Scaling up prevention and control of noncommunicable diseases in the WHO Eastern Mediterranean Region

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Review

Heba Fouad¹, Nisreen Abdel Latif¹, Rachel A Ingram¹ and Asmus Hammerich¹

¹WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to: Heba Fouad: This email address is being protected from spambots. You need JavaScript enabled to view it.)

Abstract

Surveillance is an essential component in the campaign to prevent and control noncommunicable diseases (NCDs), both globally and in the Eastern Mediterranean Region (EMR). In order to address the increasing burden from these diseases, countries must first evaluate their own systems and see what steps need to be taken to improve preparedness. Therefore, the WHO Regional Office for the Eastern Mediterranean in Cairo, Egypt, conducts country capacity surveys on a regular basis to compare each Member State’s NCD provision to the Framework for Action to implement the UN Political Declaration (2011). Ten progress indicators cover governance and planning, reducing risk factors and healthcare provision. Each one is scored for whether a country is fully, partially or not achieving this goal. This review focuses on comparing the Progress Monitor reports for the 22 EMR countries in 2015 and 2017. While the criteria used to assess some of the indicators have been updated over this period, many categories still show strong improvements. However, others still require extensive work if countries are to meet the sustainable development goal of reducing by %25 the number of premature deaths from NCDs by the year 2025.

Citation: Fouad H, Abdel Latif N, Ingram R A, Hammerich A. Scaling up prevention and control of noncommunicable diseases in the WHO Eastern Mediterranean Region. East Mediterr Health J. 2018;24(1):52–62. https://doi.org/10.26719/2018.24.1.52

Received: 11/01/18; accepted: 05/03/18

Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

The importance of measuring national progress on prevention and control of noncommunicable diseases

Noncommunicable diseases (NCDs) are now the world’s biggest killers (1) and a leading cause of death and disability in the WHO Eastern Mediterranean Region (EMR) (2). The four main NCDs are cardiovascular disease (including heart attacks and stroke), diabetes, cancer and chronic respiratory disease (such as chronic obstructed pulmonary disease and asthma) (1–3). Over half of deaths caused by NCDs are premature, occurring before the age of 70 (2). Such data show that NCDs affect economically productive individuals, which impoverishes families while also placing a considerable burden on health systems and national economies. This can subsequently stifle the potential for socioeconomic development (2–4). In the WHO Eastern Mediterranean Region, NCDs are responsible for around 60% of all deaths, a total of 1.7 million a year (2,3). This figure is expected to increase to more than 3.8 million by 2030 unless major steps are taken to combat this rise (3). The Region also has some of the highest global rates of NCD-related risk factors; namely physical inactivity, tobacco consumption, and high salt, sugar and fat intake (5). Many of the premature deaths and disability caused by NCDs have the potential to be prevented by addressing these key common risk-factors through lifestyle changes and “best buy” interventions. However, achieving this reduction will require sound and committed national, regional and international efforts.

An essential step in tackling the burden of NCDs, both globally and in the EMR, is to first understand and assess the capacity of individual countries in prevention and control of these diseases. To this end, WHO conducts country capacity surveys on a regular basis since 2000, with the two most recent Progress Monitor publications released in 2015 and September 2017 (6,7). This process of measuring and updating countries periodically on progress aims to identify their individual strengths and weaknesses. The results allow countries to devise distinct plans to scale up implementation of NCD control policies and actions by strengthening their capacities and human resources.

This review highlights the progress made in the prevention and control of NCDs among the EMR Member States. Specifically it looks at commitments made by countries to reverse this epidemic, compares progress made by countries between 2015 and 2017 to meet these targets, and discusses recommended action and ways forward for countries to stay true to their commitments.

Commitments made by countries to reverse the NCD epidemic

In 2011, a high-level meeting of the United Nations General Assembly was held to discuss the prevention and control of NCDs. The outcome of this meeting was a political declaration where countries made commitments to take specific actions to address the burden associated with NCDs (8). This was endorsed by EMR Member States in the form of the Regional Framework for Action in 2012 (9). The Regional Framework provides strategic interventions and indicators to assess country progress in the four following areas: governance; prevention and reduction of risk factors; surveillance, monitoring and evaluation; and health care (Figure 1).

Process and tools for measuring national progress on prevention and control of NCDs

Globally, WHO measures national progress on the prevention and control of NCDs using 10 progress monitoring indicators (7). In the Eastern Mediterranean Regional Framework, these indicators are divided into four areas: governance; prevention and reduction of risk factors; surveillance, monitoring and evaluation; and health care (9). In 2014, the WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt (EMRO), developed country profiles that utilize a “traffic light” system. This allows EMRO to update countries on progress made in the prevention and control of NCDs on a regular basis. The major source of information in determining achievement of the indicators is the NCD country capacity survey (NCD CCS) carried out by EMRO at regular intervals. Additional data for some sections is also provided by the WHO Global Report on the Tobacco Epidemic and by the Global Survey on Alcohol and Health.

In May 2013, the World Health Assembly endorsed the WHO Global Action Plan for the Prevention and Control of NCDs 2013–2020 (10). The Global Action Plan provides Member States, international partners and WHO with a road map and menu of policy options. When implemented collectively between 2013 and 2020, this will contribute to progress on 9 global NCD targets to be attained in 2025, including a 25% relative reduction in premature mortality from NCDs by 2025 (10). WHO’s global monitoring framework on NCDs started tracking implementation of the Global Action Plan through monitoring and reporting on the attainment of the 9 global targets against a baseline in 2010 (11). The 9 voluntary global targets (Figure 2) address key NCD risk factors, including tobacco use, salt intake, physical inactivity, high blood pressure and harmful use of alcohol. The WHO Global Action Plan (2013–2020) in its Appendix 3 provides a total of 14 “best buys” or cost-effective, high-impact interventions out of 81 recommended interventions by WHO. The original best buys included banning all forms of tobacco advertising, replacing trans fats with polyunsaturated fats, restricting or banning alcohol advertising, preventing heart attacks and strokes, promoting breastfeeding, implementing public awareness programmes on diet and physical activity, and preventing cervical cancer through screening among other policy options (10). In May 2017 an update to Appendix 3 was endorsed by the Seventieth World Health Assembly. It now reflects the latest WHO recommendations on evidence-based cost-effective strategies, comprising a total of 88 interventions, out of which there are a total of 16 “Best buys”– those considered as most effective and feasible for implementation (12).

In 2015, WHO Member States set their national targets and began measuring their progress on the 2010 baseline reported in the WHO Global Status Report on Noncommunicable Diseases 2014 (13). In 2014, an outcome document was produced by the UN High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, where countries agreed to achieve four time-bound commitments in 2015 and 2016 (14) (Table 1). As a result, WHO developed a set of 10 progress indicators to facilitate monitoring these commitments and updating countries on progress made in implementation (15). These indicators were further updated in September 2017 to ensure consistency with the updated WHO “best buys” (16). They were then used in a WHO report submitted to the UN General Assembly at the end of 2017 in preparation for a comprehensive review of progress by the General Assembly in 2018. The results of the 2017 country capacity survey have also been visualized into the traffic lights system, and will inform progress made in the Region based on these 10 progress indicators.

Key findings of the WHO NCD Country Capacity Survey: comparison between 2015 and 2017

The WHO NCD Country Capacity Survey (NCD-CCS) collects information using a structured evaluation of the national efforts to prevent and control NCDs. Categories are aligned with the 10 progress monitoring indicators that are also used for other publications with WHO. Additional data is obtained from WHO Global reports on the tobacco epidemic and Alcohol and health. The NCD-CCS was conducted in 2000, 2005, 2010, 2013, 2015 and 2017. The Regional Office visualized the results of the survey using the “traffic light” system to facilitate reporting to countries on progress made thus far in the prevention and control of NCDs, identifying areas where implementation is lagging, and making recommendations on moving forward to meet global and regional commitments.

This review focuses on comparing the 10 progress indicators that were evaluated in the 22 EMR Member States in 2015 and 2017 (Table 1). One Member State did not complete the NCD-CCS in 2015 but was included in 2017. While indicators 1, 4, 5b, 5d, 6a-c, 7b, 7c, and 10 remained the same in both surveys, some refinements were made to other categories including rewording and the addition of extra sub-indicators. The criteria used to assess attainment of each indicator were also altered in some cases in the 2017 NCD-CCS when compared to 2015 to include additional validation. These methodological disparities lead to some limitations in comparing data between the two years. However, this analysis still provides a useful measure of overall progress in the region over the recent period.

One area of notable improvement was in the governance of NCDs. Between 2015 and 2017, the number of Member States that had set time-bound national targets based on WHO guidance increased from only 3 (14%) out of 22 countries to 12 (55%) (Figure 3). In 2015, only one country in the Region had an operational multisectoral national strategy/action plan that integrates the major NCDs and their shared risk factors. By 2017, eight Member States (36%) had fully achieved this indicator. A further five Member States had partially achieved it and thus, showed their firm commitment to implementing this action in the future.

By comparison, the national surveillance of NCDs still requires development. Currently no EMR Member States have fulfilled the criteria towards having a fully functioning system for routinely generating reliable cause–specific data, although more than half (14) are working towards this target. The number conducting STEPS surveys at least every 5 years only improved slightly from two to three countries between 2015 and 2017. Clearly this is an area on which to focus in the future.

Prevention of NCDs is focused upon through reduction of the four main contributing risk factors. The work of the WHO Framework Convention for Tobacco Control (FCTC) is assessed with a number of indicators in the Progress Monitor (Figure 3). Member States’ progress in this area was mixed; on some indicators there was no improvement in the number fully achieving the target. However, encouraging increases were seen in the number of Member States comprehensively banning tobacco advertising, promotion and sponsorship, from six (27%) in 2015 to nine countries (41%) in 2017. A newly introduced indicator for 2017 required countries to implement mass media campaigns to educate the public about the comprehensive health risks of tobacco. By the time of the 2017 survey, three out of 22 countries in the Region (14%) had fully achieved this target (Figure 3) and another six had partially achieved its implementation.

Nearly half of the Member States have implemented alcohol harm reduction measures to reduce the availability and promotion of alcohol and increase its cost as per the WHO Global Strategy. Eleven (50%) countries enacted and enforced restrictions on the physical availability of retailed alcohol, 12 (55%) enacted and enforced bans or comprehensive restrictions on exposure to alcohol advertising (across multiple types of media) and nine countries (41%) increased excise taxes on alcoholic beverages (Figure 3).

The progress monitor assesses the implementation of four measures to reduce unhealthy diets. In 2017, eight countries adopted national policies to reduce population salt/sodium consumption. Twelve (55%) out the 22 Member States adopted national policies that limit saturated fatty acids and virtually eliminate industrially produced trans-fatty acids in the food supply. Nearly one third of Member States (7/22) reported implementing policies to reduce marketing of foods and non-alcoholic beverages to children. Increasing breast-feeding rates is one of the WHO “best buy” interventions. Six (27%) of the Member States have legislation/regulations fully implementing the International Code of Marketing of Breast-milk Substitutes. Twelve (55%) (12/22) of the countries reported the implementation of at least one recent national public awareness and motivational communication for physical activity, including mass media campaigns for physical activity behavioural. These results show a great degree of progress in the areas of nutrition and physical activity since 2015 when no EMR country fully achieved a single one of these indicators (Figure 3).

Finally, in the areas of health care and medication (Figure 3), between 2015 and 2017 the number of EMR countries that have evidence-based national guidelines/protocols/standards for the management of major NCDs through a primary care approach increased from six to nine. Meanwhile 9 (41%) of the countries have provision of drug therapy, including glycaemic control, and counselling for eligible persons at high risk to prevent heart attacks and strokes, with emphasis on the primary care level in 2017 compared to five countries in 2015. An overall view of these results demonstrates that considerable progress has been made in the Region across a wide range of progress indicators (Figure 4). Certain areas still require much improvement but the continued surveying of these targets will help Member States to focus on these commitments in order to control and prevent NCDs in the Region.

Discussion

Noncommunicable diseases threaten more than health and are a major challenge for development at global and regional levels. In the 2030 Agenda for Sustainable Development (adopted September 2015), countries recognized NCDs as a leading issue for sustainable development (17). The main responsibility for preventing and controlling NCDs lies with governments and requires that all sectors work together. This was highlighted in the 2011 UN Political Declaration, which called for a whole-of-government and whole-of-society approach to address the global and regional burden of NCDs and their related risk factors (11). In spite of the many declarations of political will to tackle the challenge of NCDs, the limited progress in some areas shows that barriers remain to converting intentions into actions. An honest and open exploration of these obstacles is vital to allow the scaling up of NCD prevention and control in the Region.

Maintaining momentum after the initial political statements is a major challenge that can only be achieved by ensuring the commitment of policy-makers at the highest level of government. These key decision-makers can then ensure the engagement of not only the health sector but also stakeholders from other sectors who can realize the necessary changes. This group includes (but is not limited to) agriculture, communication, education, environment, finance, housing, transport, social/welfare and urban planning. So far, only limited progress has been made in engaging these other areas of government, thus hindering the multisectorial management of NCDs necessary to curb their burden. Another vital player in this arena is the commercial sector, which has the power to make significant changes to their products for health promotion purposes if correctly motivated. Many in the business community have declared, and in some cases demonstrated, the desire to aid public health. However, there is not currently an independent mechanism for assessing the implementation and impact of these commitments.

Enacting NCD control programmes requires a significant financial investment from international, regional and national organizations. The economic case for this action is clear in the long term, but in the short term allocating the necessary funds is a challenge, especially for the many low- and middle-income countries in the Region that are facing a steep increase in the prevalence and burden of NCDs. These countries in particular need, and frequently request, technical assistance from organizations such as WHO to help them develop and re-orientate their health services in an evidence-based manner in order to efficiently combat the full range of NCDs. Investing in the “best buy” interventions recommended by WHO provides a good starting point for these changes.

The EMR countries have stated that they are committed to addressing NCDs (9). The WHO country capacity surveys of 2015 and 2017 show that change is possible, even though more action is still needed for countries to meet their time-bound commitments. Areas requiring specific attention include setting national targets and implementing operational integrated policies/strategies/action plans, the development of multisectoral action plans; the periodic as well as routine assessment of NCD risk factors; the effective implementation of the “best buys”; and the strengthening of existing regional health care systems’ capacities to prevent and control NCDs. WHO is working in close collaboration with countries, using the Regional Framework for Action and the “traffic lights” system, to support them in achieving the outcomes laid out in the UN Political Declaration and 2014 Outcome documents.

The way forward

Countries of the Region need to renew their commitments and identify those NCD champions that will aggressively push the agenda forward. A sense of urgency must be created with focus placed on four main areas for improvement. NCD prevention and control requires the involvement of multiple stakeholders and therefore multisectoral action plans. Efforts to improve stewardship and advocacy among governments, the private sector, civil society and industry (if collectively and harmoniously working together) will improve progress. Lack of coordination among sectors is costly and ineffective; working together will yield more powerful results.

Innovative solutions in both financing and policy processes are required. Implementing inclusive, integrated approaches coupled with innovative financing mechanisms gather the various NCDs under one strategy as well as supporting new developments at country level. Sound decision-making in NCD prevention and control requires up-to-date and reliable information. Integrating sustainable NCD surveillance systems (that focus on the three pillars of outcome, risk factors and national system response) into national health information systems allows for continuous monitoring and evaluation of countries’ progress. Based on the evidence provided by such systems, countries can effectively enforce planning.

Finally, health systems need to be strategically re-orientated to integrate NCD management into people-centered primary health care. Current health care provision in the Region is often vertically organized into separate disease areas, which do not account for the multiple risk factors and co-morbidities at play in NCDs. The family practice model allows practitioners to develop a holistic view of each patient which enables early detection and management of NCDs. According to the findings of the WHO country capacity surveys, countries need to focus upon stronger leadership and planning in order to tackle the burden of NCDs. The 2011 United Nations Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of NCD represents solid proof that with a strong political will and commitment, change is possible.

Funding: None.

Competing interests: None declared.

Intensifier la prévention et la maîtrise des maladies non transmissibles dans la Région OMS de la Méditerranée orientale

Résumé

La surveillance est une composante essentielle des efforts de prévention et de maîtrise des maladies non transmissibles (MNT), tant dans le monde que dans la Région de la Méditerranée orientale. Afin de s’attaquer à la charge croissante de ces maladies, les pays doivent au préalable évaluer leurs propres systèmes et voir quelles mesures doivent être prises pour améliorer la préparation. Par conséquent, le Bureau régional de l’OMS pour la Méditerranée orientale au Caire (Égypte) entreprend régulièrement des enquêtes sur les capacités des pays afin de comparer les dispositions prises par chaque État Membre par rapport au Cadre d’action pour la mise en œuvre de la Déclaration politique des Nations Unies (2011). Dix indicateurs de progrès couvrent la gouvernance et la planification, la réduction des facteurs de risque et la prestation de soins de santé. Chacune de ces catégories se voit attribuer un score permettant de savoir si un pays réalise cet objectif complètement, partiellement ou pas du tout. La présente analyse s’intéresse à la comparaison de rapports de suivi des progrès pour les 22 pays de la Région en 2015 et 2017. Alors que les critères utilisés pour évaluer certains indicateurs ont été mis à jour durant cette période, de nombreuses catégories affichent d’importantes améliorations. Cependant, d’autres catégories nécessitent encore un travail considérable si les pays veulent réaliser l’objectif de développement durable concernant la réduction de 25 % du nombre de décès prématurés dus aux MNT d’ici 2025.

توسيع نطاق الوقاية من الأمراض غير السارية والسيطرة عليها في إقليم شرق المتوسط لمنظمة الصحة العالمية

هبة فؤاد، نسرين عبد اللطيف، راشيل إنجرام، أزمس هاميرش

الخلاصة

يمثل الرصد عنصراً أساسياً في الحملة الرامية إلى الوقاية من الأمراض غير السارية والسيطرة عليها، سواءً على المستوى العالمي أو في إقليم شرق المتوسط. ويستلزم التصدِّي لزيادة العبء المتراكم من هذه الأمراض أن تضطلع البلدان أولاً بتقييم أنظمتها وتحديد الخطوات اللازم اتخاذها لتحسين التأهُّب. ومن ثم، يُجري مكتب إقليم منظمة الصحة العالمية لشرق المتوسط في القاهرة، مصر، دراسات مسحية على أساس منتظم بشأن قدرات البلدان لمقارنة المساهمات التي يقدمها كل بلد عضو على مستوى مواجهة الأمراض غير السارية في إطار العمل المتعلق بتنفيذ الإعلان السياسي للأمم المتحدة (2011). وتُستخدم في هذه الدراسة عشرة مؤشرات لقياس التقدم المحرز تغطي عناصر الإدارة والتخطيط والحد من عوامل الخطر وتوفير الرعاية الصحية. ويُسجَّل كل مقياس على أساس مدى تحقيق البلد المعني لهذا الهدف سواءً بشكل كلي أو جزئي أو عدم تحقيقه على الإطلاق. ويركِّز هذا الاستعراض على مقارنة تقارير رصد التقدم المحرز في بلدان الإقليم البالغ عددها 22 بلداً خلال عامي 2015 و2017. علماً بأنه قد أجريت تحسينات كبيرة في كثير من الفئات خلال هذه الفترة الزمنية. إلا أن ثمة فئات أخرى تحتاج إلى مزيد من العمل حتى يتسنى للبلدان تحقيق هدف التنمية المستدامة المتمثل في خفض معدل الوفيات المبكرة الناجمة عن الأمراض غير السارية بمقدار 25% بحلول عام 20٢٥.

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