UN DESA/WHO regional high-level consultation: “Addressing noncommunicable diseases: major challenges to sustainable development in the 21st century”: Oslo, Norway, 25–26 November 2010: summary report of the meeting, revised – incorporating web consultation

UNDESA/WHO Regional High-level Consultation “Addressing noncommunicable diseases: major challenges to sustainable development in the 21st century” Hosted in Oslo by the Government of Norway, 25-26 November 2010 SUMMARY REPORT OF THE MEETING Revised – incorporating web consultation Version dated 22 April 2011 Page 1 of 13 UNDESA/WHO Regional High-level Consultation in the European Region on the Prevention and Control of Noncommunicable Diseases, with a particular focus on the developmental challenges “Addressing noncommunicable diseases: major challenges to sustainable development in the 21st century” Hosted in Oslo by the Government of Norway, 25-26 November 2010 SUMMARY REPORT OF THE MEETING INTRODUCTION AND BACKGROUND 1. The Ministers of Foreign Affairs, Environment and International Development, and Health and Care Services of Norway convened a Regional High-level Consultation on Noncommunicable Diseases (NCDs) in Oslo from Thursday, 25 November 2010, to Friday, 26 November 2010, to discuss the challenges faced by the WHO European Region1 in addressing NCDs and to provide an input to the preparatory process of the High-level Meeting of the United Nations General Assembly on the Prevention and Control of NCDs, to be held in September 2011 in New York. The Regional Consultation, co-sponsored by the United Nations Department of Economic and Social Affairs (UNDESA) and the World Health Organization (WHO), was held at the Radisson Blu Plaza Hotel. 2. The objectives of the Regional Consultation were four-fold: - To review the magnitude of NCDs and their socioeconomic impact at the regional and country levels - To discuss the political and policy relevance of addressing NCDs in low- and middle-income countries as a development issue - To identify the challenges, opportunities, and actions to be recommended for integrating the prevention and control of NCDs in the development agenda at global, regional and national levels - To discuss the role of Member States of the WHO European Region in supporting the preparations for the High-level Meeting of the United Nations General Assembly on the Prevention and Control of NCDs. 3. The themes of the Regional Consultation were based on the above-mentioned objectives. Three interactive sessions were held on the themes of (i) scaling up public policy responses to address NCDs and their risk factors; (ii) including NCDs in global and national development initiatives, and (iii) identifying the desired outcomes of the High-level Meeting in September 2011. A fourth interactive session was held to discuss the 1 Albania, Andorra, Armenia, Austria, Azerbaijan, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Luxembourg, Malta, Monaco, Netherlands, Norway, Poland, Portugal, Republic of Moldova, Montenegro, Serbia, Romania, Russian Federation, San Marino, Slovakia, Slovenia, Spain, Sweden, Switzerland, Tajikistan, The Former Yugoslav Rep of Macedonia, Turkey, Turkmenistan, Ukraine, United Kingdom of Great Britain and Northern Ireland, and Uzbekistan Version dated 22 April 2011 Page 2 of 13 contributions from Member States of the WHO European Region to the High-level Meeting. 4. The Regional Consultation was inaugurated by the Minister of Health and Care Services of Norway. Speakers included the Assistant Secretary-General for Policy Coordination and Inter-Agency Affairs of UNDESA, the Regional Director of the Regional Office for Europe of WHO, and the Secretary-General of the Norwegian Diabetes Association on behalf of Norwegian Nongovernmental Organizations (NGOs) with an interest in NCDs. 5. Delegates from Albania, Armenia, Austria, Bosnia and Herzegovina, Belarus, Bulgaria, Croatia, Denmark, Estonia, Finland, France, Germany, Hungary, Italy, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Republic of Moldova, the Netherlands, Norway, Poland, Portugal, Serbia, Slovenia, Romania, Russian Federation, Slovakia, Spain, Sweden, Switzerland, Turkey, Turkmenistan, Ukraine, United Kingdom, Uzbekistan, and the former Yugoslav Republic of Macedonia, participated in the Regional Consultation, as well as representatives from the European Commission, the Organization for Economic Co- operation and Development (OECD), the United Nations Department of Economic and Social Affairs (UNDESA), the United Nations Economic Commission for Europe (UNECE), the United Nations Children’s Fund (UNICEF), the World Bank, the World Health Organization’s Regional Office for the European Region and Headquarters. 6. This summary of the main deliberations of the Regional Consultation provides an input the preparations for the High-level Meeting, as well as serving to record the proceedings of the Consultation. This version of the report, dated 22 April 2011, incorporates the input of a web consultation of Member States and agencies who attended the Oslo consultation. A further web consultation was held with other agencies over the first quarter of 2011 and inputs were excluded from consideration here but will feed into other processes in preparation for the United Nations High Level Meeting. SCALING UP PUBLIC POLICY RESPONSES 7. In the last 40 years, European countries have made striking progress in the forestalling death and extending life, as evidenced by rising life expectancy and falling infant mortality rates. Yet health is by no means assured for all citizens in European countries. Four types of noncommunicable diseases (NCDs) – cardiovascular diseases, cancers, chronic respiratory diseases and diabetes – are now the most common causes of premature death and disability in all countries of the WHO European Region. In the region, NCDs account for 8.1 million deaths in 2004 (i.e. 86% of the total number of deaths in the region), including 1.5 million deaths before the age of 60 years. Three out of four premature deaths from NCDs in the WHO European Region occur in low- and middle- income countries (i.e. 1.1 million). Tobacco smoking and the harmful use of alcohol are the highest behavioral risk factors in the WHO European Region and the region’s experience in policy approaches to both risk factors provides important lessons for incorporation in global approaches to NCDs and development2 3. The region has the highest alcohol intake in the world and a per capita consumption twice as high as the world average. Furthermore alcohol consumption is increasing most rapidly in those (lower and middle-income) 2 WHO Report on the Global Tobacco Epidemic. The MPOWER package. World Health Organization, 2008 3 Global Health Risk. Mortality and burden of disease attributable to selected major risks. World Health Organization 2009. Version dated 22 April 2011 Page 3 of 13 countries where consumption used to be on the lower side in the Region. The rapidly increasing burden of NCDs is affecting poor and disadvantaged populations (e.g. migrants) disproportionately, contributing to widening health gaps between and within countries. If action is not scaled up, deaths from NCDs will increase from 8.1 million (2004) to 8.6 million (2015). These premature deaths before the age of 60 years are largely preventable by means of effective interventions that tackle four common modifiable risk factors, namely: tobacco use, unhealthy diet, physical inactivity, the harmful use of alcohol and particularly their social determinants. In addition, improved disease management can reduce morbidity, disability, and death and contribute to better health outcomes. Despite the ample resources available in the European Region, compelling ideas and approaches which have been adopted in some countries, have not taken hold in all European countries. 8. A number of key developments in the European Region were highlighted in the opening session and echoed in the proceedings. The WHO European Regional Office is developing a European Health Policy entitled ‘Health 2020’ and an NCD Action Plan 2011 – 2015. There is a synergy between these European initiatives and the preparations for the United Nations High Level Meeting, an opportunity for mutual strengthening. These processes may also assist with national NCD policy development, given the difficulty countries face in integrating national programmes in a meaningful way and recognizing the co-determination of national policy by European policy. In particular, the following points were made:  In parallel with the process leading to the United Nations High Level Meeting, work is in hand to develop Health 2020 (H2020), an overall coherent and consistent policy framework for Europe, which will address all issues that impact on health both within the health sector as well as in other sectors. This work responds to a specific request by the 60th Regional Committee Meeting, and the first consultation on this work in progress will be held on the 61st Regional Committee;  The epidemic of NCDs will not be addressed effectively unless there is a whole-of- Government approach to address policies in other sectors and to influence the social determinants of the epidemic. The European policy framework will thus advocate horizontal health governance approaches backed by political commitment at the highest level;  The European Study on Social Determinants is also under way. This will inform the development of Health 2020 both in low and middle income as well as high income countries;  The Member States at the meeting emphasized the importance of public health capacity to address the epidemic. Renewed commitment to public health is thus required, and the Health 2020 process will particularly focus on essential public health functions and operations for health protection, disease prevention and health promotion. A special focus is needed in public health surveillance of NCDs, their social determinants and the design of indicators of health gains through specific policies.  Finally the ongoing commitment to noncommunicable diseases in Europe is further signaled by the on-going efforts to develop a five year European Action Plan for the Prevention and Control of NCDs. This will reflect the Global and European Strategies adopted by the World Health Assembly and the Regional Committee respectively. It will focus on an integrated approach to the prevention and control of NCDs, on specific actions to address the specific priority diseases, and on empowering people living with these conditions to manage their own health. Version dated 22 April 2011 Page 4 of 13 9. The Consultation as outlined below focused on the needs of low and middle income countries. This is in view of the global meeting to take place in 2011. On the other hand, the participants noted many elements of relevance to all the European Member States: the social gradients within countries in Europe that disfavor the poor; the inequities between countries, including the older and more recent members of the European Union; the opportunities for exchange and the need for harmonized intercountry approaches to the epidemic. 10. Many participants noted the synergies with other noncommunicable conditions and injuries. The importance of preventing road traffic injuries was highlighted, as well as promoting mental health and well-being. However, the importance of preventing injuries from accidents and inter-personal violence should not be forgotten. While this process is focusing on a core group of physical NCDs with their shared risk factors, countries would need to see the synergies and choose where to put their priorities. Issues such as disease management, surveillance, prevention and monitoring and evaluation would be common to all and to the benefit of all. 11. Public policy-makers in countries in Europe have placed the prevention and control of NCDs at the forefront of efforts to improve health outcomes. The World Health Organization’s Regional Committee for Europe adopted the European Strategy for the Prevention and Control of Noncommunicable Diseases in 2006, as a strategic framework for action. To this end, at least 15 Member States in the WHO European Region have a unit or department in the Ministry of Health dedicated to NCDs, while at least 14 European countries are implementing a nationally-approved policy document for the prevention and control of NCDs. The European Strategy for the Prevention and Control of Noncommunicable Diseases is fully aligned with the Global Strategy for the Prevention and Control of Noncommunicable Diseases and its Action Plan. 12. Lower income countries in Europe face particular challenges in addressing the burden of NCDs. They often have a primary care infrastructure that is well-established but lacks the capacity for prevention or that is not focused on NCDs. The prevention of NCDs needs a population-based approach to risk factor reduction rather than just focusing on high-risk individuals. They need an infrastructure to support surveillance, that combines public health and science, facilitates monitoring and provides a means of demonstrating impact of programmes. These countries often lack capacity in strategic planning, translating measures into action plans, as well as tools for collecting data in a comparable way, and the participants saw institutes of public health as having a role to play in developing professional capacity. A proper strategic framework would have a timed action plan, build consensus, and ensure sustainability from the financial and political point of view. The United Nations High Level Meeting outcome document could provide examples of best practice internationally and help to influence other sectors. 13. Public policy decisions within sectors such as agriculture, trade, finance, taxation, food production, pharmaceutical production, industry, education, transportation and urban development can have a major influence on the population levels of behavioural and environmental risk factors. Therefore, gains can be achieved much more readily by influencing public policies in these sectors than by making changes in health policy alone. 14. The meeting recognized that NCDs were a problem for the whole of society and needed a whole-of-government approach. Participants discussed ways to scale up public policy responses to address NCDs and their risk factors at national levels. In specific areas Version dated 22 April 2011 Page 5 of 13 of the prevention of NCDs, intersectoral action has already been shown to be effective: structural measures such as taxes for alcohol and tobacco have been used in a deliberate way and, combined with other measures such as a total advertising ban, had been highly cost-effective and produced a sizeable impact in a relatively short time. New efforts are being made. An increasing number of countries are raising tobacco and alcohol taxes, are warning people about the dangers of tobacco and harmful use of alcohol, and are enforcing bans on tobacco and alcohol advertising. Some countries had started to raise taxes and prices on soft drinks high in free sugars. Adopting approaches to policy development that involve all government departments is difficult, but necessary and must be done with full respect to the core remit of each ministry, in order to ensure the NCD issues receive a cross-sectoral response. The use of financial instruments to support implementation of intervention projects, such as development investment to resolve structural economic and social problems, was highlighted by a number of low- and middle-income countries as a way to scale up pilots to national levels. Active participation in existing regional and subregional networks for the prevention and control of NCDs is key to identify and disseminate lessons learned in high-income countries. However, additional research is needed on the assessment of the cost–effectiveness of public health interventions for improving health behaviours and health outcomes in low- and middle-income countries. 15. Civil society plays a crucial part in a whole-of-society approach. A pre-conference of Norwegian civil society was held and presented its findings at the regional consultation. They expressed their desire for a three-day summit in New York, for the establishment of a civil society task force and for a reporting mechanism from Member States that could be benchmarked. The civil society report emphasized that NGOs ‘‘play on the same team’’ as participants in this battle against NCDs and were a crucial resource for governments. 16. Communication is an essential component in the response to NCDs. Communication capacities are needed to promote health to other sectors. Health professionals need to demonstrate powerful skills in communicating with other ministries, shifting discussion from price to value. There is a need for communication strategies to raise awareness and improve health literacy. There is a need to strengthen the individual capacities of people to make choices, balanced with responsibilities at the policy level. There is a need to invest in newer communication and social media in order to reach young people. 17. Several participants noted the importance of knowledge transfer and capacity building. The value of this has already been demonstrated in tobacco, where there is good international collaboration and cross-border cooperation. 18. Opportunities for strengthening capacity for NCDs at the global level can be found in existing partnerships both at the bilateral and multi-lateral level, such as that of the Community of Portuguese-speaking countries, and networks such as the network of national public health institutes in EuroHealthNet. The south-east Europe health network (SEEHN) provides a forum for such exchange. The network has focused on the needs of disadvantaged populations, among other issues, and had met in the week previous to the Regional Consultation to discuss health in all policies (HiAP) and the challenge of raising awareness with other ministries of the implications of their actions for health. 19. The first ministerial global conference on NCDs and Healthy Lifestyles will be held in the Russian Federation in 2011 including multiple stakeholders. It is an opportunity to also advance European policies in this area. It is important that other sectors are invited Version dated 22 April 2011 Page 6 of 13 and are present at that conference and to be clear on the potential gains and synergies between their development objectives and the prevention and control of NCDs. In developing these links, much can be learned from the experience of the environment sector in defining co-benefits and joint action across sectors.. INCLUDING NCDS IN GLOBAL DEVELOPMENT INITIATIVES 20. The development of comprehensive policies faces a resource allocation dilemma between funding traditional public health programmes and accommodating NCDs. There is a need to recognize that there are mutual linkages between the communicable and noncommunicable diseases; health systems strengthening assists both. Examples would be task-shifting between the workforce, access to essential medicines, financing, good information and monitoring systems, good stewardship and governance. Service delivery requires a chain of care stretching from promotion through prevention, treatment and through to palliative care. Functioning primary health care systems would benefit the whole chain. 21. NCDs are a development issue because the social, economic, and physical environments in low- and middle-income countries in the Eastern part of the European Region (and beyond) afford their population much lower levels of protection from the risks and consequences of NCDs than in the Western part of the European Region, where people tend to be protected by better living and working conditions and more comprehensive interventions. The most striking differences across the region occur between the ages 15 and 59. For 30 year old males, the risk of death before reaching 45 is nearly 5 times smaller in the Western part of the European Region than in countries with a high adult mortality in the Eastern part. Although this gradient is almost 50 per cent smaller for women, it remains significant4. 22. To include NCD in the development agenda can be done in various ways. Several participants recognized the need of many low- and middle-income countries for resources beyond domestic resource through official development assistance. Denmark referred to their experience on ODA to five African countries within the health sector where they include consideration of NCD when they support health strategies. 23. Communicable diseases continues to be the highest priority for the donor countries represented, as communicable diseases remains the main challenge for the poorest countries. There was reluctance among donor countries to change these priorities. Another challenge for policy-makers will be to promote integrated, horizontal approaches to NCDs, thus avoiding to establish new vertical structures. This will mean designing interventions in a manner that strengthens health systems and investing in interventions without jeopardizing other priorities. 24. Given the strong link of NCDs with MDGs and with poverty reduction, additional ODA for poor countries could be sought. Some countries expressed hesitation to further debate this issue during the consultation, in the absence of foreign and development ministries. For this to happen, good indicators and data would be needed, as well as a clear 4 Sixty-fifth session of the United Nations General Assembly. Follow-up to the outcome of the Millennium Summit. Note by the Secretary-General transmitting the report by the Director-General of the World Health Organization on the global status of non-communicable diseases, with a particular focus on the development challenges faced by developing countries. September 2010. Version dated 22 April 2011 Page 7 of 13 package of cost-effective policy measures. The process leading to the UNHLM should allow for further debate to take place with participation of development ministries and donor community, recognizing the present difficulties faced by some donor countries as well as the interests of recipient countries for a shift in priority areas; putting an emphasis on high-impact, low-cost interventions. 25. Participants acknowledged that NCDs are affecting the poor disproportionally (within countries and across countries). A number of participants highlighted the need address NCDs within the framework of inclusive growth. More progress will be made in improving health outcomes by enabling all to participate and benefit and income distribution is fairer. While creating an enabling environment to attract foreign direct investment is vital to promote inclusive growth, reducing the level of exposure of individuals and populations to risk factors for NCDs (e.g. tobacco use) and injuries (e.g. road traffic accidents) are also essential components of promoting inclusive growth. This will require all partners – including NGOs and the private sector – to work in partnership and play a stronger role in taking concerted action against NCDs. Participants from low- and middle-income countries emphasized the need to receive support, through aid and expertise, from high-income countries to strengthen national capacities to address NCDs, even though NCDs are not included in the current MDGs. Some participants from high- income countries enquired as to whether ways have been identified to promote better health outcomes from NCDs in low- and middle-income countries, while avoiding a new vertical approach that could jeopardize support to existing programmes to promote child and maternal health and combat communicable diseases. Many participants underlined that international development agencies need to base their overall support on demand from low- and middle-income countries (based on national development strategies), in accordance with the Paris Declaration. Examples were highlighted where international development agencies have included the prevention and control of NCDs in bilateral policy dialogues in Africa. 26. NCDs trap households in a vicious cycle of poverty. This especially applies to poor, marginalized and disadvantaged populations: mothers, children and young people in low income countries, vulnerable groups like Roma and migrants, and the elderly. Addressing NCDs within the development agenda must include these groups as a priority concern in Europe. 27. NCDs cause disability, not just death, and the cost of benefits for the sick and disabled people is also a financial burden for governments. The disabled (whether disabled by NCDs or disabled people suffering from NCDs) represent another important population with special needs in considerations of NCDs and national development. 28. Behavioural approaches to prevention and control of NCDs will need to proceed together with the creation of supportive policies and environments. Focusing solely on behavioural approaches may not be sufficient in the long. Participants also noted that there work is needed to reduce stigmatization of those with NCDs giving the examples of schools being afraid to take pupils with diabetes or social insurance not covering the treatment of risk factors and disease. 29. One solution may lie in the concept of ‘inclusive growth’ having three components: visionary political leadership; a strong state; and, a business-friendly environment. Tripartite partnerships of state, business and civil society are one means of promoting inclusive growth. Version dated 22 April 2011 Page 8 of 13 30. Surveillance of NCDs (via surveys and disease registries), monitoring and evaluation were perceived to be weak, particularly in central Asia and lacked investment at the national level. There was consensus on the importance of monitoring and evaluating the NCD situation, globally and in all countries. Clear targets and priorities assist also in monitoring for impact. A global scheme of monitoring NCDs with comparative indicators for assessment was considered. A general framework might be possible and WHO was asked by the meeting to work on such a framework. 31. Research is crucial particularly epidemiological, population-level research and for low- and middle-income countries (LMIC) there is limited information about the impact of interventions, how programmes work together and their impacts on broader programmes. WHO has an important role in transferring knowledge and promoting research. The partnership between WHO and OECD was cited as a successful model in bringing together the health and economic impacts of policy interventions and this partnership could be further applied. More research is needed on the cost–benefits and the financial consequences of inaction; a rebalance between prevention and health care, and an emphasis on the positive aspects of prevention DESIRED OUTCOMES OF THE HIGH-LEVEL MEETING 32. Many participants welcomed the United Nations General Assembly’s decision to convene a high-level meeting of the General Assembly in September 2011, with the participation of Heads of State and Government, on the prevention and control of NCDs. It is expected that the High-Level Meeting will generate global commitment and momentum to implement the Global Strategy for the Prevention and Control of NCDs and its related Action Plan. 33. Some participants stressed that lack of technical support for national capacity- building programmes in low- and middle-income countries is one of the main hurdles in strengthening national policies and plans for the prevention and control of NCDs. Many participants emphasized the need to conduct a review of international experience of intersectoral action against NCDs, and recommend, based on the outcomes of the review, successful approaches to integrate prevention and control of NCDs into policies across all government departments. Many participants recognized that the participation of Heads of State and Government at the High-level Meeting will raise awareness that NCDs can only be addressed with the effective involvement of sectors outside health. Building on the Outcome Document of the High-level Plenary Meeting of the sixty-fifth session of the General Assembly on the Millennium Development Goals, in which Heads of State and Government commit themselves to strengthening the effectiveness of health systems and proven interventions to address NCDs 5 , and to undertaking concerted action and a coordinated response at the national, regional and global levels to address the developmental challenges posed by NCDs6, many speakers echoed the need to ensure that the provision of health care for NCDs is dealt with in the context of overall health system strengthening. Participants discussed the feasibility of establishing a global goal, targets and indicators to address NCDs, taking into account that the commitments of Heads of State and Government to effectively monitor progress towards the MDGs included in the above-mentioned MDG Outcome Document are weak. However, many participants emphasized the need for decisive targets and indicators; not only to include the prevention 5 Paragraph 73.k www.un.org/en/mdg/summit2010/pdf/mdg%20outcome%20document.pdf 6 Paragraph 76.i www.un.org/en/mdg/summit2010/pdf/mdg%20outcome%20document.pdf Version dated 22 April 2011 Page 9 of 13 and control of NCDs an integral part of global development initiatives and in related investment decisions, but also to unite all stakeholders around a common agenda at global, regional and national levels. (The WHO/European Strategy for the Prevention and Control of Noncommunicable Diseases “Gaining Health” sets out a number of objectives in the RC resolution (EUR/RC56/R2)). 34. NCDs cannot be taken in isolation from development, and several participants noted the relationship between life expectancy and macroeconomic development. It is possible to use the momentum created by the 2011 high-level meeting in New York to show the relationship between macroeconomics and NCD, to highlight the importance of international collaboration and to promote multisectoral approaches at the national level. This could provide valuable input to forthcoming discussions on the global health and development agenda, which will need to give due consideration to the increasing disease burden of NCDs. Using the high-level meeting at the United Nations General Assembly next September to involve other ministries and Prime Ministers could provide an opportunity to demonstrate the synergies at the international and national level. AREAS OF DISCUSSION COVERED BY THE PARTICIPATING EUROPEAN MEMBER STATES 35. All participants welcomed the United Nations General Assembly’s decision to convene a high-level meeting of the General Assembly in September 2011, with the participation of Heads of State and Government, on the prevention and control of NCDs. Many participants recognized that the High-level Meeting is an opportunity to generate global momentum and commitment to implement the Action Plan for the Global Strategy for the Prevention and Control of NCDs. 36. Participants identified the following areas which need further discussion at the High-level Meeting: a. NCDs now account for a large share of premature deaths and poverty. There is a need, therefore, to increase the priority and allocations for health, NCD prevention, control and surveillance in national health budgets. In addition, there is a need for development partners to consider including effective, appropriate and cost-effective health promotion and prevention interventions targeted at NCDs and their risk factors, in accordance with national priorities. b. National policies in sectors other than health have a major bearing on the risk factors for NCDs. Health gains can be achieved much more readily by influencing public policies in other sectors than by making changes in health policy alone. There is a need, therefore, to promote the adoption of approaches to the prevention and control of NCDs that involve all government departments at national levels. c. Global targets and indicators need to be established in order to halt and begin to reverse premature deaths from NCDs. All countries require data and information on the magnitude of and trends in NCDs as the foundation for advocacy, policy development and national action. This data and information needs to be adequate, reliable, timely and disaggregated in order to show the burden, monitor the progress and demonstrate the effects of social determinants, including gender and income, as well as risk factors, including environmental ones. WHO is invited to work on developing a limited number of global targets and indicators on NCDs and risk factors. Building on the WHO Framework Version dated 22 April 2011 Page 10 of 13 Convention on Tobacco (WHO FCTC) – which has become one of the most widely embraced treaties in the history of the United Nations and, as of today, has 172 Parties – one possible global target is the reduction of prevalence of tobacco use among adults, for which data is available in more than 140 countries, including two-thirds of countries in Africa. d. NCDs are a threat to development that neither the developed world nor the developing world can afford. The burden of NCD is increasing rapidly and threatens development, including health and wider socio-economic development, in all countries, and by any metric. The cost of inaction is unacceptable: the growth of NCDs threatens national economies, the viability of health services, and the wellbeing of poorer households. Strong political will is needed at global and at national level to scale up and sustain the response to address this epidemic. The distribution of premature deaths from NCDs shows signs of increased burden in low- and middle-income countries, hence contributing to the unfair distribution of health and wealth globally. Issues like financial and economic crisis, volatility of food and energy prices, climate change and biodiversity add uncertainty and deepen inequalities between and within countries and negatively affect development. e. Member States need to reduce the level of exposure of individuals and populations to all types of risk factors for NCDs, and respond effectively and equitably to the health- care needs of people with NCDs as part of the fundamental human rights of every human being, in accordance with the WHO Constitution7. The inequitable distribution of the burden of NCDs among individuals and populations across social groups and income quintiles, as well as the inequitable distribution of the barriers to access preventive and curative services are a threat to human health and rights. f. Measures to tackle NCDs must not only address the diseases themselves, but also health behaviours and their social determinants. Actions taken to prevent and control NCDs must improve health literacy and help people with NCDs to manage their own conditions better. This includes providing education and incentives and tools for self- management and care. In order to achieve this, more attention should be paid to upstream social policies that address the root causes of NCDs. Universal health promotion strategies must be combined with more targeted intersectoral disease prevention measures that involve not only the health sector but also other sectors like education and environment. The intersectoral promotion of the adoption of healthy lifestyles is key for the prevention and control of NCDs. g. Communication and education strategies play an essential role in fostering a positive climate for social change and for raising awareness of NCDs and their risk factors among policy-makers and the population. A life-course perspective is appropriate for NCDs in view of the fact that exposure to risk starts in utero and accumulates throughout life. Particular focus should be given to children and adolescents, as the level of exposure to risk factors for NCDs is high among the youth. Strategies for reducing tobacco use, unhealthy diets, physical inactivity, the harmful use of alcohol among youth, and children’s exposure to environmental risk factors should therefore be considered a priority. h. Maternal health is a determinant of lifelong health. The protection of the health of women, the provision of proper antenatal services and attention to proper infant and 7 "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition" is one of 9 principles that are part of the Constitution of the World Health Organization. Version dated 22 April 2011 Page 11 of 13 young child nutrition, are all essential in their own right, as well as being an investment in the prevention of preventable NCDs. i. Environmental factors are major determinants for NCDs. Global climate change has some direct consequences on health, such as the increase of infectious and respiratory diseases. NCDs are also linked to specific environmental risk factors. Income, gender inequalities and social determinants have an impact on the distribution of the exposure to environmental risks of NCDs; children are particularly exposed. Furthermore, NCDs pose challenges to sustainability (e.g. clearing of land for tobacco farming and greenhouse emissions from cattle farming in response to demand for meat). In the WHO European Region, the approach taken through the Parma Ministerial Declaration on Environment and Health provides a strong and coherent policy infrastructure to fully exploit the opportunities to prevent NCDs by addressing their environmental risk factors. The experience of two decades of intersectoral action in the field of environment and health in Member States and with IGOs and NGOs can be emulated and lessons learned can be applied to the problem of NCDs. j. In order to halt and reduce premature mortality and morbidity from NCDs, more research is needed, particularly in LMIC. Work with countries should be undertaken in building and disseminating information about the necessary evidence base and surveillance data to inform policy-makers in low- and middle-income countries on proven packages of low-cost policy interventions (“best buys”) which reduce the level of exposure of individuals and populations to the main risk factors for NCDs and promote the effective management of NCDs. Research on the financial implications of inaction can be used as a tool for convincing policy-makers to set priorities and mobilize investments. Existing cost– effectiveness studies on packages of policy interventions to reduce tobacco use and the harmful use of alcohol need to be disseminated in order to inform policy-makers. These packages include fiscal measures, regulations on advertising and availability of tobacco and alcohol among youth. Similar packages of cost-effective policy interventions aimed at reducing unhealthy diets and physical inactivity need to be developed, and include interventions that make it easier for individuals to make healthy choices. Similar packages should be developed to enable health systems to respond more effectively and equitably to the health-care needs of people with NCDs. k. In order for low-cost packages of policy interventions to be implemented successfully in low- and middle-income countries, concerted involvement of governments in high-income countries is needed to help build public health and managerial capacity among line ministries, district authorities and civil society in low- and middle-income countries. Mechanisms of networking and exchange of experiences need to be strengthened and facilitated in order to support the development of national capacity for integrated prevention and control of NCDs l. The ageing population and the surge in NCDs imply that countries must address prevention and care simultaneously. A population-based preventive strategy is needed alongside a health systems strengthening approach. The infrastructure of the health system, in both the public and private sectors, should have the elements necessary for the effective prevention, management of and care for chronic conditions. Such elements include access to essential medicines and basic technologies, a re-orientation towards a person-centred approach and integrated comprehensive delivery of primary care. The Tallinn Charter; Health Systems for Health and Wealth in the European Region provides a framework for strengthening of health systems based on primary care responses. The Charter calls for Version dated 22 April 2011 Page 12 of 13 equity in health, solidarity, social justice, universal access to services, multisectoral action, transparency, accountability, community participation and empowerment, and health literacy development. Within this framework, responses of NCDs need to be reinforced through the strengthening of international cooperation via the exchange of best practices aimed at building public health capacity, improving access to medicines, encouraging the development and transfer of technology, and the training and retaining of health professionals. The health service has a key role in advising both the whole population and at-risk patients and implementing measures to reduce risk. Local “healthy living centres” that provide help, motivation and support for behaviour change can be an important supplement to primary health care. m. Government at all levels must work in partnership with local communities in the fight against NCDs, leading, mobilizing and coordinating a whole of society response to NCDs. Central government plays an essential role in the prevention and control of NCDs. This is especially crucial for certain measures, such as the adoption of appropriate laws and regulations. The fight against NCDs also takes place in local communities in the settings where people “live, work and play”. Local government has a particular role in developing health-supporting environments, for example through good urban planning. A central issue is therefore how to strengthen local government responses to address NCDs, how to empower civil society and how to mobilize each person’s health resources. n. Civil society is a crucial resource and partner to the public sector in responding to NCDs. In most countries, civil society remains at the forefront of treatment, care and support, as well as prevention and in reaching out to key populations, including the poor and most vulnerable. The most active members of civil society are often those with personal experience of the NCD epidemic. While governments and civil society need to work together in NCD responses, challenges persist in ensuring meaningful participation of civil society in many countries. Existing international networks and partnerships provide opportunities for strengthening national approaches. o. The Global Strategy for the Prevention and Control of NCDs, and its Action Plan, when implemented, will halt and begin to reverse the prevalence of premature deaths from NCDs. The Action Plan was developed by the WHO Member States through an intergovernmental process. It is based on current scientific knowledge, available evidence and a review of international experience. It comprises a set of actions which, when performed collectively by Member States and other stakeholders, will tackle the growing burden of NCDs. In order for the Action Plan to be implemented successfully, high-level political commitment is required. p. The main discussions at the Regional Consultation centred mainly around the four types of NCDs – cardiovascular diseases, cancers, chronic respiratory diseases and diabetes – which make the largest contribution to mortality in the majority of countries and which require concerted, coordinated action. As emphasized in the Action Plan, these diseases are largely preventable by means of effective interventions that tackle shared behavioural risk factors (tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol) and their environmental risk factors. While recognizing the four types of NCDs addressed in United Nations Resolution A/RES/64/265 and their related risk factors, the participants also emphasized the need to have a comprehensive and integrated approach as outlined in the European Strategy for the Prevention and Control of NCDs and to address mental health conditions (e.g. depression, self-inflicted injury, and dementia), other chronic diseases (e.g. musculoskeletal conditions) and injuries (e.g. road traffic accidents and inter- Version dated 22 April 2011 Page 13 of 13 personal and gender related violence) in line with WHO’s Mental Health Gap Action Programme8 and the recommendations included in the WHO World Reports on Road Traffic Injury Prevention 9 , Violence and Health 10 , and Child Injury Prevention 11 , respectively. Comprehensive national strategies will set their own priorities and will take advantage of the numerous common risk factors, underlying determinants, and synergies in action. 37. The participants invited the World Health Organization, in close collaboration with the Government of Norway, to prepare a summary to the Regional Consultation as a contribution to the High-level Meeting. ooo000ooo 8 www.who.int/mental_health/evidence/mhGAP/en/index.html 9 www.who.int/violence_injury_prevention/publications/road_traffic/world_report/en/index.html 10 www.who.int/violence_injury_prevention/violence/world_report/en/index.html 11 www.who.int/violence_injury_prevention/child/injury/world_report/en/index.html