Joint mission of the United Nations Interagency Task Force on the prevention and control of noncommunicable diseases: Belarus, 14-18 July 2014

Joint Mission of the United Nations Interagency Task Force on the Prevention and Control of Noncommunicable Diseases Belarus 14–18 July 2014 WHO/NMH/NMA/17.95 © World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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This publication contains the collective views of the United Nations Interagency Task Force on the Prevention and Control of Noncommunicable Diseases and does not necessarily represent the decisions or the policies of WHO. iii Contents Background Page 3 The context Page 3 Findings of the Mission Page 5 Recommendations for UN and national cooperation Page 7 Annexes 1. Participants in the joint mission (agencies and individuals in alphabetical order) Page 10 2. Joint Mission Terms of Reference Page 11 3. Joint Mission Programme Page 14 4. Evidence-based cost-effective interventions for the prevention and control of NCDs Page 15 5. National commitments as set out in the Outcome Document of the High-Level Meeting of the General Assembly on the Review of the Progress Achieved in the Prevention and Control of NCDs Page 16 6. Cardiovascular mortality in Belarus, Kazakhstan, Moldova and the Russian Federation Page 19 7. Coverage of core population interventions assessed during the health system challenges and opportunities to respond to NCDs review, Belarus, 27 May–3 June 2014 Page 20 1 Joint Mission of the United Nations Interagency Task Force on the Prevention and Control of Noncommunicable Diseases to Belarus, 14–18 July 2014 1. A joint mission of the United Nations Interagency Task Force on the Prevention and Control of Noncommunicable Diseases (UNIATF) to Belarus was held between 14–18 July 2014. In alphabetical order, the following agencies participated in the mission: UNDP, UNFPA, UNICEF, World Bank and WHO (Annex 1). Terms of Reference for the Joint Mission are included as Annex 2 and the programme is Annex 3. The Joint Mission is grateful to the Ministry of Health and other government ministries that met with mission members. The Mission also expresses its gratitude to the civil society and other stakeholders that participated in discussions during the week. Background 2. The UNIATF was formed by the United Nations Economic and Social Council (ECOSOC) in 2013. In 2014, ECOSOC approved UNIATF’s terms of reference. 1 Activities identified in the UNIATF’s 2014–15 workplan 2 include a series of joint missions to selected countries to support governments and UN Country Teams (UNCTs) scale up their response to Noncommunicable Diseases (NCDs). The Mission to Belarus was the first of these joint missions. The need for UNCTs to prioritise the provision of support to governments around NCDs has been set out in two joint letters from the UNDP Administrator and the Director-General of WHO in 2012 and 2014. 3 The context At the global level there are clear frameworks to guide national action… 3. The 2011 Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of NCDs called upon UN agencies and key international organizations to work together in a coordinated manner to support national efforts to prevent and control NCDs and mitigate their impacts. 4 The WHO Global Action Plan for the Prevention and Control of NCDs, 2013– 2020 also highlights the role of the UN system in supporting Member States and highlights interventions for the prevention and control of NCDs (Annex 4) in four key areas: (i) tobacco control; (ii) harmful use of alcohol; (iii) unhealthy diet; and (iv) physical inactivity. 5 These interventions save lives. They also save individuals, communities and governments money in both the short and long term. They are all evidence-based, high impact, cost effective, affordable and feasible to implement. Although these interventions are simple to execute, a number require political commitment and coordinated action across government. Acting alone, ministries of health are limited to remedial action, treating the sick; a whole-of-government approach is required for the societal causes of NCDs to be addressed. In addition, strategic engagement with civil society, academia, professional bodies and selected private entities are also important when it comes to tackling NCDs. 4. In July 2014, Member States undertook a comprehensive review and assessment on the prevention and control of NCDs and progress since the 2011 Political Declaration on NCDs. 6 Key national commitments agreed at that meeting include: (i) setting national targets for NCDs for 2025; (ii) developing national multisectoral policies and plans to achieve the targets; (iii) considering establishing a national multisectoral mechanism for engaging policy coherence and mutual 1 E/2014/55, Appendix. http://www.who.int/nmh/events/2014/ecosoc-20140401.pdf?ua=1 (pages 11-18) 2 http://www.who.int/nmh/UN_Task_Force_on_NCDs_Workplan_2014_2015.pdf 3 http://www.who.int/nmh/media/undaf_20120329.pdf and http://www.who.int/nmh/UNDP_WHO_Joint_letter_on_NCDs_24Feb2014.pdf 4 Paragraph 51 of the Political Declaration “calls upon WHO, as the lead UN specialized agency for health, and all other relevant UN system agencies, funds and programmes, the international financial institutions, development banks and other key international organizations to work together in a coordinated manner to support national efforts to prevent and control NCDs and mitigate their impacts”. http://www.who.int/nmh/events/un_ncd_summit2011/political_declaration_en.pdf?ua=1 5 http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1 6 http://www.un.org/en/ga/68/resolutions.shtml 2 accountability of different spheres of policy-making that have a bearing on NCDs; (iv) reducing NCD risk factors by implementing interventions identified in the WHO NCD Global Action Plan, 2013–2020. The full set of national commitments is set out in Annex 5. At the regional level there is commitment and action too… 5. In 2012, a public health policy framework was adopted by the 53 Member States of the WHO European Region, Health 2020. 7 This policy is founded on two strategic objectives: (i) reducing inequalities in health via addressing the social determinants of health; and (ii) improving participatory governance for health. The policy is clear that the underlying causes of NCDs will only be resolved if ministries and agencies right across government recognise that they need to be part of the solution. 6. Many countries of the CIS (including Belarus) demonstrate a reduction in cardiovascular mortality (Annex 6). Economic development, changes in behaviour, and public health services are likely to have all played a role in this reduction. Although the reduction in Belarus may not be as significant as the other countries, further reductions will come about with population-based interventions to reduce NCD risk factors (e.g. tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity). 7. To support the UNIATF, a new regional Interagency Task Team on NCDs has recently been constituted. Its mission is to support governments address the economic impact of NCDs through a whole-of-society assessment using the Health 2020 and the sustainable human development framework. NCDs in Belarus are a grave concern… 8. NCDs are estimated to account for 89% of all deaths in Belarus (cardiovascular diseases, 63%; cancers, 14%). Premature mortality from NCDs 8 in Belarus, an upper-middle-income country with a population of 9.4 million, is 26%. 9 As a result, average life expectancy at birth in men is less than 65 years. In some rural areas male life expectancy is as low as 61.3 years. 10 This premature mortality, primarily among men of working age, has significant socioeconomic consequences and is a drain on the national economy. 9. Smoking among men has shown a minimal decline in recent years (from 55% in 1998 to 51% in 2011). Even more concerning is that smoking has increased nearly threefold among women (3.6% in 1995 to 11% in 2011). Alcohol consumption is also a significant public health issue with per capita adult consumption estimates of 17.5 litres of pure alcohol per annum. Nearly one in four adults is obese. 10. Nevertheless, Belarus has a number of key programmes that address health in a holistic manner. These include: (i) comprehensive youth policy that addresses health and social needs from age 0 to 31; (ii) employment schemes that seek to limit the impact of unemployment and to reduce poverty; (iii) social protection is extensive; and (iv) financial protection from the catastrophic costs of health care. Income inequality in Belarus is among the lowest in Europe and high quality education is provided with a high level of coverage. Such policies provide the citizens of Belarus with a high level of equality in health through protection from many of the social causes of ill-health. 7 http://www.euro.who.int/en/health-topics/health-policy/health-2020-the-european-policy-for-health-and-well-being 8 defined as the probability of dying between ages 30 and 70 from cardiovascular diseases, diabetes, cancer or chronic respiratory disease. 9 For further details see Noncommunicable Diseases Country Profiles 2014 (http://www.who.int/nmh/publications/ncd-profiles-2014/en/) 10 Mogilev Oblast in 2012 3 11. A review of challenges and opportunities to respond to NCDs was conducted by the WHO European Regional Office between 27 May and 3 June 2014. The review used a scorecard to assess the effectiveness of NCD interventions in three key areas at the population level: (i) tobacco control; (ii) harmful use of alcohol; and (iii) unhealthy diet. The review scored Belarus as having weak levels of implementation of many of the evidence-based interventions for these three risk factors. Detailed findings on all 13 interventions are shown in Annex 7. Findings of the Mission An emerging whole-of-government response to the NCD crisis… 12. All ministries acknowledged NCDs as a major concern in Belarus. Tobacco use and the harmful use of alcohol are considered issues that need to be addressed. Current levels of smoking, alcohol use, unhealthy diet and physical inactivity are an indication that unless emergency action is taken, the economic and social impacts of premature deaths and illness will continue. Quite simply, the health care system cannot cope with the epidemic of NCDs. 13. Government ministries regard the prevention and control of NCDs overwhelmingly as a Ministry of Health agenda. Ministries expressed willingness, however, to participate in cross- government dialogue to better understand their roles and responsibilities in tackling NCDs. Mechanisms for dialogue between Ministry of Health (MoH) and other line ministries, though, at this time are unstructured and ad hoc. 14. There is an acute awareness of the mandate boundaries between ministries. Opportunities that do exist for synergies and higher efficiency gains through strengthening interministerial cooperation in service referral, screening, risk monitoring, health promotion could be identified and better exploited. 15. If Belarus is to enjoy lower premature NCD mortality, a number of key issues stood out for us that should drive policy-making across all sectors. They include: (i) premature death, especially among men of working age, is far higher than it should be compared to Western Europe; (ii) loss of years of life is largely due to NCDs, with cardiovascular causes predominating; (iii) this loss is strongly associated with the high levels of smoking and alcohol drinking, and these point out the low to moderate level of implementation of policies to control prices, marketing, and social norms around these products, with socially unfavourable choice made between business and public health interests. Stronger emphasis should be placed on addressing unhealthy components of foods (e.g. transfats, saturated fats) and raising awareness among the populations. 16. Ministries are acutely aware of the need to evolve policy in alignment with the regional context, especially regarding pricing, taxes and excise. This presents both risks of being held back by regressive policies of neighbouring countries or of a dominant regional environment, or of opportunities by being progressive and demonstrating benefits of policy changes across a regional context. The importance of international cooperation and policy harmonisation is stressed in the context of the Eurasian Economic Community (2000), the Customs Union with Kazakhstan and Russia (since 2010), the Common Economic Space (since 2012) and the Eurasian Economic Union (since 2014). 17. Certain misconceptions are commonly held across ministries. Perceived barriers to government interventions to reduce NCD risk factors were often raised by staff, which lacked any international evidence to support them. Examples include threats to revenue of increased taxes on health harming products, unfounded fears regarding increasing in smuggling, the valuing of business interests regarding products despite their associated greater public health care and productivity-loss 4 costs, fears of social instability associated with raising tax on unhealthy products. There is also the unfounded concern that behavioural changes (both personal and institutional) take too long and are difficult to implement because of cultural norms. This institutional attitude prevents positive steps from being taken, or a common and shared set of objectives from being pursued, when the status quo is health-harming and has huge associated costs. A UNCT that is starting to work as one to support the Government of Belarus prevent and control NCDs… 18. The UNCT in Belarus consists of 12 resident agencies (in alphabetical order: IFC, ILO, IMF, UNAIDS, UNDP, UNDPI, UNFPA, UNICEF, UNHCR, UNODC, World Bank and WHO), one “partner organization” (IOM), and a number of non-resident agencies (that include FAO, ITC, OHCHR, UNCTAD, UNECE, UNESCO, and UNIDO). 19. In line with the National Strategy for Sustainable Development for the Period to 2020, 11 the UNCT’s current focus is around the harmonization of social, economic and environmental and population development. A new UNDAF is currently being developed in parallel with the National Strategy for Sustainable Socio-Economic Development for the Period to 2030 (NSSSED) and the National Development Programme 2016-2020 (NDP). A recent UNCT Strategic Prioritization Retreat (18-19 June 2014) identified the following strategic areas: governance, economic development, environment, human capital, and healthcare. Working groups for each area have been established and are co-chaired by a UNCT member and the Government. Working groups consists of UNCT members, government departments and other stakeholders. In line with post-2015 sustainable development discussions and recent UN General Assembly discussions on NCDs, NCDs will be an important component of the UNDAF and the agency-specific country programme documents. 20. The UNCT supports shared leadership and each UN agency has appointed a focal point that would facilitate, coordinate and ensure engagement of the necessary agency resources at all stages of the UN common country programming process and the agency specific Country Programme Documents (CPDs). 21. The UNCT (UNDP, UNFPA, UNICEF, and WHO) is a partner in the 2014 – 2018 EU-funded BELMED Programme, the first major donor programme to include NCDs. UN Agencies will deliver technical assistance to the MoH and directly implement pilot activities. 12 Civil society partners and leaders of local authorities are included in the programme. This programme is already enhancing UNCT working in the areas of NCDs and provides an opportunity to further do so and to provide a platform for stronger engagement with civil society and local communities. A multi stakeholder response that needs considerable strengthening… 22. Comprehensive NCD prevention and control ultimately demands a whole-of-society response; civil society, private sector, academia and international development partners, as well as the media as they are important in influencing attitudes leading to behavioural change. 23. Few independent NGOs in the area of NCDs are operating in Belarus, and the interaction of civil society with government is not strong. There is a need for greater empowerment and coordination. Opportunities exist to build on partnerships related to social contracting, but should evolve to more than service delivery, to incorporate mutual accountability, policy analysis, policy enquiry and research and working on targeted and innovative/interactive health promotion 11 http://un.by/pdf/OON_sMall.pdf 12 Key areas of the project are: (i) health promotion and NCD risk factor reduction (tobacco, alcohol, unhealthy diet, and physical inactivity); (ii) improving management of breast cancer; (iii) improving maternal and child health care; and (iv) child injuries prevention. 5 campaigns, particularly with and for young people. Interactions between government and the private sector in the area of NCDs are extremely limited. As these develop, the identification and management of conflicts of interests should be given priority. Recommendations for Action Belarus has the potential to become an exemplar in multisectoral action for the prevention of NCDs in Eurasia. It can seize this opportunity now… 24. The Joint Mission saw some powerful examples of political commitment and action across government for advancing the NCD agenda creating an opportunity to take the work to a higher level. The planned ministerial conference on a life course approach to health to be held in Minsk in the autumn of 2015 provides an opportunity for Belarus to showcase itself as an exemplar for multisectoral action for the prevention of NCDs in Eurasia and indeed Europe. 25. The Mission suggests the following actions, some of which are already underway, to be undertaken during the next 15 months in the run up to the Ministerial Conference; Belarus should take the opportunity and present the outcomes at the Conference. The UNCT is committed to providing the necessary technical assistance to support the Government of Belarus in this work over the next 15 months. i. In the first instance, the Mission welcomes the finalisation of the draft of the multisectoral NCD programme by the end of July 2014. This is currently being developed by the MoH and will then be considered by the Council of Ministers. It will be important that the programme is truly whole-of-government and multisectoral and highlights the opportunity for a whole of society approach. It is also important too that this is a costed plan and that national targets are described – even if these require later refinement based on newly available data (see iii below). The UNCT stands by to support the Council of Ministers in finalising the programme. It is recommended that the final Programme be adopted before the end of 2014. ii. At the same time, it is important to make the economic and business case for investing in the prevention of NCDs. This is not about the health sector’s investment, rather the investment of other parts of government in developing and implementing cost-effective policies that will make a rapid impact on the levels of NCDs and their underlying causes. The UNCT recommends working with government to develop Terms of Reference and then the UNCT will provide technical assistance for the development of a joint government-UN report using existing data to document the impact of NCDs on the economy. The work for this should start immediately and be completed by the end of March 2015. iii. Belarus has never had the opportunity of conducting a STEPS survey 13 and one should be carried out by June 2015. This will be important in refining the baselines for national NCD targets (see i above). A request to this effect has been received by WHO. The UNCT will support the STEPS survey technically and cover many of the costs. The survey should be seen as the first step in developing an NCD surveillance programme in Belarus. iv. To ensure the highest level of political commitment to the NCD agenda, the government should establish an Interministerial Group as soon as possible for the control and prevention of NCDs. This Group should report to the Council of Ministers which should consider and approve: (i) the investment case described above; (ii) the results of the STEPS survey; and (iii) plans for the preparation of the NCD component for the 2015 Ministerial 13 http://www.who.int/chp/steps/reports/en/ 6 Conference. The Interministerial Group should provide oversight on the NCD programme, foster and mobilise national funds and donor interest, and ensure there is policy coherence across government to meet national targets and development partner expectations. The Interministerial Group should be chaired by the prime minister or deputy prime minister to encourage this cross-government coherence. The UNCT is committed to providing technical support to the work of the Interministerial Group. v. To support the Interministerial Group, we propose that a national NCD coordination mechanism is established at a technical level. This mechanism would include government, the UNCT, donor agencies, civil society, patient groups, youth groups and selected private entities. Such an approach would replicate the successful experience of the national TB and HIV responses. vi. It is clear that Belarus’s ability to reduce many of the risk factors associated with NCDs, such as tobacco, harmful use of alcohol and levels of salt, sugar and transfats in processed food will be more feasible to undertake when done in cooperation with neighbouring countries. The mission encourages Belarus to act as a champion in the Eurasian Economic Union and use its time as chair of the health working group of this union to take a leadership role in progressive fiscal and legislative instruments for tackling the above risk factors. The UNCT and the newly established regional UN Interagency Task Team on NCDs will provide technical support and provide a facilitating role to enable this to happen and for a report to be made for the 2015 Ministerial Conference. vii. In support of delivering the national multisectoral NCD programme, it is recommended that the Government of Belarus works with the World Bank to explore a possibility of attracting a World Bank investment to support implementation and monitoring of the national multisectoral NCD programme/plan of action. In a case of a positive decision work on preparation of an investment project could start as early as September 2014. viii. To complement any World Bank loan and the EU-funded BELMED project, and to maximise the impact of the business and economic case described above, the Government of Belarus and the UNCT should advocate the need for further investment from development partners to build government, UN and civil society capacity to implement interventions that will reduce NCD risk factors in the population of Belarus (See Annex 4 and Annex 6). These discussions should be led by the UNCT as a whole and start immediately. With regards to civil society, investment should be used to build civil society capacity to: (i) engage in public health promotion; (ii) articulate the voice of local communities; (iii) hold government and the UNCT to account; and (iv) provide services building on the Belarus models of “social contracting” (contracting out service delivery). ix. Ahead of donor investment, the Government of Belarus should start to scale up existing capacity and resources to accelerate implementation of the cost-effective interventions described in Annex 4 and Annex 6. Where and when the Government of Belarus is looking to prioritise, we suggest that tobacco be a focus for action as there is evidence of broad public acceptance for smoke-free public places and other measures and it is a programme that will yield quick benefits. We therefore recommend that the Government of Belarus make an immediate request for a WHO Framework Convention on Tobacco Control country needs assessment from the Convention Secretariat in Geneva to support accelerated implementation of the WHO FCTC. 7 x. If the UNCT is going to provide coherent and effective support to Government in the ways described above, it needs to work with the Government of Belarus to finalise the UN Development Assistance Framework (UNDAF) with NCDs as one of the core elements. The UNDAF should include a description of multisectoral joint programmes for the prevention and control of NCDs with the inclusion of financing, agency roles and mechanisms for interagency coordination. All the outcome areas (not just the health and social inclusion outcome) should reflect the NCD priority in their indicators and actions. The timeframe for completing the UNDAF is November 2014. xi. In support of (x) above, we recommend that the UNCT builds on the good practice that it has developed during the development of the EU project by holding a UNCT health thematic group meeting monthly, reporting to the UNCT. Meetings should be co-chaired by UNDP and WHO and rotate among UN agencies resident in Minsk. During this mission a draft division of labour to support the Government of Belarus drive the NCD agenda forward has been developed. This should be refined and used as a tool to support delivery of the National Multisectoral NCD Programme. To support these meetings, UNDP and WHO are committed to joining some of the UNCT meetings remotely. UNCT meetings should start with immediate effect. xii. In advance of the 2015 ministerial meeting, UNDP, World Bank and WHO are committed to ensure that there is a visit from the newly established European Inter-Agency Task Team on NCDs to support the UNCT and the Government of Belarus deliver on the recommendations above. = = = = = = 8 Annex 1. Participants in the joint mission (agencies and individuals in alphabetical order) UNDP Olga Atroshchanka, Program Officer, Belarus. Christoph Hamelmann, Regional Practice Leader, HIV, Health and development, Regional Centre, Europe and the CIS. John Macauley, Regional Programme Specialist, HIV, Health and Development, Regional Centre for Europe & CIS. Douglas Webb, Cluster Leader: Mainstreaming, Gender & MDGs, HIV, Health and Development Group, New York. UNFPA Elena Kasko, Assistant Representative, Belarus. Tatiana Pronko, Programme Associate, Belarus. UNICEF Iryna Chutkova, Deputy Representative, Belarus. Victoria Lozuyk, Youth and Adolescent Development, HIV/AIDS Officer, Belarus. World Bank Paolo Belli, Human Development Program Leader for Belarus, Moldova and Ukraine, Europe and Central Asia Region, Ukraine. Irina Oleinik, Operations Officer, Belarus. WHO Nicholas Banatvala, Senior Adviser, Office of the Assistant Director-General, Noncommunciable Diseases and Mental Health, WHO HQ, Geneva. Gauden Galea, Director, Division of Division of NCDs and Lifecourse, Regional Office for Europe, Copenhagen. Gunta Lazdane, Programme Manager, Sexual and Reproductive Health, Regional Office for Europe, Copenhagen. Egor Zaitsev, Head, WHO Country Office, Belarus. 9 Annex 2. Joint Mission Terms of Reference Mission of the United Nations Interagency Task Force on the Prevention and Control of Non- communicable Diseases in Belarus, 14-18 July 2014 Rationale 1. Data from WHO estimate that in 2011 the vast majority of the premature deaths of individuals from NCDs (85% or 11.8 million) between the ages from 30 to 70 years occurred in developing countries. The probability of dying from any of the major NCDs between these ages is as high as 60% in developing countries. It is estimated that up to two thirds of premature deaths are linked to exposure to risk factors and up to half of these deaths are linked to weak health systems. 2. Heads of State and Government agreed in September 2011 that the global burden and threat of NCDs constitutes one of the major challenges for development in the 21st century and that business-as-usual was no longer an option. Accordingly, the 2011 Political Declaration of the High- level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases called upon WHO, as the lead UN specialized agency for health, and all other UN system agencies and international financial institutions to work together in a coordinated manner to support national efforts to prevent and control NCDs and mitigate their impacts through a whole-of- government and a whole-of-society effort, as appropriate. 3. Based on the outcomes of the High-level Meeting, Member States have committed to take action by (i) considering the development of national targets and indicators based on national situations, (ii) developing, implementing and allocating a budget for a national multisectoral NCD policy and plan; (iii) prioritize the implementation of very cost-effective and affordable interventions for all Member States (“best buys”); and (iv) strengthening national surveillance systems for NCDs and measuring results. 4. At the same time, WHO was requested to complete a number of global assignments that would further shape the global NCD agenda and accelerate implementation of national efforts. There is now a global agenda in place based on 9 concrete targets for 2025, 25 outcome indicators, and 9 progress indicators, organized around the WHO Global NCD Action Plan 2013-2020 that was endorsed by the World Health Assembly in May 2013, as well as regional action plans. The global action plan comprises a set of actions which, when performed collectively by Member States, international partners and WHO, will achieve a global target of a 25% reduction in premature mortality from NCDs by 2025 and attain the commitments made in the Political Declaration. The Global NCD Action Plan 2013-2020 calls on United Nations Country Teams to provide technical support to countries in implementing of strengthening nationwide action to: (i) reduce risk factors for NCDs and their determinants; (ii) enable health systems to respond; and (iii) map the NCD epidemic, monitor progress and measure results. In particular, the Global Plan calls on WHO and other UN Agencies to mobilize the United Nations Country Teams (UNCTs) to strengthen the links among NCDs, universal health coverage and sustainable development, integrating them into the United Nations Development Assistance Framework’s (UNDAF's) design processes and implementation. 5. Demand from governments is high for “how to” policy advice to support their national efforts to address NCDs. An analysis of 144 WHO country cooperation strategies found that 136 strategies included requests to support NCDs yet current bilateral and multilateral support remains inadequate. The Economic and Social Council (ECOSOC), at its substantive session of 2013, was a defining moment to set out an approach for ways that the United Nations system responds to 10 country demand for technical assistance, when it adopted resolution 2013/12 requesting the Secretary-General to establish a United Nations Interagency Task Force on the Prevention and Control of NCDs by expanding the mandate of the existing Ad Hoc Interagency Task Force on Tobacco Control. The Task Force is convened and led by WHO, and reports to the Council through the Secretary-General. Draft terms of reference and division of tasks and responsibilities for the Task Force have now been developed. These were endorsed by Member States during an ECOSOC coordination and management meeting on 12-13 June 2014. 6. The importance of a coherent UN System response to scale up technical assistance in support of national efforts to address NCDs in line with the Global NCD Action Plan 2013-2020 was highlighted in two joint letters from the UNDP Administrator and the WHO Director-General to UN Country Teams (26 March 2012 and 24 February 2014). Overall approach 7. The mission is designed to support the UN Country Team support the Government scale up their national efforts to address NCDs, taking into account the WHO Global NCD Action Plan 2013- 2020 and relevant regional WHO action plans. 8. The mission will be carried out in line with the terms of reference of the UN Interagency Task Force. Taking into account that a coherent UN response to NCDs is still in its infancy, a key element of the mission will be learning lessons and better understanding entry points for engaging with government and other partners on preventing and controlling NCDs. Purpose and objectives of the mission 9. The Purpose of the integrated UN mission is to support the resident UN Country Team: • understand the relevance of NCDs to their individual human development efforts in the country; • integrate NCDs and their determinants into their bilateral plans with countries and into the UNDAF for the country where relevant; • establish a working mechanism to coordinate support by the UNCT to the Government's efforts to address NCDs; • collect experiences and examples of good practice of UNCT work in NCDs in order to inform other countries and regional and global efforts. 10. Specific objectives of the mission are to support the Government of Belarus: 10.1 Map ongoing bilateral and multilateral processes to support the Government in their national efforts to address NCDs within the context of national health and development planning, coordination, financing, monitoring, accountability, and conflicts of interest management. 10.2 Describe the rationale and opportunities for increasing multsectoral investment for NCDs at the country level. The mission will highlight: (i) the relationship between NCDs, poverty and development; (ii) the impact of policies on the determinants of risk factors for, and consequences of NCDs; and (iii) approaches for effective, evidence-based policy-making. The mission will also assess barriers for investment and ways that these barriers can be overcome. 10.3 Establish a roadmap that lays out a set of steps and milestones over the next 12 months which will result in: (i) finalization/refinement of the national multisectoral NCD action plan (including national NCD targets); and (ii) initial implementation of the national multisectoral action plan. The road map will identify the support that the Government requires from WHO, other UN agencies, as well as the World Bank. 11 10.4 Agree (and initiate) the process for annual reviews involving: (i) relevant line Ministries; (ii) WHO, other UN agencies and the World Bank; and (iii) other relevant development partners. 3. Output of the mission A report that covers the areas set out in paragraphs 9 and 10 above. 4. Activities to be undertaken Monday 14 July 2014 Morning: arrival Afternoon: Round Table: UNIATF mission, WHO Representative, UN Resident Coordinator and UN Country Team. Tuesday 15 July 2014 Meet with the Ministry of Health Stakeholder Forum with briefings from all line ministries involved in the response to NCDs. Relevant local authorities, civil society, UN staff and key donors would also be invited to attend. Meeting of civil society, private sector, and interested donors Wednesday 16 July 2014 Meeting with Ministry of Health officials Bilateral meetings with the health sector and other government sectors Thursday 17 July 2014 UNIATF debrief Debrief with the Ministry of Health Debrief with civil society, private sector, and interested donors Debriefing with the UN Resident Coordinator and UN Country Team Subsequent activities and missions will be determined on the basis of recommendations of the mission in close consultation with the Government. The composition of any future missions would be determined in line with the activities to be undertaken and the outcomes expected. 5. Current participants for the missions (in alphabetical order) UNDP, UNFPA, UNICEF, World Bank, and WHO. 12 Annex 3. Joint Mission Programme Monday, 14 July 2014 17.00 – 19.00 Introductory meeting of members of the mission Tuesday, 15 July 2014 09.00 – 10.00 Meeting at the Minister of Health 10.30 – 12.30 Briefing of the mission members with UN Resident Coordinator 14.00 – 17.00 Stakeholder Forum, with participants from ministries, UN agencies, civil society and donors Wednesday, 16 July 2014 12.00 – 13.00 Meeting with Ministry of Trade 15.00 – 16.00 Meeting with Ministry of Economy 16.30 – 17.30 Meeting with Ministry for Taxes and Levies 17.30 – 18.30 Meeting with Ministry of Education Thursday, 17 July 2014 09.00 – 10.00 Meeting with civil society 10.30 – 11.30 Meeting with Ministry of Labour and Social Protection 12.00 – 15.30 Meeting of the Mission to discuss outcomes and recommendations 16.00 – 17.00 Bilateral meeting with interested donors (EU) – EU Office 17.00 – 18.00 Meeting with UNCT Heads of Agencies to discuss preliminary outcomes and next steps Friday, 18 July 2014 09.00 – 10.00 Concluding meeting with Minister of Health 13 Annex 4. Evidence-based cost-effective interventions for the prevention and control of NCDs 14 Tobacco use 15 • Reduce affordability of tobacco products by increasing tobacco excise taxes • Create by law completely smoke-free environments in all indoor workplaces, public places and public transport • Warn people of the dangers of tobacco and tobacco smoke through effective health warnings and mass media campaigns • Ban all forms of tobacco advertising, promotion and sponsorship Harmful use of alcohol • Regulating commercial and public availability of alcohol • Restricting or banning alcohol advertising and promotions • Using pricing policies such as excise tax increases on alcoholic beverages Unhealthy diet • Reduce salt intake (and adjust the iodine content of iodized salt, when relevant) • Replace trans fats with unsaturated fats • Implement public awareness programmes on diet and physical activity 14 Taken from the WHO NCD Global Action plan 2013-2020 (http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1, pages 66 and 67).The measures listed are recognized as very cost-effective i.e. generate an extra year of healthy life for a cost that falls below the average annual income or gross domestic product per person. In addressing each risk factor, governments should not rely on one single intervention, but should have a comprehensive approach to achieve desired results. 15 These measures reflect one or more provisions of the WHO Framework Convention on Tobacco Control (WHO FCTC). The measures included are not intended to suggest a prioritization of obligations under the WHO FCTC. Rather, these measures have been proven to be feasible, affordable and cost-effective and are intended to fulfil the criteria for assisting countries to meet the agreed targets as quickly as possible. The WHO FCTC includes a number of other important provisions, including supply-reduction measures and those to support multisectoral actions, which are part of any comprehensive tobacco control programme. 14 Annex 5. National commitments as set out in the Outcome Document of the High-Level Meeting of the General Assembly on the Review of the Progress Achieved in the Prevention and Control of NCDs (a) Enhance governance: (i) By 2015, consider setting national targets for 2025 and process indicators based on national situations, taking into account the nine voluntary global targets for non- communicable diseases, building on guidance provided by the World Health Organization, to focus on efforts to address the impacts of non-communicable diseases and to assess the progress made in the prevention and control of non-communicable diseases and their risk factors and determinants; (ii) By 2015, consider developing or strengthening national multisectoral policies and plans to achieve these national targets by 2025, taking into account the WHO Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013-2020; (iii) Continue to develop, strengthen and implement, as appropriate, multisectoral public policies and action plans to promote health education and health literacy, with a particular focus on populations with low health awareness and/or literacy; (iv) Raise awareness about the national public health burden caused by non-communicable diseases and the relationship between non-communicable diseases, poverty, and social and economic development; (v) Integrate non-communicable diseases into health planning and national development plans and policies, including the United Nations Development Assistance Framework design processes and implementation; (vi) Consider establishing, as appropriate to the respective national context, a national multisectoral mechanism, such as a high-level commission, agency or task force for engagement, policy coherence and mutual accountability of different spheres of policy making that have a bearing on non-communicable diseases, in order to implement health-in- all-policies and whole-of-government and whole-of-society approaches, and to monitor and act on the determinants of non-communicable diseases, including social and environmental determinants; (vii) Enhance the capacity, mechanisms and mandates, as appropriate, of relevant authorities in facilitating and ensuring action across government sectors; (viii) Strengthen the capacity of Ministries of Health to exercise a strategic leadership and coordination role in policy development that engages all stakeholders across government, non-governmental organizations, civil society and the private sector, ensuring that non- communicable disease issues receive an appropriate, coordinated, comprehensive and integrated response; 15 (ix) Align international cooperation on non-communicable diseases with national non- communicable diseases plans, in order to strengthen aid effectiveness and the development impact of external resources in support of non-communicable diseases; (x) Develop and implement national policies and plans, as relevant, with financial and human resources allocated particularly to addressing non-communicable diseases, in which social determinants are included. (b) By 2016, as appropriate, reduce risk factors for non-communicable diseases and underlying social determinants through implementation of interventions and policy options to create health- promoting environments, building on guidance provided by Appendix 3 of the WHO Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013-2020. (c) By 2016, as appropriate, strengthen and orient health systems to address the prevention and control of non-communicable diseases and the underlying social determinants through people- centered primary health care and universal health coverage throughout the lifecycle, building on guidance provided by Appendix 3 of the WHO Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013-2020. (d) Consider the possible linkages between non-communicable diseases and some communicable diseases, such as HIV/AIDS, call for the integration, as appropriate, of responses to HIV/AIDS and non-communicable diseases, and in this regard call for attention to be given to people living with HIV/AIDS, especially in countries with a high prevalence of HIV/AIDS, in accordance with national priorities. (e) Continue to promote the inclusion of non-communicable disease prevention and control within programs for sexual and reproductive health and maternal and child health, especially at the primary health-care level, as well as communicable disease programs, such as TB, as appropriate. (f) Consider the synergies between major non-communicable diseases and other conditions as described in Appendix 1 of the WHO Global Action Plan for the Prevention and Control of Non- Communicable Diseases 2013-2020 in order to develop a comprehensive response for the prevention and control of non-communicable diseases that also recognizes the conditions in which people live and work. (g) Monitor the trends and determinants of non-communicable diseases and evaluate progress in their prevention and control: (i) Assess progress towards attaining the voluntary global targets and report on the results using the established indicators in the Global Monitoring Framework, according to the agreed timelines, and use results from surveillance of the twenty five indicators and nine voluntary targets and other data sources to inform and guide policy and programming, aiming to maximize the impact of interventions and investments on non-communicable disease outcomes; (ii) Contribute information on trends in non-communicable diseases to the World Health Organization, according to the agreed timelines on progress made in the implementation of 16 national action plans and on the effectiveness of national policies and strategies, coordinating country reporting with global analyses; (iii) Develop or strengthen, as appropriate, surveillance systems to track social disparities in non-communicable diseases and their risk factors as a first step to addressing inequalities, and pursue and promote gender-based approaches for the prevention and control of non- communicable diseases founded on data disaggregated by sex and age and disabilities, in an effort to address the critical differences in the risks of morbidity and mortality from non- communicable diseases for women and men. (h) Continue to strengthen international cooperation in support of national, regional and global plans for the prevention and control of non-communicable diseases, inter alia, through the exchange of best practices in the areas of health promotion, legislation, regulation and health systems strengthening, training of health personnel, development of appropriate health-care infrastructure and diagnostics, and by promoting the development and dissemination of appropriate, affordable and sustainable transfer of technology on mutually agreed terms for the production of affordable, safe, effective and quality medicines and vaccines, while recognizing the leading role of the World Health Organization as the primary specialized agency for health in that regard. 31. Continue to strengthen international cooperation through North-South, South-South and triangular cooperation, in the prevention and control of non-communicable diseases to promote at the national, regional and international levels an enabling environment to facilitate healthy lifestyles and choices, bearing in mind that South-South cooperation is not a substitute for, but rather a complement to, North-South cooperation. 32. Continue to explore the provision of adequate, predictable and sustained resources, through domestic, bilateral, regional and multilateral channels, including traditional and voluntary innovative financing mechanisms. 17 Annex 6. Cardiovascular mortality in Belarus, Kazakhstan, Moldova and the Russian Federation Source: WHO/Europe HFA Database (http://data.euro.who.int/hfadb/, accessed July 23, 2014) 18 Annex 7. Coverage of core population interventions assessed during the health system challenges and opportunities to respond to NCDs review, Belarus, 27 May – 3 June 2014 Tobacco control: • Bans on advertising, promotion, sponsorship: moderate. There is a ban on all advertising and promotion, including at points of sale, with effective enforcement. However, there are advertisements of tobacco products in magazines and tobacco-sponsored public events • Raised tobacco taxes: moderate. Total tax is 42.5% of retail price (Specific excise of 25.8% and VAT of 16.7%) • Smoke-free environments: low. There is a 100% smoke-free environment in hospitals, schools, universities, public transport and workplace, but the enforcement of the law is very low. Moreover, smoke-free environments are not enforced in the hospitality sector • Warning of dangers of tobacco: moderate. There are warning labels of 30% of package size (front and back), but no pictures • Quit lines and nicotine replacement therapy: limited. There are no quit lines or government- funded cessation services. NRT is allowed and available but for full pay by individuals Harmful use of alcohol: • Minimum purchase age regulation and enforcement: moderate. The minimum age is 18 years for all alcohol products and there is effective enforcement • Allowed blood alcohol level for driving: moderate. Blood alcohol concentration when driving a vehicle is 0.03%, but there is no zero tolerance for novice and/or professional drivers. Enforcement is moderate • Raise taxes on alcohol: weak. Alcohol taxes follow price index, but are not related to alcohol content and there are no special taxes on products attractive to young people • Restrictions, bans on advertising and promotion: weak. There is no regulatory framework to regulate content and volume of alcohol marketing • Restrictions on availability of alcohol in retail sector: weak. There is no regulatory framework on serving of alcohol in governmental and educations institutions Unhealthy diet: • Reduce salt intake and salt content in foods: weak. There is no monitoring of salt intake • Trans-fatty acids elimination: weak. There is no evidence that trans-fats have been reduced in the diet • Reduce marketing pressure of foods and non-alcoholic beverages to children: weak. Marketing of foods and beverages to children is noted as a problem but has not been translated into specific action on government-led initiatives.