly, on how WHO will report to the United Nations Secretary-General on the progress made by countries for submission to the next high-level meeting in New York in 2018. The process indicators set out in the regional framework contributed to the final technical note issued by the Director-General in May 2015.

In the meantime, WHO has been working very closely with Member States on several important initiatives to implement the key commitments included in the four areas of the regional framework for action: governance, surveillance, prevention and health care.

Governance

While 38% of countries have an operational multisectoral strategy and/or action plan for noncommunicable diseases, only one fifth have set targets for 2025 based on the WHO guidance on fulfilling the time-bound commitments outlined in the 2014 outcome document. WHO is working closely with a number of countries (Lebanon, Morocco, Sudan, Islamic Republic of Iran, Oman, Tunisia and Yemen) to scale up development of multisectoral action plans, including setting national targets for 2025.

WHO has developed country profiles showing where each country is in implementing the commitments, based on the process indicators of the regional framework. The profiles were reviewed by Member States during the Regional Committee session in October 2014, and will continue to be reviewed on a regular basis during the ministerial meetings prior to the World Health Assembly and forthcoming sessions of the Regional Committee.

To enhance fiscal interventions and support countries in the area of legislation, WHO, in collaboration with the WHO Collaborating Centre at Georgetown University developed a dashboard of key legal interventions to address governance, diet, physical inactivity and tobacco control. Work will continue, in 2015, in developing guidance for Member States in implementing each of the key interventions, based on international experience and best practice.

Prevention and control of risk factors

Policy work on the shared risk factors for the main noncommunicable diseases was accelerated, particularly aiming at scaling up implementation of the proven cost-effective interventions (best buys) for prevention.

Tobacco control continues to face important challenges, particularly those posed by sociopolitical transition, the influence of the tobacco industry and the emergence of new products. The number of countries that are signatories to the first WHO protocol to the WHO Framework Convention on Tobacco Control (WHO FCTC) remains at eight. Political and technical support for the ratification of the WHO FCTC and protocol needs to be sustained. The Regional Office supported Member States in drafting two decisions of the Conference of Parties to the WHO FCTC, on control and prevention of waterpipe tobacco products and the global target on reduction of tobacco use, which will allow States Parties to report to the Conference on progress towards achieving the 30% reduction target by 2025. Following a regional consultation, national observatories to track tobacco advertising, promotion and sponsorship in drama are planned in three countries for 2015. Capacity-building initiatives were supported in the area of tobacco taxation in several countries. A checklist is being developed in order to support countries in developing national legislation consistent with international obligations. A regional package was developed for World No Tobacco Day, focusing on taxation, tobacco control, MPOWER measures, and the tobacco industry.

Nutrition received sustained attention. The current salt intake in the Region averages more than 10 g per person per day, which is double the recommended level set by WHO (5 g per person per day). Technical guidance, based on in-depth review of evidence and international experience, was developed in the form of policy statements on reducing intake of fats and salt in countries. Kuwait and Qatar reduced salt content in bread by 20% in one year. The Islamic Republic of Iran established maximum salt levels for selected food items and also issued a decree to reduce transfat content to less than 2% in oil industry products. It reduced palm oil imports to 30% of total oil imports in 2014 and will further reduce it by 15% in 2015. GCC countries are developing legislation to eliminate transfat in all locally produced or imported foods. Five countries now have food-based dietary guidelines, while a nutrition profiling model was developed and is being tested in seven countries, to help them to improve food labelling and promote healthy food.

The strategic priorities for WHO in the next biennium are to focus on helping countries to implement the policy statements, develop national action plans, review legislation and standards for food products that are high in fat and salt, promote research in reduction of salt and fat intake and set up regional nutrition profiling guidance. Training is being developed, in collaboration with the University of Liverpool, on the regulation of marketing of foods high in salt, sugar and fat. The aim is to enhance capacity in Member States for implementing the WHO recommendations on marketing of food and non-alcoholic beverages to children.

An initiative to counter the unopposed marketing of unhealthy products, especially to children, was announced during the Regional Committee session and will be launched in 2015. Also in collaboration with the University of Liverpool, WHO is now mapping the progress of 15 countries in implementing the WHO recommendations on marketing of food and non-alcoholic beverages to children. A 3-day course to build legal capacity and advance action on the recommendations was also developed and will be implemented in 2015. WHO worked with global experts to develop a draft roadmap to counteract unregulated and unopposed marketing of unhealthy products.

As reported in the previous section, a regional advisory committee was set up to support implementation of the regional call to action on physical activity and a training package is being developed on mass media and social marketing in regard to physical activity and healthy diet.

Surveillance, monitoring and evaluation

The strategic priority is to strengthen countries’ capacities to implement and strengthen the WHO surveillance framework. The core indicators under the three components of the framework – tracking health risks and determinants, monitoring outcomes (morbidity and cause specific mortality) and health systems capacity and response – have been integrated into the national health information framework endorsed by the Regional Committee at its 61st session. One priority for capacity building in surveillance is to establish a network of regional and international experts to support countries in implementing the framework as an integral part of their national health information systems. Working with the Eastern Mediterranean Public Health Network, a training workshop on surveillance for noncommunicable diseases was conducted for potential regional experts, following the development of a regional training package. This work will be followed up and strengthened in 2015.

In 2014 two countries (Kuwait and Pakistan) completed the STEPwise survey and six countries are moving forward in conducting their surveys (Djibouti, Jordan, Morocco, Somalia, Sudan and Tunisia). The Global Adult Tobacco Survey (GATS) was completed in Pakistan and Qatar, while Oman and Saudi Arabia are currently engaged in completing it. Five countries (Egypt, Iraq, Jordan, Sudan, and Yemen) completed the repeat rounds for the Global Youth Tobacco Survey (GYTS).

Analyses (SIM SMOKE) were conducted in 14 countries, the results of which will allow them to predict the health impact of full implementation of the MPOWER measures in reducing tobacco use and achieving the target set out in the global monitoring framework for noncommunicable diseases.

In collaboration with the International Agency for Research on Cancer (IARC), the cancer registry was assessed in four countries, and national capacities to develop cancer registries were strengthened.

Health care

The key strategy to improve health care for people with the four main groups of noncommunicable diseases (cardiovascular disease, diabetes mellitus, chronic respiratory disease and cancer) is to integrate their management into primary health care. Special emphasis is placed on achieving the 2025 global target 8 of 50% of eligible people receiving drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes and target 9 of 80% availability of the affordable basic technologies and essential medicines required.

Based on an online survey conducted in 2014/2015, only eight countries used a WHO-recommended approach to identify patients at high risk for heart attack and stroke; only 60% of countries had included in their essential primary health care package a WHO-defined minimum set of seven medicines to reduce the risk of heart attack and stroke. The Regional Office has drafted a framework for strengthening the integration of the management of common noncommunicable diseases, with special focus on hypertension and diabetes into primary health care and is currently developing a package of tools to support implementation including feasible approaches to address the health system constraints.

Access to quality cancer treatment is a priority for the Region. Subsequent to an expert consultation on improving cancer care, a joint programme of work between WHO and the International Agency for Research on Cancer (IARC) was initiated in 2014. Work is in progress to develop regional policy options for practical approaches to strengthening cancer care, focusing on organization of care, essential medicines and technology, financing, monitoring and evaluation, and priority research areas.

Managing noncommunicable diseases is a major challenge during emergencies and crises which unfortunately currently affect more than half of the countries of the region. A regional situation analysis was conducted to assess challenges to the provision of essential care with a focus on countries affected by the Syrian crisis. In addition to the health system constraints which are exacerbated during crises, the lack of clear guidance and tools on improving access to life saving interventions including medicines and technologies is currently receiving the highest level of attention in WHO’s work in 2015 and beyond.

Mental health and substance abuse

The huge magnitude of mental health and substance use disorders is receiving more attention as a public health problem following the adoption of the global action plan for mental health

2013–2020 by the World Health Assembly. In the Region, a major impetus to raising the profile of mental health and substance abuse programmes has been provided by the number of countries experiencing complex emergency situations, driving up need and demand for mental health and psychosocial support services. All countries in the Region have made some progress towards the integration of mental health into primary care. However, irrespective of country grouping, huge treatment gaps remain, ranging from 76% to 85%. The ATLAS survey, completed in 2014 to assess the capacities and resources available for mental health and substance abuse, helped identify the gaps in the areas of policy and legislation, service delivery, health promotion and disease prevention, and information, evidence and research.

In the area of policy and legislation, only 55% of countries have policies that have been developed or updated in the past 5 years while only 5 countries have legislation that was updated in the past 5 years. Technical support was therefore extended to countries to develop or update national mental health policies, strategies and legislation, in line with the global action plan and the United Nations Convention on the Rights of Persons with Disabilities.

WHO’s work in the Region is guided by the global action plan. The plan is comprehensive and covers the various dimensions of the mental health problem. For the plan to address the regional priorities, it was decided to focus, in our work with Member States and partners, on the development of a regional framework containing a set of evidence-based, high-impact strategies and interventions that are particularly relevant and can be feasibly implemented in the three groups of countries. The framework has been developed through intensive work with international and regional experts. It covers a set of evidence-based, high impact interventions in each of the four key components: governance, prevention and health promotion, health care and surveillance. The framework will be presented to the Regional Committee for consideration in October 2015.

As mentioned above, a significant proportion of countries are experiencing humanitarian emergencies. This has led to increased rates of mental disorders and distress on the one hand and resulted in downgrading of available services on the other. Support to enhance the capacities of emergency responders to provide mental health and psychosocial support (MHPSS) was provided in coordination with other United Nations agencies and international nongovernmental organizations, specifically in countries affected by the Syrian and Iraq crises. Staffwere recruited for MHPSS in Iraq and the Syrian Arab Republic. However, action is also needed is to strengthen MHPSS in other countries, including Libya and Yemen.

Substance abuse is of major concern in an increasing number of countries. In order to develop a coherent response to the issue of substance use in the Region, a framework for strengthening the public health response was developed in collaboration with other United Nations and regional stakeholders. The framework is supported by policy reviews which can help countries to articulate their position at the United Nations General Assembly special session on drugs in April 2016.