United Nations Agency Briefs: responding to the challenge of non-communicable diseases

RESPONDING TO THE CHALLENGE OF NON-COMMUNICABLE DISEASES United Nations Agency Briefs This set of briefs provides policy advisors and decision-makers across different United Nations agencies, Member States and development partners with information on how the UN system is responding to the challenge of non-communicable diseases (NCDs). The briefs were brought together by the WHO-led United Nations Inter-Agency Task Force on the Prevention and Control of NCDs. Heads of State and Government and representatives of States and Governments… … call upon WHO to continue to exercise its leadership, as the directing and coordinating authority on international health, in order to contribute to Member States’ efforts to prevent and control NCDs by continuing and strengthening its normative and standard-setting work and its capacity to develop and provide technical cooperation, assistance and policy advice to Member States, as well as to enhance its multi-stakeholder engagement and dialogue, including through … the United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases. Paragraph 47, Political declaration of the Third High-level Meeting of the General Assembly on the prevention and control of NCDs.1 Heads of State and Government and representatives of States and Governments… …call upon WHO to continue to promote and monitor enhanced global action to prevent and control NCDs by coordinating work with other UN agencies, development banks and other regional and international organizations.1 Paragraph 48, Political declaration of the Third High-level Meeting of the General Assembly on the prevention and control of NCDs.1 These briefs describe: • the role of the different UN system agency in making an effective contribution to the prevention and control of NCDs;1 • current and potential actions for different agencies to support the World Health Assembly-endorsed “best buys” and other recommended interventions to address NCDs;2 • the importance of partnerships for ensuring that agencies mobilize an effective response to NCDs; • the importance of partnerships in agencies’ response to NCDs; and • how agencies are mobilizing resources to deliver support to Member States. 1 Time to deliver: accelerating our response to address non-communicable diseases for the health and well-being of present and future generations. Political declaration of the Third High-level Meeting of the General Assembly on the prevention and control of NCDs, 2018. http://www.un.org/en/ga/search/view_doc.asp?symbol=A/ RES/73/2 2 WHO. “Best buys” and other recommended interventions for the prevention and control of noncommunicable diseases. 2017. www.who.int/ncds/management/best-buys/en/ The Task Force reports to the Economic and Social Council of the United Nations (ECOSOC) annually. Since 2014, ECOSOC has adopted a resolution each year on the Task Force: 2014: endorses the Task Force’s terms of reference 2015: encourages the Task Force to scale up action in countries 2016: expands the work of the Task Force to the NCD-related SDGs 2017: calls for greater financing for the work of the Task Force 2018: calls for development of partnerships to achieve public health goals 2019: encourages bilateral and multilateral donors, as well as other relevant stakeholders, to mobilize resources to support Member States, to catalyse sustainable domestic responses to NCDs and mental health conditions, including through a dedicated multi-donor trust fund. In the 2030 Agenda for Sustainable Development, adopted in September 2015, Member States recognize NCDs as a leading sustainable development issue. Agenda 2030 provides an enabling framework for identifying and implementing win-win approaches for NCDs and other development priorities. NCDs, principally cardiovascular disease, diabetes, cancer and chronic respiratory disease, are now the world’s biggest killers. Urgent and whole-of-government action is needed to prevent the annual toll of 41 million people dying from NCDs, including 15 million dying prematurely between the ages of 30 and 69 years. Often misconstrued as a problem of high- income countries only, NCDs place an equal—if not greater—burden on low- and middle-income countries (LMICs). Over 85 percent of premature NCD deaths occur in LMICs. Most premature NCD deaths are preventable by taking cost-effective action to tackle four main behavioural risk factors —tobacco use, harmful use of alcohol, physical inactivity and unhealthy diet. Also critical are ensuring affordable access to basic health services, including for mental health, and addressing environmental risks such as air pollution. Tackling NCDs and their risk factors requires a response from government. Sustainable Development Goal 3 on health and well-being includes a specific target relating to the prevention and control of NCDs and several other targets that are NCD-relevant. Achieving the NCD targets will advance the 2030 Agenda broadly, given the strong links between NCDs and poverty, social inequities, lack of access to affordable basic services, economic growth and climate action. 2018 NCD Political Declaration:1 10 takeaways for the UN system 1. 4 x 43 is expanded to 5 x 5 by including mental health conditions and air pollution. 2. Every year, over 15 million people aged 30–70 die from NCDs. Most of these premature deaths could have been avoided. 86% of these deaths occur in developing countries. NCDs will cost developing countries US$ 7 trillion over the next 15 years. 3. While the probability of dying from a major NCD between the ages of 30 and 70 continues to decline (22% in 2000 to 18% in 2016), the rate is insufficient to meet SDG target 3.4.4 4. Cost-effective, affordable and evidence-based interventions exist and need to be scaled up. 5. National NCD investment cases need to be developed to inform countries about the costs of NCDs, the return on investment from prevention and treatment, and links to poverty and socio- economic development. 6. The primary role and responsibility for combating NCDs lies with presidents and prime ministers. 7. Governments need to mobilize civil society and the private sector, where appropriate, to implement national NCDs responses, while giving due regard to managing conflicts of interest. 8. Mechanisms for national multi-stakeholder dialogue and accountability are critical. 9. There is a need to mobilize and allocate adequate, predictable and sustained resources for national NCD responses through domestic, bilateral and multilateral channels, as well as through public-private partnerships. 10. The UN system needs to step up its efforts to meet the requests for technical cooperation from Member States. WHO must continue to lead the UN Inter-Agency Task Force and explore options for innovative financing to support national NCD control efforts. 3 Four diseases (cardiovascular disease, cancer, diabetes and chronic lung disease) and four risk factors (tobacco use, harmful use of alcohol, unhealthy diets and physical inactivity). 4 By 2030, reduce by one third premature mortality from NCDs through prevention and treatment and promote mental health and well-being. WHO/UNIATF/19.98 © World Health Organization 2019. World Health Organization 2019. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. Photo credits (clockwise): © Nicholas Banatvala © UNDP (2) © Asian Development Bank © UNDP © AMISOM © World Bank © FMSC 1 Responding to the Challenge of NCDs: FAO Food and Agriculture Organization of the United Nations Responding to the Challenge of Non-communicable Diseases 1. The food and agriculture sector is crucial for an effective response to NCDs The food and agriculture sector plays a major role in nourishing people by increasing the availability of and access to diverse, safe and nutritious food, which meets dietary recommendations and principles relating to environmental sustainability.1 Most of today’s food systems need to be re-aligned from the production of high- yielding staple food crops such as cereals to sustainable provision of non-staple foods such as fruits and vegetables that will enhance dietary diversity. Improved food systems need to address all forms of malnutrition, such as overweight and obesity as well as wasting, stunting and micronutrient deficiencies. In today’s food systems, the nutritious foods that make up a healthy diet are not always available or affordable for many people.2 Various UN instruments have re-affirmed several fundamental nutrition- related rights, namely the right to have access to safe, sufficient and nutritious food, as well as the right to be free from hunger.3 The rise in obesity and NCDs is associated with a shift towards energy-dense diets, which are characterized by highly processed foods 1 FAO. 2018. Strengthening sector policies for better food security and nutrition results: food systems for healthy diets. Available at: www.fao.org/3/CA2797EN/ ca2797en.pdf. 2 FAO. 2013. The State of Food and Agriculture 2013: food systems for better nutrition. Available at: www.fao.org/docrep/018/i3300e/i3300e.pdf. 3 FAO & WHO. 2014. Second International Conference on Nutrition, Rome, 19-21 November 2014. Conference Outcome Document: Rome Declaration on Nutrition. Available at: http://www.fao.org/3/a-ml542e.pdf. high in refined starches, sugar, fats, and/or salt, accompanied by an insufficient intake of fresh fruits and vegetables, wholegrains, pulses, nuts and seeds.4 This shift is also coupled with sedentary lifestyles and low levels of physical activity. Most of the world's population now lives in countries where overweight and obesity kill more people than underweight.5 The way we produce, process, store and bring our food to markets is changing rapidly. Food production and supply chains have intensified, 4 FAO. 2017. The State of Food and Agriculture 2017: leveraging food systems for inclusive rural transformation. Available at: www.fao.org/3/a-I7658e.pdf. 5 WHO. 2019. Obesity and overweight [website]. Available at: https://www.who.int/ en/news-room/fact-sheets/detail/obesity-and-overweight. United Nations high-level meetings have highlighted the need for UN agencies, including FAO, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries (LMICs). Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as unhealthy diet, tobacco use, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. becoming industrialized and globalized, with people eating more purchased, processed and packaged food. Large-scale production has led to the use of a narrow range of high-yielding food crop and animal varieties, which has contributed to a reduction in agro-biodiversity. In addition, harmful chemicals used in food production are known to cause cancer. Widespread marketing of foods high in fat, sugar and/or salt, particularly those targeted at children, is a source of concern. This development is related to the steady growth and increasing influence of the private sector, including large-scale international food and agri-businesses and retailers. FAO is uniquely positioned to contribute to global efforts to reduce the prevalence of overweight, obesity and NCDs through the support it provides to countries in reforming their food systems and its work with line ministries responsible for agriculture, trade, environment and rural development, as well as with other UN agencies and development partners. Key areas for FAO engagement include: Situation analyses and awareness raising on how food systems and dietary changes drive overweight, obesity and NCDs. Engaging food systems stakeholders in policy analysis and dialogue, and encouraging them to implement public policy and regulations in order to create an appropriate set of incentives and disincentives to drive change in food systems. Political economy analysis to identify how different sectors impact on food systems and changes required to prevent and control NCDs. 2. FAO has a role to play in supporting countries in the prevention and control of NCDs For the first time FAO’s Medium-Term Plan 2018–2021 and Programme of Work and Budget 2018–2019 explicitly mention the issues of overweight, obesity and NCDs, and refer to the related targets under Sustainable Development Goals (SDGs) 2 and 3.6 FAO has reviewed the recommended cost- effective interventions endorsed by the World Health Assembly (WHA) to identify those linked to FAO’s work at global, regional and country levels. Examples are included in the table. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.7 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 6 FAO. 2017. The Director-General’s Medium-term Plan 2018-21 and Programme of Work and Budget 2018-19. Available at: www.fao.org/3/a-ms278e.pdf. 7 WHO. 2017. ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf. Responding to the Challenge of NCDs: FAO 2 Evidence-based interventions FAO actions Implement mass media campaign on healthy diets, including social marketing to reduce the intake of total fat, saturated fats, sugars and salt, and promote the intake of fruits. FAO supports countries to form action networks to promote healthy diets, nutrition labelling and food reformulation as part of the UN Decade of Action on Nutrition. Limiting portion and package size to reduce energy intake and the risk of overweight/ obesity. FAO supports countries to develop food-based dietary guidelines addressing overweight, obesity and undernutrition.8 Implement nutrition education and counselling in different settings (e.g. preschools, schools, workplaces, hospitals) to increase the intake of fruits and vegetables. FAO implements school- based food and nutrition education programmes, and supports governments to develop policies and programmes in schools to encourage healthy diets. Raise public and political awareness, understanding and practice about prevention and control of NCDs. FAO supports countries to raise awareness on NCDs and their risk factors, including obesity and steps that can be taken to prevent NCDs. Integrate NCDs into the social and development agenda and poverty alleviation strategies. FAO ensures that nutrition- sensitive social protection interventions also tackle the problem of diet-related NCDs. FAO integrates nutrition objectives into food and agriculture policy, programme design and implementation to enhance nutrition-sensitive agriculture, ensure food security and enable healthy diets for the prevention of overweight, obesity and NCDs. FAO supports countries in the development of easy-to-understand labels contributing to sustainable food systems. 8 Food-based dietary guidelines (also known as dietary guidelines) establish a basis for public food and nutrition, health and agricultural policies and nutrition education programmes to foster healthy eating habits and lifestyles. They provide advice on foods, food groups and dietary patterns to provide the required nutrients to the general public to promote overall health and prevent NCDs. See: www.fao.org/ nutrition/education/food-dietary-guidelines/en/. UN Decade of Action on Nutrition (2016–2025). In 2016, the UN General Assembly mandated FAO and the World Health Organization (WHO) to lead implementation of the Nutrition Decade with the aim to achieve the global nutrition and diet-related NCD targets by 20259 as well as the nutrition- and NCD-related targets in the 2030 Agenda for Sustainable Development (General Assembly resolution 70/1). It also called on FAO and WHO to accelerate the implementation of commitments made at the 2014 Second International Conference on Nutrition.10 Global Individual Food consumption data Tool (GIFT). FAO/WHO GIFT is an online platform providing individual dietary data that enables policy-makers to answer the question “What are people eating?” and to create better informed public policies for healthy diets.11 Kyoto University. This collaboration includes knowledge exchange, the provision of technical expertise, and awareness raising about urban food policy, food waste, and agriculture modelling, and study of the linkages between climate change and sustainable food and agriculture systems. The Rockefeller Foundation. Established in 2016, this partnership supports food security and seeks to reduce food losses by expanding the capacity of small-scale producers in sub- Saharan Africa. UN Habitat. This collaboration involves building resilient food systems by improving rural-urban food supply chains, e.g. in Kenya. 9 UN. 2019. UN Decade of Action on Nutrition [website]. Available at: www.un.org/ nutrition/. 10 FAO. 2014. The Second International Conference on Nutrition (ICN2) [website]. Available at: www.fao.org/about/meetings/icn2/en/. 11 More information on this tool is available at: www.fao.org/gift-individual-food- consumption. 3. Partnerships are critical for FAO in mobilizing an effective response to NCDs Responding to the Challenge of NCDs: FAO 3 Consumers International. This partnership aims to enhance Consumer International’s (CI) access to FAO’s wealth of knowledge and information while allowing FAO to work more closely with the network of CI membership organizations across the world which liaise with and advocate for individual consumers. In Latin America and the Caribbean, for example, both organizations cooperate to support the development of public policies for improved access to nutritious food and nutritional information. World Obesity Federation. This partnership, recently formalized in a memorandum of understanding, will increase awareness of the agriculture and food systems-related policy measures that have led to the current overweight and obesity situation and related disease burdens. FAO has developed a portfolio of programme priorities12 and invited partners to increase their investment in food and agriculture to improve health and achieve the SDGs. Among the NCD-related priorities are: • Tackling obesity through sustainable food systems: transforming food systems for health and well-being. • Food and green environments for healthy cities: improving the accessibility of nutritious food and green spaces for all. 12 FAO. 2019. Business development portfolio: opportunities to invest in sustainable development, 2019–2020 cycle. Available at: http://www.fao.org/3/ca4265en/ ca4265en.pdf. 4. Mobilizing resources to deliver Due diligence is required to ensure that all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by FAO as part of a set of United Nations system agency briefs under the Task Force (WHO/UNIATF/19.98) Responding to the Challenge of NCDs: FAO 4 1 Responding to the Challenge of NCDs: FCTC Secretariat of the WHO Framework Convention on Tobacco Control and Protocol to Eliminate Illicit Trade in Tobacco Products Responding to the Challenge of Non-communicable Diseases 1. WHO FCTC and its Protocol are essential legal instruments to ensure the attainment of global NCD targets Tobacco use is responsible for one in six deaths from NCDs. While gains have been made by many countries on tobacco control, the fact remains that approximately 80% of the world’s one billion smokers live in low- and middle-income countries: the tobacco industry is constantly looking for new markets in these countries and blocking tobacco control efforts.1 Governments negotiated and adopted the WHO FCTC in 2003. This evidence-based treaty entered into force in 2005, becoming one of the most rapidly embraced conventions of the United Nations system. Currently there are 181 Parties to the WHO FCTC, representing 90% of the world’s population. The Protocol to Eliminate Illicit Trade in Tobacco Products was adopted in 2014, entered into force in 2018 and currently has 56 Parties. The Meeting of the Parties (MOP) was established in 2018 and has put into motion the mechanisms for implementing the Protocol.2 1 UNGA, Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, A/RES/66/2 (2011); UNGA, Political Declaration of the Third High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (2018); United Nations, Economic and Social Council, United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases, E/RES/2018/13 (2018). 2 WHO FCTC Secretariat, Protocol to Eliminate Illicit Trade in Tobacco Products (2013). Available at: https://www.who.int/fctc/protocol/illicit_trade/protocol- publication/en/ United Nations high-level meetings have highlighted the need for the UN to scale up its work on NCDs as part of the 2030 Agenda for Sustainable Development.1 NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in developing countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioral risk factors, such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2 Responding to the Challenge of NCDs: FCTC Two MOP working groups have been established: one on tracking and tracing systems and another on assistance and cooperation.3 The Convention Secretariat (CS) is also the Secretariat of the Protocol. The political declarations of the high-level meetings of the General Assembly on the prevention and control of NCDs called on full implementation of the WHO FCTC while continuing to implement tobacco control measures without any tobacco industry interference; it urged Member States who have yet to ratify the WHO FCTC to accelerate the ratification process. Target 3.a of the Sustainable Development Goals (SDG2030) calls for strengthening the implementation of the WHO FCTC, which also contributes directly to Target 3.4 on prevention and control of the NCDs. Tobacco control can accelerate sustainable development in all its social, economic and environmental dimensions,4 and contributes to other health issues beyond those relating solely to NCDs, e.g. by addressing HIV and tuberculosis co-morbidities,5 maternal and child health, reproductive health and universal health coverage. Target 5 of the WHO Global NCD Action Plan 2013–2020 is a 30% relative reduction in the prevalence of current tobacco use in persons aged 15 years and over. 3 WHO FCTC Secretariat, Establishment of Expert and Working Groups to advance global tobacco control (2019). Available at: https://www.who.int/fctc/mediacentre/ news/2019/expert-working-groups-cop-mop-advance-tobacco-control/en/ 4 WHO FCTC Secretariat and UNDP, The WHO Framework Convention on Tobacco Control an Accelerator for Sustainable Development (2017). Available at: https:// www.who.int/fctc/implementation/publications/who-fctc-accelerator-for- sustainable-development/en/ 5 WHO FCTC Secretariat, Issue Brief: Integrating Tobacco Control into Tuberculosis and HIV Responses (2018). Available at: https://www.who.int/fctc/publications/ WHO-FCTC-HIV-TB.pdf?ua=1 As a legally binding instrument, the WHO FCTC is a powerful mechanism that reaffirms the right of all people to the highest standard of health. In 2018, the Conference of the Parties (COP)6 adopted the Global Strategy to Accelerate Tobacco Control: Advancing Sustainable Development through the Implementation of the WHO FCTC 2019–2025 (GS2025). The Strategy seeks to make a meaningful contribution to reaching the overall health goal of SDG 3 and target 3.4 on NCDs. Furthermore, the Strategy adopted the voluntary global target of “a 30% reduction in the age-standardized prevalence of current tobacco use in persons aged 15 years and over by 2025” as its own overall target, thus harmonizing WHO FCTC implementation with global NCD efforts. The COP has recognized the strong contribution it can make to achieving the global NCD target on the reduction of tobacco use. Subsequently, the COP has called upon Parties to integrate WHO FCTC implementation with national multisectoral NCD policies. It also requested the Convention Secretariat to promote WHO FCTC implementation as an essential and high-impact strategy for achieving SDG target 3.4, and report on the efforts taken in the next COP sessions. Protecting public health policies from the commercial and vested interests of the tobacco industry and establishing measures7 to protect the integrity of the decisions adopted by the governing bodies of WHO FCTC and its Protocol is at the core of the Parties’ obligations under the Convention and its protocols. 6 The Conference of the Parties (COP) is the governing body of the WHO FCTC and is comprised of all Parties to the Convention. The work of the COP is governed by its Rules of Procedure and keeps under regular review the implementation of the Convention: it takes decisions necessary to promote its effective implementation and may also adopt protocols, annexes and amendments to the Convention. For more information: https://www.who.int/fctc/cop/governance/en/ 7 See decisions FCTC/COP8(4), (12), (18) at https://www.who.int/fctc/cop/sessions/ cop8/decisions/en/ 3 Responding to the Challenge of NCDs: FCTC 2. The Convention Secretariat has a role to play in supporting countries in preventing and controlling NCDs The Convention Secretariat is a global authority overseeing implementation of the WHO FCTC. It promotes multisectoral, comprehensive tobacco-control policies and legislation at country level through strengthened coordination and planning. Over the years, the Convention Secretariat has supported close to 60 Parties, mostly developing country Parties and Parties with economies in transition by conducting needs assessments8 in the light of their obligations under the Convention. Parties have also received further support in development assistance including South- South and triangular cooperation with emphasis on the FCTC2030 project implemented in 15 Parties. Capacity- building initiatives at global, regional and country levels, sharing of best practices and dissemination of information, statements and position papers through the regular use of formal and informal communications with governments are part of the core attributions of the Convention Secretariat. The Convention Secretariat has also a network of CS-Knowledge Hubs with expertise in different areas of Convention implementation which provide technical support to the Parties in various fields, e.g. research, legal, economic, surveillance and policy-making. 8 WHO FCTC Secretariat, Needs assessments (2019). Available at: https://www.who. int/fctc/implementation/needs/en/ As part of the synergy framework promoted through COP decisions and resolutions of the World Health Assembly (WHA),9 the Convention Secretariat has reviewed the recommended cost-effective interventions endorsed by the WHA in order to identify those that are linked to its work at global, regional and country levels: specific examples are given in the table. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.10 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 9 Seventh Session of the Conference of the Parties to the WHO FCTC, Strengthening synergy between the Conference of the Parties and the World Health Assembly: Report of the Convention Secretariat, FCTC/COP/7/32 (2016). Available at https:// www.who.int/fctc/cop/cop7/FCTC_COP_7_32_EN.pdf and Seventh Session of the Conference of the Parties to the WHO FCTC, Strengthening synergy between the Conference of the Parties and the World Health Assembly, FCTC/COP7(18) (2016). Available at: https://www.who.int/fctc/cop/cop7/FCTC_COP7_18_EN.pdf?ua=1 10 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf 4 Responding to the Challenge of NCDs: FCTC Evidence-based interventions Convention Secretariat actions Increase excise taxes and prices on tobacco products. This is one of the specific objectives of the GS2025. Article 6 of the WHO FCTC is therefore a priority in the core work of the CS and includes development assistance projects such as the FCTC2030. Its application is supported by the Guidelines to implement Article 6 adopted by COP. Additionally, the CS-Knowledge Hub on taxation supports the CS in assisting Parties to implement Article 6 of the WHO FCTC.11 Implement plain/standardized packaging and/or large graphic health warnings on all tobacco packages. This is one of the specific objectives of the GS2025 and bears on Article 11 of the WHO FCTC. Its application is supported by the Guidelines to implement Article 11 adopted by COP. As one of the time-bound measures under the Convention, country development assistance projects coordinated by the CS frequently cover pictorial health warning legislation. The CS also encourages granting licences for pictorial health warnings to promote large-scale and effective pictorial health warnings. The CS-Knowledge Hub on international cooperation also supports the CS in assisting Parties to implement Article 11 of the WHO FCTC. Enact and enforce comprehensive bans on tobacco advertising, promotion and sponsorship (TAPS). Ban cross-border advertising, including using modern means of communication. TAPS bans are one of the specific objectives of the GS2025 and bears on Article 13 of the WHO FCTC as one of the time-bound measures under the Convention. Country development assistance projects frequently cover tobacco advertising, promotion and sponsorship legislation supported by the Guidelines to implement Article 13 adopted by COP. Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public places public transport. Guidelines on cross-border TAPS will be further elaborated. In decision FCTC/COP8(17), the COP established an intersessional working group to develop specific guidelines to address cross-border TAPS and the depiction of tobacco in the entertainment media under Article 13 of the WHO FCTC in the light of technological advances over the past decade such as the Internet and mobile communications.12 Implement effective mass media campaigns that educate the public about the harms of smoking/tobacco use and second-hand smoke. This is one of the specific time-bound objectives of the GS2025. Its implementation is supported by the Guidelines to implement Article 8 adopted by COP. As one of the time-bound measures under the Convention, country development assistance projects frequently cover smoke-free legislation. The CS-Knowledge Hub on international cooperation also supports the CS in assisting Parties to implement Article 8 of the WHO FCTC.13 Provide cost-covered, effective and population-wide support (including brief advice, national toll-free quit line services) for tobacco cessation to all those who want to quit. As one of the demand reduction measures under the Convention, country development assistance projects frequently cover education campaigns including mass media campaigns in line with Guidelines to implement article 12 adopted by COP. Provide mobile phone-based tobacco cessation services for all those who want to quit. As one of the demand reduction measures under the Convention, country development assistance projects frequently promote as broad a range of interventions as possible in order to support cessation in line with the Guidelines to implement Article 14 adopted by COP. The Convention Secretariat also works to promote targeted cessation initiatives when addressing co-morbidities such as HIV and tuberculosis.14 Additionally, the CS- Knowledge Hub on international cooperation promotes implementation of Article 14 of the Convention.15 Implement measures to minimize illicit trade in tobacco products. The Convention Secretariat has promoted the legal adoption of the Protocol and continues to endorse awareness-raising initiatives to encourage Parties to the Convention to become Parties to the Protocol and to begin its implementation. The CS is working to bring its development assistance initiatives in line with MOP guidance and decisions. 11 WHO FCTC Secretariat, WHO FCTC Knowledge Hub on Taxation (2019). Available at: https://untobaccocontrol.org/kh/taxation/ 12 Eighth Session of the Conference of the Parties to the WHO FCTC, Tobacco advertising, promotion and sponsorship: depiction of tobacco in entertainment media, FCTC/COP8(17) (2018). Available at: https://www.who.int/fctc/cop/sessions/cop8/FCTC__COP8(17).pdf?ua=1 13 WHO FCTC Secretariat, WHO FCTC Knowledge Hub on International Cooperation (2019). Available at: https://untobaccocontrol.org/kh/int-cooperation/ 14 WHO FCTC Secretariat, Issue Brief: Integrating Tobacco Control into Tuberculosis and HIV Responses (2018). Available at: https://www.who.int/fctc/publications/WHO-FCTC-HIV- TB.pdf?ua=1 15 ibid 5 Responding to the Challenge of NCDs: FCTC Twenty-eight international intergovernmental organizations and 21 nongovernmental organizations are accredited to the COP as observers. The Convention Secretariat cooperates with all observers in providing support to all Parties of both the WHO FCTC and its Protocol. The UK- and Australia-funded FCTC2030 project16 has enabled the Convention Secretariat to work with UNDP and WHO to support 15 low- and middle-income countries (LMICs) in promoting and supporting governments to accelerate implementation of the WHO FCTC. The Convention Secretariat leads the UNIATF Thematic Group on Tobacco Control under which several initiatives are taking place: • The Convention Secretariat takes the lead in developing and promoting the Model Policy on preventing tobacco industry interference among the UN agencies.17 After it was adopted by the seventh meeting of the UNIATF, it was endorsed by the UN Economic and Social Council (ECOSOC) meeting in 201718 and reiterated again in 2018.19 16 WHO FCTC Secretariat, FCTC 2030 (2019). Available at: https://www.who.int/fctc/ implementation/fctc2030/ 17 The purpose of this policy is to ensure that efforts to protect tobacco control from commercial and other vested interests of the tobacco industry are comprehensive, effective and consistent across the United Nations system including the UN itself and its funds, programmes, specialized agencies, other entities and related organizations. To download the model policy: https://www.who.int/ncds/un-task- force/events/model-policy-agencies-united-nations1.pdf 18 United Nations, Economic and Social Council, United Nations Inter-Agency Task Force on the Prevention and Control of Non-Communicable Diseases, E/ RES/2017/L.21 (2017). Available at: http://www.un.org/ga/search/view_doc. asp?symbol=E/2017/L.21 19 United Nations, Economic and Social Council, United Nations Inter-Agency Task Force on the Prevention and Control of Non-Communicable Diseases, E/ RES/2018/13 (2018). Available at: https://undocs.org/E/RES/2018/13 3. Partnerships are critical for the Convention Secretariat to mobilize and implement the WHO FCTC and its Protocol and provide an effective response to NCDs • The Convention Secretariat and WHO joined forces with FAO and ILO to support their Governing Body decision to stop funding from the tobacco industry for child labour in tobacco growing areas. • The Convention Secretariat is working with several UN agencies to develop a new joint programme to support low- and middle- income countries in developing economically sustainable alternatives to livelihoods based on tobacco growing. • The Convention Secretariat promotes a smoke-free UN campus in the UNIATF and has joined forces with WHO to develop tools and guides. Due diligence is required to ensure all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens for example by working to increase or preserve the availability, accessibility and/ or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. 6 Responding to the Challenge of NCDs: FCTC 4. Mobilizing resources to deliver COP8 has developed a fundraising strategy for implementing the WHO FCTC in line with GS2025, including the concept of an Investment Fund as a regular and sustainable fundraising mechanism.20 The Convention Secretariat has been actively mobilizing funds to support developing country Parties and Parties with economies in transition to strengthen their implementation of the WHO FCTC.21 20 Eighth Session of the Conference of the Parties to the WHO FCTC, Convention Secretariat’s fundraising strategies: Investment fund concept, FCTC/COP8(5) (2018). Available at: https://www.who.int/fctc/cop/sessions/cop8/FCTC__COP8(5). pdf?ua=1 21 WHO FCTC Secretariat, Donors and partners from 2018 (2019). Available at: https:// www.who.int/fctc/about/donorspartners/en/ The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the Convention Secretariat as part of a set of United Nations system agency briefs under the Task Force (WHO/UNIATF/19.98) Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr 1 Responding to the Challenge of NCDs: IAEA International Atomic Energy Agency Responding to the Challenge of Non-communicable Diseases 1. Nuclear techniques assist in the prevention, early detection, diagnosis and treatment of NCDs1 Nuclear techniques play an integral role in the management of non-communicable diseases (NCDs)1 such as cancer, cardiovascular diseases, and neurological conditions, and can be used to design and evaluate interventions to address malnutrition in all its forms. Cancer. Cancer causes 9 million deaths each year.2 Medical imaging, including X-rays, and nuclear medicine techniques are critical in cancer care, in terms of: early and accurate diagnosis, including assessment of the location and spread of the disease (staging); follow-up of the patient to detect relapses; prognostic evaluation; and appropriate therapeutic decisions and follow-up of the response to treatment.3 Radiotherapy is a key element of cancer treatment for every second cancer patient worldwide. Modern radiotherapy allows automated delivery of a precise dose to the tumour and avoids the surrounding critical structures, giving the patient a chance to recover with minimal side- effects. 1 This UNIATF brief draws from the IAEA Brief for policymakers, “Prevention, Early Diagnosis and Treatment of Non-Communicable Diseases: The Role of Nuclear Techniques.” Available at: https://www.iaea.org/sites/default/files/18/10/ prevention-early-diagnosis-and-treatment-of-non-communicable-diseases.pdf 2 WHO. Key facts. NCDs. https://www.who.int/news-room/fact-sheets/detail/ noncommunicable-diseases 3 For more information, see: https://www.iaea.org/topics/cancer-diagnosis United Nations high-level meetings have highlighted the need for UN agencies, including IAEA, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as unhealthy diet, tobacco use, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2 Responding to the Challenge of NCDs: IAEA Cardiovascular disease. Cardiovascular diseases account for most NCD deaths, claiming the lives of 17.9 million people annually.4 Cardiac imaging using nuclear techniques is an important diagnostic tool, enabling earlier diagnosis and the planning of more effective treatment, as well as follow- up of patient response. Neurological conditions. Worldwide, around 50 million people have dementia, and there are nearly 10 million new cases every year. Alzheimer’s disease is the most common form of dementia and may contribute to 60– 70% of cases.5 Molecular imaging, including brain perfusion techniques, is helpful in the diagnosis of Alzheimer’s and other forms of dementia.6 Malnutrition. The effects of poor nutrition add to the burdens on health-care systems. In 2018, globally 149 million children under 5 years of age were stunted, 49 million wasted and 40 million overweight.7 Nuclear and stable isotope techniques provide important accurate data on body composition, breastfeeding practices, total daily energy expenditure, micronutrient bioavailability and vitamin A status, all of which directly relate to the prevention of diet-related NCDs. 4 WHO. Key facts. NCDs. https://www.who.int/news-room/fact-sheets/detail/ noncommunicable-diseases 5 WHO. Dementia: Key facts. https://www.who.int/news-room/fact-sheets/detail/ dementia 6 Torosyan N, Silverman S. (2012). Neuronuclear Imaging in the Evaluation of Dementia and Mild Decline in Cognition. Semin Nucl Med; 42(6): 415–422. 7 Global Health Observatory: Child malnutrition https://www.who.int/gho/child- malnutrition/en/ 2. IAEA has a role to play in preventing and controlling NCDs Working with governments, research and health institutions and development partners, IAEA provides technical assistance to Members States to strengthen their capacity in cancer diagnostics and treatment, and to evaluate preventive interventions for diet-related NCDs using stable isotope techniques.8 This support consists of developing, adopting and strengthening practices, providing technical advice and training, engaging in coordinated research projects, provision of equipment, preparation of technical publications and public information, and resource mobilization activities. IAEA also strengthens the evaluation of a range of nutrition interventions to prevent and support treatment of NCDs such as those that increase physical activity, promote breastfeeding and assess body composition and energy expenditure. IAEA has supported more than 110 low- and middle-income countries (LMICs) to address issues related to NCDs. IAEA has established a dedicated service (imPACT Review)9 to assess national capacities in cancer control and subsequently support Member States in evidence-based planning of cancer control resources. This service is delivered in cooperation with the World Health Organization (WHO) and International Agency for Research on Cancer (IARC). 8 IAEA Brief on Human Health for Policy Makers. https://www.iaea.org/sites/default/ files/18/10/prevention-early-diagnosis-and-treatment-of-non-communicable- diseases.pdf 9 https://www.sciencedirect.com/science/article/abs/pii/S1470204517303728 Abdel-Wahab M, Lahoupe B, Polo A, et al. (2017). Assessment of Cancer Control Capacity and Readiness: The Role of the International Atomic Energy Ageny. Lancet Oncol; 18(10): 587-594. 3 Responding to the Challenge of NCDs: IAEA IAEA’s Quality Management Audit for Nuclear Medicine Practice aims to support facilities to improve the quality of their clinical practice. Since 2009, IAEA has conducted 72 audits in 38 countries.10, 11, 12 IAEA has compiled the first comprehensive database on global energy expenditure data. Between 1981 and 2017, over 6600 measurements from 23 countries were collected using the Doubly Labelled Water method. These data help countries develop better health policies to combat the growing obesity epidemic. IAEA has reviewed the recommended cost- effective interventions endorsed by the WHA for NCDs to identify those that can be advanced through IAEA’s work at global, regional and country levels. Examples are provided in the table below. 10 Dondi M, Paez D, Torres L, et al. (2018). Implementation of Quality Systems in Nuclear Medicine: Why It Matters. An Outcome Analysis (Quality Management Audits in Nuclear Medicine Part III). Semin Nucl Med; 48(3):299-306. 11 Dondi M, Torres L, Marengo M, et al. (2017). Comprehensive Auditing in Nuclear Medicine Through the International Atomic Energy Agency Quality Management Audits in Nuclear Medicine Program. Part 2: Analysis of Results. Semin Nucl Med;47(6):687-693. 12 Dondi M, Torres L, Marengo M, et al. (2017). Comprehensive Auditing in Nuclear Medicine Through the International Atomic Energy Agency Quality Management Audits in Nuclear Medicine (QUANUM) Program. Part 1: the QUANUM Program and Methodology. Semin Nucl Med;47(6):680-686. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.13 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 13 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. http://apps.who.int/iris/bitstream/ handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf 4 Responding to the Challenge of NCDs: IAEA Evidence-based interventions IAEA actions Treatment of heart attacks. Building capacity in appropriate and safe use of medical imaging, including nuclear medicine (SPECT and PET) and radiology. Establishing sustainable medical imaging facilities for evaluation of patients with CVD. Treatment of heart failure. Breast screening using mammography with timely diagnosis and treatment of breast cancer. Ensuring quality control, image quality and dose optimization of mammography units. Assisting in the development of national diagnostic reference levels. Building capacity for the appropriate and safe use of mammography. Establishing sustainable mammography facilities. Treatment of colorectal cancer stages I and II and basic palliative care for cancer. Planning, establishing and sustaining radiotherapy services. Supporting radiotherapy quality assurance programmes. Provision of training in radiotherapy. Raising public and political awareness, understanding and practice relating to the prevention and control of NCDs. Highlighting NCD issues through media including social media. Strengthening international cooperation for resource mobilization, capacity-building, health workforce training, and exchange of information on lessons learned and best practices. Supporting education and training activities for health practitioners. Supporting the development of national resource mobilization strategies, technical documents and targeted funding proposals. Assessing national capacity for the prevention and control of NCDs. Supporting the development of national cancer control plans and strategies. Providing recommendations on national treatment and palliative care programmes. Conducting national assessments to strengthen national cancer control programmes. Strengthening human resources and institutional capacity for research. Supporting countries to train healthcare staff. Supporting countries to build clinical research capacity. Strengthening research capacity through cooperation with domestic and foreign research institutes. Partnering with joint research programmes. Supporting clinical research protocols in LMICs. Promoting and supporting exclusive breastfeeding for the first six months of life. Evaluating breastfeeding practices using stable isotope techniques. 5 Responding to the Challenge of NCDs: IAEA The IAEA collaborates with a number of partners in response to NCD burdens. Examples include: • IAEA/WHO (Network of Secondary Standards Dosimetry Laboratories) which provides calibrations for dosimetry equipment that are used to determine radiation dose levels for patients, staff or the public; • UN Joint Global Programme on Cervical Cancer Prevention and Control, which supports countries to reduce the burden of cervical cancer – IAEA has a key role in supporting Member States in the diagnosis and treatment of cervical cancer, including radiotherapy and palliative treatment; • International Union of Nutritional Sciences’ Task Force on Nutrition and Cancer which, at national, regional and global levels, catalyses capacity and collaboration across nutrition and cancer; • International Organization for Medical Physics in the development of guidelines and American Association of Physicists in Medicine in the development of dosimetry codes of practice; and • International Centre for Theoretical Physics, European Society for Radiotherapy and Oncology and a range of other professional organizations in building capacity through training courses, conferences and workshops. 3. Partnerships are critical for IAEA in mobilizing an effective response to NCDs A formal mechanism for due diligence, which also addresses conflicts of interest in safeguarding the reputational risk to the organization, should be in place to ensure that all partnerships advance health and development outcomes. 6 Responding to the Challenge of NCDs: IAEA 4. Mobilizing resources to deliver As Member States struggle with inadequate resources to tackle their increasing cancer burden, IAEA has adopted a new resource mobilization approach, joining forces with the private sector and international financial institutions to support low- and middle-income countries in order to secure financial and non- financial resources: in 2012, for instance, IAEA launched a focused partnership effort with the Organization of Islamic Cooperation and the Islamic Development Bank to expand access to effective, safe and sustainable cancer care in common Member States. The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the IAEA as part of a set of United Nations system agency briefs under the Task Force (WHO/UNIATF/19.98) Photo credits: © IAEA © World Bank (p.3, top) © UNICEF (p.3, bottom) International Organization for Migration Responding to the Challenge of Non-communicable Diseases Migration is an important determinant of health. It can challenge physical, mental and social well-being. Throughout the migration process, migrants experience difficulties in accessing health services and face increased exposure and vulnerability to NCDs and their risk factors as well as mental ill-health and injuries. In their community of origin, migrants may face poverty, violence and social conflict, as well as limited access to health care. For families left behind, the social cost is considerable, and has significant mental health implications. Remittances that could be used for accessing long-term health protection schemes are often used for out-of-pocket health expenditure. During transit, stressful and unsafe travel conditions and discontinued care can exacerbate migrants’ risk of developing NCDs or worsen pre-existing conditions. At their destination, migrants often face social exclusion and experience difficulties adapting to a new culture, which may lead to an increase in unhealthy behaviour patterns such as tobacco and alcohol use, poor diet and inadequate health care. United Nations high-level meetings have highlighted the need for UN agencies, including IOM, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. Stigma, discrimination and restrictive policies also expose migrants to NCD risk factors. In addition, migrant workers are reported to have a higher risk of work-related injuries and chronic illnesses than native workers. During return, especially after crisis situations, their access to health services may be limited. Migrants and mobile populations can face many obstacles in accessing essential health care services due to, among other factors, their irregular immigration status, language barriers, the absence of migrant-inclusive health policies and inaccessible services. 1. Migrants are at increased risk of NCDs and mental health conditions 1 Responding to the Challenge of NCDs: IOM 2. IOM has a role to play in supporting countries in preventing and controlling NCDs “Life Is Better”—psychoactive substances abuse primary prevention campaign, Georgia (2016–2017) IOM Georgia implemented a multisectoral approach involving local authorities in seven public schools. The “Life is Better” school-based campaign used an innovative and interactive two-pronged educational approach combining information dissemination on the risks of drug use and skill-building which targeted youth and their families in migrant communities and among ethnic minorities. The campaign reached 4,067 school children who were shown to be comparatively more aware of drug-related risks and better equipped to face social pressures relating to drug use. The “Life is Better” campaign acts as a primary prevention method to combat NCDs since substance abuse can lead to mental health problems such as depression and anxiety. Substance abuse can also increase the risk of developing cancer, diabetes and other NCDs. The campaign was adopted by the Ministry of Education and Science of Georgia and has been expanded nationwide. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.3 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. IOM, as the UN migration agency, is committed to the inclusion of migrant and mobile populations in all relevant policies and programmes to reduce NCDs. This commitment is reflected in IOM’s support for implementation of the Global Compact for Safe, Orderly and Regular Migration,1 as well as World Health Assembly (WHA) Resolution 70.15 on promoting the health of refugees and migrants. Growing clarity on the multiple and unique risks migrants face with respect to NCDs, mental ill-health and injuries, not least obstacles to life-saving health services, calls for strong partnerships and sustainable programmes to address NCDs in migrant populations. IOM delivers and promotes comprehensive preventive and curative health programmes for migrants and mobile populations. NCDs and mental conditions are diagnosed, treated and, if necessary, referred to a healthcare facility as part of IOM’s health programming. IOM serves as the coordinator and secretariat of the United Nations network on migration, in line with the “Making Migration Work for All”2 global platform from which migration health actions and policies will be promoted and coordinated to address NCDs. IOM is committed to supporting partnerships to ensure the inclusion of migrants and mobile populations in national and global health policies including Universal Health Coverage (UHC). Migrants should be afforded equitable access to high-quality health services including to prevent, treat and manage NCDs. 1 Global Compact for Safe, Orderly and Regular Migration, endorsed by the United Nations General Assembly in resolution 73/195 (2018). 2 A/72/643. Making migration work for all. Report of the Secretary-General. https:// refugeesmigrants.un.org/sites/default/files/sg_report_en.pdf 3 3 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf 2 Responding to the Challenge of NCDs: IOM IOM has reviewed the recommended WHA- endorsed cost-effective interventions and recommended policy actions to identify those that are linked to IOM’s work at the global, regional and country level. Evidence-based interventions IOM actions Raise public and political awareness, understanding and practice in relation to the prevention and control of NCDs. Include NCDs in the tools used to monitor the health of migrant populations, and enhance IOM’s knowledge- base to inform evidence- based programming and policy development. Strengthen community-based surveillance (CBS) systems to monitor NCD trends and identify the health priorities of migrants. Integrate NCDs into the social and development agenda and poverty alleviation strategies. Implement NCD-focused interventions for migrants and displaced populations in transit and destination communities. Provide clinicians and public health planners in host countries with adequate knowledge of NCD profiles in migrants’ countries of origin. Advocate for psychosocial support to be provided to migrant and mobile populations. Strengthen international cooperation for resource mobilization, capacity building, health workforce training and exchange of information on lessons learned and best practices. Raise awareness of NCDs in national and regional capacity development activities. Foster multisectoral dialogues to address migrants’ structural vulnerabilities to NCDs. 3. Partnerships are critical for IOM in mobilizing an effective response to NCDs IOM has partnerships with multiple stakeholders on issues relating to international health and migration. At the national level, IOM works closely with relevant government ministries, particularly ministries of health and immigration, NGOs and private sector entities (e.g. employment agencies). At the regional and global levels, key partners include UN agencies such as WHO, UNAIDS, UNHCR and ILO, as well as civil society partners such as migrants’ associations and academia. Due diligence is required to ensure all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. 3 Responding to the Challenge of NCDs: IOM Ph ot o cr ed its : © IO M The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by IOM as part of a set of United Nations system agency briefs under the Task Force (WHO/UNIATF/19.98) 4. Mobilizing resources to deliver IOM will continue to highlight NCDs as an important issue with donors, and ensure that IOM country and regional offices include NCDs in project development and implementation. 4 Responding to the Challenge of NCDs: IOM 1 Responding to the Challenge of NCDs: UNAIDS Joint United Nations Programme on HIV and AIDS Responding to the Challenge of Non-communicable Diseases 1. NCDs among people living with HIV is an increasing global public health issue Many countries with HIV epidemics are now experiencing growing rates of NCDs.1 Death rates from NCDs are nearly twice as high in low- and middle-income countries (LMICs) compared to high-income countries. Antiretroviral therapy (ART) for HIV enables people living with HIV to lead long and productive lives. However, there are now becoming susceptible to NCDs in later life. The four NCDs that account for the greatest number of comorbidities among people living with HIV in LMICs are cardiovascular diseases (CVD), cervical cancer, depression and diabetes.2 The risk of cervical cancer among women living with HIV compared to women without HIV is increased up to fivefold.3 HIV-hepatitis C virus coinfection is associated with CVD, diabetes and/or death in people living with HIV.4, 5 1 General Assembly Resolution 66/2, Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, A/RES/66/2 (19 December 2011), available from https://undocs.org/A/ RES/66/2 2 Patel P, Rose C, Collins P, Nuche-Berenguer B, Sahasrabuddhe V, Peprah et al. (2018). Non-communicable diseases among HIV-infected persons in low-income and middle-income countries. AIDS, 32:S5-S20. doi: 10.1097/ QAD.0000000000001888. 3 HPV, HIV and cervical cancer: leveraging synergies to save women’s lives. Geneva: UNAIDS; 2016 (UNAIDS/JC2851E; https://www.unaids.org/en/resources/ documents/2016/HPV-HIV-cervical-cancer). 4 Jenny-Avita ER. (2003). HCV-Coinfection Is Associated with Diabetes and CD4 Decline. AIDS Clinical Care 3:1(12). 5 Kakinami L, Block R, Adams M, Cohn S, Maliakkal B and Fisher S. (2012). Risk of cardiovascular disease in HIV, hepatitis C, or HIV/hepatitis C patients compared to the general population. International Journal of Clinical Practice, 67(1):6-13 doi: 10.1111/j.1742-1241.2012.02953.x HIV, cervical cancer and NCDs are all diseases associated with gender and socioeconomic inequalities, and health disparities across and within countries. HIV infection may increase the risk of NCDs due to stimulation of inflammatory markers and adverse events associated with some anti-retroviral medicines for HIV treatment. This risk is compounded by NCD risk factors, e.g. tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity. United Nations high-level meetings have highlighted the need for the UN, including UNAIDS, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development.1 NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in developing countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2Smoking is associated with a twofold increase in mortality among people living with HIV mainly due to lung cancer. In LMICs, tobacco use among people living with HIV is higher than among those without HIV.6 Smoking is predicted to produce an excess of 18 million cases and 40 million deaths related to tuberculosis (TB) between 2010 and 2050, increasing TB cases and deaths by 7 percent and 66 percent respectively over this period.7 Given the HIV-TB syndemic, smoking, thus, constitutes a major exacerbating factor for HIV, TB and HIV-TB co-infections. Harmful use of alcohol is associated with: risky sexual behaviour with an increased risk of acquiring HIV, resulting in an estimated 33,000 new cases of HIV each year;8 reduced adherence to ART; alcohol-drug interactions and toxicities; and an increased risk of antiretroviral resistance. Harmful use of alcohol also increases the risk of TB infection9 and is associated with delays in seeking TB care.10 Alcohol increases the risk for HIV-related comorbidities, including liver disease, CVD, cerebrovascular disease, pulmonary disease, bone disease and cancer. Alcohol dependence further impacts the progression of HIV infection, as well as associated TB and viral hepatitis. People with mental health and substance use conditions are often at greater risk of HIV infection and are less likely to access education, prevention, testing and treatment services. People living with HIV are at an increased risk of developing mental health conditions, such as depression and anxiety. Key populations, people living with HIV and people with mental health conditions experience multifaceted stigma and the effects of interlocking systems of discrimination.11, 12 Stigma associated with HIV and marginalized identities have been linked to anxiety, depression, poor self-esteem and poor adherence to HIV care.13 Stigma also remains a barrier to accessing drug dependence treatment, mental health care and HIV services. 14, 15 6 Mdege N, Shah S, Ayo-Yusuf O, Hakim J and Siddiqi K. (2017). Tobacco use among people living with HIV: analysis of data from Demographic and Health Surveys from 28 low- income and middle-income countries. The Lancet Global Health, 5(6):e578-e592. 7 Basu S, Stuckler D, Bitton A, and Glantz SA. (2011). Projected effects of tobacco smoking on worldwide tuberculosis control: mathematical modelling analysis. BMJ, (343): doi: https://doi.org/10.1136/bmj.d5506 8 Global status report on alcohol and health 2018. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO. 9 Imtiaz S, Shield KD, Roerecke M, et al. (2017). Alcohol consumption as a risk factor for tuberculosis: meta-analyses and burden of disease. European Respiratory Journal, (50) : doi: 10.1183/13993003.00216-2017 10 Van Ness SE, Chandra A, Sarkar S et al. (2017). Predictors of delayed care seeking for tuberculosis in southern India: an observational study. BMC Infect Dis, (17):567: doi: 10.1186/ s12879-017-2629-9 11 Collins PY, Unger Hv, Armbrister A. Church ladies, good girls, and locas: Stigma and the intersection of gender, ethnicity, mental illness, and sexuality in relation to HIV risk. Social Science & Medicine. 2008;67(3):389-97. 12 Earnshaw VA, Bogart LM, Dovidio JF, Williams DR. Stigma and racial/ethnic HIV disparities: moving toward resilience. The American psychologist. 2013;68(4):225-36. 13 Patton GC, Sawyer SM, Santelli JS, Ross DA, Afifi R, Allen NB, et al. Our future: a Lancet commission on adolescent health and wellbeing. Lancet. 2016;387(10036):2423-78 14 Global Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. Geneva: World Health Organization; 2017. 15 Bundy DAP, de Silva N, Horton S, Patton GC, Schultz L, Jamison DT. Investment in child and adolescent health and development: key messages from Disease Control Priorities, 3rd Edition. Lancet. 2018;391(10121):687-99. Responding to the Challenge of NCDs: UNAIDS 3In partnership with the United Nations Interagency Task Force on NCDs, UNAIDS focuses on developing policies for integration of HIV and NCDs, and HIV and mental health strategies. This approach is aligned with the 2016 UN Political Declaration on Ending AIDS by 2030 and the 2016–2021 UNAIDS Strategy: On the Fast-Track to End AIDS.16 The UNAIDS Global Strategy for 2016–2021 supports multisectoral, integrated, people- centred, human rights and evidence-based services for HIV and HPV/cervical cancer, HIV and NCDs, HIV and mental health as well as for tuberculosis, sexual and reproductive health, maternal, newborn and child health with the active engagement of communities and civil society. 16 UNAIDS 2016–2021 Strategy. Geneva: UNAIDS; 2015 (https://www.unaids.org/ sites/default/files/media_asset/20151027_UNAIDS_PCB37_15_18_EN_rev1.pdf) 2. UNAIDS has a role to play in supporting countries in NCD prevention and control The 43rd and 44th UNAIDS Programme Coordinating Board (PCB) meetings were dedicated to mental health and HIV: promoting human rights, an integrated and person-centred approach to improving ART adherence, well- being and quality of life.17, 18 At its 44th meeting, UNAIDS PCB called on: • Member States to implement evidence- based, people-centred, human rights and community-based policies and programmes to promote mental health and quality of life with a focus on addressing stigma and discrimination related to both HIV and mental health conditions as part of HIV prevention, treatment and care services. • Member States to address social determinants of mental health and HIV by adopting and implementing social protection policies and programmes to reduce stigma and discrimination. • the UNAIDS Joint Programme to review and revise existing practices and guidelines in order to ensure integration of mental health and substance use services into HIV service delivery platforms, and HIV services into mental health and substance use prevention and treatment programmes, and to provide respective implementation guidance. • the UNAIDS Joint Programme to take into account the intersection between mental health and HIV, and the importance of improving psychosocial wellbeing and upholding the quality of life of people affected and living with HIV, as part of a person-centred and human rights approach when developing the next UNAIDS strategy for 2021–2030. 17 The 43rd UNAIDS Programme Coordinating Board (11–13 December 2018), available from https://www.unaids.org/sites/default/files/media_asset/20181214_ UNAIDS_PCB43_Decisions_EN.pdf 18 The 44th UNAIDS Programme Coordinating Board (27 June 2019), available from https://www.unaids.org/en/resources/documents/2019/PCB44_Decisions Responding to the Challenge of NCDs: UNAIDS 4UNAIDS has reviewed the recommended cost-effective interventions endorsed by the WHA—”best buys”—to identify those that are linked to its work at global, regional and country levels. These interventions address the synergies between HIV and HPV/ cervical cancer, HIV and NCDs, and HIV and mental health. UNAIDS plays an advocacy and facilitating role for global, regional and country level multisectoral partnerships as well as resource mobilization efforts to support countrywide responses to cervical cancer, NCDs and mental health issues. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.19 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 19 “Best buys” and other recommended interventions for the prevention and control of non-communicable diseases, Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO. Available at: http://apps.who.int/iris/bitstream/ handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf Evidence-based interventions UNAIDS actions Vaccination against human papillomavirus (2 doses) of 9–13-year-old girls. Prevention of cervical cancer by screening women aged 30–49 years. UNAIDS advocates for an HIV-cervical cancer policy, services and partnerships, along with community engagement; it also supports a focus on HPV vaccination for HIV-positive girls, and cervical pre-cancer and cancer screening, treatment and care for women living with and at risk of HIV. UNAIDS collects, analyses and tracks country reports on the Global AIDS Monitoring and National Composite Policy Index indicators for cervical cancer screening among women living with HIV, and integrated cervical cancer- HIV policies and services. Raise public and political awareness, understanding and practice about prevention and control of NCDs. UNAIDS raises political and public awareness at global and country levels for integrating NCDs and mental health into HIV strategies, policies and programmes with a focus on people living with and at risk of HIV, HIV-NCDs and HIV-mental health comorbidities; emphasis is also put on addressing human rights issues, stigma and discrimination, and health, social and gender inequalities which are common across HIV, NCDs and mental health issues. Integrate NCDs into the social and development agenda and poverty alleviation strategies. UNAIDS advocates for tackling the social determinants of mental health and HIV by means of social protection policies and other programmes to reduce stigma and discrimination. Responding to the Challenge of NCDs: UNAIDS 5UNAIDS actively seeks to strengthen partnerships to address NCDs: some of them are listed below. • UNAIDS is a co-founding partner of the PEPFAR-G.W. Bush Institute-UNAIDS-Merck public-private partnership to end AIDS and cervical cancer among HIV-positive women in Africa. This initiative enables UNAIDS to support policy advocacy and reforms, resource mobilization and community engagement. • In partnership with WHO, United Nations Population Fund (UNFPA) and other partners, UNAIDS is supporting national governments in fast-track countries to develop cervical cancer indicators and targets in their respective national health plans, and advocates for the realization of the WHO Global Call to Action towards the elimination of cervical cancer at the country level and development of the WHO Global Strategy towards the Elimination of Cervical Cancer. • UNAIDS is supporting the H6 partnership for the health of women, children and adolescents (currently under WHO chairmanship) at the global and country level by enhancing the centrality of sexual, reproductive, maternal, newborn, child and adolescent (RMNCAH) health: this programme prioritizes HPV- cervical cancer prevention, screening and treatment for girls and young women and engages communities and mobilizes resources to enable these services to be scaled up. • UNAIDS and WHO are in the process of developing an implementation guidance for integrating mental health and substance use services into HIV service delivery programmes. 3. Partnerships are critical for UNAIDS in mobilizing an effective response to NCDs Due diligence is required to ensure all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. Responding to the Challenge of NCDs: UNAIDS 6The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the UNAIDS as part of a set of United Nations system agency briefs under the Task Force (WHO/UNIATF/19.98) Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr 4. Mobilizing resources to deliver UNAIDS advocates and supports countries to mobilize domestic and donor resources for integrating HIV and cervical cancer prevention and care in countries with a high burden of HIV and cervical cancer. UNAIDS has also mobilized resources for the integration of mental health and HIV services and for addressing human rights and quality of life issues. Responding to the Challenge of NCDs: UNAIDS 1 Responding to the Challenge of NCDs: UNDP United Nations Development Programme Responding to the Challenge of Non-communicable Diseases 1. NCDs are a development issue1 NCDs, such as cardiovascular disease, cancer, diabetes and chronic respiratory disease, are the greatest source of preventable illness, disability and mortality worldwide. NCDs place a significant burden on health systems, presenting a challenge to universal health coverage and other development aims.1 Out-of-pocket healthcare expenditures in response to NCDs can be financially ‘catastrophic’ for those affected. NCDs can also force household earners out of the labour market. Children may drop out of school to care for a sick relative or to make up for lost wages. Women and girls particularly sacrifice their time and opportunities.2 At the national level, NCDs sap public resources and impede economic growth. Between 2011 and 2030, NCDs including mental illnesses project to cost low- and middle-income countries (LMICs) US$ 21.3 trillion in healthcare costs and lost productive capacities.3 1 For in-depth information on UNDP’s response to NCDs, please see ‘UNDP Issue Brief: Preventing and Controlling Noncommunicable Diseases’: https://www.undp. org/content/undp/en/home/librarypage/hiv-aids/preventing-and-controlling-non- communicable-diseases0.html 2 See UNDP’s Discussion Paper on Addressing the Social Determinants of NCDs; and the World Bank’s Thwarting a Disease Crisis in the Pacific. 3 HSPH and WEF. 2011. ‘The Global Economic Burden of Non-communicable Diseases’. http://www3.weforum.org/docs/WEF_Harvard_HE_ GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf United Nations high-level meetings have highlighted the need for UN agencies, including UNDP, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development.4 NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as unhealthy diet, tobacco use, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. NCDs are linked to ageing, rapid unplanned urbanization, changing consumption patterns and environmental degradation. Many NCD risks are enmeshed with commercial interests which may conflict with public health objectives. Underlying social exclusion, marginalization, discrimination and inequities across different dimensions shape exposure to behavioural and environmental NCD risks, as well as access to basic services. 4 Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (2011); Political Declaration of the Third High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (2018); E/RES/13/2018 United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases. 2The Sustainable Development Goals include a specific target (3.4) to reduce premature mortality from NCDs. Shared gains across the 2030 Agenda for Sustainable Development are possible given the strong relationship between NCDs and priorities such as poverty and inequality reduction, economic growth, climate action and financing for development. Reducing the nine million premature deaths caused by pollution each year5 would, for instance, improve health while protecting the planet. 5 Landrigan, PJ, et al. The Lancet Commission on pollution and health. Lancet 2018; 391(10119); 462-512. The health sector cannot address NCDs on its own: whole-of-government and whole-of- society responses are essential. Differential exposures to behavioural and environmental risk factors for NCDs are often rooted in public policy choices that span sectors beyond health. Achieving coherence across sectors and ministries means confronting conflicts and countering vested interests which may act against public health objectives. UNDP is uniquely positioned to support integrated health and development solutions, building on its development portfolio, partnerships and networks, and country-level presence.6 In line with the SDG 3 ‘Global Action Plan for Healthy Lives and Well-Being for All’, UNDP, in cooperation with WHO, the Secretariat of the WHO Framework Convention on Tobacco Control (WHO FCTC), the broader UN Inter-Agency Task Force on NCDs and other partners, supports governments in all regions to implement or strengthen whole- of-government NCD responses. This support centres on strengthening national capacity, leadership, governance, multisectoral action and partnerships to accelerate country responses. UNDP leverages its core competencies in areas that intersect with NCD prevention and control, including access to basic services, poverty and inequality reduction, environment and energy, good governance, sustainable financing, gender, and south-south and triangular cooperation. 6 UNDP’s Discussion Paper on Addressing the Social Determinants of NCDs outlines entry points for development actors. https://www.undp.org/content/dam/undp/ library/hivaids/English/Discussion_Paper_Addressing_the_Social_Determinants_ of_NCDs_UNDP_2013.pdf 2. UNDP has a role to play in supporting countries to prevent and control NCDs Responding to the Challenge of NCDs: UNDP 3UNDP’s work on NCDs promotes effective and inclusive governance for health, a priority of its ‘HIV, Health and Development Strategy 2016–2021’.7 It aligns with its ‘Strategic Plan 2018–2021’,8 which recognizes the direct relationship between health, poverty eradication and other development aims. UNDP has reviewed the recommended World Health Assembly-endorsed policy options to identify those that are linked to UNDP’s work at global, regional and country level. Five indicative examples are given in the table. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.9 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 7 UNDP (2016). HIV, Health and Development Strategy 2016-2021. http://www.undp. org/content/undp/en/home/librarypage/hiv-aids/hiv--health-and-development- strategy-2016-2021.html 8 UNDP Strategic Plan, 2018-2021. http://undocs.org/DP/2017/38 9 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. http://apps.who.int/iris/bitstream/ handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf Evidence-based interventions UNDP actions Raise public and political awareness, understanding and practice about prevention and control of NCDs. Support non-health ministries to understand how NCDs impact their sector, and how they can support the national response.10 Work with parliamentary unions/associations to highlight the role for parliamentarians in NCD advocacy and in ensuring NCD-sensitive legal environments. Integrate NCDs into the social and development agenda and poverty alleviation strategies. Support countries to establish NCD prevention and control and tobacco control as development priorities within their national planning instruments/SDG action plans and corresponding UN Sustainable Development Frameworks.11 Prioritize and increase, as needed, budgetary allocations for prevention and control of NCDs, without prejudice to the sovereign right of nations to determine taxation and other policies. Work with partners to support ministries of health to develop national investment cases for scaled-up action. Analyse institutions and contexts to advance policy coherence, financing opportunities, and institutional roles and accountabilities. Develop and implement a national multisectoral policy and plan for the prevention and control of NCDs through multi-stakeholder engagement. Work with partners to support the drafting, costing and adoption of ambitious national NCD and tobacco control strategies, establishment of functional national and/ or subnational coordination mechanisms, and the passing, enforcement and monitoring of effective NCD-related legislation. Engage and mobilize civil society and the private sector as appropriate and strengthen international cooperation to support implementation of the action plan at global, regional and national levels. Strengthen the capacity of civil society organizations to advocate for multisectoral NCD action including through community mobilization and by linking with HIV/AIDS, TB and environment and climate communities. 10 UNDP and WHO have jointly produced a series of briefs on ‘What Government Ministries Need to Know about Non-communicable Diseases’. https://www.undp. org/content/undp/en/home/librarypage/hiv-aids/what-government-ministries- need-to-know-about-non-communicable-diseases.html 11 UNDP and WHO have developed a Guidance Note for UN Country Teams and governments on how to integrate NCDs into UN Development Assistance Frameworks. https://www.undp.org/content/undp/en/home/librarypage/hiv-aids/ guidance-note-NCDs-UNDAF.html; With the Convention Secretariat of the WHO FCTC, UNDP has developed guidance on integrating the WHO FCTC into UN and national development planning instruments. https://www.undp.org/content/ undp/en/home/librarypage/hiv-aids/development-planning-and-tobacco-control-- integrating-the-who-fr.html Responding to the Challenge of NCDs: UNDP 4UNDP and WHO are implementing a Global Joint Programme (GJP) on NCD Governance, with support from the Russian Federation. For LMICs, the GJP aims to support the development of national NCD investment cases, strengthen national coordinating mechanisms and municipal action, and integrate NCDs into domestic SDG frameworks. GJP assesses and seeks to expand fiscal space for universal access to NCD-related health services, while driving legislation, policies and targeted interventions for prevention. Through the FCTC 2030 project, conducted with the assistance of the UK and Australian Governments, UNDP is working with the Convention Secretariat of the WHO FCTC and WHO to support 15 LMICs in developing investment cases for accelerated implementation of the WHO FCTC. UNDP supports national coordination, the development and implementation of country-specific tobacco control plans, integrating tobacco control into broader SDG implementation efforts, and capacity building including for parliamentarians. UNDP supports national governments in the procurement of health products for NCDs, for example medicines for diabetes and cancer. In 2017 this procurement totaled approximately US$ 94 million. With the Global Environment Facility, UNDP manages over 800 projects across 141 countries on environmental challenges. Many projects support the NCD response. Examples include projects which reduce use of and people’s exposure to hazardous chemicals, and sustainable transport projects which support the construction of lanes for cycling (this promotes physical activity while reducing air pollution from vehicle emissions).12 12 UNDP (2018). Annual Performance Report 2017 – UNDP Global Environmental Finance Unit. https://www.undp.org/content/undp/en/home/librarypage/poverty- reduction/global-environmental-finance/2017-undp-gef-annual-performance-report. html 3. Partnerships are critical for UNDP in mobilizing an effective response to NCDs Due diligence is required to ensure that all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. Responding to the Challenge of NCDs: UNDP Responding to the Challenge of NCDs: UNDP 5 UNDP, other UN agencies and partners are supporting the implementation of the National Clean Air Programme of the Government of India. This work aims to tackle air pollution, a major cause of premature death from NCDs, through a systematic and coordinated multi-sector approach involving government departments and agencies, the corporate sector, academic institutions, civil society and local institutions. UNDP has extensive expertise in implementing large-scale health programmes, for example through its partnership with the Global Fund to Fight AIDS, Tuberculosis and Malaria. UNDP is working to ensure that Global Fund grants, where appropriate, address interactions between infectious diseases and NCDs and their risk factors.13 In the Pacific region, UNDP is managing a multicountry Global Fund programme to ensure that national tuberculosis guidelines include elements of the WHO ‘Collaborative Framework for Care and Control of Tuberculosis and Diabetes’.14 13 In 2015, the Global Fund approved a framework for financing interventions that respond to co-infections or co-morbidities that can exacerbate HIV, TB or malaria. https://www.theglobalfund.org/media/4167/bm33_11-co-infectionsandco- morbidities_report_en.pdf 14 UNDP and the Convention Secretariat of the WHO FCTC have produced an Issue Brief to support Global Fund applicants in integrating tobacco cessation into Global Fund HIV and TB grants. http://www.undp.org/content/undp/en/home/librarypage/ hiv-aids/integrating-tobacco-control-into-tuberculosis-and-hiv-responses.html UNDP plays a role in driving investments and efficiencies related to NCD prevention and control. Actions include but are not limited to: • supporting partners to advocate for the establishment of a multidonor trust fund to enable countries to catalyse financing on NCDs and mental health while strengthening policy coherence at the country level;15 • providing targeted technical support to countries to analyze the return on investment (ROI) in select NCD and tobacco control interventions, and to consider ROI in allocating resources to the national response; • strengthening partnerships and programmes oriented around “best buys” (e.g. the SAFER initiative to support countries to tackle harmful use of alcohol) as well as emerging relevant programmatic areas (e.g. air pollution); • supporting domestic financing for NCD responses including through innovative taxation measures for tobacco, alcohol, sugar-sweetened beverages and other health- harming products. Globally, increased taxes on tobacco, alcohol and sugary beverages could avert 50 million premature deaths and raise US$ 20.5 trillion in revenue over the next 20 years,16 while delivering benefits across the SDGs;17 and • collaborating with development banks to ensure that NCD loans seek to strengthen public health legislation and regulations to prevent NCDs, in addition to focusing on health system strengthening. 15 In line with ‘Time to Deliver’, the Report of the WHO Independent High-level Commission on Noncommunicable diseases. https://apps.who.int/iris/bitstream/ handle/10665/272710/9789241514163-eng.pdf?ua=1 16 Task Force on Fiscal Policy for Health. 2019. Health Taxes to Save Lives: Employing Effective Excise Taxes on Tobacco, Alcohol, and Sugary Beverages. https://www. bbhub.io/dotorg/sites/2/2019/04/Health-Taxes-to-Save-Lives.pdf 17 Sugar, Tobacco, and Alcohol Taxes (STAX) Group. Sugar, tobacco, and alcohol taxes to achieve the SDGs. Lancet 2018, 391(10138): 2400-2401. https://www.thelancet. com/journals/lancet/article/PIIS0140-6736(18)31219-4/fulltext 4. Mobilizing resources to deliver Responding to the Challenge of NCDs: UNDP 6 The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the UNDP as part of a set of United Nations system agency briefs under the Task Force (WHO/UNIATF/19.98) Photo credits: © World Bank via Flickr; page 5 © Omer Sadaat via The Global Fund 1 Responding to the Challenge of NCDs: UNFPA United Nations Population Fund Responding to the Challenge of Non-communicable Diseases 1.There are strong links between protecting and promoting sexual and reproductive health and rights, and preventing and controlling non-communicable diseases NCDs have a significant impact on the sexual and reproductive health of both men and women.1 • Obesity, hypertension and diabetes during pregnancy lead to poorer maternal and neonatal outcomes. • Tobacco use, by both pregnant women and other family members, adversely affects the foetus, newborn and children, as does maternal alcohol consumption. • Lack of breastfeeding increases the risk of NCDs in later life. • Poor diet, tobacco, alcohol and exposure to chemicals also affect fertility, reducing sperm viability and increasing erectile dysfunction in men. • Harmful use of alcohol increases the risk of unprotected sex, unintended pregnancies, HIV and other STIs including human papilloma virus (HPV), as well as the risk of domestic and gender-based violence. 1 Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (2011); Political Declaration of the Third High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable diseases (2018); E/RES/2018/13 United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases. United Nations high-level meetings have highlighted the need for UN agencies, including UNFPA, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development.1 NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in developing countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. Premature deaths from NCDs are largely preventable by encouraging women, men and young people to reduce their use of tobacco and consumption of harmful amounts of alcohol, adopt a healthy diet and step up their levels of physical activity. Cervical cancer is a global public health issue and can largely be prevented by vaccinating 9 to 13-year-old girls and boys against HPV. Penile and oropharyngeal cancers can also be prevented through HPV vaccination. Mental health is now an integral part of the NCD agenda and post-natal depression is considered a major public health issue. 2 Responding to the Challenge of NCDs: UNFPA NCDs are an increasing priority for UNFPA. By expanding its activities to include the prevention and control of NCDs, UNFPA will have a significant impact on reducing the current and future NCD burden. By tackling NCDs, UNFPA contributes to a direct improvement in maternal and neonatal health outcomes. UNFPA can support sexual and reproductive health and rights (SRHR) policy-makers and service providers to help young people and women of childbearing age reduce their exposure to, and use of tobacco and alcohol, and promote healthy diets and physical activity. Ante- and postnatal care also provide significant opportunities for the detection, prevention and management of diabetes and high blood pressure in women. UNFPA promotes exclusive breastfeeding for at least the first six months of life. Breastfeeding has long-term benefits for mothers and children in reducing the risk of NCDs. Several UNFPA programmes strengthen services which provide support to women with postpartum depression and other psychosocial conditions that impact them and their families. UNFPA is making a significant contribution to the elimination of cervical cancer globally by supporting countries in their efforts to scale up HPV vaccination, as well as through cervical cancer screening and early diagnosis activities as part of comprehensive cervical cancer control programmes. 2. UNFPA has a role to play in supporting countries to prevent and control NCDs in line with UNFPA’s commitment to improve public health throughout the lifecycle. UNFPA works with men and boys to reduce gender-based violence: this includes reducing the exposure to, and harmful use of alcohol by men in order to lessen alcohol-related violence. UNFPA is also committed to raising awareness about the socioeconomic impact of an ageing population, including the impact of NCDs in this group. In relation to this activity, UNFPA supports national censuses and demographic health surveys in order to improve population projections and strengthen policy and planning, including NCD programming. UNFPA has reviewed the cost-effective interventions endorsed by the World Health Assembly in order to identify those that are linked to UNFPA’s work at global, regional and country level: specific examples are given in the table. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.2 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 2 WHO. 2017. ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf. 3 Responding to the Challenge of NCDs: UNFPA Evidence-based interventions UNFPA actions Promote and support exclusive breastfeeding for the first six months of life. Exclusive breastfeeding is promoted by midwives as part of their comprehensive antenatal and postnatal care interventions and services. Preconception care among women of reproductive age who have impaired glucose tolerance or diabetes, including patient education and intensive glucose management. Midwives and other antenatal care providers include diabetic screening and management, specifically for expectant women in antenatal clinic settings, and via outreach services where possible. Human papillomavirus vaccination (2 doses) for 9 to 13-year-old girls and boys. UNFPA supports delivery of HPV vaccination through primary health care services and school vaccination programmes. Prevention of cervical cancer by screening women aged 30–49 years. UNFPA is assisting countries to strengthen cervical cancer screening and referral for treatment from family planning, HIV and primary health care services. Screening with mammography (once every two years for women aged 50–69 years) linked with timely diagnosis and treatment of breast cancer. Breast cancer screening services are being supported by a limited number of UNFPA country offices. Comprehensive sexuality education (CSE). Governments are supported in implementing “in and out-of-school” CSE programmes: these promote healthy behaviour patterns, reduce NCD risk factors and endeavour to lessen unprotected sex in order to lower the incidence of unplanned pregnancies and STIs including HPV. Promote tobacco avoidance and cessation in young people. Through adolescent CSE and SRH services, youth community centres and peer outreach programmes, young people are supported in making healthier life choices that reduce their exposure to NCD risk factors. Implement nutrition education and counselling in order to increase the intake of fruit and vegetables and reduce salt intake. Promote physical activity. UNFPA is a member of the UN Joint Global Programme on Cervical Cancer Prevention and Control, which assists countries to reduce the burden of cervical cancer via the WHO-led Global Cervical Cancer Elimination Initiative. UNFPA is an adviser to GAVI and a number of countries in rolling out HPV vaccination as part of adolescent health, screening and treatment programmes. At the regional level, UNFPA is working to strengthen the capacity of service providers, especially in delivering cervical cancer screening and treatment programmes. For example, in Eastern Europe and Central Asia, UNFPA has developed a training programme for health care providers in cervical cancer screening and treatment. UNFPA is supporting the rolling out of HPV vaccination in the Arab States and is currently contributing to regional training programmes, as well as to assessments of NCD prevention and control needs, including opportunities for scaling up the “best buys”. UNFPA country programmes provide backing for the strengthening of safe motherhood programmes in all countries, as well as for developing partnerships with youth and women’s organizations to include activities in favour of NCD prevention. 3. Partnerships with UN and other development agencies are critical for UNFPA in mobilizing an effective response to NCDs Due diligence is required to ensure all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. 4 Responding to the Challenge of NCDs: UNFPA While UNFPA’s focus is on improving sexual and reproductive health and rights, it is increasingly looking to identify opportunities to mobilize resources for incorporating NCD prevention and control into its programmes, in the expectation that these efforts will have a direct impact on improving sexual and reproductive health for all. 4. Mobilizing resources to deliver Photo credits (from top clockwise): © UNFPA ©World Bank via Flickr (also page 2) © UNV The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by UNFPA as part of a set of United Nations system agency briefs under the Task Force (WHO/UNIATF/19.98) 1 Responding to the Challenge of NCDs: UNICEF United Nations Children’s Fund Responding to the Challenge of Non-communicable Diseases 1. Many NCDs have their origins in early life NCDs undermine children and adolescents’ right to health, nutrition, education and play. Each year, about 1.2 million children and adolescents aged under 20 die from often treatable NCDs such as chronic respiratory diseases and cancers, accounting for 13% of overall NCD mortality. NCD risk factors, e.g. childhood overweight and obesity, have a negative impact on children’s mental and emotional well-being, peer relations, learning and opportunities to participate in education and recreation. Exposure to NCD risk factors is often established very early in life. Prenatal maternal undernutrition and/or low birthweight predispose an individual to obesity, high blood pressure, heart disease and diabetes later in life. Maternal obesity and gestational diabetes are associated with cardiovascular disease and diabetes in both mother and child. Childhood and adolescence are also periods when behaviours which lead to the onset of NCDs are adopted including tobacco use, alcohol use, unhealthy diets and physical inactivity as well as unsafe sex (which can result in the spread of HPV, a cause of cervical cancer). These behaviours contribute to an estimated 70% of premature deaths in adulthood. United Nations high-level meetings have highlighted the need for UN agencies, including UNICEF, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs account for 14.6% of all-cause mortality and 24.8% of disability-affected life years (DALYs) amongst children and adolescents. Exposure to NCD risk factors may begin before or during pregnancy and continue during infancy and childhood and adolescence, underlining the importance of action across these age groups Childhood and adolescence are periods where significant impact can be made in risk reduction through evidence-based interventions on diet, physical activity, tobacco and alcohol consumption Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. Children and adolescents are often targeted by companies producing, marketing and/ or selling unhealthy products (e.g. tobacco, alcohol and foods high in fat, sugar and/or salt). Many children and adolescents also grow up in built environments that are not conducive to healthy behaviours (e.g. urban areas that combine limited opportunities for physical activity, exposure to unsafe roads and high levels of air pollution). 2 Responding to the Challenge of NCDs: UNICEF Children and adolescents with NCDs, or those tasked to provide care for family members with NCDs, have lower educational attainments and less access to employment opportunities, leading to an increased risk of financial insecurity later in life. In addition to the psychological impact on offspring, NCD- linked adult illness and premature death are associated with household poverty, food insecurity, social stigma and an increased work burden on children. NCDs can contribute to gender inequality as they usually present a need for long- term caregiving which historically is disproportionately borne by female family members. NCD risk factors, such as alcohol and tobacco use, are also linked with child deprivation and violence against children, especially girls. The UNICEF Strategic Plan for 2018–2021 has strong links to NCD prevention and control, namely: • enhancing maternal, newborn and child health to reduce NCD risks; • improving immunisation, particularly against human papillomavirus (HPV); • preventing low birth weight, stunting, and other forms of malnutrition, including overweight and obesity; • preventing and treating HIV (HIV and its treatment increase the risks of NCDs and related problems); • investing in early childhood development (positive and responsive parenting); 2. UNICEF has a role to play in supporting countries in preventing and controlling NCDs • addressing adolescent health and nutrition (e.g. developing inclusive, multisectoral and gender-responsive national plans for adolescent health and well-being which included reducing behavioural risk factors for NCDs); and • adolescent mental health, suicide and road safety. Given its focus on childhood and adolescence and its cross-sectoral approach, UNICEF is well positioned to integrate early prevention of NCDs and their risk factors into its work. UNICEF has reviewed the recommended cost-effective NCD interventions endorsed by the WHA to identify those that are linked to UNICEF’s work at global, regional and country levels. Many of the recommended “best buy” interventions are already being implemented by UNICEF’s country offices (e.g. breastfeeding promotion), while some require the promotion of new activities (e.g. school-based policies and programmes, supportive infrastructure for active transportation in road safety programmes) and a focus on preconception health for females and males. Some areas of current and potential programming in relation to the “best buys” are highlighted in the table on page 3. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.1 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 1 WHO. 2017. ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf. 3 Responding to the Challenge of NCDs: UNICEF Evidence-based interventions UNICEF actions Advocate for legislation on food regulation and taxation. On the global platform, UNICEF has been at the forefront of breastmilk substitute regulation. UNICEF has been engaged with global level advocacy on the regulation of food composition and marketing and has promoted food labelling. UNICEF has also worked at global and country level to advocate for fiscal measures to control the consumption of sugar- sweetened beverages. Promote and support exclusive breastfeeding for the first 6 months of life, including promotion of breastfeeding. UNICEF’s Nutrition programme focuses on protection, promotion and support for exclusive breastfeeding for the first six months of life and continued breastfeeding with safe and adequate complementary feeding up to two years and beyond as well as promoting a healthy diet and addressing multiple micronutrient deficiencies among children aged 6–23 months. Implement nutrition education and counselling in different settings (e.g. preschools, schools, workplaces, health clinics and hospitals) to increase the intake of fruits and vegetables. To advance UNICEF’s Nutrition programme on NCDs and nutrition, guidance documents on the prevention of overweight and obesity, school nutrition and nutrition among adolescents are currently under development. Implement mass media campaign including social marketing on healthy diets to reduce the intake of total fat, saturated fats, sugars and salt, and to promote the intake of fruits and vegetables. UNICEF’s Communication for Development (C4D) programme can contribute to advocacy and community engagement efforts by creating an enabling policy and legislative environment for NCD prevention: this can engage communities, amplify the voices of affected children and adolescents, encourage participation particularly of adolescents and guarantee that governments and other stakeholders deliver on NCD prevention and control. Implement whole-of-school programmes that include quality physical education, availability of adequate facilities and programmes to support physical activity for all children. The UNICEF Education programme plays a significant role in NCD prevention through its preschool, primary and secondary school programmes for children over five years, and for adolescents. Developing and supporting whole-of-school policies and programmes that protect children and adolescents from harmful subsidies, encourage physical activity and address healthy diets are all potential entry points for UNICEF action. Implement community-wide public education and awareness campaign for physical activity which includes a mass media campaign combined with other community-based education, motivational and environmental programmes aimed at supporting behavioural change and physical activity levels. Through its Community Health programme, UNICEF is able provide support to mass media campaigns and targeted community-based health promotion activities via community health and social worker platforms. Primary prevention of rheumatic fever and rheumatic heart diseases by increasing appropriate treatment of streptococcal pharyngitis at the primary care level. UNICEF’s community and child health service delivery infrastructure, part of its Integrated Management of Childhood Illness programme, has the capacity to promote early detection and effective treatment of rheumatic fever as a preventive measure against rheumatic heart disease. Vaccination against HPV (2 doses) of 9- to 13-year-old girls. These campaigns are part of UNICEF’s Extended Programme on Immunization and delivered via in-country programmes. Prevention of liver cancer through hepatitis B immunisation. 4 Responding to the Challenge of NCDs: UNICEF Guidance on UNICEF’s approach on early life prevention of NCDs was issued in 2019. The UNICEF Strategy for Health 2016–2030 covers four areas that enable action at country level. Across these areas, there are many opportunities for UNICEF to strengthen its support to national NCD responses. Advocate for legislation on food regulation and taxation. Promote comprehensive laws that reduce the direct and indirect exposure of children and adolescents to tobacco, alcohol, illicit drugs, unhealthy foods and beverages, polluted air, water and soil (or polluted environment) and unsafe roads. Encourage school and community-based initiatives that enable healthy lifestyles and promote healthy food and physical activity. Reinforce health systems that, in coordination with education and social services, deliver NCD prevention, screening and care. Foster environmental initiatives that encourage physical activity and healthier diets (e.g. through sustainable transport and urban planning for health that prioritizes walkability and active mobility, in particular for school environments and safe and clean routes for schoolchildren). Target actions on environmental pollution monitoring, prevention and control. Integrate pollution control and NCD agenda. Pollution accounts for 22% of all deaths from cardiovascular disease, 53% of deaths from chronic obstructive pulmonary disease (COPD) and 40% of deaths from lung cancer). Identify data gaps and strengthen mechanisms for the collection and monitoring of NCD risk and related data across sectors. Influencing government policies. Provide technical support, convene stakeholders, facilitate knowledge exchange and mobilize resources to support governments in evidence-based policy-making and financing, including the adoption and implementation of laws, policies and programmes to protect children and adolescents from exposure to NCD risk factors. Make pollution prevention a core component of the intersectoral NCD agenda. Support the development of programmes for protective environments that discourage risk behaviours and support and protect health. Compile lessons learned, promote direct knowledge exchange between countries and foster South-South collaboration on effective strategies, policies and interventions. Strengthening service delivery Address NCDs more effectively across the lifecycle by leveraging existing platforms such as primary health care (PHC) facilities, community health platforms, schools and child protection systems,2 as well as guaranteeing clean and safe environments. Empowering communities Work with local civil society organizations (CSOs), governments and other local influencers to create demand for NCD prevention; use information and communication technologies (ICTs) to increase knowledge on healthy behavior patterns; and develop compelling and contextually appropriate messages to promote NCD prevention, delivered via communication-for- development (C4D) multimedia strategies. 2 UNICEF-supported maternal, newborn and child health programmes are well positioned to further integrate NCD prevention. 5 Responding to the Challenge of NCDs: UNICEF 3. Partnerships are critical for UNICEF in mobilizing an effective response to NCDs In addition to strengthening partnerships with governments, UNICEF can advance strategic partnerships with UN and multilateral partners. Examples include: • United Nations Population Fund (UNFPA), particularly programmes addressing antenatal care (ANC), HPV and risk factors during adolescence; • UN Women on gender policy; • Food and Agriculture Organisation (FAO) and World Food Programme (WFP) on nutrition and agriculture; • Gavi Alliance on HPV and hepatitis C; • World Bank and regional development banks on infrastructure programmes, financing and taxation; • United Nations Educational, Scientific and Cultural Organization (UNESCO) on health education and physical activity; • UN Environment Programme on clean, safe and healthy environments; • United Nations Development Programme (UNDP) on whole-of-government and whole- of-society NCD responses; • UN-Habitat on sustainable urban mobility; and • WHO on data/evidence/policy on prevention and control of pollution-related NCDs. UNICEF is also able to strengthen its collaboration with civil society on the prevention and control of NCDs, e.g. through NCD Child, NCD Alliance, Global Alliance for Improved Nutrition (GAIN), Child Health Initiative and EAT Foundation,3 including the EAT Food Forum. Engagement with the private sector can help leverage business data and expertise, e.g. to generate evidence, while business assets, technology, communications and outreach can be developed to deliver services or promote behaviour change on a large scale. 3 For example, UNICEF and EAT have initiated a collaboration, Children Eating Well (CHEW), to conduct research into and evaluate interventions related to food environments and children’s interactions with them, particularly in the urban context. Due diligence is required to ensure that desired results are obtained from private sector engagement, particularly as the activities of some businesses have an impact on children’s well-being through the marketing of tobacco, alcohol, and foods and beverages that are high in fat, sugar and/or salt. Partnerships with some pharmaceutical companies may also pose potential or real conflicts of interest. 6 Responding to the Challenge of NCDs: UNICEF The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the UNICEF as part of a set of United Nations system agency briefs under the Task Force (WHO/UNIATF/19.98) Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr 4. Mobilizing resources to deliver Funding NCD prevention will enable UNICEF to protect children and adolescents from NCD risk factors and their impacts. However, while existing health, nutrition and education programmes can be adapted to include NCD prevention, it should not be assumed that this can be done easily, or at no cost. Nor should it be assumed that governments are always able to finance NCD prevention and control on their own, as many still require technical support to strengthen NCD-related services, policies, plans and programmes. Decision-makers must be made aware of the significant social and economic costs of NCD burdens. In addition to UNICEF’s traditional sources of funding for programmes and advocacy, private sector entities can be a potential source of funding provided they meet due diligence requirements. This technical brief is drawn from the UNICEF Programme Guidance on Early Life Prevention of Non-Communicable Diseases (2019).4 4 The full document can be accessed here: https://unicef-my.sharepoint.com/:b:/g/ personal/rbermejo_unicef_org1/EemhcUrpmFFLrDYURRM2uk8BmDV8IMjS_ LYcXbZOYWbgjg?e=V8frzU 1 Responding to the Challenge of NCDs: The World Bank The World Bank Responding to the Challenge of Non-communicable Diseases 1. The rising burden of NCDs poses a threat to health and development NCDs are a growing concern in all countries. NCDs are projected to rise in low- and middle- income countries (LMICs) by 2030 in line with changing lifestyles, ageing populations, urbanization and other factors. Many countries face a double burden of disease with an unfinished communicable disease burden and a rising NCD epidemic. Likewise, some LMICs face both a high prevalence of childhood stunting and the growing problem of obesity (the number of obese children and adolescents has grown more than tenfold over the past 40 years). NCDs result in increased health care spending and significant economic losses due to the often complex, costly and/or chronic nature of care, as well as to lost productivity. Between 2011 and 2025, NCDs are projected to cost LMICs more than US$7 trillion.1 Households bear the brunt of health care spending on NCDs and have limited financial protection in most LMICs. Considering the impoverishing effect of many NCDs, it will not be possible to attain the equity and financial protection goals of the UHC agenda if NCDs are not addressed. 1 Bloom, D. E., Chisholm, D., Jané-Llopis, E., Prettner, K., Stein, A., & Feigl, A. (2011). From burden to “best buys”: reducing the economic impact of non-communicable diseases in low-and middle-income countries (No. 7511). Available at: https:// www.who.int/nmh/publications/best_buys_summary.pdf. NCDs are defined as cardiovascular disease, cancers, diabetes and chronic respiratory diseases. United Nations high-level meetings have highlighted the need for UN agencies, including WB, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as unhealthy diet, tobacco use, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2 Responding to the Challenge of NCDs: The World Bank Regardless of their income levels, countries should not neglect the NCD burden given its implications for human capital development. Since NCDs are a major cause of premature death, disability and foregone wages, investments in the prevention and treatment of these conditions will improve adult health and economic growth. Investing in cost-effective NCD interventions in poorer countries will generate US$350 billion in economic benefits and save 8.2 million lives by 2030. This is a return of US$7 per person for every dollar invested.2 Financing of NCDs remains inadequate and out of line with the growing burden in LMICs. About 80% of the NCD burden is in LMICs, and NCDs overall represent over two thirds of the global disease burden; financing for NCDs is however concentrated in high- income countries and overseas development assistance for NCDs accounts for less than 3% of total assistance for health.3 NCD prevention requires a multisectoral, whole-of-government, whole-of-society approach which focuses on reducing population exposure to environmental and behavioural risk factors while increasing affordable access to basic services. Integrated care models which are patient-centered and leverage investments in infectious diseases and maternal, newborn and child health will be critical to managing both the rising burden of disease and spiralling costs. Despite several high-level NCD events since 2011, progress remains slow. The third UN High-Level Meeting on NCDs in September 2018 aimed to intensify political support in the context of the SDG agenda with a focus on “reducing premature mortality from NCDs by one third by 2030”, in line with SDG target 3.4. 2 WHO GCM/NCD Working Group on the Inclusion of NCDs in Other Programmatic Areas (2018). Final Report: Working Group on the Inclusion of NCDs in Other Programmatic Areas. Retrieved from https://www.who.int/global-coordination- mechanism/activities/working-groups/3-1-report.PDF?ua=1 3 Health Finance Institute. Addressing the economic burden of underinvestment in NCDs. Available at: http://healthfinanceinstitute.org/ Urgent action is needed to accelerate progress in health service coverage and financial protection, and to address the broader socioeconomic determinants of NCDs. 3 Responding to the Challenge of NCDs: The World Bank The World Bank’s health sector strategy supports countries to accelerate progress towards UHC. Its three main pillars include: (a) expanding financial protection so that no one is tipped into poverty because of catastrophic health spending; (b) increasing coverage of quality health services for the poorest 40% of the population; and (c) fostering a healthy society, including investments that reduce risk factors for NCDs. The prevention and control of NCDs cut across the three pillars. The World Bank responds to client demand to prevent and control NCDs by providing financial support, policy advice and technical assistance to strengthen the health system response and address key risk factors for NCDs. The World Bank has produced analytic work to understand the nature and magnitude of the NCD problem, identify risk factors and propose mitigation measures. It has also conducted expenditure analyses to determine the efficiency of public spending and identify strategies to expand domestic resource mobilization (including through taxation of health-harming products) in order to increase those available for primary health care (PHC). The World Bank plays an important knowledge-sharing role by producing a wide range of knowledge products and sharing experiences and lessons across countries. The Bank has brokered various partnerships to leverage technical and financial support, working in close collaboration with technical agencies, the private sector and UN agencies. 2. The World Bank has a role to play in supporting countries in preventing and controlling NCDs Investment lending is effective for scaling up domestic action on the prevention and control of NCDs The Bank has a diversified portfolio of investment operations in health systems and health services in support of NCDs, totaling about US$1.5 billion (2019): this represents about 12% of the Bank’s overall health, nutrition and population (HNP) lending. Projects include: (a) strengthening early detection and screening for NCDs; (b) promoting NCD risk reduction; and (c) revamping health systems and facilitating transformational reforms to shift attention from costly secondary care to primary health care. Over a half of all NCD health investments are on integrated projects with both disease prevention and chronic disease management activities. Other projects use communicable disease investments to support NCD prevention and treatment. The Bank portfolio also includes roughly US$0.2 billion of non-health investment operations that directly or indirectly contribute to NCD prevention. Examples include: (a) promoting environmental health; (b) expanding the use of safe and efficient cookstoves; (c) enhancing awareness and knowledge; (d) promoting fiscal and regulatory reforms; and (e) reducing the risk of road injuries. 4 Responding to the Challenge of NCDs: The World Bank Protecting Vulnerable People against NCDs in Argentina. NCDs generate a heavy health and economic burden. The US$350 million project (2015–2020) in Argentina aims to improve the readiness of public health facilities to deliver higher quality NCD services for vulnerable population groups and expand the scope of selected services, as well as to protect vulnerable population groups against prevalent NCD risk factors. Regional Programme of Cancer Registries in East Africa. In 2012, sub-Saharan Africa had about 850,000 new cancer cases and 600,000 deaths. The World Bank is supporting Burundi, Kenya, Rwanda, Tanzania and Uganda to strengthen their capacity for collecting, analysing and sharing data on cancers. Access to timely information on the rising cancer disease burden is critical to develop financial protection mechanisms to ensure that households are not impoverished by catastrophic health spending, provide quality services in a timely manner in order to facilitate early detection and treatment, and address risk factors associated with cancers. Leveraging Investments in Infectious Diseases to combat NCDs in Egypt. The World Bank supported a combined national hepatitis C and NCD risk factor (hypertension, high blood sugar and body mass index) screening campaign, with high-level political support from the President. Individuals with hepatitis C and/or at risk of NCDs were enrolled in structured treatment programmes. To date, 49.8 million adults aged of 18 or over have been screened. This innovative initiative demonstrates the potential for leveraging existing infectious disease platforms to address NCDs. Examples of World Bank-funded NCD Interventions Towards Population-Based Screening and Community-Level Outreach for NCDs in India. Tamil Nadu is India’s sixth most populous state and is dealing with a double burden of communicable and non-communicable diseases. Cardiovascular disease, diabetes, and cancer are the leading causes of death for people aged above 40. The World Bank has provided a US$287 million loan to strengthen management of NCDs, with a focus on health promotion and NCD prevention, population- based screening of NCDs among the eligible population, treatment and follow- up, and improvement of NCD monitoring and evaluation. The project aims to support a move from opportunistic screening to population-based screening. Establishment of Health Lifestyle Centres (HLCs) for NCD Screening and Referral in Sri Lanka and Turkey. The World Bank has supported the establishment of Healthy Life Centres at the PHC level for the detection and management of patients with a high NCD risk. In Sri Lanka this is being done by strengthening PHC capacity, population screening and better treatment and follow-up. Performance-Based Financing for NCDs in Tajikistan. Ischaemic heart disease is one of the leading causes of death in Tajikistan. The World Bank is supporting the government’s performance-based financing scheme to improve the coverage and quality of basic primary health services in rural health facilities in 10 districts. Under this supply-side project, the Ministry of Health contracts rural health centers to enhance both the quantity and quality of NCD services, providing coverage in about 450 health facilities to approximately 15 percent of the country’s total population. 5 Responding to the Challenge of NCDs: The World Bank Analytic work and knowledge management: Linking evidence to operations The Bank undertakes a wide range of country, regional and global studies to better understand and address the risk factors associated with NCDs, as well as to provide an analytic underpinning for investment lending and inform public policy. Examples are given in the box. The World Bank Group’s Global Tobacco Control Programme supports knowledge exchange among selected countries on the economics of tobacco control. Experts in health, governance and macroeconomic and financial management, poverty and equity, agriculture and trade engage actively in this programme, which is a win-win for both public health and domestic resource mobilization.4 The programme assists countries to design tobacco tax policy reforms and increase tobacco tax rates in order to: (a) achieve public health goals by increasing prices, reducing smoking, and preventing initiation among youth; (b) raise domestic resources for investments that benefit the entire population; and (c) enhance equity by reducing the health risks associated with tobacco-attributable diseases and the risk of impoverishment due to high out-of-pocket expenditure among the lowest income population groups. Achievements include providing support for tobacco tax policy reforms in several countries and the launch of the World Bank Group report “Tobacco Tax Reform: At the Crossroads of Health and Development”. 4 The World Bank. Global Tobacco control. https://www.worldbank.org/en/topic/ tobacco Impact of NCDs on Human Capital (2019). The WB is collaborating with several partners to produce a report that describes how human capital and productivity can be enhanced by tackling NCDs, with recommendations for action. This work is part of the World Bank’s Human Capital Project to improve human capital at the country level through investing in health and education. Obesity: A Ticking Time Bomb – What can the World Bank do to Defuse It? (2019). This report highlights the growing epidemic of obesity in both low- and high-income countries, and its health and economic costs. The report lays out the drivers of obesity, lessons learned from obesity-prevention efforts across the globe, and the policy and investment tools that the World Bank can deploy across different sectors to address obesity. How to Improve the Use of Fiscal Policy to Address the NCD Crisis: Lesson Learned from Tonga (2019). Tonga has a very high burden of NCDs. This study generates policy-relevant findings and insights on the implementation of taxation policy on tobacco, alcohol, food and behaviours, pricing, government revenues and the country’s response to the rising NCD burden. The Challenge of NCDs and Road Traffic Injuries in sub-Saharan Africa (2013). This is a comprehensive review of the literature with input from policy-makers, researchers and practitioners. It describes how resource- constrained governments can prevent and control NCDs and increase road safety. The Challenge of NCDs and Road Traffic Injuries in sub-Saharan Africa (2013). This is a comprehensive review of the literature with input from policy-makers, researchers and practitioners. It describes how resource- constrained governments can prevent and control NCDs and increase road safety. 6 Responding to the Challenge of NCDs: The World Bank The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the World Bank as part of a set of United Nations system agency briefs under the Task Force (WHO/UNIATF/19.98) Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr 3. Partnerships are critical for the World Bank in mobilizing an effective response to NCDs The Bank has been an active member of several key partnerships and/or leader in key initiatives (e.g. tobacco control and mental health) to prevent and control NCDs. Examples include: • Access Accelerated. The Bank brokered this partnership with the private sector to leverage funding for pilot projects that aim to support early screening, detection and initial treatment for NCDs in countries such as Kenya and El Salvador. • Union for International Cancer Control (UICC) — City Cancer Challenge. The Bank participated in the UICC-led City Cancer Challenge initiative which supports cities to design, plan and implement cancer treatment solutions to reduce cancer mortality by 2025. • World Bank Umbrella Facility for Gender Equality (UFGE). The UFGE is a multidonor trust fund that aims to strengthen awareness, knowledge and capacity for gender-informed policy-making; it also explores new approaches to improve human capital, such as through the control of NCDs. 1 Responding to the Challenge of NCDs: WFP World Food Programme Responding to the Challenge of Non-communicable Diseases 1. The nutrition and food security sectors are central to an effective response to NCDs WFP is the food-assistance branch of the United Nations (UN), delivering food assistance in developing and emergency contexts, and working with communities to improve nutrition and build resilience. Unhealthy diets1 are a leading risk factor for NCDs. Diet-related NCDs include cancers, diabetes and cardiovascular disease. The right to food must not be reduced to “the right to not starve.”2 Ensuring access to diverse, safe and nutritious foods can prevent NCDs and their impacts on sustainable development. The triple burden of malnutrition— undernutrition and hunger, overweight and obesity, and micronutrient deficiencies— remains unacceptable. Children under five face large and multiple burdens: 149 million are stunted, 49.5 million are affected by wasting, and 40.1 million are overweight.3 1 Unhealthy diets include energy-dense and highly processed foods that are high in refined starches, sugar, fats and/or salt, accompanied by an insufficient intake of fresh fruits and vegetables, wholegrains, pulses, nuts and seeds. FAO (2017). The State of Food and Agriculture 2017: Leveraging Food Systems for Inclusive Rural Transformation. Available at: www.fao.org/3/a-I7658e.pdf. 2 A/HRC/19/59. Report submitted by the Special Rapporteur on the right to food, Olivier De Schutter. Available at: https://www.ohchr.org/Documents/HRBodies/ HRCouncil/RegularSession/Session19/A-HRC-19-59_en.pdf 3 United Nations Children’s Fund (UNICEF), World Health Organization, International Bank for Reconstruction and Development/The World Bank. Levels and trends in child malnutrition: key findings of the 2019 Edition of the Joint Child Malnutrition Estimates. Geneva: World Health Organization; 2019 Licence: CC BY-NC-SA 3.0 IGO. United Nations high-level meetings have highlighted the need for UN agencies, including WFP to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. An approach to the prevention of NCDs requires food system transformation and policies that address aspects of the wider food system, encompassing nutrition, food culture and identity, public food and meals, food loss and waste and sustainable diets. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2 Responding to the Challenge of NCDs: WFP The world is now experiencing record levels of overweight and obesity among adults (38.9%), with trends increasing, particularly among adolescents.4 Supporting good nutrition during the first 1,000 days of life and adopting healthy dietary habits during adolescence can reduce the risk of NCDs later in life. Supporting prematernal and gestational nutrition can reduce NCD risks for both mother and child. WFP supports governments to implement a comprehensive multisectoral package of actions that address the triple burden of malnutrition and the prevention of diet-related NCDs. Through its core work on nutrition and food security, and in collaboration with various stakeholders, WFP is uniquely positioned to contribute to global efforts to address NCDs.5 WFP’s nutrition policy (2017–2021) articulates its role in addressing NCDs and supporting governments to achieve the NCD-related targets in the 2030 Agenda for Sustainable Development. WFP works with government counterparts and partners to develop five-year country strategic plans, which are subsequently endorsed by WFP Executive Board members. A review of the cost-effective interventions endorsed by the WHA identified relevant WFP interventions at the global, regional and country level. Six examples are shown in the table. 4 United Nations Children’s Fund (UNICEF), World Health Organization, International Bank for Reconstruction and Development/The World Bank. Levels and trends in child malnutrition: key findings of the 2019 Edition of the Joint Child Malnutrition Estimates. Geneva: World Health Organization; 2019 Licence: CC BY-NC-SA 3.0 IGO. 5 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf. 2. WFP has a role to play in supporting countries in preventing and controlling NCDs Evidence-based interventions WFP actions Implement mass media campaign on healthy diets including social marketing to reduce the intake of total fat, saturated fats, sugars and salt, and promote the intake of fruits. Work with governments on strategies and programming for social and behavioural change and communication (SBCC), nutrition education and messaging across a variety of electronic and traditional media platforms including social media and press/radio. Related activities have been rolled out in countries, e.g. Sudan, Madagascar and Mozambique. Promote and support exclusive breastfeeding for the first six months of life. Promote infant and young child feeding through existing platforms such as community management of acute malnutrition and food assistance programmes. Implement nutrition education and counselling in different settings (e.g. in pre- schools, schools, workplaces and hospitals) to increase the intake of fruits and vegetables. Support governments to ensure that school meals programmes are nutritious. Support governments to develop policies and programmes in schools to encourage healthy diets. Implement nutrition labelling to reduce total energy intake (kcal), sugars, sodium and unhealthy fats. Work through the SUN Business Network to support governments in encouraging the private sector to strengthen nutrition labelling to inform consumers about total energy intake, sugars, sodium and unhealthy fats. Access to improved stoves and cleaner fuels to reduce indoor air pollution. Country-level implementation of the initiatives contained in the WFP Handbook on Safe Access to Firewood and Alternative Energy. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.5 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 3 Responding to the Challenge of NCDs: WFP WFP collaborates with a range of partners including the UN and the private sector to address malnutrition in all its forms. Partnerships are aimed at strengthening coordination, developing multisectoral policy, enhancing research and development, strengthening logistics and supply chain, and promoting digital technology and education. WFP ensures that partnerships are in the interest of public health. The Scaling Up Nutrition (SUN) Business Network. WFP and GAIN co-convene the SUN Business Network which, at the global and country levels, provides a platform to advance the dialogue on nutrition between the private sector, governments and other stakeholders. Depending on national nutrition priorities and the local private sector setting, efforts of the SUN Business Network may focus on reducing undernutrition, overnutrition or micronutrient deficiencies. Committee on World Food Security (CFS). The CFS is the foremost international and intergovernmental platform to promote food security and nutrition for all. In 2017, CFS started developing a set of voluntary guidelines on food systems and nutrition. Scaling Up Nutrition (SUN) United Nations Network (UNN)/REACH. ‘The SUN UNN/ REACH initiative’ is a partnership between WFP, Food and Agriculture Organisation (FAO), United Nations Children’s Fund (UNICEF), the World Health Organization (WHO) and the International Fund for Agricultural Development (IFAD). Its mandate is to accelerate the scaling up of food and nutrition actions in countries experiencing a high burden of child malnutrition. 3. Partnerships are critical for WFP in mobilizing an effective response to NCDs The UNN was established in 2013 by WFP, Food and Agriculture Organisation (FAO), United Nations Children’s Fund (UNICEF), the World Health Organization (WHO) and the International Fund for Agricultural Development (IFAD). The UNN works in countries to elevate national nutrition dialogue through its senior leadership and helps to leverage the collective strengths of the UN agencies, to foster innovations, find efficiencies and enhance complementarity across agencies and with government and SUN networks. Global Fund. WFP partners with organizations and companies to ensure that food and nutrition assistance is available to communities in some of the world’s hardest- to-reach areas. WFP’s partnership with the Global Fund is addressing logistics and supply chain issues around health and nutrition commodities in countries such as the Central African Republic and Burundi. IASC Humanitarian Cluster Mechanism. WFP is the lead agency in the Logistics Cluster6 (a coordination mechanism to ensure an efficient and effective emergency response, including the provision of NCD-related medicines during emergencies). WFP and FAO co-lead the Food Security Cluster7 (a coordination mechanism for food security response in humanitarian crises). 6 World Food Programme. Logistic cluster. https://www.wfp.org/logistics-cluster 7 Food Security Cluster. Coordinating the food security response in humanitarian crises. https://fscluster.org/ 4 Responding to the Challenge of NCDs: WFP P ho to c re di ts : © W or ld B an k vi a Fl ic kr The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by WFP as part of a set of United Nations system agency briefs under the Task Force (WHO/UNIATF/19.98) Due diligence is required to ensure that all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. 4. Mobilizing resources to deliver WFP leverages existing programmes to drive actions against undernutrition and hunger, overweight and obesity, and micronutrient deficiencies. Priorities include: • Fill the Nutrient Gap (FNG). This tool analyses the nutrition situation in a country and identifies the barriers faced by the most vulnerable in accessing and consuming healthy and nutritious foods; the FNG tool is used to inform government policies and WFP programming. In Madagascar, FNG helped to make the school meal food basket more nutritious. • School meals. Schools can encourage healthy eating among students, their families and communities. WFP’s Regional Bureau in Latin America and the Caribbean (LAC) is currently at the forefront of efforts to address overweight and obesity in schools in the LAC region. As part of the Latin American Network for School Meals initiative, WFP recently published an analysis on how nutrition-sensitive national school meals programmes can address malnutrition (undernutrition, overweight and obesity and micronutrient deficiencies), as well as accelerate progress towards achieving the SDGs (particularly SDG 2 and 3). • Social protection systems. WFP supports governments in the design of nutrition- sensitive social policies, mainstreaming nutrition education and supporting the design of shock-responsive social protection systems. • Social and behaviour change communication. This aims to improve behaviour around access to, selection, preparation and consumption of nutritious foods, to strengthen nutrition education and behaviour change communication in nutrition-specific programmes and to mainstream nutrition education aligned with national food-based dietary guidelines. • Food environments. WFP works to ensure balanced food baskets through diversification and micronutrient fortification, advocates for regulatory policies that improve the availability of safe, nutritious food and work environments, and negotiates with the private sector to increase the availability and marketing of age-appropriate and nutritious food.

RESPONDING TO THE CHALLENGE OF NON-COMMUNICABLE DISEASES United Nations Agency Briefs This set of briefs provides policy advisors and decision-makers across different United Nations agencies, Member States and development partners with information on how the UN system is responding to the challenge of non-communicable diseases (NCDs). The briefs were brought together by the WHO-led United Nations Inter-Agency Task Force on the Prevention and Control of NCDs. Heads of State and Government and representatives of States and Governments… … call upon WHO to continue to exercise its leadership, as the directing and coordinating authority on international health, in order to contribute to Member States’ efforts to prevent and control NCDs by continuing and strengthening its normative and standard-setting work and its capacity to develop and provide technical cooperation, assistance and policy advice to Member States, as well as to enhance its multi-stakeholder engagement and dialogue, including through … the United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases. Paragraph 47, Political declaration of the Third High-level Meeting of the General Assembly on the prevention and control of NCDs.1 Heads of State and Government and representatives of States and Governments… …call upon WHO to continue to promote and monitor enhanced global action to prevent and control NCDs by coordinating work with other UN agencies, development banks and other regional and international organizations.1 Paragraph 48, Political declaration of the Third High-level Meeting of the General Assembly on the prevention and control of NCDs.1 These briefs describe: • the role of the different UN system agency in making an effective contribution to the prevention and control of NCDs;1 • current and potential actions for different agencies to support the World Health Assembly-endorsed “best buys” and other recommended interventions to address NCDs;2 • the importance of partnerships for ensuring that agencies mobilize an effective response to NCDs; • the importance of partnerships in agencies’ response to NCDs; and • how agencies are mobilizing resources to deliver support to Member States. 1 Time to deliver: accelerating our response to address non-communicable diseases for the health and well-being of present and future generations. Political declaration of the Third High-level Meeting of the General Assembly on the prevention and control of NCDs, 2018. http://www.un.org/en/ga/search/view_doc.asp?symbol=A/ RES/73/2 2 WHO. “Best buys” and other recommended interventions for the prevention and control of noncommunicable diseases. 2017. www.who.int/ncds/management/best-buys/en/ The Task Force reports to the Economic and Social Council of the United Nations (ECOSOC) annually. Since 2014, ECOSOC has adopted a resolution each year on the Task Force: 2014: endorses the Task Force’s terms of reference 2015: encourages the Task Force to scale up action in countries 2016: expands the work of the Task Force to the NCD-related SDGs 2017: calls for greater financing for the work of the Task Force 2018: calls for development of partnerships to achieve public health goals 2019: encourages bilateral and multilateral donors, as well as other relevant stakeholders, to mobilize resources to support Member States, to catalyse sustainable domestic responses to NCDs and mental health conditions, including through a dedicated multi-donor trust fund. In the 2030 Agenda for Sustainable Development, adopted in September 2015, Member States recognize NCDs as a leading sustainable development issue. Agenda 2030 provides an enabling framework for identifying and implementing win-win approaches for NCDs and other development priorities. NCDs, principally cardiovascular disease, diabetes, cancer and chronic respiratory disease, are now the world’s biggest killers. Urgent and whole-of-government action is needed to prevent the annual toll of 41 million people dying from NCDs, including 15 million dying prematurely between the ages of 30 and 69 years. Often misconstrued as a problem of high- income countries only, NCDs place an equal—if not greater—burden on low- and middle-income countries (LMICs). Over 85 percent of premature NCD deaths occur in LMICs. Most premature NCD deaths are preventable by taking cost-effective action to tackle four main behavioural risk factors —tobacco use, harmful use of alcohol, physical inactivity and unhealthy diet. Also critical are ensuring affordable access to basic health services, including for mental health, and addressing environmental risks such as air pollution. Tackling NCDs and their risk factors requires a response from government. Sustainable Development Goal 3 on health and well-being includes a specific target relating to the prevention and control of NCDs and several other targets that are NCD-relevant. Achieving the NCD targets will advance the 2030 Agenda broadly, given the strong links between NCDs and poverty, social inequities, lack of access to affordable basic services, economic growth and climate action. 2018 NCD Political Declaration:1 10 takeaways for the UN system 1. 4 x 43 is expanded to 5 x 5 by including mental health conditions and air pollution. 2. Every year, over 15 million people aged 30–70 die from NCDs. Most of these premature deaths could have been avoided. 86% of these deaths occur in developing countries. NCDs will cost developing countries US$ 7 trillion over the next 15 years. 3. While the probability of dying from a major NCD between the ages of 30 and 70 continues to decline (22% in 2000 to 18% in 2016), the rate is insufficient to meet SDG target 3.4.4 4. Cost-effective, affordable and evidence-based interventions exist and need to be scaled up. 5. National NCD investment cases need to be developed to inform countries about the costs of NCDs, the return on investment from prevention and treatment, and links to poverty and socio- economic development. 6. The primary role and responsibility for combating NCDs lies with presidents and prime ministers. 7. Governments need to mobilize civil society and the private sector, where appropriate, to implement national NCDs responses, while giving due regard to managing conflicts of interest. 8. Mechanisms for national multi-stakeholder dialogue and accountability are critical. 9. There is a need to mobilize and allocate adequate, predictable and sustained resources for national NCD responses through domestic, bilateral and multilateral channels, as well as through public-private partnerships. 10. The UN system needs to step up its efforts to meet the requests for technical cooperation from Member States. WHO must continue to lead the UN Inter-Agency Task Force and explore options for innovative financing to support national NCD control efforts. 3 Four diseases (cardiovascular disease, cancer, diabetes and chronic lung disease) and four risk factors (tobacco use, harmful use of alcohol, unhealthy diets and physical inactivity). 4 By 2030, reduce by one third premature mortality from NCDs through prevention and treatment and promote mental health and well-being. WHO/UNIATF/19.98 © World Health Organization 2019. World Health Organization 2019. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. Photo credits (clockwise): © Nicholas Banatvala © UNDP (2) © Asian Development Bank © UNDP © AMISOM © World Bank © FMSC 1 Responding to the Challenge of NCDs: FAO Food and Agriculture Organization of the United Nations Responding to the Challenge of Non-communicable Diseases 1. The food and agriculture sector is crucial for an effective response to NCDs The food and agriculture sector plays a major role in nourishing people by increasing the availability of and access to diverse, safe and nutritious food, which meets dietary recommendations and principles relating to environmental sustainability.1 Most of today’s food systems need to be re-aligned from the production of high- yielding staple food crops such as cereals to sustainable provision of non-staple foods such as fruits and vegetables that will enhance dietary diversity. Improved food systems need to address all forms of malnutrition, such as overweight and obesity as well as wasting, stunting and micronutrient deficiencies. In today’s food systems, the nutritious foods that make up a healthy diet are not always available or affordable for many people.2 Various UN instruments have re-affirmed several fundamental nutrition- related rights, namely the right to have access to safe, sufficient and nutritious food, as well as the right to be free from hunger.3 The rise in obesity and NCDs is associated with a shift towards energy-dense diets, which are characterized by highly processed foods 1 FAO. 2018. Strengthening sector policies for better food security and nutrition results: food systems for healthy diets. Available at: www.fao.org/3/CA2797EN/ ca2797en.pdf. 2 FAO. 2013. The State of Food and Agriculture 2013: food systems for better nutrition. Available at: www.fao.org/docrep/018/i3300e/i3300e.pdf. 3 FAO & WHO. 2014. Second International Conference on Nutrition, Rome, 19-21 November 2014. Conference Outcome Document: Rome Declaration on Nutrition. Available at: http://www.fao.org/3/a-ml542e.pdf. high in refined starches, sugar, fats, and/or salt, accompanied by an insufficient intake of fresh fruits and vegetables, wholegrains, pulses, nuts and seeds.4 This shift is also coupled with sedentary lifestyles and low levels of physical activity. Most of the world's population now lives in countries where overweight and obesity kill more people than underweight.5 The way we produce, process, store and bring our food to markets is changing rapidly. Food production and supply chains have intensified, 4 FAO. 2017. The State of Food and Agriculture 2017: leveraging food systems for inclusive rural transformation. Available at: www.fao.org/3/a-I7658e.pdf. 5 WHO. 2019. Obesity and overweight [website]. Available at: https://www.who.int/ en/news-room/fact-sheets/detail/obesity-and-overweight. United Nations high-level meetings have highlighted the need for UN agencies, including FAO, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries (LMICs). Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as unhealthy diet, tobacco use, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. becoming industrialized and globalized, with people eating more purchased, processed and packaged food. Large-scale production has led to the use of a narrow range of high-yielding food crop and animal varieties, which has contributed to a reduction in agro-biodiversity. In addition, harmful chemicals used in food production are known to cause cancer. Widespread marketing of foods high in fat, sugar and/or salt, particularly those targeted at children, is a source of concern. This development is related to the steady growth and increasing influence of the private sector, including large-scale international food and agri-businesses and retailers. FAO is uniquely positioned to contribute to global efforts to reduce the prevalence of overweight, obesity and NCDs through the support it provides to countries in reforming their food systems and its work with line ministries responsible for agriculture, trade, environment and rural development, as well as with other UN agencies and development partners. Key areas for FAO engagement include: Situation analyses and awareness raising on how food systems and dietary changes drive overweight, obesity and NCDs. Engaging food systems stakeholders in policy analysis and dialogue, and encouraging them to implement public policy and regulations in order to create an appropriate set of incentives and disincentives to drive change in food systems. Political economy analysis to identify how different sectors impact on food systems and changes required to prevent and control NCDs. 2. FAO has a role to play in supporting countries in the prevention and control of NCDs For the first time FAO’s Medium-Term Plan 2018–2021 and Programme of Work and Budget 2018–2019 explicitly mention the issues of overweight, obesity and NCDs, and refer to the related targets under Sustainable Development Goals (SDGs) 2 and 3.6 FAO has reviewed the recommended cost- effective interventions endorsed by the World Health Assembly (WHA) to identify those linked to FAO’s work at global, regional and country levels. Examples are included in the table. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.7 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 6 FAO. 2017. The Director-General’s Medium-term Plan 2018-21 and Programme of Work and Budget 2018-19. Available at: www.fao.org/3/a-ms278e.pdf. 7 WHO. 2017. ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf. Responding to the Challenge of NCDs: FAO 2 Evidence-based interventions FAO actions Implement mass media campaign on healthy diets, including social marketing to reduce the intake of total fat, saturated fats, sugars and salt, and promote the intake of fruits. FAO supports countries to form action networks to promote healthy diets, nutrition labelling and food reformulation as part of the UN Decade of Action on Nutrition. Limiting portion and package size to reduce energy intake and the risk of overweight/ obesity. FAO supports countries to develop food-based dietary guidelines addressing overweight, obesity and undernutrition.8 Implement nutrition education and counselling in different settings (e.g. preschools, schools, workplaces, hospitals) to increase the intake of fruits and vegetables. FAO implements school- based food and nutrition education programmes, and supports governments to develop policies and programmes in schools to encourage healthy diets. Raise public and political awareness, understanding and practice about prevention and control of NCDs. FAO supports countries to raise awareness on NCDs and their risk factors, including obesity and steps that can be taken to prevent NCDs. Integrate NCDs into the social and development agenda and poverty alleviation strategies. FAO ensures that nutrition- sensitive social protection interventions also tackle the problem of diet-related NCDs. FAO integrates nutrition objectives into food and agriculture policy, programme design and implementation to enhance nutrition-sensitive agriculture, ensure food security and enable healthy diets for the prevention of overweight, obesity and NCDs. FAO supports countries in the development of easy-to-understand labels contributing to sustainable food systems. 8 Food-based dietary guidelines (also known as dietary guidelines) establish a basis for public food and nutrition, health and agricultural policies and nutrition education programmes to foster healthy eating habits and lifestyles. They provide advice on foods, food groups and dietary patterns to provide the required nutrients to the general public to promote overall health and prevent NCDs. See: www.fao.org/ nutrition/education/food-dietary-guidelines/en/. UN Decade of Action on Nutrition (2016–2025). In 2016, the UN General Assembly mandated FAO and the World Health Organization (WHO) to lead implementation of the Nutrition Decade with the aim to achieve the global nutrition and diet-related NCD targets by 20259 as well as the nutrition- and NCD-related targets in the 2030 Agenda for Sustainable Development (General Assembly resolution 70/1). It also called on FAO and WHO to accelerate the implementation of commitments made at the 2014 Second International Conference on Nutrition.10 Global Individual Food consumption data Tool (GIFT). FAO/WHO GIFT is an online platform providing individual dietary data that enables policy-makers to answer the question “What are people eating?” and to create better informed public policies for healthy diets.11 Kyoto University. This collaboration includes knowledge exchange, the provision of technical expertise, and awareness raising about urban food policy, food waste, and agriculture modelling, and study of the linkages between climate change and sustainable food and agriculture systems. The Rockefeller Foundation. Established in 2016, this partnership supports food security and seeks to reduce food losses by expanding the capacity of small-scale producers in sub- Saharan Africa. UN Habitat. This collaboration involves building resilient food systems by improving rural-urban food supply chains, e.g. in Kenya. 9 UN. 2019. UN Decade of Action on Nutrition [website]. Available at: www.un.org/ nutrition/. 10 FAO. 2014. The Second International Conference on Nutrition (ICN2) [website]. Available at: www.fao.org/about/meetings/icn2/en/. 11 More information on this tool is available at: www.fao.org/gift-individual-food- consumption. 3. Partnerships are critical for FAO in mobilizing an effective response to NCDs Responding to the Challenge of NCDs: FAO 3 Consumers International. This partnership aims to enhance Consumer International’s (CI) access to FAO’s wealth of knowledge and information while allowing FAO to work more closely with the network of CI membership organizations across the world which liaise with and advocate for individual consumers. In Latin America and the Caribbean, for example, both organizations cooperate to support the development of public policies for improved access to nutritious food and nutritional information. World Obesity Federation. This partnership, recently formalized in a memorandum of understanding, will increase awareness of the agriculture and food systems-related policy measures that have led to the current overweight and obesity situation and related disease burdens. FAO has developed a portfolio of programme priorities12 and invited partners to increase their investment in food and agriculture to improve health and achieve the SDGs. Among the NCD-related priorities are: • Tackling obesity through sustainable food systems: transforming food systems for health and well-being. • Food and green environments for healthy cities: improving the accessibility of nutritious food and green spaces for all. 12 FAO. 2019. Business development portfolio: opportunities to invest in sustainable development, 2019–2020 cycle. Available at: http://www.fao.org/3/ca4265en/ ca4265en.pdf. 4. Mobilizing resources to deliver Due diligence is required to ensure that all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by FAO as part of a set of United Nations system agency briefs under the Task Force Responding to the Challenge of NCDs: FAO 4 1 Responding to the Challenge of NCDs: FCTC Secretariat of the WHO Framework Convention on Tobacco Control and Protocol to Eliminate Illicit Trade in Tobacco Products Responding to the Challenge of Non-communicable Diseases 1. WHO FCTC and its Protocol are essential legal instruments to ensure the attainment of global NCD targets Tobacco use is responsible for one in six deaths from NCDs. While gains have been made by many countries on tobacco control, the fact remains that approximately 80% of the world’s one billion smokers live in low- and middle-income countries: the tobacco industry is constantly looking for new markets in these countries and blocking tobacco control efforts.1 Governments negotiated and adopted the WHO FCTC in 2003. This evidence-based treaty entered into force in 2005, becoming one of the most rapidly embraced conventions of the United Nations system. Currently there are 181 Parties to the WHO FCTC, representing 90% of the world’s population. The Protocol to Eliminate Illicit Trade in Tobacco Products was adopted in 2014, entered into force in 2018 and currently has 56 Parties. The Meeting of the Parties (MOP) was established in 2018 and has put into motion the mechanisms for implementing the Protocol.2 1 UNGA, Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, A/RES/66/2 (2011); UNGA, Political Declaration of the Third High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (2018); United Nations, Economic and Social Council, United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases, E/RES/2018/13 (2018). 2 WHO FCTC Secretariat, Protocol to Eliminate Illicit Trade in Tobacco Products (2013). Available at: https://www.who.int/fctc/protocol/illicit_trade/protocol- publication/en/ United Nations high-level meetings have highlighted the need for the UN to scale up its work on NCDs as part of the 2030 Agenda for Sustainable Development.1 NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in developing countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioral risk factors, such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2 Responding to the Challenge of NCDs: FCTC Two MOP working groups have been established: one on tracking and tracing systems and another on assistance and cooperation.3 The Convention Secretariat (CS) is also the Secretariat of the Protocol. The political declarations of the high-level meetings of the General Assembly on the prevention and control of NCDs called on full implementation of the WHO FCTC while continuing to implement tobacco control measures without any tobacco industry interference; it urged Member States who have yet to ratify the WHO FCTC to accelerate the ratification process. Target 3.a of the Sustainable Development Goals (SDG2030) calls for strengthening the implementation of the WHO FCTC, which also contributes directly to Target 3.4 on prevention and control of the NCDs. Tobacco control can accelerate sustainable development in all its social, economic and environmental dimensions,4 and contributes to other health issues beyond those relating solely to NCDs, e.g. by addressing HIV and tuberculosis co-morbidities,5 maternal and child health, reproductive health and universal health coverage. Target 5 of the WHO Global NCD Action Plan 2013–2020 is a 30% relative reduction in the prevalence of current tobacco use in persons aged 15 years and over. 3 WHO FCTC Secretariat, Establishment of Expert and Working Groups to advance global tobacco control (2019). Available at: https://www.who.int/fctc/mediacentre/ news/2019/expert-working-groups-cop-mop-advance-tobacco-control/en/ 4 WHO FCTC Secretariat and UNDP, The WHO Framework Convention on Tobacco Control an Accelerator for Sustainable Development (2017). Available at: https:// www.who.int/fctc/implementation/publications/who-fctc-accelerator-for- sustainable-development/en/ 5 WHO FCTC Secretariat, Issue Brief: Integrating Tobacco Control into Tuberculosis and HIV Responses (2018). Available at: https://www.who.int/fctc/publications/ WHO-FCTC-HIV-TB.pdf?ua=1 As a legally binding instrument, the WHO FCTC is a powerful mechanism that reaffirms the right of all people to the highest standard of health. In 2018, the Conference of the Parties (COP)6 adopted the Global Strategy to Accelerate Tobacco Control: Advancing Sustainable Development through the Implementation of the WHO FCTC 2019–2025 (GS2025). The Strategy seeks to make a meaningful contribution to reaching the overall health goal of SDG 3 and target 3.4 on NCDs. Furthermore, the Strategy adopted the voluntary global target of “a 30% reduction in the age-standardized prevalence of current tobacco use in persons aged 15 years and over by 2025” as its own overall target, thus harmonizing WHO FCTC implementation with global NCD efforts. The COP has recognized the strong contribution it can make to achieving the global NCD target on the reduction of tobacco use. Subsequently, the COP has called upon Parties to integrate WHO FCTC implementation with national multisectoral NCD policies. It also requested the Convention Secretariat to promote WHO FCTC implementation as an essential and high-impact strategy for achieving SDG target 3.4, and report on the efforts taken in the next COP sessions. Protecting public health policies from the commercial and vested interests of the tobacco industry and establishing measures7 to protect the integrity of the decisions adopted by the governing bodies of WHO FCTC and its Protocol is at the core of the Parties’ obligations under the Convention and its protocols. 6 The Conference of the Parties (COP) is the governing body of the WHO FCTC and is comprised of all Parties to the Convention. The work of the COP is governed by its Rules of Procedure and keeps under regular review the implementation of the Convention: it takes decisions necessary to promote its effective implementation and may also adopt protocols, annexes and amendments to the Convention. For more information: https://www.who.int/fctc/cop/governance/en/ 7 See decisions FCTC/COP8(4), (12), (18) at https://www.who.int/fctc/cop/sessions/ cop8/decisions/en/ 3 Responding to the Challenge of NCDs: FCTC 2. The Convention Secretariat has a role to play in supporting countries in preventing and controlling NCDs The Convention Secretariat is a global authority overseeing implementation of the WHO FCTC. It promotes multisectoral, comprehensive tobacco-control policies and legislation at country level through strengthened coordination and planning. Over the years, the Convention Secretariat has supported close to 60 Parties, mostly developing country Parties and Parties with economies in transition by conducting needs assessments8 in the light of their obligations under the Convention. Parties have also received further support in development assistance including South- South and triangular cooperation with emphasis on the FCTC2030 project implemented in 15 Parties. Capacity- building initiatives at global, regional and country levels, sharing of best practices and dissemination of information, statements and position papers through the regular use of formal and informal communications with governments are part of the core attributions of the Convention Secretariat. The Convention Secretariat has also a network of CS-Knowledge Hubs with expertise in different areas of Convention implementation which provide technical support to the Parties in various fields, e.g. research, legal, economic, surveillance and policy-making. 8 WHO FCTC Secretariat, Needs assessments (2019). Available at: https://www.who. int/fctc/implementation/needs/en/ As part of the synergy framework promoted through COP decisions and resolutions of the World Health Assembly (WHA),9 the Convention Secretariat has reviewed the recommended cost-effective interventions endorsed by the WHA in order to identify those that are linked to its work at global, regional and country levels: specific examples are given in the table. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.10 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 9 Seventh Session of the Conference of the Parties to the WHO FCTC, Strengthening synergy between the Conference of the Parties and the World Health Assembly: Report of the Convention Secretariat, FCTC/COP/7/32 (2016). Available at https:// www.who.int/fctc/cop/cop7/FCTC_COP_7_32_EN.pdf and Seventh Session of the Conference of the Parties to the WHO FCTC, Strengthening synergy between the Conference of the Parties and the World Health Assembly, FCTC/COP7(18) (2016). Available at: https://www.who.int/fctc/cop/cop7/FCTC_COP7_18_EN.pdf?ua=1 10 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf 4 Responding to the Challenge of NCDs: FCTC Evidence-based interventions Convention Secretariat actions Increase excise taxes and prices on tobacco products. This is one of the specific objectives of the GS2025. Article 6 of the WHO FCTC is therefore a priority in the core work of the CS and includes development assistance projects such as the FCTC2030. Its application is supported by the Guidelines to implement Article 6 adopted by COP. Additionally, the CS-Knowledge Hub on taxation supports the CS in assisting Parties to implement Article 6 of the WHO FCTC.11 Implement plain/standardized packaging and/or large graphic health warnings on all tobacco packages. This is one of the specific objectives of the GS2025 and bears on Article 11 of the WHO FCTC. Its application is supported by the Guidelines to implement Article 11 adopted by COP. As one of the time-bound measures under the Convention, country development assistance projects coordinated by the CS frequently cover pictorial health warning legislation. The CS also encourages granting licences for pictorial health warnings to promote large-scale and effective pictorial health warnings. The CS-Knowledge Hub on international cooperation also supports the CS in assisting Parties to implement Article 11 of the WHO FCTC. Enact and enforce comprehensive bans on tobacco advertising, promotion and sponsorship (TAPS). Ban cross-border advertising, including using modern means of communication. TAPS bans are one of the specific objectives of the GS2025 and bears on Article 13 of the WHO FCTC as one of the time-bound measures under the Convention. Country development assistance projects frequently cover tobacco advertising, promotion and sponsorship legislation supported by the Guidelines to implement Article 13 adopted by COP. Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public places public transport. Guidelines on cross-border TAPS will be further elaborated. In decision FCTC/COP8(17), the COP established an intersessional working group to develop specific guidelines to address cross-border TAPS and the depiction of tobacco in the entertainment media under Article 13 of the WHO FCTC in the light of technological advances over the past decade such as the Internet and mobile communications.12 Implement effective mass media campaigns that educate the public about the harms of smoking/tobacco use and second-hand smoke. This is one of the specific time-bound objectives of the GS2025. Its implementation is supported by the Guidelines to implement Article 8 adopted by COP. As one of the time-bound measures under the Convention, country development assistance projects frequently cover smoke-free legislation. The CS-Knowledge Hub on international cooperation also supports the CS in assisting Parties to implement Article 8 of the WHO FCTC.13 Provide cost-covered, effective and population-wide support (including brief advice, national toll-free quit line services) for tobacco cessation to all those who want to quit. As one of the demand reduction measures under the Convention, country development assistance projects frequently cover education campaigns including mass media campaigns in line with Guidelines to implement article 12 adopted by COP. Provide mobile phone-based tobacco cessation services for all those who want to quit. As one of the demand reduction measures under the Convention, country development assistance projects frequently promote as broad a range of interventions as possible in order to support cessation in line with the Guidelines to implement Article 14 adopted by COP. The Convention Secretariat also works to promote targeted cessation initiatives when addressing co-morbidities such as HIV and tuberculosis.14 Additionally, the CS- Knowledge Hub on international cooperation promotes implementation of Article 14 of the Convention.15 Implement measures to minimize illicit trade in tobacco products. The Convention Secretariat has promoted the legal adoption of the Protocol and continues to endorse awareness-raising initiatives to encourage Parties to the Convention to become Parties to the Protocol and to begin its implementation. The CS is working to bring its development assistance initiatives in line with MOP guidance and decisions. 11 WHO FCTC Secretariat, WHO FCTC Knowledge Hub on Taxation (2019). Available at: https://untobaccocontrol.org/kh/taxation/ 12 Eighth Session of the Conference of the Parties to the WHO FCTC, Tobacco advertising, promotion and sponsorship: depiction of tobacco in entertainment media, FCTC/COP8(17) (2018). Available at: https://www.who.int/fctc/cop/sessions/cop8/FCTC__COP8(17).pdf?ua=1 13 WHO FCTC Secretariat, WHO FCTC Knowledge Hub on International Cooperation (2019). Available at: https://untobaccocontrol.org/kh/int-cooperation/ 14 WHO FCTC Secretariat, Issue Brief: Integrating Tobacco Control into Tuberculosis and HIV Responses (2018). Available at: https://www.who.int/fctc/publications/WHO-FCTC-HIV- TB.pdf?ua=1 15 ibid 5 Responding to the Challenge of NCDs: FCTC Twenty-eight international intergovernmental organizations and 21 nongovernmental organizations are accredited to the COP as observers. The Convention Secretariat cooperates with all observers in providing support to all Parties of both the WHO FCTC and its Protocol. The UK- and Australia-funded FCTC2030 project16 has enabled the Convention Secretariat to work with UNDP and WHO to support 15 low- and middle-income countries (LMICs) in promoting and supporting governments to accelerate implementation of the WHO FCTC. The Convention Secretariat leads the UNIATF Thematic Group on Tobacco Control under which several initiatives are taking place: • The Convention Secretariat takes the lead in developing and promoting the Model Policy on preventing tobacco industry interference among the UN agencies.17 After it was adopted by the seventh meeting of the UNIATF, it was endorsed by the UN Economic and Social Council (ECOSOC) meeting in 201718 and reiterated again in 2018.19 16 WHO FCTC Secretariat, FCTC 2030 (2019). Available at: https://www.who.int/fctc/ implementation/fctc2030/ 17 The purpose of this policy is to ensure that efforts to protect tobacco control from commercial and other vested interests of the tobacco industry are comprehensive, effective and consistent across the United Nations system including the UN itself and its funds, programmes, specialized agencies, other entities and related organizations. To download the model policy: https://www.who.int/ncds/un-task- force/events/model-policy-agencies-united-nations1.pdf 18 United Nations, Economic and Social Council, United Nations Inter-Agency Task Force on the Prevention and Control of Non-Communicable Diseases, E/ RES/2017/L.21 (2017). Available at: http://www.un.org/ga/search/view_doc. asp?symbol=E/2017/L.21 19 United Nations, Economic and Social Council, United Nations Inter-Agency Task Force on the Prevention and Control of Non-Communicable Diseases, E/ RES/2018/13 (2018). Available at: https://undocs.org/E/RES/2018/13 3. Partnerships are critical for the Convention Secretariat to mobilize and implement the WHO FCTC and its Protocol and provide an effective response to NCDs • The Convention Secretariat and WHO joined forces with FAO and ILO to support their Governing Body decision to stop funding from the tobacco industry for child labour in tobacco growing areas. • The Convention Secretariat is working with several UN agencies to develop a new joint programme to support low- and middle- income countries in developing economically sustainable alternatives to livelihoods based on tobacco growing. • The Convention Secretariat promotes a smoke-free UN campus in the UNIATF and has joined forces with WHO to develop tools and guides. Due diligence is required to ensure all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens for example by working to increase or preserve the availability, accessibility and/ or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. 6 Responding to the Challenge of NCDs: FCTC 4. Mobilizing resources to deliver COP8 has developed a fundraising strategy for implementing the WHO FCTC in line with GS2025, including the concept of an Investment Fund as a regular and sustainable fundraising mechanism.20 The Convention Secretariat has been actively mobilizing funds to support developing country Parties and Parties with economies in transition to strengthen their implementation of the WHO FCTC.21 20 Eighth Session of the Conference of the Parties to the WHO FCTC, Convention Secretariat’s fundraising strategies: Investment fund concept, FCTC/COP8(5) (2018). Available at: https://www.who.int/fctc/cop/sessions/cop8/FCTC__COP8(5). pdf?ua=1 21 WHO FCTC Secretariat, Donors and partners from 2018 (2019). Available at: https:// www.who.int/fctc/about/donorspartners/en/ The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the Convention Secretariat as part of a set of United Nations system agency briefs under the Task Force Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr 1 Responding to the Challenge of NCDs: IAEA International Atomic Energy Agency Responding to the Challenge of Non-communicable Diseases 1. Nuclear techniques assist in the prevention, early detection, diagnosis and treatment of NCDs1 Nuclear techniques play an integral role in the management of non-communicable diseases (NCDs)1 such as cancer, cardiovascular diseases, and neurological conditions, and can be used to design and evaluate interventions to address malnutrition in all its forms. Cancer. Cancer causes 9 million deaths each year.2 Medical imaging, including X-rays, and nuclear medicine techniques are critical in cancer care, in terms of: early and accurate diagnosis, including assessment of the location and spread of the disease (staging); follow-up of the patient to detect relapses; prognostic evaluation; and appropriate therapeutic decisions and follow-up of the response to treatment.3 Radiotherapy is a key element of cancer treatment for every second cancer patient worldwide. Modern radiotherapy allows automated delivery of a precise dose to the tumour and avoids the surrounding critical structures, giving the patient a chance to recover with minimal side- effects. 1 This UNIATF brief draws from the IAEA Brief for policymakers, “Prevention, Early Diagnosis and Treatment of Non-Communicable Diseases: The Role of Nuclear Techniques.” Available at: https://www.iaea.org/sites/default/files/18/10/ prevention-early-diagnosis-and-treatment-of-non-communicable-diseases.pdf 2 WHO. Key facts. NCDs. https://www.who.int/news-room/fact-sheets/detail/ noncommunicable-diseases 3 For more information, see: https://www.iaea.org/topics/cancer-diagnosis United Nations high-level meetings have highlighted the need for UN agencies, including IAEA, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as unhealthy diet, tobacco use, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2 Responding to the Challenge of NCDs: IAEA Cardiovascular disease. Cardiovascular diseases account for most NCD deaths, claiming the lives of 17.9 million people annually.4 Cardiac imaging using nuclear techniques is an important diagnostic tool, enabling earlier diagnosis and the planning of more effective treatment, as well as follow- up of patient response. Neurological conditions. Worldwide, around 50 million people have dementia, and there are nearly 10 million new cases every year. Alzheimer’s disease is the most common form of dementia and may contribute to 60– 70% of cases.5 Molecular imaging, including brain perfusion techniques, is helpful in the diagnosis of Alzheimer’s and other forms of dementia.6 Malnutrition. The effects of poor nutrition add to the burdens on health-care systems. In 2018, globally 149 million children under 5 years of age were stunted, 49 million wasted and 40 million overweight.7 Nuclear and stable isotope techniques provide important accurate data on body composition, breastfeeding practices, total daily energy expenditure, micronutrient bioavailability and vitamin A status, all of which directly relate to the prevention of diet-related NCDs. 4 WHO. Key facts. NCDs. https://www.who.int/news-room/fact-sheets/detail/ noncommunicable-diseases 5 WHO. Dementia: Key facts. https://www.who.int/news-room/fact-sheets/detail/ dementia 6 Torosyan N, Silverman S. (2012). Neuronuclear Imaging in the Evaluation of Dementia and Mild Decline in Cognition. Semin Nucl Med; 42(6): 415–422. 7 Global Health Observatory: Child malnutrition https://www.who.int/gho/child- malnutrition/en/ 2. IAEA has a role to play in preventing and controlling NCDs Working with governments, research and health institutions and development partners, IAEA provides technical assistance to Members States to strengthen their capacity in cancer diagnostics and treatment, and to evaluate preventive interventions for diet-related NCDs using stable isotope techniques.8 This support consists of developing, adopting and strengthening practices, providing technical advice and training, engaging in coordinated research projects, provision of equipment, preparation of technical publications and public information, and resource mobilization activities. IAEA also strengthens the evaluation of a range of nutrition interventions to prevent and support treatment of NCDs such as those that increase physical activity, promote breastfeeding and assess body composition and energy expenditure. IAEA has supported more than 110 low- and middle-income countries (LMICs) to address issues related to NCDs. IAEA has established a dedicated service (imPACT Review)9 to assess national capacities in cancer control and subsequently support Member States in evidence-based planning of cancer control resources. This service is delivered in cooperation with the World Health Organization (WHO) and International Agency for Research on Cancer (IARC). 8 IAEA Brief on Human Health for Policy Makers. https://www.iaea.org/sites/default/ files/18/10/prevention-early-diagnosis-and-treatment-of-non-communicable- diseases.pdf 9 https://www.sciencedirect.com/science/article/abs/pii/S1470204517303728 Abdel-Wahab M, Lahoupe B, Polo A, et al. (2017). Assessment of Cancer Control Capacity and Readiness: The Role of the International Atomic Energy Ageny. Lancet Oncol; 18(10): 587-594. 3 Responding to the Challenge of NCDs: IAEA IAEA’s Quality Management Audit for Nuclear Medicine Practice aims to support facilities to improve the quality of their clinical practice. Since 2009, IAEA has conducted 72 audits in 38 countries.10, 11, 12 IAEA has compiled the first comprehensive database on global energy expenditure data. Between 1981 and 2017, over 6600 measurements from 23 countries were collected using the Doubly Labelled Water method. These data help countries develop better health policies to combat the growing obesity epidemic. IAEA has reviewed the recommended cost- effective interventions endorsed by the WHA for NCDs to identify those that can be advanced through IAEA’s work at global, regional and country levels. Examples are provided in the table below. 10 Dondi M, Paez D, Torres L, et al. (2018). Implementation of Quality Systems in Nuclear Medicine: Why It Matters. An Outcome Analysis (Quality Management Audits in Nuclear Medicine Part III). Semin Nucl Med; 48(3):299-306. 11 Dondi M, Torres L, Marengo M, et al. (2017). Comprehensive Auditing in Nuclear Medicine Through the International Atomic Energy Agency Quality Management Audits in Nuclear Medicine Program. Part 2: Analysis of Results. Semin Nucl Med;47(6):687-693. 12 Dondi M, Torres L, Marengo M, et al. (2017). Comprehensive Auditing in Nuclear Medicine Through the International Atomic Energy Agency Quality Management Audits in Nuclear Medicine (QUANUM) Program. Part 1: the QUANUM Program and Methodology. Semin Nucl Med;47(6):680-686. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.13 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 13 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. http://apps.who.int/iris/bitstream/ handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf 4 Responding to the Challenge of NCDs: IAEA Evidence-based interventions IAEA actions Treatment of heart attacks. Building capacity in appropriate and safe use of medical imaging, including nuclear medicine (SPECT and PET) and radiology. Establishing sustainable medical imaging facilities for evaluation of patients with CVD. Treatment of heart failure. Breast screening using mammography with timely diagnosis and treatment of breast cancer. Ensuring quality control, image quality and dose optimization of mammography units. Assisting in the development of national diagnostic reference levels. Building capacity for the appropriate and safe use of mammography. Establishing sustainable mammography facilities. Treatment of colorectal cancer stages I and II and basic palliative care for cancer. Planning, establishing and sustaining radiotherapy services. Supporting radiotherapy quality assurance programmes. Provision of training in radiotherapy. Raising public and political awareness, understanding and practice relating to the prevention and control of NCDs. Highlighting NCD issues through media including social media. Strengthening international cooperation for resource mobilization, capacity-building, health workforce training, and exchange of information on lessons learned and best practices. Supporting education and training activities for health practitioners. Supporting the development of national resource mobilization strategies, technical documents and targeted funding proposals. Assessing national capacity for the prevention and control of NCDs. Supporting the development of national cancer control plans and strategies. Providing recommendations on national treatment and palliative care programmes. Conducting national assessments to strengthen national cancer control programmes. Strengthening human resources and institutional capacity for research. Supporting countries to train healthcare staff. Supporting countries to build clinical research capacity. Strengthening research capacity through cooperation with domestic and foreign research institutes. Partnering with joint research programmes. Supporting clinical research protocols in LMICs. Promoting and supporting exclusive breastfeeding for the first six months of life. Evaluating breastfeeding practices using stable isotope techniques. 5 Responding to the Challenge of NCDs: IAEA The IAEA collaborates with a number of partners in response to NCD burdens. Examples include: • IAEA/WHO (Network of Secondary Standards Dosimetry Laboratories) which provides calibrations for dosimetry equipment that are used to determine radiation dose levels for patients, staff or the public; • UN Joint Global Programme on Cervical Cancer Prevention and Control, which supports countries to reduce the burden of cervical cancer – IAEA has a key role in supporting Member States in the diagnosis and treatment of cervical cancer, including radiotherapy and palliative treatment; • International Union of Nutritional Sciences’ Task Force on Nutrition and Cancer which, at national, regional and global levels, catalyses capacity and collaboration across nutrition and cancer; • International Organization for Medical Physics in the development of guidelines and American Association of Physicists in Medicine in the development of dosimetry codes of practice; and • International Centre for Theoretical Physics, European Society for Radiotherapy and Oncology and a range of other professional organizations in building capacity through training courses, conferences and workshops. 3. Partnerships are critical for IAEA in mobilizing an effective response to NCDs A formal mechanism for due diligence, which also addresses conflicts of interest in safeguarding the reputational risk to the organization, should be in place to ensure that all partnerships advance health and development outcomes. 6 Responding to the Challenge of NCDs: IAEA 4. Mobilizing resources to deliver As Member States struggle with inadequate resources to tackle their increasing cancer burden, IAEA has adopted a new resource mobilization approach, joining forces with the private sector and international financial institutions to support low- and middle-income countries in order to secure financial and non- financial resources: in 2012, for instance, IAEA launched a focused partnership effort with the Organization of Islamic Cooperation and the Islamic Development Bank to expand access to effective, safe and sustainable cancer care in common Member States. The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the IAEA as part of a set of United Nations system agency briefs under the Task Force Photo credits: © IAEA © World Bank (p.3, top) © UNICEF (p.3, bottom) International Organization for Migration Responding to the Challenge of Non-communicable Diseases Migration is an important determinant of health. It can challenge physical, mental and social well-being. Throughout the migration process, migrants experience difficulties in accessing health services and face increased exposure and vulnerability to NCDs and their risk factors as well as mental ill-health and injuries. In their community of origin, migrants may face poverty, violence and social conflict, as well as limited access to health care. For families left behind, the social cost is considerable, and has significant mental health implications. Remittances that could be used for accessing long-term health protection schemes are often used for out-of-pocket health expenditure. During transit, stressful and unsafe travel conditions and discontinued care can exacerbate migrants’ risk of developing NCDs or worsen pre-existing conditions. At their destination, migrants often face social exclusion and experience difficulties adapting to a new culture, which may lead to an increase in unhealthy behaviour patterns such as tobacco and alcohol use, poor diet and inadequate health care. United Nations high-level meetings have highlighted the need for UN agencies, including IOM, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. Stigma, discrimination and restrictive policies also expose migrants to NCD risk factors. In addition, migrant workers are reported to have a higher risk of work-related injuries and chronic illnesses than native workers. During return, especially after crisis situations, their access to health services may be limited. Migrants and mobile populations can face many obstacles in accessing essential health care services due to, among other factors, their irregular immigration status, language barriers, the absence of migrant-inclusive health policies and inaccessible services. 1. Migrants are at increased risk of NCDs and mental health conditions 1 Responding to the Challenge of NCDs: IOM 2. IOM has a role to play in supporting countries in preventing and controlling NCDs “Life Is Better”—psychoactive substances abuse primary prevention campaign, Georgia (2016–2017) IOM Georgia implemented a multisectoral approach involving local authorities in seven public schools. The “Life is Better” school-based campaign used an innovative and interactive two-pronged educational approach combining information dissemination on the risks of drug use and skill-building which targeted youth and their families in migrant communities and among ethnic minorities. The campaign reached 4,067 school children who were shown to be comparatively more aware of drug-related risks and better equipped to face social pressures relating to drug use. The “Life is Better” campaign acts as a primary prevention method to combat NCDs since substance abuse can lead to mental health problems such as depression and anxiety. Substance abuse can also increase the risk of developing cancer, diabetes and other NCDs. The campaign was adopted by the Ministry of Education and Science of Georgia and has been expanded nationwide. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.3 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. IOM, as the UN migration agency, is committed to the inclusion of migrant and mobile populations in all relevant policies and programmes to reduce NCDs. This commitment is reflected in IOM’s support for implementation of the Global Compact for Safe, Orderly and Regular Migration,1 as well as World Health Assembly (WHA) Resolution 70.15 on promoting the health of refugees and migrants. Growing clarity on the multiple and unique risks migrants face with respect to NCDs, mental ill-health and injuries, not least obstacles to life-saving health services, calls for strong partnerships and sustainable programmes to address NCDs in migrant populations. IOM delivers and promotes comprehensive preventive and curative health programmes for migrants and mobile populations. NCDs and mental conditions are diagnosed, treated and, if necessary, referred to a healthcare facility as part of IOM’s health programming. IOM serves as the coordinator and secretariat of the United Nations network on migration, in line with the “Making Migration Work for All”2 global platform from which migration health actions and policies will be promoted and coordinated to address NCDs. IOM is committed to supporting partnerships to ensure the inclusion of migrants and mobile populations in national and global health policies including Universal Health Coverage (UHC). Migrants should be afforded equitable access to high-quality health services including to prevent, treat and manage NCDs. 1 Global Compact for Safe, Orderly and Regular Migration, endorsed by the United Nations General Assembly in resolution 73/195 (2018). 2 A/72/643. Making migration work for all. Report of the Secretary-General. https:// refugeesmigrants.un.org/sites/default/files/sg_report_en.pdf 3 3 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf 2 Responding to the Challenge of NCDs: IOM IOM has reviewed the recommended WHA- endorsed cost-effective interventions and recommended policy actions to identify those that are linked to IOM’s work at the global, regional and country level. Evidence-based interventions IOM actions Raise public and political awareness, understanding and practice in relation to the prevention and control of NCDs. Include NCDs in the tools used to monitor the health of migrant populations, and enhance IOM’s knowledge- base to inform evidence- based programming and policy development. Strengthen community-based surveillance (CBS) systems to monitor NCD trends and identify the health priorities of migrants. Integrate NCDs into the social and development agenda and poverty alleviation strategies. Implement NCD-focused interventions for migrants and displaced populations in transit and destination communities. Provide clinicians and public health planners in host countries with adequate knowledge of NCD profiles in migrants’ countries of origin. Advocate for psychosocial support to be provided to migrant and mobile populations. Strengthen international cooperation for resource mobilization, capacity building, health workforce training and exchange of information on lessons learned and best practices. Raise awareness of NCDs in national and regional capacity development activities. Foster multisectoral dialogues to address migrants’ structural vulnerabilities to NCDs. 3. Partnerships are critical for IOM in mobilizing an effective response to NCDs IOM has partnerships with multiple stakeholders on issues relating to international health and migration. At the national level, IOM works closely with relevant government ministries, particularly ministries of health and immigration, NGOs and private sector entities (e.g. employment agencies). At the regional and global levels, key partners include UN agencies such as WHO, UNAIDS, UNHCR and ILO, as well as civil society partners such as migrants’ associations and academia. Due diligence is required to ensure all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. 3 Responding to the Challenge of NCDs: IOM Ph ot o cr ed its : © IO M The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by IOM as part of a set of United Nations system agency briefs under the Task Force 4. Mobilizing resources to deliver IOM will continue to highlight NCDs as an important issue with donors, and ensure that IOM country and regional offices include NCDs in project development and implementation. 4 Responding to the Challenge of NCDs: IOM 1 Responding to the Challenge of NCDs: UNAIDS Joint United Nations Programme on HIV and AIDS Responding to the Challenge of Non-communicable Diseases 1. NCDs among people living with HIV is an increasing global public health issue Many countries with HIV epidemics are now experiencing growing rates of NCDs.1 Death rates from NCDs are nearly twice as high in low- and middle-income countries (LMICs) compared to high-income countries. Antiretroviral therapy (ART) for HIV enables people living with HIV to lead long and productive lives. However, there are now becoming susceptible to NCDs in later life. The four NCDs that account for the greatest number of comorbidities among people living with HIV in LMICs are cardiovascular diseases (CVD), cervical cancer, depression and diabetes.2 The risk of cervical cancer among women living with HIV compared to women without HIV is increased up to fivefold.3 HIV-hepatitis C virus coinfection is associated with CVD, diabetes and/or death in people living with HIV.4, 5 1 General Assembly Resolution 66/2, Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, A/RES/66/2 (19 December 2011), available from https://undocs.org/A/ RES/66/2 2 Patel P, Rose C, Collins P, Nuche-Berenguer B, Sahasrabuddhe V, Peprah et al. (2018). Non-communicable diseases among HIV-infected persons in low-income and middle-income countries. AIDS, 32:S5-S20. doi: 10.1097/ QAD.0000000000001888. 3 HPV, HIV and cervical cancer: leveraging synergies to save women’s lives. Geneva: UNAIDS; 2016 (UNAIDS/JC2851E; https://www.unaids.org/en/resources/ documents/2016/HPV-HIV-cervical-cancer). 4 Jenny-Avita ER. (2003). HCV-Coinfection Is Associated with Diabetes and CD4 Decline. AIDS Clinical Care 3:1(12). 5 Kakinami L, Block R, Adams M, Cohn S, Maliakkal B and Fisher S. (2012). Risk of cardiovascular disease in HIV, hepatitis C, or HIV/hepatitis C patients compared to the general population. International Journal of Clinical Practice, 67(1):6-13 doi: 10.1111/j.1742-1241.2012.02953.x HIV, cervical cancer and NCDs are all diseases associated with gender and socioeconomic inequalities, and health disparities across and within countries. HIV infection may increase the risk of NCDs due to stimulation of inflammatory markers and adverse events associated with some anti-retroviral medicines for HIV treatment. This risk is compounded by NCD risk factors, e.g. tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity. United Nations high-level meetings have highlighted the need for the UN, including UNAIDS, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development.1 NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in developing countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2Smoking is associated with a twofold increase in mortality among people living with HIV mainly due to lung cancer. In LMICs, tobacco use among people living with HIV is higher than among those without HIV.6 Smoking is predicted to produce an excess of 18 million cases and 40 million deaths related to tuberculosis (TB) between 2010 and 2050, increasing TB cases and deaths by 7 percent and 66 percent respectively over this period.7 Given the HIV-TB syndemic, smoking, thus, constitutes a major exacerbating factor for HIV, TB and HIV-TB co-infections. Harmful use of alcohol is associated with: risky sexual behaviour with an increased risk of acquiring HIV, resulting in an estimated 33,000 new cases of HIV each year;8 reduced adherence to ART; alcohol-drug interactions and toxicities; and an increased risk of antiretroviral resistance. Harmful use of alcohol also increases the risk of TB infection9 and is associated with delays in seeking TB care.10 Alcohol increases the risk for HIV-related comorbidities, including liver disease, CVD, cerebrovascular disease, pulmonary disease, bone disease and cancer. Alcohol dependence further impacts the progression of HIV infection, as well as associated TB and viral hepatitis. People with mental health and substance use conditions are often at greater risk of HIV infection and are less likely to access education, prevention, testing and treatment services. People living with HIV are at an increased risk of developing mental health conditions, such as depression and anxiety. Key populations, people living with HIV and people with mental health conditions experience multifaceted stigma and the effects of interlocking systems of discrimination.11, 12 Stigma associated with HIV and marginalized identities have been linked to anxiety, depression, poor self-esteem and poor adherence to HIV care.13 Stigma also remains a barrier to accessing drug dependence treatment, mental health care and HIV services. 14, 15 6 Mdege N, Shah S, Ayo-Yusuf O, Hakim J and Siddiqi K. (2017). Tobacco use among people living with HIV: analysis of data from Demographic and Health Surveys from 28 low- income and middle-income countries. The Lancet Global Health, 5(6):e578-e592. 7 Basu S, Stuckler D, Bitton A, and Glantz SA. (2011). Projected effects of tobacco smoking on worldwide tuberculosis control: mathematical modelling analysis. BMJ, (343): doi: https://doi.org/10.1136/bmj.d5506 8 Global status report on alcohol and health 2018. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO. 9 Imtiaz S, Shield KD, Roerecke M, et al. (2017). Alcohol consumption as a risk factor for tuberculosis: meta-analyses and burden of disease. European Respiratory Journal, (50) : doi: 10.1183/13993003.00216-2017 10 Van Ness SE, Chandra A, Sarkar S et al. (2017). Predictors of delayed care seeking for tuberculosis in southern India: an observational study. BMC Infect Dis, (17):567: doi: 10.1186/ s12879-017-2629-9 11 Collins PY, Unger Hv, Armbrister A. Church ladies, good girls, and locas: Stigma and the intersection of gender, ethnicity, mental illness, and sexuality in relation to HIV risk. Social Science & Medicine. 2008;67(3):389-97. 12 Earnshaw VA, Bogart LM, Dovidio JF, Williams DR. Stigma and racial/ethnic HIV disparities: moving toward resilience. The American psychologist. 2013;68(4):225-36. 13 Patton GC, Sawyer SM, Santelli JS, Ross DA, Afifi R, Allen NB, et al. Our future: a Lancet commission on adolescent health and wellbeing. Lancet. 2016;387(10036):2423-78 14 Global Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. Geneva: World Health Organization; 2017. 15 Bundy DAP, de Silva N, Horton S, Patton GC, Schultz L, Jamison DT. Investment in child and adolescent health and development: key messages from Disease Control Priorities, 3rd Edition. Lancet. 2018;391(10121):687-99. Responding to the Challenge of NCDs: UNAIDS 3In partnership with the United Nations Interagency Task Force on NCDs, UNAIDS focuses on developing policies for integration of HIV and NCDs, and HIV and mental health strategies. This approach is aligned with the 2016 UN Political Declaration on Ending AIDS by 2030 and the 2016–2021 UNAIDS Strategy: On the Fast-Track to End AIDS.16 The UNAIDS Global Strategy for 2016–2021 supports multisectoral, integrated, people- centred, human rights and evidence-based services for HIV and HPV/cervical cancer, HIV and NCDs, HIV and mental health as well as for tuberculosis, sexual and reproductive health, maternal, newborn and child health with the active engagement of communities and civil society. 16 UNAIDS 2016–2021 Strategy. Geneva: UNAIDS; 2015 (https://www.unaids.org/ sites/default/files/media_asset/20151027_UNAIDS_PCB37_15_18_EN_rev1.pdf) 2. UNAIDS has a role to play in supporting countries in NCD prevention and control The 43rd and 44th UNAIDS Programme Coordinating Board (PCB) meetings were dedicated to mental health and HIV: promoting human rights, an integrated and person-centred approach to improving ART adherence, well- being and quality of life.17, 18 At its 44th meeting, UNAIDS PCB called on: • Member States to implement evidence- based, people-centred, human rights and community-based policies and programmes to promote mental health and quality of life with a focus on addressing stigma and discrimination related to both HIV and mental health conditions as part of HIV prevention, treatment and care services. • Member States to address social determinants of mental health and HIV by adopting and implementing social protection policies and programmes to reduce stigma and discrimination. • the UNAIDS Joint Programme to review and revise existing practices and guidelines in order to ensure integration of mental health and substance use services into HIV service delivery platforms, and HIV services into mental health and substance use prevention and treatment programmes, and to provide respective implementation guidance. • the UNAIDS Joint Programme to take into account the intersection between mental health and HIV, and the importance of improving psychosocial wellbeing and upholding the quality of life of people affected and living with HIV, as part of a person-centred and human rights approach when developing the next UNAIDS strategy for 2021–2030. 17 The 43rd UNAIDS Programme Coordinating Board (11–13 December 2018), available from https://www.unaids.org/sites/default/files/media_asset/20181214_ UNAIDS_PCB43_Decisions_EN.pdf 18 The 44th UNAIDS Programme Coordinating Board (27 June 2019), available from https://www.unaids.org/en/resources/documents/2019/PCB44_Decisions Responding to the Challenge of NCDs: UNAIDS 4UNAIDS has reviewed the recommended cost-effective interventions endorsed by the WHA—”best buys”—to identify those that are linked to its work at global, regional and country levels. These interventions address the synergies between HIV and HPV/ cervical cancer, HIV and NCDs, and HIV and mental health. UNAIDS plays an advocacy and facilitating role for global, regional and country level multisectoral partnerships as well as resource mobilization efforts to support countrywide responses to cervical cancer, NCDs and mental health issues. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.19 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 19 “Best buys” and other recommended interventions for the prevention and control of non-communicable diseases, Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO. Available at: http://apps.who.int/iris/bitstream/ handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf Evidence-based interventions UNAIDS actions Vaccination against human papillomavirus (2 doses) of 9–13-year-old girls. Prevention of cervical cancer by screening women aged 30–49 years. UNAIDS advocates for an HIV-cervical cancer policy, services and partnerships, along with community engagement; it also supports a focus on HPV vaccination for HIV-positive girls, and cervical pre-cancer and cancer screening, treatment and care for women living with and at risk of HIV. UNAIDS collects, analyses and tracks country reports on the Global AIDS Monitoring and National Composite Policy Index indicators for cervical cancer screening among women living with HIV, and integrated cervical cancer- HIV policies and services. Raise public and political awareness, understanding and practice about prevention and control of NCDs. UNAIDS raises political and public awareness at global and country levels for integrating NCDs and mental health into HIV strategies, policies and programmes with a focus on people living with and at risk of HIV, HIV-NCDs and HIV-mental health comorbidities; emphasis is also put on addressing human rights issues, stigma and discrimination, and health, social and gender inequalities which are common across HIV, NCDs and mental health issues. Integrate NCDs into the social and development agenda and poverty alleviation strategies. UNAIDS advocates for tackling the social determinants of mental health and HIV by means of social protection policies and other programmes to reduce stigma and discrimination. Responding to the Challenge of NCDs: UNAIDS 5UNAIDS actively seeks to strengthen partnerships to address NCDs: some of them are listed below. • UNAIDS is a co-founding partner of the PEPFAR-G.W. Bush Institute-UNAIDS-Merck public-private partnership to end AIDS and cervical cancer among HIV-positive women in Africa. This initiative enables UNAIDS to support policy advocacy and reforms, resource mobilization and community engagement. • In partnership with WHO, United Nations Population Fund (UNFPA) and other partners, UNAIDS is supporting national governments in fast-track countries to develop cervical cancer indicators and targets in their respective national health plans, and advocates for the realization of the WHO Global Call to Action towards the elimination of cervical cancer at the country level and development of the WHO Global Strategy towards the Elimination of Cervical Cancer. • UNAIDS is supporting the H6 partnership for the health of women, children and adolescents (currently under WHO chairmanship) at the global and country level by enhancing the centrality of sexual, reproductive, maternal, newborn, child and adolescent (RMNCAH) health: this programme prioritizes HPV- cervical cancer prevention, screening and treatment for girls and young women and engages communities and mobilizes resources to enable these services to be scaled up. • UNAIDS and WHO are in the process of developing an implementation guidance for integrating mental health and substance use services into HIV service delivery programmes. 3. Partnerships are critical for UNAIDS in mobilizing an effective response to NCDs Due diligence is required to ensure all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. Responding to the Challenge of NCDs: UNAIDS 6The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the UNAIDS as part of a set of United Nations system agency briefs under the Task Force Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr 4. Mobilizing resources to deliver UNAIDS advocates and supports countries to mobilize domestic and donor resources for integrating HIV and cervical cancer prevention and care in countries with a high burden of HIV and cervical cancer. UNAIDS has also mobilized resources for the integration of mental health and HIV services and for addressing human rights and quality of life issues. Responding to the Challenge of NCDs: UNAIDS 1 Responding to the Challenge of NCDs: UNDP United Nations Development Programme Responding to the Challenge of Non-communicable Diseases 1. NCDs are a development issue1 NCDs, such as cardiovascular disease, cancer, diabetes and chronic respiratory disease, are the greatest source of preventable illness, disability and mortality worldwide. NCDs place a significant burden on health systems, presenting a challenge to universal health coverage and other development aims.1 Out-of-pocket healthcare expenditures in response to NCDs can be financially ‘catastrophic’ for those affected. NCDs can also force household earners out of the labour market. Children may drop out of school to care for a sick relative or to make up for lost wages. Women and girls particularly sacrifice their time and opportunities.2 At the national level, NCDs sap public resources and impede economic growth. Between 2011 and 2030, NCDs including mental illnesses project to cost low- and middle-income countries (LMICs) US$ 21.3 trillion in healthcare costs and lost productive capacities.3 1 For in-depth information on UNDP’s response to NCDs, please see ‘UNDP Issue Brief: Preventing and Controlling Noncommunicable Diseases’: https://www.undp. org/content/undp/en/home/librarypage/hiv-aids/preventing-and-controlling-non- communicable-diseases0.html 2 See UNDP’s Discussion Paper on Addressing the Social Determinants of NCDs; and the World Bank’s Thwarting a Disease Crisis in the Pacific. 3 HSPH and WEF. 2011. ‘The Global Economic Burden of Non-communicable Diseases’. http://www3.weforum.org/docs/WEF_Harvard_HE_ GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf United Nations high-level meetings have highlighted the need for UN agencies, including UNDP, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development.4 NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as unhealthy diet, tobacco use, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. NCDs are linked to ageing, rapid unplanned urbanization, changing consumption patterns and environmental degradation. Many NCD risks are enmeshed with commercial interests which may conflict with public health objectives. Underlying social exclusion, marginalization, discrimination and inequities across different dimensions shape exposure to behavioural and environmental NCD risks, as well as access to basic services. 4 Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (2011); Political Declaration of the Third High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (2018); E/RES/13/2018 United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases. 2The Sustainable Development Goals include a specific target (3.4) to reduce premature mortality from NCDs. Shared gains across the 2030 Agenda for Sustainable Development are possible given the strong relationship between NCDs and priorities such as poverty and inequality reduction, economic growth, climate action and financing for development. Reducing the nine million premature deaths caused by pollution each year5 would, for instance, improve health while protecting the planet. 5 Landrigan, PJ, et al. The Lancet Commission on pollution and health. Lancet 2018; 391(10119); 462-512. The health sector cannot address NCDs on its own: whole-of-government and whole-of- society responses are essential. Differential exposures to behavioural and environmental risk factors for NCDs are often rooted in public policy choices that span sectors beyond health. Achieving coherence across sectors and ministries means confronting conflicts and countering vested interests which may act against public health objectives. UNDP is uniquely positioned to support integrated health and development solutions, building on its development portfolio, partnerships and networks, and country-level presence.6 In line with the SDG 3 ‘Global Action Plan for Healthy Lives and Well-Being for All’, UNDP, in cooperation with WHO, the Secretariat of the WHO Framework Convention on Tobacco Control (WHO FCTC), the broader UN Inter-Agency Task Force on NCDs and other partners, supports governments in all regions to implement or strengthen whole- of-government NCD responses. This support centres on strengthening national capacity, leadership, governance, multisectoral action and partnerships to accelerate country responses. UNDP leverages its core competencies in areas that intersect with NCD prevention and control, including access to basic services, poverty and inequality reduction, environment and energy, good governance, sustainable financing, gender, and south-south and triangular cooperation. 6 UNDP’s Discussion Paper on Addressing the Social Determinants of NCDs outlines entry points for development actors. https://www.undp.org/content/dam/undp/ library/hivaids/English/Discussion_Paper_Addressing_the_Social_Determinants_ of_NCDs_UNDP_2013.pdf 2. UNDP has a role to play in supporting countries to prevent and control NCDs Responding to the Challenge of NCDs: UNDP 3UNDP’s work on NCDs promotes effective and inclusive governance for health, a priority of its ‘HIV, Health and Development Strategy 2016–2021’.7 It aligns with its ‘Strategic Plan 2018–2021’,8 which recognizes the direct relationship between health, poverty eradication and other development aims. UNDP has reviewed the recommended World Health Assembly-endorsed policy options to identify those that are linked to UNDP’s work at global, regional and country level. Five indicative examples are given in the table. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.9 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 7 UNDP (2016). HIV, Health and Development Strategy 2016-2021. http://www.undp. org/content/undp/en/home/librarypage/hiv-aids/hiv--health-and-development- strategy-2016-2021.html 8 UNDP Strategic Plan, 2018-2021. http://undocs.org/DP/2017/38 9 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. http://apps.who.int/iris/bitstream/ handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf Evidence-based interventions UNDP actions Raise public and political awareness, understanding and practice about prevention and control of NCDs. Support non-health ministries to understand how NCDs impact their sector, and how they can support the national response.10 Work with parliamentary unions/associations to highlight the role for parliamentarians in NCD advocacy and in ensuring NCD-sensitive legal environments. Integrate NCDs into the social and development agenda and poverty alleviation strategies. Support countries to establish NCD prevention and control and tobacco control as development priorities within their national planning instruments/SDG action plans and corresponding UN Sustainable Development Frameworks.11 Prioritize and increase, as needed, budgetary allocations for prevention and control of NCDs, without prejudice to the sovereign right of nations to determine taxation and other policies. Work with partners to support ministries of health to develop national investment cases for scaled-up action. Analyse institutions and contexts to advance policy coherence, financing opportunities, and institutional roles and accountabilities. Develop and implement a national multisectoral policy and plan for the prevention and control of NCDs through multi-stakeholder engagement. Work with partners to support the drafting, costing and adoption of ambitious national NCD and tobacco control strategies, establishment of functional national and/ or subnational coordination mechanisms, and the passing, enforcement and monitoring of effective NCD-related legislation. Engage and mobilize civil society and the private sector as appropriate and strengthen international cooperation to support implementation of the action plan at global, regional and national levels. Strengthen the capacity of civil society organizations to advocate for multisectoral NCD action including through community mobilization and by linking with HIV/AIDS, TB and environment and climate communities. 10 UNDP and WHO have jointly produced a series of briefs on ‘What Government Ministries Need to Know about Non-communicable Diseases’. https://www.undp. org/content/undp/en/home/librarypage/hiv-aids/what-government-ministries- need-to-know-about-non-communicable-diseases.html 11 UNDP and WHO have developed a Guidance Note for UN Country Teams and governments on how to integrate NCDs into UN Development Assistance Frameworks. https://www.undp.org/content/undp/en/home/librarypage/hiv-aids/ guidance-note-NCDs-UNDAF.html; With the Convention Secretariat of the WHO FCTC, UNDP has developed guidance on integrating the WHO FCTC into UN and national development planning instruments. https://www.undp.org/content/ undp/en/home/librarypage/hiv-aids/development-planning-and-tobacco-control-- integrating-the-who-fr.html Responding to the Challenge of NCDs: UNDP 4UNDP and WHO are implementing a Global Joint Programme (GJP) on NCD Governance, with support from the Russian Federation. For LMICs, the GJP aims to support the development of national NCD investment cases, strengthen national coordinating mechanisms and municipal action, and integrate NCDs into domestic SDG frameworks. GJP assesses and seeks to expand fiscal space for universal access to NCD-related health services, while driving legislation, policies and targeted interventions for prevention. Through the FCTC 2030 project, conducted with the assistance of the UK and Australian Governments, UNDP is working with the Convention Secretariat of the WHO FCTC and WHO to support 15 LMICs in developing investment cases for accelerated implementation of the WHO FCTC. UNDP supports national coordination, the development and implementation of country-specific tobacco control plans, integrating tobacco control into broader SDG implementation efforts, and capacity building including for parliamentarians. UNDP supports national governments in the procurement of health products for NCDs, for example medicines for diabetes and cancer. In 2017 this procurement totaled approximately US$ 94 million. With the Global Environment Facility, UNDP manages over 800 projects across 141 countries on environmental challenges. Many projects support the NCD response. Examples include projects which reduce use of and people’s exposure to hazardous chemicals, and sustainable transport projects which support the construction of lanes for cycling (this promotes physical activity while reducing air pollution from vehicle emissions).12 12 UNDP (2018). Annual Performance Report 2017 – UNDP Global Environmental Finance Unit. https://www.undp.org/content/undp/en/home/librarypage/poverty- reduction/global-environmental-finance/2017-undp-gef-annual-performance-report. html 3. Partnerships are critical for UNDP in mobilizing an effective response to NCDs Due diligence is required to ensure that all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. Responding to the Challenge of NCDs: UNDP Responding to the Challenge of NCDs: UNDP 5 UNDP, other UN agencies and partners are supporting the implementation of the National Clean Air Programme of the Government of India. This work aims to tackle air pollution, a major cause of premature death from NCDs, through a systematic and coordinated multi-sector approach involving government departments and agencies, the corporate sector, academic institutions, civil society and local institutions. UNDP has extensive expertise in implementing large-scale health programmes, for example through its partnership with the Global Fund to Fight AIDS, Tuberculosis and Malaria. UNDP is working to ensure that Global Fund grants, where appropriate, address interactions between infectious diseases and NCDs and their risk factors.13 In the Pacific region, UNDP is managing a multicountry Global Fund programme to ensure that national tuberculosis guidelines include elements of the WHO ‘Collaborative Framework for Care and Control of Tuberculosis and Diabetes’.14 13 In 2015, the Global Fund approved a framework for financing interventions that respond to co-infections or co-morbidities that can exacerbate HIV, TB or malaria. https://www.theglobalfund.org/media/4167/bm33_11-co-infectionsandco- morbidities_report_en.pdf 14 UNDP and the Convention Secretariat of the WHO FCTC have produced an Issue Brief to support Global Fund applicants in integrating tobacco cessation into Global Fund HIV and TB grants. http://www.undp.org/content/undp/en/home/librarypage/ hiv-aids/integrating-tobacco-control-into-tuberculosis-and-hiv-responses.html UNDP plays a role in driving investments and efficiencies related to NCD prevention and control. Actions include but are not limited to: • supporting partners to advocate for the establishment of a multidonor trust fund to enable countries to catalyse financing on NCDs and mental health while strengthening policy coherence at the country level;15 • providing targeted technical support to countries to analyze the return on investment (ROI) in select NCD and tobacco control interventions, and to consider ROI in allocating resources to the national response; • strengthening partnerships and programmes oriented around “best buys” (e.g. the SAFER initiative to support countries to tackle harmful use of alcohol) as well as emerging relevant programmatic areas (e.g. air pollution); • supporting domestic financing for NCD responses including through innovative taxation measures for tobacco, alcohol, sugar-sweetened beverages and other health- harming products. Globally, increased taxes on tobacco, alcohol and sugary beverages could avert 50 million premature deaths and raise US$ 20.5 trillion in revenue over the next 20 years,16 while delivering benefits across the SDGs;17 and • collaborating with development banks to ensure that NCD loans seek to strengthen public health legislation and regulations to prevent NCDs, in addition to focusing on health system strengthening. 15 In line with ‘Time to Deliver’, the Report of the WHO Independent High-level Commission on Noncommunicable diseases. https://apps.who.int/iris/bitstream/ handle/10665/272710/9789241514163-eng.pdf?ua=1 16 Task Force on Fiscal Policy for Health. 2019. Health Taxes to Save Lives: Employing Effective Excise Taxes on Tobacco, Alcohol, and Sugary Beverages. https://www. bbhub.io/dotorg/sites/2/2019/04/Health-Taxes-to-Save-Lives.pdf 17 Sugar, Tobacco, and Alcohol Taxes (STAX) Group. Sugar, tobacco, and alcohol taxes to achieve the SDGs. Lancet 2018, 391(10138): 2400-2401. https://www.thelancet. com/journals/lancet/article/PIIS0140-6736(18)31219-4/fulltext 4. Mobilizing resources to deliver Responding to the Challenge of NCDs: UNDP 6 The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the UNDP as part of a set of United Nations system agency briefs under the Task Force Photo credits: © World Bank via Flickr; page 5 © Omer Sadaat via The Global Fund 1 Responding to the Challenge of NCDs: UNFPA United Nations Population Fund Responding to the Challenge of Non-communicable Diseases 1.There are strong links between protecting and promoting sexual and reproductive health and rights, and preventing and controlling non-communicable diseases NCDs have a significant impact on the sexual and reproductive health of both men and women.1 • Obesity, hypertension and diabetes during pregnancy lead to poorer maternal and neonatal outcomes. • Tobacco use, by both pregnant women and other family members, adversely affects the foetus, newborn and children, as does maternal alcohol consumption. • Lack of breastfeeding increases the risk of NCDs in later life. • Poor diet, tobacco, alcohol and exposure to chemicals also affect fertility, reducing sperm viability and increasing erectile dysfunction in men. • Harmful use of alcohol increases the risk of unprotected sex, unintended pregnancies, HIV and other STIs including human papilloma virus (HPV), as well as the risk of domestic and gender-based violence. 1 Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (2011); Political Declaration of the Third High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable diseases (2018); E/RES/2018/13 United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases. United Nations high-level meetings have highlighted the need for UN agencies, including UNFPA, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development.1 NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in developing countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. Premature deaths from NCDs are largely preventable by encouraging women, men and young people to reduce their use of tobacco and consumption of harmful amounts of alcohol, adopt a healthy diet and step up their levels of physical activity. Cervical cancer is a global public health issue and can largely be prevented by vaccinating 9 to 13-year-old girls and boys against HPV. Penile and oropharyngeal cancers can also be prevented through HPV vaccination. Mental health is now an integral part of the NCD agenda and post-natal depression is considered a major public health issue. 2 Responding to the Challenge of NCDs: UNFPA NCDs are an increasing priority for UNFPA. By expanding its activities to include the prevention and control of NCDs, UNFPA will have a significant impact on reducing the current and future NCD burden. By tackling NCDs, UNFPA contributes to a direct improvement in maternal and neonatal health outcomes. UNFPA can support sexual and reproductive health and rights (SRHR) policy-makers and service providers to help young people and women of childbearing age reduce their exposure to, and use of tobacco and alcohol, and promote healthy diets and physical activity. Ante- and postnatal care also provide significant opportunities for the detection, prevention and management of diabetes and high blood pressure in women. UNFPA promotes exclusive breastfeeding for at least the first six months of life. Breastfeeding has long-term benefits for mothers and children in reducing the risk of NCDs. Several UNFPA programmes strengthen services which provide support to women with postpartum depression and other psychosocial conditions that impact them and their families. UNFPA is making a significant contribution to the elimination of cervical cancer globally by supporting countries in their efforts to scale up HPV vaccination, as well as through cervical cancer screening and early diagnosis activities as part of comprehensive cervical cancer control programmes. 2. UNFPA has a role to play in supporting countries to prevent and control NCDs in line with UNFPA’s commitment to improve public health throughout the lifecycle. UNFPA works with men and boys to reduce gender-based violence: this includes reducing the exposure to, and harmful use of alcohol by men in order to lessen alcohol-related violence. UNFPA is also committed to raising awareness about the socioeconomic impact of an ageing population, including the impact of NCDs in this group. In relation to this activity, UNFPA supports national censuses and demographic health surveys in order to improve population projections and strengthen policy and planning, including NCD programming. UNFPA has reviewed the cost-effective interventions endorsed by the World Health Assembly in order to identify those that are linked to UNFPA’s work at global, regional and country level: specific examples are given in the table. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.2 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 2 WHO. 2017. ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf. 3 Responding to the Challenge of NCDs: UNFPA Evidence-based interventions UNFPA actions Promote and support exclusive breastfeeding for the first six months of life. Exclusive breastfeeding is promoted by midwives as part of their comprehensive antenatal and postnatal care interventions and services. Preconception care among women of reproductive age who have impaired glucose tolerance or diabetes, including patient education and intensive glucose management. Midwives and other antenatal care providers include diabetic screening and management, specifically for expectant women in antenatal clinic settings, and via outreach services where possible. Human papillomavirus vaccination (2 doses) for 9 to 13-year-old girls and boys. UNFPA supports delivery of HPV vaccination through primary health care services and school vaccination programmes. Prevention of cervical cancer by screening women aged 30–49 years. UNFPA is assisting countries to strengthen cervical cancer screening and referral for treatment from family planning, HIV and primary health care services. Screening with mammography (once every two years for women aged 50–69 years) linked with timely diagnosis and treatment of breast cancer. Breast cancer screening services are being supported by a limited number of UNFPA country offices. Comprehensive sexuality education (CSE). Governments are supported in implementing “in and out-of-school” CSE programmes: these promote healthy behaviour patterns, reduce NCD risk factors and endeavour to lessen unprotected sex in order to lower the incidence of unplanned pregnancies and STIs including HPV. Promote tobacco avoidance and cessation in young people. Through adolescent CSE and SRH services, youth community centres and peer outreach programmes, young people are supported in making healthier life choices that reduce their exposure to NCD risk factors. Implement nutrition education and counselling in order to increase the intake of fruit and vegetables and reduce salt intake. Promote physical activity. UNFPA is a member of the UN Joint Global Programme on Cervical Cancer Prevention and Control, which assists countries to reduce the burden of cervical cancer via the WHO-led Global Cervical Cancer Elimination Initiative. UNFPA is an adviser to GAVI and a number of countries in rolling out HPV vaccination as part of adolescent health, screening and treatment programmes. At the regional level, UNFPA is working to strengthen the capacity of service providers, especially in delivering cervical cancer screening and treatment programmes. For example, in Eastern Europe and Central Asia, UNFPA has developed a training programme for health care providers in cervical cancer screening and treatment. UNFPA is supporting the rolling out of HPV vaccination in the Arab States and is currently contributing to regional training programmes, as well as to assessments of NCD prevention and control needs, including opportunities for scaling up the “best buys”. UNFPA country programmes provide backing for the strengthening of safe motherhood programmes in all countries, as well as for developing partnerships with youth and women’s organizations to include activities in favour of NCD prevention. 3. Partnerships with UN and other development agencies are critical for UNFPA in mobilizing an effective response to NCDs Due diligence is required to ensure all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. 4 Responding to the Challenge of NCDs: UNFPA While UNFPA’s focus is on improving sexual and reproductive health and rights, it is increasingly looking to identify opportunities to mobilize resources for incorporating NCD prevention and control into its programmes, in the expectation that these efforts will have a direct impact on improving sexual and reproductive health for all. 4. Mobilizing resources to deliver Photo credits (from top clockwise): © UNFPA ©World Bank via Flickr (also page 2) © UNV The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by UNFPA as part of a set of United Nations system agency briefs under the Task Force 1 Responding to the Challenge of NCDs: UNICEF United Nations Children’s Fund Responding to the Challenge of Non-communicable Diseases 1. Many NCDs have their origins in early life NCDs undermine children and adolescents’ right to health, nutrition, education and play. Each year, about 1.2 million children and adolescents aged under 20 die from often treatable NCDs such as chronic respiratory diseases and cancers, accounting for 13% of overall NCD mortality. NCD risk factors, e.g. childhood overweight and obesity, have a negative impact on children’s mental and emotional well-being, peer relations, learning and opportunities to participate in education and recreation. Exposure to NCD risk factors is often established very early in life. Prenatal maternal undernutrition and/or low birthweight predispose an individual to obesity, high blood pressure, heart disease and diabetes later in life. Maternal obesity and gestational diabetes are associated with cardiovascular disease and diabetes in both mother and child. Childhood and adolescence are also periods when behaviours which lead to the onset of NCDs are adopted including tobacco use, alcohol use, unhealthy diets and physical inactivity as well as unsafe sex (which can result in the spread of HPV, a cause of cervical cancer). These behaviours contribute to an estimated 70% of premature deaths in adulthood. United Nations high-level meetings have highlighted the need for UN agencies, including UNICEF, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs account for 14.6% of all-cause mortality and 24.8% of disability-affected life years (DALYs) amongst children and adolescents. Exposure to NCD risk factors may begin before or during pregnancy and continue during infancy and childhood and adolescence, underlining the importance of action across these age groups Childhood and adolescence are periods where significant impact can be made in risk reduction through evidence-based interventions on diet, physical activity, tobacco and alcohol consumption Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. Children and adolescents are often targeted by companies producing, marketing and/ or selling unhealthy products (e.g. tobacco, alcohol and foods high in fat, sugar and/or salt). Many children and adolescents also grow up in built environments that are not conducive to healthy behaviours (e.g. urban areas that combine limited opportunities for physical activity, exposure to unsafe roads and high levels of air pollution). 2 Responding to the Challenge of NCDs: UNICEF Children and adolescents with NCDs, or those tasked to provide care for family members with NCDs, have lower educational attainments and less access to employment opportunities, leading to an increased risk of financial insecurity later in life. In addition to the psychological impact on offspring, NCD- linked adult illness and premature death are associated with household poverty, food insecurity, social stigma and an increased work burden on children. NCDs can contribute to gender inequality as they usually present a need for long- term caregiving which historically is disproportionately borne by female family members. NCD risk factors, such as alcohol and tobacco use, are also linked with child deprivation and violence against children, especially girls. The UNICEF Strategic Plan for 2018–2021 has strong links to NCD prevention and control, namely: • enhancing maternal, newborn and child health to reduce NCD risks; • improving immunisation, particularly against human papillomavirus (HPV); • preventing low birth weight, stunting, and other forms of malnutrition, including overweight and obesity; • preventing and treating HIV (HIV and its treatment increase the risks of NCDs and related problems); • investing in early childhood development (positive and responsive parenting); 2. UNICEF has a role to play in supporting countries in preventing and controlling NCDs • addressing adolescent health and nutrition (e.g. developing inclusive, multisectoral and gender-responsive national plans for adolescent health and well-being which included reducing behavioural risk factors for NCDs); and • adolescent mental health, suicide and road safety. Given its focus on childhood and adolescence and its cross-sectoral approach, UNICEF is well positioned to integrate early prevention of NCDs and their risk factors into its work. UNICEF has reviewed the recommended cost-effective NCD interventions endorsed by the WHA to identify those that are linked to UNICEF’s work at global, regional and country levels. Many of the recommended “best buy” interventions are already being implemented by UNICEF’s country offices (e.g. breastfeeding promotion), while some require the promotion of new activities (e.g. school-based policies and programmes, supportive infrastructure for active transportation in road safety programmes) and a focus on preconception health for females and males. Some areas of current and potential programming in relation to the “best buys” are highlighted in the table on page 3. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.1 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 1 WHO. 2017. ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf. 3 Responding to the Challenge of NCDs: UNICEF Evidence-based interventions UNICEF actions Advocate for legislation on food regulation and taxation. On the global platform, UNICEF has been at the forefront of breastmilk substitute regulation. UNICEF has been engaged with global level advocacy on the regulation of food composition and marketing and has promoted food labelling. UNICEF has also worked at global and country level to advocate for fiscal measures to control the consumption of sugar- sweetened beverages. Promote and support exclusive breastfeeding for the first 6 months of life, including promotion of breastfeeding. UNICEF’s Nutrition programme focuses on protection, promotion and support for exclusive breastfeeding for the first six months of life and continued breastfeeding with safe and adequate complementary feeding up to two years and beyond as well as promoting a healthy diet and addressing multiple micronutrient deficiencies among children aged 6–23 months. Implement nutrition education and counselling in different settings (e.g. preschools, schools, workplaces, health clinics and hospitals) to increase the intake of fruits and vegetables. To advance UNICEF’s Nutrition programme on NCDs and nutrition, guidance documents on the prevention of overweight and obesity, school nutrition and nutrition among adolescents are currently under development. Implement mass media campaign including social marketing on healthy diets to reduce the intake of total fat, saturated fats, sugars and salt, and to promote the intake of fruits and vegetables. UNICEF’s Communication for Development (C4D) programme can contribute to advocacy and community engagement efforts by creating an enabling policy and legislative environment for NCD prevention: this can engage communities, amplify the voices of affected children and adolescents, encourage participation particularly of adolescents and guarantee that governments and other stakeholders deliver on NCD prevention and control. Implement whole-of-school programmes that include quality physical education, availability of adequate facilities and programmes to support physical activity for all children. The UNICEF Education programme plays a significant role in NCD prevention through its preschool, primary and secondary school programmes for children over five years, and for adolescents. Developing and supporting whole-of-school policies and programmes that protect children and adolescents from harmful subsidies, encourage physical activity and address healthy diets are all potential entry points for UNICEF action. Implement community-wide public education and awareness campaign for physical activity which includes a mass media campaign combined with other community-based education, motivational and environmental programmes aimed at supporting behavioural change and physical activity levels. Through its Community Health programme, UNICEF is able provide support to mass media campaigns and targeted community-based health promotion activities via community health and social worker platforms. Primary prevention of rheumatic fever and rheumatic heart diseases by increasing appropriate treatment of streptococcal pharyngitis at the primary care level. UNICEF’s community and child health service delivery infrastructure, part of its Integrated Management of Childhood Illness programme, has the capacity to promote early detection and effective treatment of rheumatic fever as a preventive measure against rheumatic heart disease. Vaccination against HPV (2 doses) of 9- to 13-year-old girls. These campaigns are part of UNICEF’s Extended Programme on Immunization and delivered via in-country programmes. Prevention of liver cancer through hepatitis B immunisation. 4 Responding to the Challenge of NCDs: UNICEF Guidance on UNICEF’s approach on early life prevention of NCDs was issued in 2019. The UNICEF Strategy for Health 2016–2030 covers four areas that enable action at country level. Across these areas, there are many opportunities for UNICEF to strengthen its support to national NCD responses. Advocate for legislation on food regulation and taxation. Promote comprehensive laws that reduce the direct and indirect exposure of children and adolescents to tobacco, alcohol, illicit drugs, unhealthy foods and beverages, polluted air, water and soil (or polluted environment) and unsafe roads. Encourage school and community-based initiatives that enable healthy lifestyles and promote healthy food and physical activity. Reinforce health systems that, in coordination with education and social services, deliver NCD prevention, screening and care. Foster environmental initiatives that encourage physical activity and healthier diets (e.g. through sustainable transport and urban planning for health that prioritizes walkability and active mobility, in particular for school environments and safe and clean routes for schoolchildren). Target actions on environmental pollution monitoring, prevention and control. Integrate pollution control and NCD agenda. Pollution accounts for 22% of all deaths from cardiovascular disease, 53% of deaths from chronic obstructive pulmonary disease (COPD) and 40% of deaths from lung cancer). Identify data gaps and strengthen mechanisms for the collection and monitoring of NCD risk and related data across sectors. Influencing government policies. Provide technical support, convene stakeholders, facilitate knowledge exchange and mobilize resources to support governments in evidence-based policy-making and financing, including the adoption and implementation of laws, policies and programmes to protect children and adolescents from exposure to NCD risk factors. Make pollution prevention a core component of the intersectoral NCD agenda. Support the development of programmes for protective environments that discourage risk behaviours and support and protect health. Compile lessons learned, promote direct knowledge exchange between countries and foster South-South collaboration on effective strategies, policies and interventions. Strengthening service delivery Address NCDs more effectively across the lifecycle by leveraging existing platforms such as primary health care (PHC) facilities, community health platforms, schools and child protection systems,2 as well as guaranteeing clean and safe environments. Empowering communities Work with local civil society organizations (CSOs), governments and other local influencers to create demand for NCD prevention; use information and communication technologies (ICTs) to increase knowledge on healthy behavior patterns; and develop compelling and contextually appropriate messages to promote NCD prevention, delivered via communication-for- development (C4D) multimedia strategies. 2 UNICEF-supported maternal, newborn and child health programmes are well positioned to further integrate NCD prevention. 5 Responding to the Challenge of NCDs: UNICEF 3. Partnerships are critical for UNICEF in mobilizing an effective response to NCDs In addition to strengthening partnerships with governments, UNICEF can advance strategic partnerships with UN and multilateral partners. Examples include: • United Nations Population Fund (UNFPA), particularly programmes addressing antenatal care (ANC), HPV and risk factors during adolescence; • UN Women on gender policy; • Food and Agriculture Organisation (FAO) and World Food Programme (WFP) on nutrition and agriculture; • Gavi Alliance on HPV and hepatitis C; • World Bank and regional development banks on infrastructure programmes, financing and taxation; • United Nations Educational, Scientific and Cultural Organization (UNESCO) on health education and physical activity; • UN Environment Programme on clean, safe and healthy environments; • United Nations Development Programme (UNDP) on whole-of-government and whole- of-society NCD responses; • UN-Habitat on sustainable urban mobility; and • WHO on data/evidence/policy on prevention and control of pollution-related NCDs. UNICEF is also able to strengthen its collaboration with civil society on the prevention and control of NCDs, e.g. through NCD Child, NCD Alliance, Global Alliance for Improved Nutrition (GAIN), Child Health Initiative and EAT Foundation,3 including the EAT Food Forum. Engagement with the private sector can help leverage business data and expertise, e.g. to generate evidence, while business assets, technology, communications and outreach can be developed to deliver services or promote behaviour change on a large scale. 3 For example, UNICEF and EAT have initiated a collaboration, Children Eating Well (CHEW), to conduct research into and evaluate interventions related to food environments and children’s interactions with them, particularly in the urban context. Due diligence is required to ensure that desired results are obtained from private sector engagement, particularly as the activities of some businesses have an impact on children’s well-being through the marketing of tobacco, alcohol, and foods and beverages that are high in fat, sugar and/or salt. Partnerships with some pharmaceutical companies may also pose potential or real conflicts of interest. 6 Responding to the Challenge of NCDs: UNICEF The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the UNICEF as part of a set of United Nations system agency briefs under the Task Force Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr 4. Mobilizing resources to deliver Funding NCD prevention will enable UNICEF to protect children and adolescents from NCD risk factors and their impacts. However, while existing health, nutrition and education programmes can be adapted to include NCD prevention, it should not be assumed that this can be done easily, or at no cost. Nor should it be assumed that governments are always able to finance NCD prevention and control on their own, as many still require technical support to strengthen NCD-related services, policies, plans and programmes. Decision-makers must be made aware of the significant social and economic costs of NCD burdens. In addition to UNICEF’s traditional sources of funding for programmes and advocacy, private sector entities can be a potential source of funding provided they meet due diligence requirements. This technical brief is drawn from the UNICEF Programme Guidance on Early Life Prevention of Non-Communicable Diseases (2019).4 4 The full document can be accessed here: https://unicef-my.sharepoint.com/:b:/g/ personal/rbermejo_unicef_org1/EemhcUrpmFFLrDYURRM2uk8BmDV8IMjS_ LYcXbZOYWbgjg?e=V8frzU 1 Responding to the Challenge of NCDs: The World Bank The World Bank Responding to the Challenge of Non-communicable Diseases 1. The rising burden of NCDs poses a threat to health and development NCDs are a growing concern in all countries. NCDs are projected to rise in low- and middle- income countries (LMICs) by 2030 in line with changing lifestyles, ageing populations, urbanization and other factors. Many countries face a double burden of disease with an unfinished communicable disease burden and a rising NCD epidemic. Likewise, some LMICs face both a high prevalence of childhood stunting and the growing problem of obesity (the number of obese children and adolescents has grown more than tenfold over the past 40 years). NCDs result in increased health care spending and significant economic losses due to the often complex, costly and/or chronic nature of care, as well as to lost productivity. Between 2011 and 2025, NCDs are projected to cost LMICs more than US$7 trillion.1 Households bear the brunt of health care spending on NCDs and have limited financial protection in most LMICs. Considering the impoverishing effect of many NCDs, it will not be possible to attain the equity and financial protection goals of the UHC agenda if NCDs are not addressed. 1 Bloom, D. E., Chisholm, D., Jané-Llopis, E., Prettner, K., Stein, A., & Feigl, A. (2011). From burden to “best buys”: reducing the economic impact of non-communicable diseases in low-and middle-income countries (No. 7511). Available at: https:// www.who.int/nmh/publications/best_buys_summary.pdf. NCDs are defined as cardiovascular disease, cancers, diabetes and chronic respiratory diseases. United Nations high-level meetings have highlighted the need for UN agencies, including WB, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as unhealthy diet, tobacco use, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2 Responding to the Challenge of NCDs: The World Bank Regardless of their income levels, countries should not neglect the NCD burden given its implications for human capital development. Since NCDs are a major cause of premature death, disability and foregone wages, investments in the prevention and treatment of these conditions will improve adult health and economic growth. Investing in cost-effective NCD interventions in poorer countries will generate US$350 billion in economic benefits and save 8.2 million lives by 2030. This is a return of US$7 per person for every dollar invested.2 Financing of NCDs remains inadequate and out of line with the growing burden in LMICs. About 80% of the NCD burden is in LMICs, and NCDs overall represent over two thirds of the global disease burden; financing for NCDs is however concentrated in high- income countries and overseas development assistance for NCDs accounts for less than 3% of total assistance for health.3 NCD prevention requires a multisectoral, whole-of-government, whole-of-society approach which focuses on reducing population exposure to environmental and behavioural risk factors while increasing affordable access to basic services. Integrated care models which are patient-centered and leverage investments in infectious diseases and maternal, newborn and child health will be critical to managing both the rising burden of disease and spiralling costs. Despite several high-level NCD events since 2011, progress remains slow. The third UN High-Level Meeting on NCDs in September 2018 aimed to intensify political support in the context of the SDG agenda with a focus on “reducing premature mortality from NCDs by one third by 2030”, in line with SDG target 3.4. 2 WHO GCM/NCD Working Group on the Inclusion of NCDs in Other Programmatic Areas (2018). Final Report: Working Group on the Inclusion of NCDs in Other Programmatic Areas. Retrieved from https://www.who.int/global-coordination- mechanism/activities/working-groups/3-1-report.PDF?ua=1 3 Health Finance Institute. Addressing the economic burden of underinvestment in NCDs. Available at: http://healthfinanceinstitute.org/ Urgent action is needed to accelerate progress in health service coverage and financial protection, and to address the broader socioeconomic determinants of NCDs. 3 Responding to the Challenge of NCDs: The World Bank The World Bank’s health sector strategy supports countries to accelerate progress towards UHC. Its three main pillars include: (a) expanding financial protection so that no one is tipped into poverty because of catastrophic health spending; (b) increasing coverage of quality health services for the poorest 40% of the population; and (c) fostering a healthy society, including investments that reduce risk factors for NCDs. The prevention and control of NCDs cut across the three pillars. The World Bank responds to client demand to prevent and control NCDs by providing financial support, policy advice and technical assistance to strengthen the health system response and address key risk factors for NCDs. The World Bank has produced analytic work to understand the nature and magnitude of the NCD problem, identify risk factors and propose mitigation measures. It has also conducted expenditure analyses to determine the efficiency of public spending and identify strategies to expand domestic resource mobilization (including through taxation of health-harming products) in order to increase those available for primary health care (PHC). The World Bank plays an important knowledge-sharing role by producing a wide range of knowledge products and sharing experiences and lessons across countries. The Bank has brokered various partnerships to leverage technical and financial support, working in close collaboration with technical agencies, the private sector and UN agencies. 2. The World Bank has a role to play in supporting countries in preventing and controlling NCDs Investment lending is effective for scaling up domestic action on the prevention and control of NCDs The Bank has a diversified portfolio of investment operations in health systems and health services in support of NCDs, totaling about US$1.5 billion (2019): this represents about 12% of the Bank’s overall health, nutrition and population (HNP) lending. Projects include: (a) strengthening early detection and screening for NCDs; (b) promoting NCD risk reduction; and (c) revamping health systems and facilitating transformational reforms to shift attention from costly secondary care to primary health care. Over a half of all NCD health investments are on integrated projects with both disease prevention and chronic disease management activities. Other projects use communicable disease investments to support NCD prevention and treatment. The Bank portfolio also includes roughly US$0.2 billion of non-health investment operations that directly or indirectly contribute to NCD prevention. Examples include: (a) promoting environmental health; (b) expanding the use of safe and efficient cookstoves; (c) enhancing awareness and knowledge; (d) promoting fiscal and regulatory reforms; and (e) reducing the risk of road injuries. 4 Responding to the Challenge of NCDs: The World Bank Protecting Vulnerable People against NCDs in Argentina. NCDs generate a heavy health and economic burden. The US$350 million project (2015–2020) in Argentina aims to improve the readiness of public health facilities to deliver higher quality NCD services for vulnerable population groups and expand the scope of selected services, as well as to protect vulnerable population groups against prevalent NCD risk factors. Regional Programme of Cancer Registries in East Africa. In 2012, sub-Saharan Africa had about 850,000 new cancer cases and 600,000 deaths. The World Bank is supporting Burundi, Kenya, Rwanda, Tanzania and Uganda to strengthen their capacity for collecting, analysing and sharing data on cancers. Access to timely information on the rising cancer disease burden is critical to develop financial protection mechanisms to ensure that households are not impoverished by catastrophic health spending, provide quality services in a timely manner in order to facilitate early detection and treatment, and address risk factors associated with cancers. Leveraging Investments in Infectious Diseases to combat NCDs in Egypt. The World Bank supported a combined national hepatitis C and NCD risk factor (hypertension, high blood sugar and body mass index) screening campaign, with high-level political support from the President. Individuals with hepatitis C and/or at risk of NCDs were enrolled in structured treatment programmes. To date, 49.8 million adults aged of 18 or over have been screened. This innovative initiative demonstrates the potential for leveraging existing infectious disease platforms to address NCDs. Examples of World Bank-funded NCD Interventions Towards Population-Based Screening and Community-Level Outreach for NCDs in India. Tamil Nadu is India’s sixth most populous state and is dealing with a double burden of communicable and non-communicable diseases. Cardiovascular disease, diabetes, and cancer are the leading causes of death for people aged above 40. The World Bank has provided a US$287 million loan to strengthen management of NCDs, with a focus on health promotion and NCD prevention, population- based screening of NCDs among the eligible population, treatment and follow- up, and improvement of NCD monitoring and evaluation. The project aims to support a move from opportunistic screening to population-based screening. Establishment of Health Lifestyle Centres (HLCs) for NCD Screening and Referral in Sri Lanka and Turkey. The World Bank has supported the establishment of Healthy Life Centres at the PHC level for the detection and management of patients with a high NCD risk. In Sri Lanka this is being done by strengthening PHC capacity, population screening and better treatment and follow-up. Performance-Based Financing for NCDs in Tajikistan. Ischaemic heart disease is one of the leading causes of death in Tajikistan. The World Bank is supporting the government’s performance-based financing scheme to improve the coverage and quality of basic primary health services in rural health facilities in 10 districts. Under this supply-side project, the Ministry of Health contracts rural health centers to enhance both the quantity and quality of NCD services, providing coverage in about 450 health facilities to approximately 15 percent of the country’s total population. 5 Responding to the Challenge of NCDs: The World Bank Analytic work and knowledge management: Linking evidence to operations The Bank undertakes a wide range of country, regional and global studies to better understand and address the risk factors associated with NCDs, as well as to provide an analytic underpinning for investment lending and inform public policy. Examples are given in the box. The World Bank Group’s Global Tobacco Control Programme supports knowledge exchange among selected countries on the economics of tobacco control. Experts in health, governance and macroeconomic and financial management, poverty and equity, agriculture and trade engage actively in this programme, which is a win-win for both public health and domestic resource mobilization.4 The programme assists countries to design tobacco tax policy reforms and increase tobacco tax rates in order to: (a) achieve public health goals by increasing prices, reducing smoking, and preventing initiation among youth; (b) raise domestic resources for investments that benefit the entire population; and (c) enhance equity by reducing the health risks associated with tobacco-attributable diseases and the risk of impoverishment due to high out-of-pocket expenditure among the lowest income population groups. Achievements include providing support for tobacco tax policy reforms in several countries and the launch of the World Bank Group report “Tobacco Tax Reform: At the Crossroads of Health and Development”. 4 The World Bank. Global Tobacco control. https://www.worldbank.org/en/topic/ tobacco Impact of NCDs on Human Capital (2019). The WB is collaborating with several partners to produce a report that describes how human capital and productivity can be enhanced by tackling NCDs, with recommendations for action. This work is part of the World Bank’s Human Capital Project to improve human capital at the country level through investing in health and education. Obesity: A Ticking Time Bomb – What can the World Bank do to Defuse It? (2019). This report highlights the growing epidemic of obesity in both low- and high-income countries, and its health and economic costs. The report lays out the drivers of obesity, lessons learned from obesity-prevention efforts across the globe, and the policy and investment tools that the World Bank can deploy across different sectors to address obesity. How to Improve the Use of Fiscal Policy to Address the NCD Crisis: Lesson Learned from Tonga (2019). Tonga has a very high burden of NCDs. This study generates policy-relevant findings and insights on the implementation of taxation policy on tobacco, alcohol, food and behaviours, pricing, government revenues and the country’s response to the rising NCD burden. The Challenge of NCDs and Road Traffic Injuries in sub-Saharan Africa (2013). This is a comprehensive review of the literature with input from policy-makers, researchers and practitioners. It describes how resource- constrained governments can prevent and control NCDs and increase road safety. The Challenge of NCDs and Road Traffic Injuries in sub-Saharan Africa (2013). This is a comprehensive review of the literature with input from policy-makers, researchers and practitioners. It describes how resource- constrained governments can prevent and control NCDs and increase road safety. 6 Responding to the Challenge of NCDs: The World Bank The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the World Bank as part of a set of United Nations system agency briefs under the Task Force Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr 3. Partnerships are critical for the World Bank in mobilizing an effective response to NCDs The Bank has been an active member of several key partnerships and/or leader in key initiatives (e.g. tobacco control and mental health) to prevent and control NCDs. Examples include: • Access Accelerated. The Bank brokered this partnership with the private sector to leverage funding for pilot projects that aim to support early screening, detection and initial treatment for NCDs in countries such as Kenya and El Salvador. • Union for International Cancer Control (UICC) — City Cancer Challenge. The Bank participated in the UICC-led City Cancer Challenge initiative which supports cities to design, plan and implement cancer treatment solutions to reduce cancer mortality by 2025. • World Bank Umbrella Facility for Gender Equality (UFGE). The UFGE is a multidonor trust fund that aims to strengthen awareness, knowledge and capacity for gender-informed policy-making; it also explores new approaches to improve human capital, such as through the control of NCDs. 1 Responding to the Challenge of NCDs: WFP World Food Programme Responding to the Challenge of Non-communicable Diseases 1. The nutrition and food security sectors are central to an effective response to NCDs WFP is the food-assistance branch of the United Nations (UN), delivering food assistance in developing and emergency contexts, and working with communities to improve nutrition and build resilience. Unhealthy diets1 are a leading risk factor for NCDs. Diet-related NCDs include cancers, diabetes and cardiovascular disease. The right to food must not be reduced to “the right to not starve.”2 Ensuring access to diverse, safe and nutritious foods can prevent NCDs and their impacts on sustainable development. The triple burden of malnutrition— undernutrition and hunger, overweight and obesity, and micronutrient deficiencies— remains unacceptable. Children under five face large and multiple burdens: 149 million are stunted, 49.5 million are affected by wasting, and 40.1 million are overweight.3 1 Unhealthy diets include energy-dense and highly processed foods that are high in refined starches, sugar, fats and/or salt, accompanied by an insufficient intake of fresh fruits and vegetables, wholegrains, pulses, nuts and seeds. FAO (2017). The State of Food and Agriculture 2017: Leveraging Food Systems for Inclusive Rural Transformation. Available at: www.fao.org/3/a-I7658e.pdf. 2 A/HRC/19/59. Report submitted by the Special Rapporteur on the right to food, Olivier De Schutter. Available at: https://www.ohchr.org/Documents/HRBodies/ HRCouncil/RegularSession/Session19/A-HRC-19-59_en.pdf 3 United Nations Children’s Fund (UNICEF), World Health Organization, International Bank for Reconstruction and Development/The World Bank. Levels and trends in child malnutrition: key findings of the 2019 Edition of the Joint Child Malnutrition Estimates. Geneva: World Health Organization; 2019 Licence: CC BY-NC-SA 3.0 IGO. United Nations high-level meetings have highlighted the need for UN agencies, including WFP to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. An approach to the prevention of NCDs requires food system transformation and policies that address aspects of the wider food system, encompassing nutrition, food culture and identity, public food and meals, food loss and waste and sustainable diets. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2 Responding to the Challenge of NCDs: WFP The world is now experiencing record levels of overweight and obesity among adults (38.9%), with trends increasing, particularly among adolescents.4 Supporting good nutrition during the first 1,000 days of life and adopting healthy dietary habits during adolescence can reduce the risk of NCDs later in life. Supporting prematernal and gestational nutrition can reduce NCD risks for both mother and child. WFP supports governments to implement a comprehensive multisectoral package of actions that address the triple burden of malnutrition and the prevention of diet-related NCDs. Through its core work on nutrition and food security, and in collaboration with various stakeholders, WFP is uniquely positioned to contribute to global efforts to address NCDs.5 WFP’s nutrition policy (2017–2021) articulates its role in addressing NCDs and supporting governments to achieve the NCD-related targets in the 2030 Agenda for Sustainable Development. WFP works with government counterparts and partners to develop five-year country strategic plans, which are subsequently endorsed by WFP Executive Board members. A review of the cost-effective interventions endorsed by the WHA identified relevant WFP interventions at the global, regional and country level. Six examples are shown in the table. 4 United Nations Children’s Fund (UNICEF), World Health Organization, International Bank for Reconstruction and Development/The World Bank. Levels and trends in child malnutrition: key findings of the 2019 Edition of the Joint Child Malnutrition Estimates. Geneva: World Health Organization; 2019 Licence: CC BY-NC-SA 3.0 IGO. 5 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf. 2. WFP has a role to play in supporting countries in preventing and controlling NCDs Evidence-based interventions WFP actions Implement mass media campaign on healthy diets including social marketing to reduce the intake of total fat, saturated fats, sugars and salt, and promote the intake of fruits. Work with governments on strategies and programming for social and behavioural change and communication (SBCC), nutrition education and messaging across a variety of electronic and traditional media platforms including social media and press/radio. Related activities have been rolled out in countries, e.g. Sudan, Madagascar and Mozambique. Promote and support exclusive breastfeeding for the first six months of life. Promote infant and young child feeding through existing platforms such as community management of acute malnutrition and food assistance programmes. Implement nutrition education and counselling in different settings (e.g. in pre- schools, schools, workplaces and hospitals) to increase the intake of fruits and vegetables. Support governments to ensure that school meals programmes are nutritious. Support governments to develop policies and programmes in schools to encourage healthy diets. Implement nutrition labelling to reduce total energy intake (kcal), sugars, sodium and unhealthy fats. Work through the SUN Business Network to support governments in encouraging the private sector to strengthen nutrition labelling to inform consumers about total energy intake, sugars, sodium and unhealthy fats. Access to improved stoves and cleaner fuels to reduce indoor air pollution. Country-level implementation of the initiatives contained in the WFP Handbook on Safe Access to Firewood and Alternative Energy. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.5 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 3 Responding to the Challenge of NCDs: WFP WFP collaborates with a range of partners including the UN and the private sector to address malnutrition in all its forms. Partnerships are aimed at strengthening coordination, developing multisectoral policy, enhancing research and development, strengthening logistics and supply chain, and promoting digital technology and education. WFP ensures that partnerships are in the interest of public health. The Scaling Up Nutrition (SUN) Business Network. WFP and GAIN co-convene the SUN Business Network which, at the global and country levels, provides a platform to advance the dialogue on nutrition between the private sector, governments and other stakeholders. Depending on national nutrition priorities and the local private sector setting, efforts of the SUN Business Network may focus on reducing undernutrition, overnutrition or micronutrient deficiencies. Committee on World Food Security (CFS). The CFS is the foremost international and intergovernmental platform to promote food security and nutrition for all. In 2017, CFS started developing a set of voluntary guidelines on food systems and nutrition. Scaling Up Nutrition (SUN) United Nations Network (UNN)/REACH. ‘The SUN UNN/ REACH initiative’ is a partnership between WFP, Food and Agriculture Organisation (FAO), United Nations Children’s Fund (UNICEF), the World Health Organization (WHO) and the International Fund for Agricultural Development (IFAD). Its mandate is to accelerate the scaling up of food and nutrition actions in countries experiencing a high burden of child malnutrition. 3. Partnerships are critical for WFP in mobilizing an effective response to NCDs The UNN was established in 2013 by WFP, Food and Agriculture Organisation (FAO), United Nations Children’s Fund (UNICEF), the World Health Organization (WHO) and the International Fund for Agricultural Development (IFAD). The UNN works in countries to elevate national nutrition dialogue through its senior leadership and helps to leverage the collective strengths of the UN agencies, to foster innovations, find efficiencies and enhance complementarity across agencies and with government and SUN networks. Global Fund. WFP partners with organizations and companies to ensure that food and nutrition assistance is available to communities in some of the world’s hardest- to-reach areas. WFP’s partnership with the Global Fund is addressing logistics and supply chain issues around health and nutrition commodities in countries such as the Central African Republic and Burundi. IASC Humanitarian Cluster Mechanism. WFP is the lead agency in the Logistics Cluster6 (a coordination mechanism to ensure an efficient and effective emergency response, including the provision of NCD-related medicines during emergencies). WFP and FAO co-lead the Food Security Cluster7 (a coordination mechanism for food security response in humanitarian crises). 6 World Food Programme. Logistic cluster. https://www.wfp.org/logistics-cluster 7 Food Security Cluster. Coordinating the food security response in humanitarian crises. https://fscluster.org/ 4 Responding to the Challenge of NCDs: WFP P ho to c re di ts : © W or ld B an k vi a Fl ic kr The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by WFP as part of a set of United Nations system agency briefs under the Task Force Due diligence is required to ensure that all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. 4. Mobilizing resources to deliver WFP leverages existing programmes to drive actions against undernutrition and hunger, overweight and obesity, and micronutrient deficiencies. Priorities include: • Fill the Nutrient Gap (FNG). This tool analyses the nutrition situation in a country and identifies the barriers faced by the most vulnerable in accessing and consuming healthy and nutritious foods; the FNG tool is used to inform government policies and WFP programming. In Madagascar, FNG helped to make the school meal food basket more nutritious. • School meals. Schools can encourage healthy eating among students, their families and communities. WFP’s Regional Bureau in Latin America and the Caribbean (LAC) is currently at the forefront of efforts to address overweight and obesity in schools in the LAC region. As part of the Latin American Network for School Meals initiative, WFP recently published an analysis on how nutrition-sensitive national school meals programmes can address malnutrition (undernutrition, overweight and obesity and micronutrient deficiencies), as well as accelerate progress towards achieving the SDGs (particularly SDG 2 and 3). • Social protection systems. WFP supports governments in the design of nutrition- sensitive social policies, mainstreaming nutrition education and supporting the design of shock-responsive social protection systems. • Social and behaviour change communication. This aims to improve behaviour around access to, selection, preparation and consumption of nutritious foods, to strengthen nutrition education and behaviour change communication in nutrition-specific programmes and to mainstream nutrition education aligned with national food-based dietary guidelines. • Food environments. WFP works to ensure balanced food baskets through diversification and micronutrient fortification, advocates for regulatory policies that improve the availability of safe, nutritious food and work environments, and negotiates with the private sector to increase the availability and marketing of age-appropriate and nutritious food.

RESPONDING TO THE CHALLENGE OF NON-COMMUNICABLE DISEASES United Nations Agency Briefs This set of briefs provides policy advisors and decision-makers across different United Nations agencies, Member States and development partners with information on how the UN system is responding to the challenge of non-communicable diseases (NCDs). The briefs were brought together by the WHO-led United Nations Inter-Agency Task Force on the Prevention and Control of NCDs. Heads of State and Government and representatives of States and Governments… … call upon WHO to continue to exercise its leadership, as the directing and coordinating authority on international health, in order to contribute to Member States’ efforts to prevent and control NCDs by continuing and strengthening its normative and standard-setting work and its capacity to develop and provide technical cooperation, assistance and policy advice to Member States, as well as to enhance its multi-stakeholder engagement and dialogue, including through … the United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases. Paragraph 47, Political declaration of the Third High-level Meeting of the General Assembly on the prevention and control of NCDs.1 Heads of State and Government and representatives of States and Governments… …call upon WHO to continue to promote and monitor enhanced global action to prevent and control NCDs by coordinating work with other UN agencies, development banks and other regional and international organizations.1 Paragraph 48, Political declaration of the Third High-level Meeting of the General Assembly on the prevention and control of NCDs.1 These briefs describe: • the role of the different UN system agency in making an effective contribution to the prevention and control of NCDs;1 • current and potential actions for different agencies to support the World Health Assembly-endorsed “best buys” and other recommended interventions to address NCDs;2 • the importance of partnerships for ensuring that agencies mobilize an effective response to NCDs; • the importance of partnerships in agencies’ response to NCDs; and • how agencies are mobilizing resources to deliver support to Member States. 1 Time to deliver: accelerating our response to address non-communicable diseases for the health and well-being of present and future generations. Political declaration of the Third High-level Meeting of the General Assembly on the prevention and control of NCDs, 2018. http://www.un.org/en/ga/search/view_doc.asp?symbol=A/ RES/73/2 2 WHO. “Best buys” and other recommended interventions for the prevention and control of noncommunicable diseases. 2017. www.who.int/ncds/management/best-buys/en/ The Task Force reports to the Economic and Social Council of the United Nations (ECOSOC) annually. Since 2014, ECOSOC has adopted a resolution each year on the Task Force: 2014: endorses the Task Force’s terms of reference 2015: encourages the Task Force to scale up action in countries 2016: expands the work of the Task Force to the NCD-related SDGs 2017: calls for greater financing for the work of the Task Force 2018: calls for development of partnerships to achieve public health goals 2019: encourages bilateral and multilateral donors, as well as other relevant stakeholders, to mobilize resources to support Member States, to catalyse sustainable domestic responses to NCDs and mental health conditions, including through a dedicated multi-donor trust fund. In the 2030 Agenda for Sustainable Development, adopted in September 2015, Member States recognize NCDs as a leading sustainable development issue. Agenda 2030 provides an enabling framework for identifying and implementing win-win approaches for NCDs and other development priorities. NCDs, principally cardiovascular disease, diabetes, cancer and chronic respiratory disease, are now the world’s biggest killers. Urgent and whole-of-government action is needed to prevent the annual toll of 41 million people dying from NCDs, including 15 million dying prematurely between the ages of 30 and 69 years. Often misconstrued as a problem of high- income countries only, NCDs place an equal—if not greater—burden on low- and middle-income countries (LMICs). Over 85 percent of premature NCD deaths occur in LMICs. Most premature NCD deaths are preventable by taking cost-effective action to tackle four main behavioural risk factors —tobacco use, harmful use of alcohol, physical inactivity and unhealthy diet. Also critical are ensuring affordable access to basic health services, including for mental health, and addressing environmental risks such as air pollution. Tackling NCDs and their risk factors requires a response from government. Sustainable Development Goal 3 on health and well-being includes a specific target relating to the prevention and control of NCDs and several other targets that are NCD-relevant. Achieving the NCD targets will advance the 2030 Agenda broadly, given the strong links between NCDs and poverty, social inequities, lack of access to affordable basic services, economic growth and climate action. 2018 NCD Political Declaration:1 10 takeaways for the UN system 1. 4 x 43 is expanded to 5 x 5 by including mental health conditions and air pollution. 2. Every year, over 15 million people aged 30–70 die from NCDs. Most of these premature deaths could have been avoided. 86% of these deaths occur in developing countries. NCDs will cost developing countries US$ 7 trillion over the next 15 years. 3. While the probability of dying from a major NCD between the ages of 30 and 70 continues to decline (22% in 2000 to 18% in 2016), the rate is insufficient to meet SDG target 3.4.4 4. Cost-effective, affordable and evidence-based interventions exist and need to be scaled up. 5. National NCD investment cases need to be developed to inform countries about the costs of NCDs, the return on investment from prevention and treatment, and links to poverty and socio- economic development. 6. The primary role and responsibility for combating NCDs lies with presidents and prime ministers. 7. Governments need to mobilize civil society and the private sector, where appropriate, to implement national NCDs responses, while giving due regard to managing conflicts of interest. 8. Mechanisms for national multi-stakeholder dialogue and accountability are critical. 9. There is a need to mobilize and allocate adequate, predictable and sustained resources for national NCD responses through domestic, bilateral and multilateral channels, as well as through public-private partnerships. 10. The UN system needs to step up its efforts to meet the requests for technical cooperation from Member States. WHO must continue to lead the UN Inter-Agency Task Force and explore options for innovative financing to support national NCD control efforts. 3 Four diseases (cardiovascular disease, cancer, diabetes and chronic lung disease) and four risk factors (tobacco use, harmful use of alcohol, unhealthy diets and physical inactivity). 4 By 2030, reduce by one third premature mortality from NCDs through prevention and treatment and promote mental health and well-being. WHO/UNIATF/19.98 Publication date: September 2019. © World Health Organization 2019. World Health Organization 2019. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. Photo credits (clockwise): © Nicholas Banatvala © UNDP (2) © Asian Development Bank © UNDP © AMISOM © World Bank © FMSC 1 Responding to the Challenge of NCDs: FAO Food and Agriculture Organization of the United Nations Responding to the Challenge of Non-communicable Diseases 1. The food and agriculture sector is crucial for an effective response to NCDs The food and agriculture sector plays a major role in nourishing people by increasing the availability of and access to diverse, safe and nutritious food, which meets dietary recommendations and principles relating to environmental sustainability.1 Most of today’s food systems need to be re-aligned from the production of high- yielding staple food crops such as cereals to sustainable provision of non-staple foods such as fruits and vegetables that will enhance dietary diversity. Improved food systems need to address all forms of malnutrition, such as overweight and obesity as well as wasting, stunting and micronutrient deficiencies. In today’s food systems, the nutritious foods that make up a healthy diet are not always available or affordable for many people.2 Various UN instruments have re-affirmed several fundamental nutrition- related rights, namely the right to have access to safe, sufficient and nutritious food, as well as the right to be free from hunger.3 The rise in obesity and NCDs is associated with a shift towards energy-dense diets, which are characterized by highly processed foods 1 FAO. 2018. Strengthening sector policies for better food security and nutrition results: food systems for healthy diets. Available at: www.fao.org/3/CA2797EN/ ca2797en.pdf. 2 FAO. 2013. The State of Food and Agriculture 2013: food systems for better nutrition. Available at: www.fao.org/docrep/018/i3300e/i3300e.pdf. 3 FAO & WHO. 2014. Second International Conference on Nutrition, Rome, 19-21 November 2014. Conference Outcome Document: Rome Declaration on Nutrition. Available at: http://www.fao.org/3/a-ml542e.pdf. high in refined starches, sugar, fats, and/or salt, accompanied by an insufficient intake of fresh fruits and vegetables, wholegrains, pulses, nuts and seeds.4 This shift is also coupled with sedentary lifestyles and low levels of physical activity. Most of the world's population now lives in countries where overweight and obesity kill more people than underweight.5 The way we produce, process, store and bring our food to markets is changing rapidly. Food production and supply chains have intensified, 4 FAO. 2017. The State of Food and Agriculture 2017: leveraging food systems for inclusive rural transformation. Available at: www.fao.org/3/a-I7658e.pdf. 5 WHO. 2019. Obesity and overweight [website]. Available at: https://www.who.int/ en/news-room/fact-sheets/detail/obesity-and-overweight. United Nations high-level meetings have highlighted the need for UN agencies, including FAO, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries (LMICs). Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as unhealthy diet, tobacco use, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. becoming industrialized and globalized, with people eating more purchased, processed and packaged food. Large-scale production has led to the use of a narrow range of high-yielding food crop and animal varieties, which has contributed to a reduction in agro-biodiversity. In addition, harmful chemicals used in food production are known to cause cancer. Widespread marketing of foods high in fat, sugar and/or salt, particularly those targeted at children, is a source of concern. This development is related to the steady growth and increasing influence of the private sector, including large-scale international food and agri-businesses and retailers. FAO is uniquely positioned to contribute to global efforts to reduce the prevalence of overweight, obesity and NCDs through the support it provides to countries in reforming their food systems and its work with line ministries responsible for agriculture, trade, environment and rural development, as well as with other UN agencies and development partners. Key areas for FAO engagement include: Situation analyses and awareness raising on how food systems and dietary changes drive overweight, obesity and NCDs. Engaging food systems stakeholders in policy analysis and dialogue, and encouraging them to implement public policy and regulations in order to create an appropriate set of incentives and disincentives to drive change in food systems. Political economy analysis to identify how different sectors impact on food systems and changes required to prevent and control NCDs. 2. FAO has a role to play in supporting countries in the prevention and control of NCDs For the first time FAO’s Medium-Term Plan 2018–2021 and Programme of Work and Budget 2018–2019 explicitly mention the issues of overweight, obesity and NCDs, and refer to the related targets under Sustainable Development Goals (SDGs) 2 and 3.6 FAO has reviewed the recommended cost- effective interventions endorsed by the World Health Assembly (WHA) to identify those linked to FAO’s work at global, regional and country levels. Examples are included in the table. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.7 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 6 FAO. 2017. The Director-General’s Medium-term Plan 2018-21 and Programme of Work and Budget 2018-19. Available at: www.fao.org/3/a-ms278e.pdf. 7 WHO. 2017. ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf. Responding to the Challenge of NCDs: FAO 2 Evidence-based interventions FAO actions Implement mass media campaign on healthy diets, including social marketing to reduce the intake of total fat, saturated fats, sugars and salt, and promote the intake of fruits. FAO supports countries to form action networks to promote healthy diets, nutrition labelling and food reformulation as part of the UN Decade of Action on Nutrition. Limiting portion and package size to reduce energy intake and the risk of overweight/ obesity. FAO supports countries to develop food-based dietary guidelines addressing overweight, obesity and undernutrition.8 Implement nutrition education and counselling in different settings (e.g. preschools, schools, workplaces, hospitals) to increase the intake of fruits and vegetables. FAO implements school- based food and nutrition education programmes, and supports governments to develop policies and programmes in schools to encourage healthy diets. Raise public and political awareness, understanding and practice about prevention and control of NCDs. FAO supports countries to raise awareness on NCDs and their risk factors, including obesity and steps that can be taken to prevent NCDs. Integrate NCDs into the social and development agenda and poverty alleviation strategies. FAO ensures that nutrition- sensitive social protection interventions also tackle the problem of diet-related NCDs. FAO integrates nutrition objectives into food and agriculture policy, programme design and implementation to enhance nutrition-sensitive agriculture, ensure food security and enable healthy diets for the prevention of overweight, obesity and NCDs. FAO supports countries in the development of easy-to-understand labels contributing to sustainable food systems. 8 Food-based dietary guidelines (also known as dietary guidelines) establish a basis for public food and nutrition, health and agricultural policies and nutrition education programmes to foster healthy eating habits and lifestyles. They provide advice on foods, food groups and dietary patterns to provide the required nutrients to the general public to promote overall health and prevent NCDs. See: www.fao.org/ nutrition/education/food-dietary-guidelines/en/. UN Decade of Action on Nutrition (2016–2025). In 2016, the UN General Assembly mandated FAO and the World Health Organization (WHO) to lead implementation of the Nutrition Decade with the aim to achieve the global nutrition and diet-related NCD targets by 20259 as well as the nutrition- and NCD-related targets in the 2030 Agenda for Sustainable Development (General Assembly resolution 70/1). It also called on FAO and WHO to accelerate the implementation of commitments made at the 2014 Second International Conference on Nutrition.10 Global Individual Food consumption data Tool (GIFT). FAO/WHO GIFT is an online platform providing individual dietary data that enables policy-makers to answer the question “What are people eating?” and to create better informed public policies for healthy diets.11 Kyoto University. This collaboration includes knowledge exchange, the provision of technical expertise, and awareness raising about urban food policy, food waste, and agriculture modelling, and study of the linkages between climate change and sustainable food and agriculture systems. The Rockefeller Foundation. Established in 2016, this partnership supports food security and seeks to reduce food losses by expanding the capacity of small-scale producers in sub- Saharan Africa. UN Habitat. This collaboration involves building resilient food systems by improving rural-urban food supply chains, e.g. in Kenya. 9 UN. 2019. UN Decade of Action on Nutrition [website]. Available at: www.un.org/ nutrition/. 10 FAO. 2014. The Second International Conference on Nutrition (ICN2) [website]. Available at: www.fao.org/about/meetings/icn2/en/. 11 More information on this tool is available at: www.fao.org/gift-individual-food- consumption. 3. Partnerships are critical for FAO in mobilizing an effective response to NCDs Responding to the Challenge of NCDs: FAO 3 Consumers International. This partnership aims to enhance Consumer International’s (CI) access to FAO’s wealth of knowledge and information while allowing FAO to work more closely with the network of CI membership organizations across the world which liaise with and advocate for individual consumers. In Latin America and the Caribbean, for example, both organizations cooperate to support the development of public policies for improved access to nutritious food and nutritional information. World Obesity Federation. This partnership, recently formalized in a memorandum of understanding, will increase awareness of the agriculture and food systems-related policy measures that have led to the current overweight and obesity situation and related disease burdens. FAO has developed a portfolio of programme priorities12 and invited partners to increase their investment in food and agriculture to improve health and achieve the SDGs. Among the NCD-related priorities are: • Tackling obesity through sustainable food systems: transforming food systems for health and well-being. • Food and green environments for healthy cities: improving the accessibility of nutritious food and green spaces for all. 12 FAO. 2019. Business development portfolio: opportunities to invest in sustainable development, 2019–2020 cycle. Available at: http://www.fao.org/3/ca4265en/ ca4265en.pdf. 4. Mobilizing resources to deliver Due diligence is required to ensure that all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by FAO as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. Responding to the Challenge of NCDs: FAO 4 1 Responding to the Challenge of NCDs: FCTC Secretariat of the WHO Framework Convention on Tobacco Control and Protocol to Eliminate Illicit Trade in Tobacco Products Responding to the Challenge of Non-communicable Diseases 1. WHO FCTC and its Protocol are essential legal instruments to ensure the attainment of global NCD targets Tobacco use is responsible for one in six deaths from NCDs. While gains have been made by many countries on tobacco control, the fact remains that approximately 80% of the world’s one billion smokers live in low- and middle-income countries: the tobacco industry is constantly looking for new markets in these countries and blocking tobacco control efforts.1 Governments negotiated and adopted the WHO FCTC in 2003. This evidence-based treaty entered into force in 2005, becoming one of the most rapidly embraced conventions of the United Nations system. Currently there are 181 Parties to the WHO FCTC, representing 90% of the world’s population. The Protocol to Eliminate Illicit Trade in Tobacco Products was adopted in 2014, entered into force in 2018 and currently has 56 Parties. The Meeting of the Parties (MOP) was established in 2018 and has put into motion the mechanisms for implementing the Protocol.2 1 UNGA, Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, A/RES/66/2 (2011); UNGA, Political Declaration of the Third High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (2018); United Nations, Economic and Social Council, United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases, E/RES/2018/13 (2018). 2 WHO FCTC Secretariat, Protocol to Eliminate Illicit Trade in Tobacco Products (2013). Available at: https://www.who.int/fctc/protocol/illicit_trade/protocol- publication/en/ United Nations high-level meetings have highlighted the need for the UN to scale up its work on NCDs as part of the 2030 Agenda for Sustainable Development.1 NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in developing countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioral risk factors, such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2 Responding to the Challenge of NCDs: FCTC Two MOP working groups have been established: one on tracking and tracing systems and another on assistance and cooperation.3 The Convention Secretariat (CS) is also the Secretariat of the Protocol. The political declarations of the high-level meetings of the General Assembly on the prevention and control of NCDs called on full implementation of the WHO FCTC while continuing to implement tobacco control measures without any tobacco industry interference; it urged Member States who have yet to ratify the WHO FCTC to accelerate the ratification process. Target 3.a of the Sustainable Development Goals (SDG2030) calls for strengthening the implementation of the WHO FCTC, which also contributes directly to Target 3.4 on prevention and control of the NCDs. Tobacco control can accelerate sustainable development in all its social, economic and environmental dimensions,4 and contributes to other health issues beyond those relating solely to NCDs, e.g. by addressing HIV and tuberculosis co-morbidities,5 maternal and child health, reproductive health and universal health coverage. Target 5 of the WHO Global NCD Action Plan 2013–2020 is a 30% relative reduction in the prevalence of current tobacco use in persons aged 15 years and over. 3 WHO FCTC Secretariat, Establishment of Expert and Working Groups to advance global tobacco control (2019). Available at: https://www.who.int/fctc/mediacentre/ news/2019/expert-working-groups-cop-mop-advance-tobacco-control/en/ 4 WHO FCTC Secretariat and UNDP, The WHO Framework Convention on Tobacco Control an Accelerator for Sustainable Development (2017). Available at: https:// www.who.int/fctc/implementation/publications/who-fctc-accelerator-for- sustainable-development/en/ 5 WHO FCTC Secretariat, Issue Brief: Integrating Tobacco Control into Tuberculosis and HIV Responses (2018). Available at: https://www.who.int/fctc/publications/ WHO-FCTC-HIV-TB.pdf?ua=1 As a legally binding instrument, the WHO FCTC is a powerful mechanism that reaffirms the right of all people to the highest standard of health. In 2018, the Conference of the Parties (COP)6 adopted the Global Strategy to Accelerate Tobacco Control: Advancing Sustainable Development through the Implementation of the WHO FCTC 2019–2025 (GS2025). The Strategy seeks to make a meaningful contribution to reaching the overall health goal of SDG 3 and target 3.4 on NCDs. Furthermore, the Strategy adopted the voluntary global target of “a 30% reduction in the age-standardized prevalence of current tobacco use in persons aged 15 years and over by 2025” as its own overall target, thus harmonizing WHO FCTC implementation with global NCD efforts. The COP has recognized the strong contribution it can make to achieving the global NCD target on the reduction of tobacco use. Subsequently, the COP has called upon Parties to integrate WHO FCTC implementation with national multisectoral NCD policies. It also requested the Convention Secretariat to promote WHO FCTC implementation as an essential and high-impact strategy for achieving SDG target 3.4, and report on the efforts taken in the next COP sessions. Protecting public health policies from the commercial and vested interests of the tobacco industry and establishing measures7 to protect the integrity of the decisions adopted by the governing bodies of WHO FCTC and its Protocol is at the core of the Parties’ obligations under the Convention and its protocols. 6 The Conference of the Parties (COP) is the governing body of the WHO FCTC and is comprised of all Parties to the Convention. The work of the COP is governed by its Rules of Procedure and keeps under regular review the implementation of the Convention: it takes decisions necessary to promote its effective implementation and may also adopt protocols, annexes and amendments to the Convention. For more information: https://www.who.int/fctc/cop/governance/en/ 7 See decisions FCTC/COP8(4), (12), (18) at https://www.who.int/fctc/cop/sessions/ cop8/decisions/en/ 3 Responding to the Challenge of NCDs: FCTC 2. The Convention Secretariat has a role to play in supporting countries in preventing and controlling NCDs The Convention Secretariat is a global authority overseeing implementation of the WHO FCTC. It promotes multisectoral, comprehensive tobacco-control policies and legislation at country level through strengthened coordination and planning. Over the years, the Convention Secretariat has supported close to 60 Parties, mostly developing country Parties and Parties with economies in transition by conducting needs assessments8 in the light of their obligations under the Convention. Parties have also received further support in development assistance including South- South and triangular cooperation with emphasis on the FCTC2030 project implemented in 15 Parties. Capacity- building initiatives at global, regional and country levels, sharing of best practices and dissemination of information, statements and position papers through the regular use of formal and informal communications with governments are part of the core attributions of the Convention Secretariat. The Convention Secretariat has also a network of CS-Knowledge Hubs with expertise in different areas of Convention implementation which provide technical support to the Parties in various fields, e.g. research, legal, economic, surveillance and policy-making. 8 WHO FCTC Secretariat, Needs assessments (2019). Available at: https://www.who. int/fctc/implementation/needs/en/ As part of the synergy framework promoted through COP decisions and resolutions of the World Health Assembly (WHA),9 the Convention Secretariat has reviewed the recommended cost-effective interventions endorsed by the WHA in order to identify those that are linked to its work at global, regional and country levels: specific examples are given in the table. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.10 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 9 Seventh Session of the Conference of the Parties to the WHO FCTC, Strengthening synergy between the Conference of the Parties and the World Health Assembly: Report of the Convention Secretariat, FCTC/COP/7/32 (2016). Available at https:// www.who.int/fctc/cop/cop7/FCTC_COP_7_32_EN.pdf and Seventh Session of the Conference of the Parties to the WHO FCTC, Strengthening synergy between the Conference of the Parties and the World Health Assembly, FCTC/COP7(18) (2016). Available at: https://www.who.int/fctc/cop/cop7/FCTC_COP7_18_EN.pdf?ua=1 10 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf 4 Responding to the Challenge of NCDs: FCTC Evidence-based interventions Convention Secretariat actions Increase excise taxes and prices on tobacco products. This is one of the specific objectives of the GS2025. Article 6 of the WHO FCTC is therefore a priority in the core work of the CS and includes development assistance projects such as the FCTC2030. Its application is supported by the Guidelines to implement Article 6 adopted by COP. Additionally, the CS-Knowledge Hub on taxation supports the CS in assisting Parties to implement Article 6 of the WHO FCTC.11 Implement plain/standardized packaging and/or large graphic health warnings on all tobacco packages. This is one of the specific objectives of the GS2025 and bears on Article 11 of the WHO FCTC. Its application is supported by the Guidelines to implement Article 11 adopted by COP. As one of the time-bound measures under the Convention, country development assistance projects coordinated by the CS frequently cover pictorial health warning legislation. The CS also encourages granting licences for pictorial health warnings to promote large-scale and effective pictorial health warnings. The CS-Knowledge Hub on international cooperation also supports the CS in assisting Parties to implement Article 11 of the WHO FCTC. Enact and enforce comprehensive bans on tobacco advertising, promotion and sponsorship (TAPS). Ban cross-border advertising, including using modern means of communication. TAPS bans are one of the specific objectives of the GS2025 and bears on Article 13 of the WHO FCTC as one of the time-bound measures under the Convention. Country development assistance projects frequently cover tobacco advertising, promotion and sponsorship legislation supported by the Guidelines to implement Article 13 adopted by COP. Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public places public transport. Guidelines on cross-border TAPS will be further elaborated. In decision FCTC/COP8(17), the COP established an intersessional working group to develop specific guidelines to address cross-border TAPS and the depiction of tobacco in the entertainment media under Article 13 of the WHO FCTC in the light of technological advances over the past decade such as the Internet and mobile communications.12 Implement effective mass media campaigns that educate the public about the harms of smoking/tobacco use and second-hand smoke. This is one of the specific time-bound objectives of the GS2025. Its implementation is supported by the Guidelines to implement Article 8 adopted by COP. As one of the time-bound measures under the Convention, country development assistance projects frequently cover smoke-free legislation. The CS-Knowledge Hub on international cooperation also supports the CS in assisting Parties to implement Article 8 of the WHO FCTC.13 Provide cost-covered, effective and population-wide support (including brief advice, national toll-free quit line services) for tobacco cessation to all those who want to quit. As one of the demand reduction measures under the Convention, country development assistance projects frequently cover education campaigns including mass media campaigns in line with Guidelines to implement article 12 adopted by COP. Provide mobile phone-based tobacco cessation services for all those who want to quit. As one of the demand reduction measures under the Convention, country development assistance projects frequently promote as broad a range of interventions as possible in order to support cessation in line with the Guidelines to implement Article 14 adopted by COP. The Convention Secretariat also works to promote targeted cessation initiatives when addressing co-morbidities such as HIV and tuberculosis.14 Additionally, the CS- Knowledge Hub on international cooperation promotes implementation of Article 14 of the Convention.15 Implement measures to minimize illicit trade in tobacco products. The Convention Secretariat has promoted the legal adoption of the Protocol and continues to endorse awareness-raising initiatives to encourage Parties to the Convention to become Parties to the Protocol and to begin its implementation. The CS is working to bring its development assistance initiatives in line with MOP guidance and decisions. 11 WHO FCTC Secretariat, WHO FCTC Knowledge Hub on Taxation (2019). Available at: https://untobaccocontrol.org/kh/taxation/ 12 Eighth Session of the Conference of the Parties to the WHO FCTC, Tobacco advertising, promotion and sponsorship: depiction of tobacco in entertainment media, FCTC/COP8(17) (2018). Available at: https://www.who.int/fctc/cop/sessions/cop8/FCTC__COP8(17).pdf?ua=1 13 WHO FCTC Secretariat, WHO FCTC Knowledge Hub on International Cooperation (2019). Available at: https://untobaccocontrol.org/kh/int-cooperation/ 14 WHO FCTC Secretariat, Issue Brief: Integrating Tobacco Control into Tuberculosis and HIV Responses (2018). Available at: https://www.who.int/fctc/publications/WHO-FCTC-HIV- TB.pdf?ua=1 15 ibid 5 Responding to the Challenge of NCDs: FCTC Twenty-eight international intergovernmental organizations and 21 nongovernmental organizations are accredited to the COP as observers. The Convention Secretariat cooperates with all observers in providing support to all Parties of both the WHO FCTC and its Protocol. The UK- and Australia-funded FCTC2030 project16 has enabled the Convention Secretariat to work with UNDP and WHO to support 15 low- and middle-income countries (LMICs) in promoting and supporting governments to accelerate implementation of the WHO FCTC. The Convention Secretariat leads the UNIATF Thematic Group on Tobacco Control under which several initiatives are taking place: • The Convention Secretariat takes the lead in developing and promoting the Model Policy on preventing tobacco industry interference among the UN agencies.17 After it was adopted by the seventh meeting of the UNIATF, it was endorsed by the UN Economic and Social Council (ECOSOC) meeting in 201718 and reiterated again in 2018.19 16 WHO FCTC Secretariat, FCTC 2030 (2019). Available at: https://www.who.int/fctc/ implementation/fctc2030/ 17 The purpose of this policy is to ensure that efforts to protect tobacco control from commercial and other vested interests of the tobacco industry are comprehensive, effective and consistent across the United Nations system including the UN itself and its funds, programmes, specialized agencies, other entities and related organizations. To download the model policy: https://www.who.int/ncds/un-task- force/events/model-policy-agencies-united-nations1.pdf 18 United Nations, Economic and Social Council, United Nations Inter-Agency Task Force on the Prevention and Control of Non-Communicable Diseases, E/ RES/2017/L.21 (2017). Available at: http://www.un.org/ga/search/view_doc. asp?symbol=E/2017/L.21 19 United Nations, Economic and Social Council, United Nations Inter-Agency Task Force on the Prevention and Control of Non-Communicable Diseases, E/ RES/2018/13 (2018). Available at: https://undocs.org/E/RES/2018/13 3. Partnerships are critical for the Convention Secretariat to mobilize and implement the WHO FCTC and its Protocol and provide an effective response to NCDs • The Convention Secretariat and WHO joined forces with FAO and ILO to support their Governing Body decision to stop funding from the tobacco industry for child labour in tobacco growing areas. • The Convention Secretariat is working with several UN agencies to develop a new joint programme to support low- and middle- income countries in developing economically sustainable alternatives to livelihoods based on tobacco growing. • The Convention Secretariat promotes a smoke-free UN campus in the UNIATF and has joined forces with WHO to develop tools and guides. Due diligence is required to ensure all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens for example by working to increase or preserve the availability, accessibility and/ or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. 6 Responding to the Challenge of NCDs: FCTC 4. Mobilizing resources to deliver COP8 has developed a fundraising strategy for implementing the WHO FCTC in line with GS2025, including the concept of an Investment Fund as a regular and sustainable fundraising mechanism.20 The Convention Secretariat has been actively mobilizing funds to support developing country Parties and Parties with economies in transition to strengthen their implementation of the WHO FCTC.21 20 Eighth Session of the Conference of the Parties to the WHO FCTC, Convention Secretariat’s fundraising strategies: Investment fund concept, FCTC/COP8(5) (2018). Available at: https://www.who.int/fctc/cop/sessions/cop8/FCTC__COP8(5). pdf?ua=1 21 WHO FCTC Secretariat, Donors and partners from 2018 (2019). Available at: https:// www.who.int/fctc/about/donorspartners/en/ The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the Convention Secretariat as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr 1 Responding to the Challenge of NCDs: IAEA International Atomic Energy Agency Responding to the Challenge of Non-communicable Diseases 1. Nuclear techniques assist in the prevention, early detection, diagnosis and treatment of NCDs1 Nuclear techniques play an integral role in the management of non-communicable diseases (NCDs)1 such as cancer, cardiovascular diseases, and neurological conditions, and can be used to design and evaluate interventions to address malnutrition in all its forms. Cancer. Cancer causes 9 million deaths each year.2 Medical imaging, including X-rays, and nuclear medicine techniques are critical in cancer care, in terms of: early and accurate diagnosis, including assessment of the location and spread of the disease (staging); follow-up of the patient to detect relapses; prognostic evaluation; and appropriate therapeutic decisions and follow-up of the response to treatment.3 Radiotherapy is a key element of cancer treatment for every second cancer patient worldwide. Modern radiotherapy allows automated delivery of a precise dose to the tumour and avoids the surrounding critical structures, giving the patient a chance to recover with minimal side- effects. 1 This UNIATF brief draws from the IAEA Brief for policymakers, “Prevention, Early Diagnosis and Treatment of Non-Communicable Diseases: The Role of Nuclear Techniques.” Available at: https://www.iaea.org/sites/default/files/18/10/ prevention-early-diagnosis-and-treatment-of-non-communicable-diseases.pdf 2 WHO. Key facts. NCDs. https://www.who.int/news-room/fact-sheets/detail/ noncommunicable-diseases 3 For more information, see: https://www.iaea.org/topics/cancer-diagnosis United Nations high-level meetings have highlighted the need for UN agencies, including IAEA, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as unhealthy diet, tobacco use, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2 Responding to the Challenge of NCDs: IAEA Cardiovascular disease. Cardiovascular diseases account for most NCD deaths, claiming the lives of 17.9 million people annually.4 Cardiac imaging using nuclear techniques is an important diagnostic tool, enabling earlier diagnosis and the planning of more effective treatment, as well as follow- up of patient response. Neurological conditions. Worldwide, around 50 million people have dementia, and there are nearly 10 million new cases every year. Alzheimer’s disease is the most common form of dementia and may contribute to 60– 70% of cases.5 Molecular imaging, including brain perfusion techniques, is helpful in the diagnosis of Alzheimer’s and other forms of dementia.6 Malnutrition. The effects of poor nutrition add to the burdens on health-care systems. In 2018, globally 149 million children under 5 years of age were stunted, 49 million wasted and 40 million overweight.7 Nuclear and stable isotope techniques provide important accurate data on body composition, breastfeeding practices, total daily energy expenditure, micronutrient bioavailability and vitamin A status, all of which directly relate to the prevention of diet-related NCDs. 4 WHO. Key facts. NCDs. https://www.who.int/news-room/fact-sheets/detail/ noncommunicable-diseases 5 WHO. Dementia: Key facts. https://www.who.int/news-room/fact-sheets/detail/ dementia 6 Torosyan N, Silverman S. (2012). Neuronuclear Imaging in the Evaluation of Dementia and Mild Decline in Cognition. Semin Nucl Med; 42(6): 415–422. 7 Global Health Observatory: Child malnutrition https://www.who.int/gho/child- malnutrition/en/ 2. IAEA has a role to play in preventing and controlling NCDs Working with governments, research and health institutions and development partners, IAEA provides technical assistance to Members States to strengthen their capacity in cancer diagnostics and treatment, and to evaluate preventive interventions for diet-related NCDs using stable isotope techniques.8 This support consists of developing, adopting and strengthening practices, providing technical advice and training, engaging in coordinated research projects, provision of equipment, preparation of technical publications and public information, and resource mobilization activities. IAEA also strengthens the evaluation of a range of nutrition interventions to prevent and support treatment of NCDs such as those that increase physical activity, promote breastfeeding and assess body composition and energy expenditure. IAEA has supported more than 110 low- and middle-income countries (LMICs) to address issues related to NCDs. IAEA has established a dedicated service (imPACT Review)9 to assess national capacities in cancer control and subsequently support Member States in evidence-based planning of cancer control resources. This service is delivered in cooperation with the World Health Organization (WHO) and International Agency for Research on Cancer (IARC). 8 IAEA Brief on Human Health for Policy Makers. https://www.iaea.org/sites/default/ files/18/10/prevention-early-diagnosis-and-treatment-of-non-communicable- diseases.pdf 9 https://www.sciencedirect.com/science/article/abs/pii/S1470204517303728 Abdel-Wahab M, Lahoupe B, Polo A, et al. (2017). Assessment of Cancer Control Capacity and Readiness: The Role of the International Atomic Energy Ageny. Lancet Oncol; 18(10): 587-594. 3 Responding to the Challenge of NCDs: IAEA IAEA’s Quality Management Audit for Nuclear Medicine Practice aims to support facilities to improve the quality of their clinical practice. Since 2009, IAEA has conducted 72 audits in 38 countries.10, 11, 12 IAEA has compiled the first comprehensive database on global energy expenditure data. Between 1981 and 2017, over 6600 measurements from 23 countries were collected using the Doubly Labelled Water method. These data help countries develop better health policies to combat the growing obesity epidemic. IAEA has reviewed the recommended cost- effective interventions endorsed by the WHA for NCDs to identify those that can be advanced through IAEA’s work at global, regional and country levels. Examples are provided in the table below. 10 Dondi M, Paez D, Torres L, et al. (2018). Implementation of Quality Systems in Nuclear Medicine: Why It Matters. An Outcome Analysis (Quality Management Audits in Nuclear Medicine Part III). Semin Nucl Med; 48(3):299-306. 11 Dondi M, Torres L, Marengo M, et al. (2017). Comprehensive Auditing in Nuclear Medicine Through the International Atomic Energy Agency Quality Management Audits in Nuclear Medicine Program. Part 2: Analysis of Results. Semin Nucl Med;47(6):687-693. 12 Dondi M, Torres L, Marengo M, et al. (2017). Comprehensive Auditing in Nuclear Medicine Through the International Atomic Energy Agency Quality Management Audits in Nuclear Medicine (QUANUM) Program. Part 1: the QUANUM Program and Methodology. Semin Nucl Med;47(6):680-686. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.13 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 13 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. http://apps.who.int/iris/bitstream/ handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf 4 Responding to the Challenge of NCDs: IAEA Evidence-based interventions IAEA actions Treatment of heart attacks. Building capacity in appropriate and safe use of medical imaging, including nuclear medicine (SPECT and PET) and radiology. Establishing sustainable medical imaging facilities for evaluation of patients with CVD. Treatment of heart failure. Breast screening using mammography with timely diagnosis and treatment of breast cancer. Ensuring quality control, image quality and dose optimization of mammography units. Assisting in the development of national diagnostic reference levels. Building capacity for the appropriate and safe use of mammography. Establishing sustainable mammography facilities. Treatment of colorectal cancer stages I and II and basic palliative care for cancer. Planning, establishing and sustaining radiotherapy services. Supporting radiotherapy quality assurance programmes. Provision of training in radiotherapy. Raising public and political awareness, understanding and practice relating to the prevention and control of NCDs. Highlighting NCD issues through media including social media. Strengthening international cooperation for resource mobilization, capacity-building, health workforce training, and exchange of information on lessons learned and best practices. Supporting education and training activities for health practitioners. Supporting the development of national resource mobilization strategies, technical documents and targeted funding proposals. Assessing national capacity for the prevention and control of NCDs. Supporting the development of national cancer control plans and strategies. Providing recommendations on national treatment and palliative care programmes. Conducting national assessments to strengthen national cancer control programmes. Strengthening human resources and institutional capacity for research. Supporting countries to train healthcare staff. Supporting countries to build clinical research capacity. Strengthening research capacity through cooperation with domestic and foreign research institutes. Partnering with joint research programmes. Supporting clinical research protocols in LMICs. Promoting and supporting exclusive breastfeeding for the first six months of life. Evaluating breastfeeding practices using stable isotope techniques. 5 Responding to the Challenge of NCDs: IAEA The IAEA collaborates with a number of partners in response to NCD burdens. Examples include: • IAEA/WHO (Network of Secondary Standards Dosimetry Laboratories) which provides calibrations for dosimetry equipment that are used to determine radiation dose levels for patients, staff or the public; • UN Joint Global Programme on Cervical Cancer Prevention and Control, which supports countries to reduce the burden of cervical cancer – IAEA has a key role in supporting Member States in the diagnosis and treatment of cervical cancer, including radiotherapy and palliative treatment; • International Union of Nutritional Sciences’ Task Force on Nutrition and Cancer which, at national, regional and global levels, catalyses capacity and collaboration across nutrition and cancer; • International Organization for Medical Physics in the development of guidelines and American Association of Physicists in Medicine in the development of dosimetry codes of practice; and • International Centre for Theoretical Physics, European Society for Radiotherapy and Oncology and a range of other professional organizations in building capacity through training courses, conferences and workshops. 3. Partnerships are critical for IAEA in mobilizing an effective response to NCDs A formal mechanism for due diligence, which also addresses conflicts of interest in safeguarding the reputational risk to the organization, should be in place to ensure that all partnerships advance health and development outcomes. 6 Responding to the Challenge of NCDs: IAEA 4. Mobilizing resources to deliver As Member States struggle with inadequate resources to tackle their increasing cancer burden, IAEA has adopted a new resource mobilization approach, joining forces with the private sector and international financial institutions to support low- and middle-income countries in order to secure financial and non- financial resources: in 2012, for instance, IAEA launched a focused partnership effort with the Organization of Islamic Cooperation and the Islamic Development Bank to expand access to effective, safe and sustainable cancer care in common Member States. The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the IAEA as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. Photo credits: © IAEA © World Bank (p.3, top) © UNICEF (p.3, bottom) International Organization for Migration Responding to the Challenge of Non-communicable Diseases Migration is an important determinant of health. It can challenge physical, mental and social well-being. Throughout the migration process, migrants experience difficulties in accessing health services and face increased exposure and vulnerability to NCDs and their risk factors as well as mental ill-health and injuries. In their community of origin, migrants may face poverty, violence and social conflict, as well as limited access to health care. For families left behind, the social cost is considerable, and has significant mental health implications. Remittances that could be used for accessing long-term health protection schemes are often used for out-of-pocket health expenditure. During transit, stressful and unsafe travel conditions and discontinued care can exacerbate migrants’ risk of developing NCDs or worsen pre-existing conditions. At destination, potential challenges in continuity of care, coupled with difficulty adapting to a new culture, may lead to the adoption of unhealthy lifestyle behaviors which further increase the burden of NCDs on migrant communities. United Nations high-level meetings have highlighted the need for UN agencies, including IOM, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. Stigma, discrimination and restrictive policies also expose migrants to NCD risk factors. In addition, migrant workers are reported to have a higher risk of work-related injuries and chronic illnesses than native workers. During return, especially after crisis situations, their access to health services may be limited. Migrants and mobile populations can face many obstacles in accessing essential health care services due to, among other factors, their irregular immigration status, language barriers, the absence of migrant-inclusive health policies and inaccessible services. 1. Migrants are at increased risk of NCDs and mental health conditions 1 Responding to the Challenge of NCDs: IOM 2. IOM has a role to play in supporting countries in preventing and controlling NCDs “Life Is Better”—psychoactive substances abuse primary prevention campaign, Georgia (2016–2017) IOM Georgia implemented a multisectoral approach involving local authorities in seven public schools. The “Life is Better” school-based campaign used an innovative and interactive two-pronged educational approach combining information dissemination on the risks of drug use and skill-building which targeted youth and their families in migrant communities and among ethnic minorities. The campaign reached 4,067 school children who were shown to be comparatively more aware of drug-related risks and better equipped to face social pressures relating to drug use. The “Life is Better” campaign acts as a primary prevention method to combat NCDs since substance abuse can lead to mental health problems such as depression and anxiety. Substance abuse can also increase the risk of developing cancer, diabetes and other NCDs. The campaign was adopted by the Ministry of Education and Science of Georgia and has been expanded nationwide. IOM, as the UN migration agency, is committed to the inclusion of migrant and mobile populations in all relevant policies and programmes to reduce NCDs. This commitment is reflected in IOM’s support for implementation of the Global Compact for Safe, Orderly and Regular Migration,1 as well as World Health Assembly (WHA) Resolution 70.15 and the related Global Action Plan on promoting the health of refugees and migrants. IOM serves as the Coordinator and hosts the Secretariat of the UN Network on Migration, which was established to ensure effective, timely and coordinated system-wide support to Member States in the implementation of the GCM. The Network working groups, especially related to improving access to services, can provide a further platform to promote NCDs related activities to promote health of migrants. IOM is committed to supporting partnerships to ensure the inclusion of migrants and mobile populations in national and regional plans including Universal Health Coverage (UHC). Migrants should be afforded equitable access to high-quality health services including to prevent, treat and manage NCDs. Continuity of care should be guaranteed, especially at the point of destination where they can receive more comprehensive treatment for diseases developed during the migration process, specifically NCDs. To ensure that migrants are not excluded from accessing healthcare regardless of their race, gender, or legal status, it is important to develop migrant-inclusive policies and develop migration-sensitive and culturally appropriate health systems able to deal with NCD risk factors associated with population movements. 1 Global Compact for Safe, Orderly and Regular Migration, endorsed by the United Nations General Assembly in resolution 73/195 (2018). 2 Responding to the Challenge of NCDs: IOM MANAGEMENT OF NCDS WITHIN THE IOM HEALTH ASSESSMENT PROGRAMME (HAP) IOM provides comprehensive pre-departure health assessment services for immigrants and refugees; these services generally include medical history-taking, physical examination, laboratory tests and radiology, through which the presence of NCDs may be disclosed or diagnosed. If an NCD is detected or suspected based on health assessment findings, the refugee or immigrant is provided with counselling and is referred for follow-up care or further investigations. If the beneficiary is a refugee for resettlement and will be traveling under the auspices of the Organization, IOM takes responsibility for the management of the refugee’s medical condition, including pre- departure stabilization and care, travel health assistance, such as medical escorts, post- arrival follow-up care, and confidential transfer of medical information to the receiving entity to ensure the continuity of care. 3. Partnerships are critical for IOM in mobilizing an effective response to NCDs IOM has partnerships with multiple stakeholders on issues relating to international health and migration. At the national level, IOM works closely with relevant government ministries, particularly ministries of health and immigration, NGOs and private sector entities (e.g. employment agencies). At the regional and global levels, key partners include UN agencies such as WHO, UNAIDS, UNHCR and ILO, as well as civil society partners such as migrants’ associations and academia. 3 Responding to the Challenge of NCDs: IOM BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.2 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. IOM has reviewed the recommended WHA- endorsed cost-effective interventions and recommended policy actions to identify those that are linked to IOM’s work at the global, regional and country level. Evidence-based interventions IOM actions Raise public and political awareness, understanding and practice in relation to the prevention and control of NCDs. Include NCDs in the tools used to monitor the health of migrant populations, and enhance IOM’s knowledge- base to inform evidence- based programming and policy development. Strengthen community-based surveillance (CBS) systems to monitor NCD trends and identify the health priorities of migrants. Integrate NCDs into the social and development agenda and poverty alleviation strategies. Implement NCD-focused interventions for migrants and displaced populations in transit and destination communities. Provide clinicians and public health planners in host countries with adequate knowledge of NCD profiles in migrants’ countries of origin. Advocate for psychosocial support to be provided to migrant and mobile populations. Strengthen international cooperation for resource mobilization, capacity building, health workforce training and exchange of information on lessons learned and best practices. Raise awareness of NCDs in national and regional capacity development activities. Foster multisectoral dialogues to address migrants’ structural vulnerabilities to NCDs. 2 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. Available at: http://apps.who. int/iris/bitstream/handle/259232/10665/WHO-NMH-NVI-17.9-eng.pdf Ph ot o cr ed its : © IO M The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by IOM as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. 4 Responding to the Challenge of NCDs: IOM 4. Mobilizing resources to deliver IOM will continue to highlight NCDs as an important issue with donors, and ensure that IOM country and regional offices include NCDs in project development and implementation. 1 Responding to the Challenge of NCDs: UNAIDS Joint United Nations Programme on HIV/AIDS Responding to the Challenge of Non-communicable Diseases 1. NCDs among people living with HIV is an increasing global public health issue Many countries with HIV epidemics are now experiencing growing rates of NCDs.1 Death rates from NCDs are nearly twice as high in low- and middle-income countries (LMICs) compared to high-income countries. Antiretroviral therapy (ART) for HIV enables people living with HIV to lead long and productive lives. However, they are now becoming susceptible to NCDs in later life. The four NCDs that account for the greatest number of comorbidities among people living with HIV in LMICs are cardiovascular diseases (CVD), cervical cancer, depression and diabetes.2 The risk of cervical cancer among women living with HIV compared to women without HIV is increased up to fivefold.3 HIV-hepatitis C virus coinfection is associated with CVD, diabetes and/or death in people living with HIV.4, 5 1 General Assembly Resolution 66/2, Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, A/RES/66/2 (19 December 2011), available from https://undocs.org/A/ RES/66/2 2 Patel P, Rose C, Collins P, Nuche-Berenguer B, Sahasrabuddhe V, Peprah et al. (2018). Non-communicable diseases among HIV-infected persons in low-income and middle-income countries. AIDS, 32:S5-S20. doi: 10.1097/ QAD.0000000000001888. 3 HPV, HIV and cervical cancer: leveraging synergies to save women’s lives. Geneva: UNAIDS; 2016 (UNAIDS/JC2851E; https://www.unaids.org/en/resources/ documents/2016/HPV-HIV-cervical-cancer). 4 Jenny-Avita ER. (2003). HCV-Coinfection Is Associated with Diabetes and CD4 Decline. AIDS Clinical Care 3:1(12). 5 Kakinami L, Block R, Adams M, Cohn S, Maliakkal B and Fisher S. (2012). Risk of cardiovascular disease in HIV, hepatitis C, or HIV/hepatitis C patients compared to the general population. International Journal of Clinical Practice, 67(1):6-13 doi: 10.1111/j.1742-1241.2012.02953.x HIV, cervical cancer and NCDs are all diseases associated with gender and socioeconomic inequalities, and health disparities across and within countries. HIV infection may increase the risk of NCDs due to stimulation of inflammatory markers and adverse events associated with some antiretroviral medicines for HIV treatment. This risk is compounded by NCD risk factors, e.g. tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity. United Nations high-level meetings have highlighted the need for the UN, including UNAIDS, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development.1 NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in developing countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2Smoking is associated with a twofold increase in mortality among people living with HIV mainly due to lung cancer. In LMICs, tobacco use among people living with HIV is higher than among those without HIV.6 Smoking is predicted to produce an excess of 18 million cases and 40 million deaths related to tuberculosis (TB) between 2010 and 2050, increasing TB cases and deaths by 7 percent and 66 percent respectively over this period.7 Given the HIV-TB syndemic, smoking, thus, constitutes a major exacerbating factor for HIV, TB and HIV-TB co-infections. Harmful use of alcohol is associated with: risky sexual behaviour with an increased risk of acquiring HIV, resulting in an estimated 33,000 new cases of HIV each year;8 reduced adherence to ART; alcohol-drug interactions and toxicities; and an increased risk of antiretroviral resistance. Harmful use of alcohol also increases the risk of TB infection9 and is associated with delays in seeking TB care.10 Alcohol increases the risk for HIV-related comorbidities, including liver disease, CVD, cerebrovascular disease, pulmonary disease, bone disease and cancer. Alcohol dependence further impacts the progression of HIV infection, as well as associated TB and viral hepatitis. People with mental health and substance use conditions are often at greater risk of HIV infection and are less likely to access education, prevention, testing and treatment services. People living with HIV are at an increased risk of developing mental health conditions, such as depression and anxiety. Key populations, people living with HIV and people with mental health conditions experience multifaceted stigma and the effects of interlocking systems of discrimination.11, 12 Stigma associated with HIV and marginalized identities have been linked to anxiety, depression, poor self-esteem and poor adherence to HIV care.13 Stigma also remains a barrier to accessing drug dependence treatment, mental health care and HIV services. 14, 15 6 Mdege N, Shah S, Ayo-Yusuf O, Hakim J and Siddiqi K. (2017). Tobacco use among people living with HIV: analysis of data from Demographic and Health Surveys from 28 low- income and middle-income countries. The Lancet Global Health, 5(6):e578-e592. 7 Basu S, Stuckler D, Bitton A, and Glantz SA. (2011). Projected effects of tobacco smoking on worldwide tuberculosis control: mathematical modelling analysis. BMJ, (343): doi: https://doi.org/10.1136/bmj.d5506 8 Global status report on alcohol and health 2018. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO. 9 Imtiaz S, Shield KD, Roerecke M, et al. (2017). Alcohol consumption as a risk factor for tuberculosis: meta-analyses and burden of disease. European Respiratory Journal, (50) : doi: 10.1183/13993003.00216-2017 10 Van Ness SE, Chandra A, Sarkar S et al. (2017). Predictors of delayed care seeking for tuberculosis in southern India: an observational study. BMC Infect Dis, (17):567: doi: 10.1186/ s12879-017-2629-9 11 Collins PY, Unger Hv, Armbrister A. Church ladies, good girls, and locas: Stigma and the intersection of gender, ethnicity, mental illness, and sexuality in relation to HIV risk. Social Science & Medicine. 2008;67(3):389-97. 12 Earnshaw VA, Bogart LM, Dovidio JF, Williams DR. Stigma and racial/ethnic HIV disparities: moving toward resilience. The American psychologist. 2013;68(4):225-36. 13 Patton GC, Sawyer SM, Santelli JS, Ross DA, Afifi R, Allen NB, et al. Our future: a Lancet commission on adolescent health and wellbeing. Lancet. 2016;387(10036):2423-78 14 Global Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. Geneva: World Health Organization; 2017. 15 Bundy DAP, de Silva N, Horton S, Patton GC, Schultz L, Jamison DT. Investment in child and adolescent health and development: key messages from Disease Control Priorities, 3rd Edition. Lancet. 2018;391(10121):687-99. Responding to the Challenge of NCDs: UNAIDS 3In partnership with the United Nations Interagency Task Force on NCDs, UNAIDS focuses on developing policies for integration of HIV and NCDs, and HIV and mental health strategies. This approach is aligned with the 2016 UN Political Declaration on Ending AIDS by 2030 and the 2016–2021 UNAIDS Strategy: On the Fast-Track to End AIDS.16 The UNAIDS Global Strategy for 2016–2021 supports multisectoral, integrated, people- centred, human rights and evidence-based services for HIV and HPV/cervical cancer, HIV and NCDs, HIV and mental health as well as for tuberculosis, sexual and reproductive health, maternal, newborn and child health with the active engagement of communities and civil society. 16 UNAIDS 2016–2021 Strategy. Geneva: UNAIDS; 2015 (https://www.unaids.org/ sites/default/files/media_asset/20151027_UNAIDS_PCB37_15_18_EN_rev1.pdf) 2. UNAIDS has a role to play in supporting countries in NCD prevention and control The Thematic Segment of the 43rd UNAIDS Programme Coordinating Board (PCB) meeting was dedicated to mental health and HIV: promoting human rights, an integrated and person-centred approach to improving ART adherence, well-being and quality of life.17 In follow up to the Thematic Segment, at its 44th meeting,18 UNAIDS PCB called on: • Member States to implement evidence- based, people-centred, human rights and community-based policies and programmes to promote mental health and quality of life with a focus on addressing stigma and discrimination related to both HIV and mental health conditions as part of HIV prevention, treatment and care services. • Member States to address social determinants of mental health and HIV by adopting and implementing social protection policies and programmes to reduce stigma and discrimination. • the UNAIDS Joint Programme to review and revise existing practices and guidelines in order to ensure integration of mental health and substance use services into HIV service delivery platforms, and HIV services into mental health and substance use prevention and treatment programmes, and to provide respective implementation guidance. • the UNAIDS Joint Programme to take into account the intersection between mental health and HIV, and the importance of improving psychosocial wellbeing and upholding the quality of life of people affected and living with HIV, as part of a person-centred and human rights approach when developing the next UNAIDS strategy for 2021–2030. 17 The 43rd UNAIDS Programme Coordinating Board (11–13 December 2018), available from https://www.unaids.org/sites/default/files/media_asset/20181214_ UNAIDS_PCB43_Decisions_EN.pdf 18 The 44th UNAIDS Programme Coordinating Board (27 June 2019), available from https://www.unaids.org/en/resources/documents/2019/PCB44_Decisions Responding to the Challenge of NCDs: UNAIDS 4UNAIDS has reviewed the recommended cost-effective interventions endorsed by the WHA—”best buys”—to identify those that are linked to its work at global, regional and country levels. These interventions address the synergies between HIV and HPV/ cervical cancer, HIV and NCDs, and HIV and mental health. UNAIDS plays an advocacy and facilitating role for global, regional and country level multisectoral partnerships as well as resource mobilization efforts to support countrywide responses to cervical cancer, NCDs and mental health issues. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.19 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 19 “Best buys” and other recommended interventions for the prevention and control of non-communicable diseases, Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO. Available at: http://apps.who.int/iris/bitstream/ handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf Evidence-based interventions UNAIDS actions Vaccination against human papillomavirus (2 doses) of 9–13-year-old girls. Prevention of cervical cancer by screening women aged 30–49 years. UNAIDS advocates for an HIV-cervical cancer policy, services and partnerships, along with community engagement; it also supports a focus on HPV vaccination for HIV-positive girls, and cervical pre-cancer and cancer screening, treatment and care for women living with and at risk of HIV. UNAIDS collects, analyses and tracks country reports on the Global AIDS Monitoring and National Composite Policy Index indicators for cervical cancer screening among women living with HIV, and integrated cervical cancer- HIV policies and services. Raise public and political awareness, understanding and practice about prevention and control of NCDs. UNAIDS raises political and public awareness at global and country levels for integrating NCDs and mental health into HIV strategies, policies and programmes with a focus on people living with and at risk of HIV, HIV-NCDs and HIV-mental health comorbidities; emphasis is also put on addressing human rights issues, stigma and discrimination, and health, social and gender inequalities which are common across HIV, NCDs and mental health issues. Integrate NCDs into the social and development agenda and poverty alleviation strategies. UNAIDS advocates for tackling the social determinants of mental health and HIV by means of social protection policies and other programmes to reduce stigma and discrimination. Responding to the Challenge of NCDs: UNAIDS 5UNAIDS actively seeks to strengthen partnerships to address NCDs: some of them are listed below. • UNAIDS is a co-founding partner of the PEPFAR-G.W. Bush Institute-UNAIDS-Merck public-private partnership to end AIDS and cervical cancer among HIV-positive women in Africa. This initiative enables UNAIDS to support policy advocacy and reforms, resource mobilization and community engagement. • In partnership with WHO, United Nations Population Fund (UNFPA) and other partners, UNAIDS is supporting national governments in fast-track countries to develop cervical cancer indicators and targets in their respective national health plans, and advocates for the realization of the WHO Global Call to Action towards the elimination of cervical cancer at the country level and development of the WHO Global Strategy towards the Elimination of Cervical Cancer. • UNAIDS is supporting the H6 partnership for the health of women, children and adolescents (currently under WHO chairmanship) at the global and country level by enhancing the centrality of sexual, reproductive, maternal, newborn, child and adolescent (RMNCAH) health: this programme prioritizes HPV- cervical cancer prevention, screening and treatment for girls and young women and engages communities and mobilizes resources to enable these services to be scaled up. • UNAIDS and WHO are in the process of developing an implementation guidance for integrating mental health and substance use services into HIV service delivery programmes. 3. Partnerships are critical for UNAIDS in mobilizing an effective response to NCDs Due diligence is required to ensure all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. Responding to the Challenge of NCDs: UNAIDS 6The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the UNAIDS as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr 4. Mobilizing resources to deliver UNAIDS advocates and supports countries to mobilize domestic and donor resources for integrating HIV and cervical cancer prevention and care in countries with a high burden of HIV and cervical cancer. UNAIDS has also mobilized resources for the integration of mental health and HIV services and for addressing human rights and quality of life issues. Responding to the Challenge of NCDs: UNAIDS 1 Responding to the Challenge of NCDs: UNDP United Nations Development Programme Responding to the Challenge of Non-communicable Diseases 1. NCDs are a development issue1 NCDs, such as cardiovascular disease, cancer, diabetes and chronic respiratory disease, are the greatest source of preventable illness, disability and mortality worldwide. NCDs place a significant burden on health systems, presenting a challenge to universal health coverage and other development aims.1 Out-of-pocket healthcare expenditures in response to NCDs can be financially ‘catastrophic’ for those affected. NCDs can also force household earners out of the labour market. Children may drop out of school to care for a sick relative or to make up for lost wages. Women and girls particularly sacrifice their time and opportunities.2 At the national level, NCDs sap public resources and impede economic growth. Between 2011 and 2030, NCDs including mental illnesses project to cost low- and middle-income countries (LMICs) US$ 21.3 trillion in healthcare costs and lost productive capacities.3 1 For in-depth information on UNDP’s response to NCDs, please see ‘UNDP Issue Brief: Preventing and Controlling Noncommunicable Diseases’: https://www.undp. org/content/undp/en/home/librarypage/hiv-aids/preventing-and-controlling-non- communicable-diseases0.html 2 See UNDP’s Discussion Paper on Addressing the Social Determinants of NCDs; and the World Bank’s Thwarting a Disease Crisis in the Pacific. 3 HSPH and WEF. 2011. ‘The Global Economic Burden of Non-communicable Diseases’. http://www3.weforum.org/docs/WEF_Harvard_HE_ GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf United Nations high-level meetings have highlighted the need for UN agencies, including UNDP, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development.4 NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as unhealthy diet, tobacco use, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. NCDs are linked to ageing, rapid unplanned urbanization, changing consumption patterns and environmental degradation. Many NCD risks are enmeshed with commercial interests which may conflict with public health objectives. Underlying social exclusion, marginalization, discrimination and inequities across different dimensions shape exposure to behavioural and environmental NCD risks, as well as access to basic services. 4 Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (2011); Political Declaration of the Third High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (2018); E/RES/13/2018 United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases. 2The Sustainable Development Goals include a specific target (3.4) to reduce premature mortality from NCDs. Shared gains across the 2030 Agenda for Sustainable Development are possible given the strong relationship between NCDs and priorities such as poverty and inequality reduction, economic growth, climate action and financing for development. Reducing the nine million premature deaths caused by pollution each year5 would, for instance, improve health while protecting the planet. 5 Landrigan, PJ, et al. The Lancet Commission on pollution and health. Lancet 2018; 391(10119); 462-512. The health sector cannot address NCDs on its own: whole-of-government and whole-of- society responses are essential. Differential exposures to behavioural and environmental risk factors for NCDs are often rooted in public policy choices that span sectors beyond health. Achieving coherence across sectors and ministries means confronting conflicts and countering vested interests which may act against public health objectives. UNDP is uniquely positioned to support integrated health and development solutions, building on its development portfolio, partnerships and networks, and country-level presence.6 In line with the SDG 3 ‘Global Action Plan for Healthy Lives and Well-Being for All’, UNDP, in cooperation with WHO, the Secretariat of the WHO Framework Convention on Tobacco Control (WHO FCTC), the broader UN Inter-Agency Task Force on NCDs and other partners, supports governments in all regions to implement or strengthen whole- of-government NCD responses. This support centres on strengthening national capacity, leadership, governance, multisectoral action and partnerships to accelerate country responses. UNDP leverages its core competencies in areas that intersect with NCD prevention and control, including access to basic services, poverty and inequality reduction, environment and energy, good governance, sustainable financing, gender, and south-south and triangular cooperation. 6 UNDP’s Discussion Paper on Addressing the Social Determinants of NCDs outlines entry points for development actors. https://www.undp.org/content/dam/undp/ library/hivaids/English/Discussion_Paper_Addressing_the_Social_Determinants_ of_NCDs_UNDP_2013.pdf 2. UNDP has a role to play in supporting countries to prevent and control NCDs Responding to the Challenge of NCDs: UNDP 3UNDP’s work on NCDs promotes effective and inclusive governance for health, a priority of its ‘HIV, Health and Development Strategy 2016–2021’.7 It aligns with its ‘Strategic Plan 2018–2021’,8 which recognizes the direct relationship between health, poverty eradication and other development aims. UNDP has reviewed the recommended World Health Assembly-endorsed policy options to identify those that are linked to UNDP’s work at global, regional and country level. Five indicative examples are given in the table. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.9 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 7 UNDP (2016). HIV, Health and Development Strategy 2016-2021. http://www.undp. org/content/undp/en/home/librarypage/hiv-aids/hiv--health-and-development- strategy-2016-2021.html 8 UNDP Strategic Plan, 2018-2021. http://undocs.org/DP/2017/38 9 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. http://apps.who.int/iris/bitstream/ handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf Evidence-based interventions UNDP actions Raise public and political awareness, understanding and practice about prevention and control of NCDs. Support non-health ministries to understand how NCDs impact their sector, and how they can support the national response.10 Work with parliamentary unions/associations to highlight the role for parliamentarians in NCD advocacy and in ensuring NCD-sensitive legal environments. Integrate NCDs into the social and development agenda and poverty alleviation strategies. Support countries to establish NCD prevention and control and tobacco control as development priorities within their national planning instruments/SDG action plans and corresponding UN Sustainable Development Frameworks.11 Prioritize and increase, as needed, budgetary allocations for prevention and control of NCDs, without prejudice to the sovereign right of nations to determine taxation and other policies. Work with partners to support ministries of health to develop national investment cases for scaled-up action. Analyse institutions and contexts to advance policy coherence, financing opportunities, and institutional roles and accountabilities. Develop and implement a national multisectoral policy and plan for the prevention and control of NCDs through multi-stakeholder engagement. Work with partners to support the drafting, costing and adoption of ambitious national NCD and tobacco control strategies, establishment of functional national and/ or subnational coordination mechanisms, and the passing, enforcement and monitoring of effective NCD-related legislation. Engage and mobilize civil society and the private sector as appropriate and strengthen international cooperation to support implementation of the action plan at global, regional and national levels. Strengthen the capacity of civil society organizations to advocate for multisectoral NCD action including through community mobilization and by linking with HIV/AIDS, TB and environment and climate communities. 10 UNDP and WHO have jointly produced a series of briefs on ‘What Government Ministries Need to Know about Non-communicable Diseases’. https://www.undp. org/content/undp/en/home/librarypage/hiv-aids/what-government-ministries- need-to-know-about-non-communicable-diseases.html 11 UNDP and WHO have developed a Guidance Note for UN Country Teams and governments on how to integrate NCDs into UN Development Assistance Frameworks. https://www.undp.org/content/undp/en/home/librarypage/hiv-aids/ guidance-note-NCDs-UNDAF.html; With the Convention Secretariat of the WHO FCTC, UNDP has developed guidance on integrating the WHO FCTC into UN and national development planning instruments. https://www.undp.org/content/ undp/en/home/librarypage/hiv-aids/development-planning-and-tobacco-control-- integrating-the-who-fr.html Responding to the Challenge of NCDs: UNDP 4UNDP and WHO are implementing a Global Joint Programme (GJP) on NCD Governance, with support from the Russian Federation. For LMICs, the GJP aims to support the development of national NCD investment cases, strengthen national coordinating mechanisms and municipal action, and integrate NCDs into domestic SDG frameworks. GJP assesses and seeks to expand fiscal space for universal access to NCD-related health services, while driving legislation, policies and targeted interventions for prevention. Through the FCTC 2030 project, conducted with the assistance of the UK and Australian Governments, UNDP is working with the Convention Secretariat of the WHO FCTC and WHO to support 15 LMICs in developing investment cases for accelerated implementation of the WHO FCTC. UNDP supports national coordination, the development and implementation of country-specific tobacco control plans, integrating tobacco control into broader SDG implementation efforts, and capacity building including for parliamentarians. UNDP supports national governments in the procurement of health products for NCDs, for example medicines for diabetes and cancer. In 2017 this procurement totaled approximately US$ 94 million. With the Global Environment Facility, UNDP manages over 800 projects across 141 countries on environmental challenges. Many projects support the NCD response. Examples include projects which reduce use of and people’s exposure to hazardous chemicals, and sustainable transport projects which support the construction of lanes for cycling (this promotes physical activity while reducing air pollution from vehicle emissions).12 12 UNDP (2018). Annual Performance Report 2017 – UNDP Global Environmental Finance Unit. https://www.undp.org/content/undp/en/home/librarypage/poverty- reduction/global-environmental-finance/2017-undp-gef-annual-performance-report. html 3. Partnerships are critical for UNDP in mobilizing an effective response to NCDs Due diligence is required to ensure that all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. Responding to the Challenge of NCDs: UNDP Responding to the Challenge of NCDs: UNDP 5 UNDP, other UN agencies and partners are supporting the implementation of the National Clean Air Programme of the Government of India. This work aims to tackle air pollution, a major cause of premature death from NCDs, through a systematic and coordinated multi-sector approach involving government departments and agencies, the corporate sector, academic institutions, civil society and local institutions. UNDP has extensive expertise in implementing large-scale health programmes, for example through its partnership with the Global Fund to Fight AIDS, Tuberculosis and Malaria. UNDP is working to ensure that Global Fund grants, where appropriate, address interactions between infectious diseases and NCDs and their risk factors.13 In the Pacific region, UNDP is managing a multicountry Global Fund programme to ensure that national tuberculosis guidelines include elements of the WHO ‘Collaborative Framework for Care and Control of Tuberculosis and Diabetes’.14 13 In 2015, the Global Fund approved a framework for financing interventions that respond to co-infections or co-morbidities that can exacerbate HIV, TB or malaria. https://www.theglobalfund.org/media/4167/bm33_11-co-infectionsandco- morbidities_report_en.pdf 14 UNDP and the Convention Secretariat of the WHO FCTC have produced an Issue Brief to support Global Fund applicants in integrating tobacco cessation into Global Fund HIV and TB grants. http://www.undp.org/content/undp/en/home/librarypage/ hiv-aids/integrating-tobacco-control-into-tuberculosis-and-hiv-responses.html UNDP plays a role in driving investments and efficiencies related to NCD prevention and control. Actions include but are not limited to: • supporting partners to advocate for the establishment of a multidonor trust fund to enable countries to catalyse financing on NCDs and mental health while strengthening policy coherence at the country level;15 • providing targeted technical support to countries to analyze the return on investment (ROI) in select NCD and tobacco control interventions, and to consider ROI in allocating resources to the national response; • strengthening partnerships and programmes oriented around “best buys” (e.g. the SAFER initiative to support countries to tackle harmful use of alcohol) as well as emerging relevant programmatic areas (e.g. air pollution); • supporting domestic financing for NCD responses including through innovative taxation measures for tobacco, alcohol, sugar-sweetened beverages and other health- harming products. Globally, increased taxes on tobacco, alcohol and sugary beverages could avert 50 million premature deaths and raise US$ 20.5 trillion in revenue over the next 20 years,16 while delivering benefits across the SDGs;17 and • collaborating with development banks to ensure that NCD loans seek to strengthen public health legislation and regulations to prevent NCDs, in addition to focusing on health system strengthening. 15 In line with ‘Time to Deliver’, the Report of the WHO Independent High-level Commission on Noncommunicable diseases. https://apps.who.int/iris/bitstream/ handle/10665/272710/9789241514163-eng.pdf?ua=1 16 Task Force on Fiscal Policy for Health. 2019. Health Taxes to Save Lives: Employing Effective Excise Taxes on Tobacco, Alcohol, and Sugary Beverages. https://www. bbhub.io/dotorg/sites/2/2019/04/Health-Taxes-to-Save-Lives.pdf 17 Sugar, Tobacco, and Alcohol Taxes (STAX) Group. Sugar, tobacco, and alcohol taxes to achieve the SDGs. Lancet 2018, 391(10138): 2400-2401. https://www.thelancet. com/journals/lancet/article/PIIS0140-6736(18)31219-4/fulltext 4. Mobilizing resources to deliver Responding to the Challenge of NCDs: UNDP 6 The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the UNDP as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. Photo credits: © World Bank via Flickr; page 5 © Omer Sadaat via The Global Fund 1 Responding to the Challenge of NCDs: UNFPA United Nations Population Fund Responding to the Challenge of Non-communicable Diseases 1.There are strong links between protecting and promoting sexual and reproductive health and rights, and preventing and controlling non-communicable diseases NCDs have a significant impact on the sexual and reproductive health of both men and women.1 • Obesity, hypertension and diabetes during pregnancy lead to poorer maternal and neonatal outcomes. • Tobacco use, by both pregnant women and other family members, adversely affects the foetus, newborn and children, as does maternal alcohol consumption. • Lack of breastfeeding increases the risk of NCDs in later life. • Poor diet, tobacco, alcohol and exposure to chemicals also affect fertility, reducing sperm viability and increasing erectile dysfunction in men. • Harmful use of alcohol increases the risk of unprotected sex, unintended pregnancies, HIV and other STIs including human papilloma virus (HPV), as well as the risk of domestic and gender-based violence. 1 Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (2011); Political Declaration of the Third High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable diseases (2018); E/RES/2018/13 United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases. United Nations high-level meetings have highlighted the need for UN agencies, including UNFPA, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development.1 NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in developing countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. Premature deaths from NCDs are largely preventable by encouraging women, men and young people to reduce their use of tobacco and consumption of harmful amounts of alcohol, adopt a healthy diet and step up their levels of physical activity. Cervical cancer is a global public health issue and can largely be prevented by vaccinating 9 to 13-year-old girls and boys against HPV. Penile and oropharyngeal cancers can also be prevented through HPV vaccination. Mental health is now an integral part of the NCD agenda and post-natal depression is considered a major public health issue. 2 Responding to the Challenge of NCDs: UNFPA NCDs are an increasing priority for UNFPA. By expanding its activities to include the prevention and control of NCDs, UNFPA will have a significant impact on reducing the current and future NCD burden. By tackling NCDs, UNFPA contributes to a direct improvement in maternal and neonatal health outcomes. UNFPA can support sexual and reproductive health and rights (SRHR) policy-makers and service providers to help young people and women of childbearing age reduce their exposure to, and use of tobacco and alcohol, and promote healthy diets and physical activity. Ante- and postnatal care also provide significant opportunities for the detection, prevention and management of diabetes and high blood pressure in women. UNFPA promotes exclusive breastfeeding for at least the first six months of life. Breastfeeding has long-term benefits for mothers and children in reducing the risk of NCDs. Several UNFPA programmes strengthen services which provide support to women with postpartum depression and other psychosocial conditions that impact them and their families. UNFPA is making a significant contribution to the elimination of cervical cancer globally by supporting countries in their efforts to scale up HPV vaccination, as well as through cervical cancer screening and early diagnosis activities as part of comprehensive cervical cancer control programmes. 2. UNFPA has a role to play in supporting countries to prevent and control NCDs in line with UNFPA’s commitment to improve public health throughout the lifecycle. UNFPA works with men and boys to reduce gender-based violence: this includes reducing the exposure to, and harmful use of alcohol by men in order to lessen alcohol-related violence. UNFPA is also committed to raising awareness about the socioeconomic impact of an ageing population, including the impact of NCDs in this group. In relation to this activity, UNFPA supports national censuses and demographic health surveys in order to improve population projections and strengthen policy and planning, including NCD programming. UNFPA has reviewed the cost-effective interventions endorsed by the World Health Assembly in order to identify those that are linked to UNFPA’s work at global, regional and country level: specific examples are given in the table. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.2 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 2 WHO. 2017. ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf. 3 Responding to the Challenge of NCDs: UNFPA Evidence-based interventions UNFPA actions Promote and support exclusive breastfeeding for the first six months of life. Exclusive breastfeeding is promoted by midwives as part of their comprehensive antenatal and postnatal care interventions and services. Preconception care among women of reproductive age who have impaired glucose tolerance or diabetes, including patient education and intensive glucose management. Midwives and other antenatal care providers include diabetic screening and management, specifically for expectant women in antenatal clinic settings, and via outreach services where possible. Human papillomavirus vaccination (2 doses) for 9 to 13-year-old girls and boys. UNFPA supports delivery of HPV vaccination through primary health care services and school vaccination programmes. Prevention of cervical cancer by screening women aged 30–49 years. UNFPA is assisting countries to strengthen cervical cancer screening and referral for treatment from family planning, HIV and primary health care services. Screening with mammography (once every two years for women aged 50–69 years) linked with timely diagnosis and treatment of breast cancer. Breast cancer screening services are being supported by a limited number of UNFPA country offices. Comprehensive sexuality education (CSE). Governments are supported in implementing “in and out-of-school” CSE programmes: these promote healthy behaviour patterns, reduce NCD risk factors and endeavour to lessen unprotected sex in order to lower the incidence of unplanned pregnancies and STIs including HPV. Promote tobacco avoidance and cessation in young people. Through adolescent CSE and SRH services, youth community centres and peer outreach programmes, young people are supported in making healthier life choices that reduce their exposure to NCD risk factors. Implement nutrition education and counselling in order to increase the intake of fruit and vegetables and reduce salt intake. Promote physical activity. UNFPA is a member of the UN Joint Global Programme on Cervical Cancer Prevention and Control, which assists countries to reduce the burden of cervical cancer via the WHO-led Global Cervical Cancer Elimination Initiative. UNFPA is an adviser to GAVI and a number of countries in rolling out HPV vaccination as part of adolescent health, screening and treatment programmes. At the regional level, UNFPA is working to strengthen the capacity of service providers, especially in delivering cervical cancer screening and treatment programmes. For example, in Eastern Europe and Central Asia, UNFPA has developed a training programme for health care providers in cervical cancer screening and treatment. UNFPA is supporting the rolling out of HPV vaccination in the Arab States and is currently contributing to regional training programmes, as well as to assessments of NCD prevention and control needs, including opportunities for scaling up the “best buys”. UNFPA country programmes provide backing for the strengthening of safe motherhood programmes in all countries, as well as for developing partnerships with youth and women’s organizations to include activities in favour of NCD prevention. 3. Partnerships with UN and other development agencies are critical for UNFPA in mobilizing an effective response to NCDs Due diligence is required to ensure all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. 4 Responding to the Challenge of NCDs: UNFPA While UNFPA’s focus is on improving sexual and reproductive health and rights, it is increasingly looking to identify opportunities to mobilize resources for incorporating NCD prevention and control into its programmes, in the expectation that these efforts will have a direct impact on improving sexual and reproductive health for all. 4. Mobilizing resources to deliver Photo credits (from top clockwise): © UNFPA ©World Bank via Flickr (also page 2) © UNV The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by UNFPA as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. 1 Responding to the Challenge of NCDs: UNHCR United Nations High Commissioner for Refugees Responding to the Challenge of Non-communicable Diseases 1. Refugees and asylum seekers are particularly vulnerable to NCDs including mental health conditions and may face barriers to adequate health care. NCDs, such as cardiovascular disease, cancers, diabetes, chronic respiratory disease and mental health conditions, are the greatest source of preventable illness, disability and mortality worldwide. In the country of origin, prior to flight, refugees may have limited access to health care, including due to a disrupted health care system. Consequently, they may have undiagnosed or poorly controlled NCDs. During flight, refugees may face harsh conditions and lack of continuity of care which may exacerbate NCDs. Apart from the health risks associated with the forced migration, access to comprehensive healthcare may be limited for refugees. Key barriers to healthcare access may include language and cultural differences; protection issues resulting from a lack of legal status; and an inability to afford healthcare due to inadequate livelihoods.1 1 The health needs and access barriers among refugees and asylum- seekers in Malaysia: a qualitative study. Int J Equity Health. 2018. https:// equityhealthj.biomedcentral.com/articles/10.1186/s12939-018-0833-x United Nations high-level meetings have highlighted the need for UN agencies, including UNHCR, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. Multiple stressors (experiences of violence, disrupted social support systems and marginalization) in the country of origin, during flight and country of asylum, may lead to mental health conditions. Displacement and lack of livelihood opportunities may increase unhealthy behaviors, such as tobacco and alcohol use as well as unhealthy diet. During return, returnees may be returning to a country with a disrupted health system and lack access to quality health services, further threatening continuity of care. 2 Responding to the Challenge of NCDs: UNHCR 2. UNHCR has a key role to play in supporting countries to prevent and control NCDs UNHCR, as the UN refugee agency, is committed to the inclusion of refugees and asylum seekers in all relevant policies and programmes to reduce NCDs. This commitment is reflected in UNHCR’s support to the implementation of the Global Compact for Refugees,2 as well as World Health Assembly (WHA) Resolution 70.15 on promoting the health of refugees and migrants.3, 4 UNHCR facilitates the integration of refugee NCD programmes into national systems. UNHCR’s aim is to reduce morbidity and mortality amongst refugees from NCDs by improving the quality, accessibility and affordability of preventive and treatment services, ensuring the rational use of medicines, and strengthening the clinical and community-based management of NCDs. Improved NCD care improves quality of life, reduces premature death and disability, and, if provided early, significantly reduces financial strains on health systems due to the costs associated with disease progression and complications. 2 Report of the United Nations High Commissioner for Refugees Part II Global compact on refugees. General Assembly Official Records Seventy-third Session Supplement No. 12 (A/73/12 (Part II)) https://www.unhcr.org/gcr/GCR_ English.pdf 3 https://www.iom.int/sites/default/files/our_work/DMM/Migration-Health/ WHA_RES_70.15-Promoting-the-health-of-refugees-and-migrants.pdf 4 https://www.who.int/migrants/about/framework_refugees-migrants.pdf In 2014, UNHCR expanded the support of NCD programmes for refugees through a dedicated capacity building programme ‘Caring for Refugees with NCDs’ in Algeria, Bangladesh, Burkina Faso, Burundi, Chad, Democratic Republic of the Congo, Ethiopia, Jordan, Kenya, Rwanda, Tanzania and Uganda. Key activities of the project are: • Training of Trainers, including learning material in clinical- and system-level NCD management for UNHCR and partners’ public health staff (medical doctors, clinical officers) at regional and country level. This includes group workshops, individual coaching, diagnostic tool application, action learning, remote learning, dissemination of online resources, and case study discussions contributing towards a community of practice. • Development of adapted screening and clinical management protocols based on country protocols and discussions with ministries of health including the community- based management approach for follow up of persons with NCDs. • Development of a system of continuous professional development for local and regional trainers which might include e-portfolios, online forums and access to a specific library of material. • Ensuring that the UNHCR Essential Medicines List (based on the WHO Model List of Essential Medicines5) includes evidence-based cost- effective medication to provide care for NCDs in line with national protocols. • Strengthening data collection and monitoring tools for NCD care. 5 World Health Organization Model List of Essential Medicines (2019). https://apps.who.int/iris/bitstream/handle/10665/325771/WHO-MVP-EMP-IAU- 2019.06-eng.pdf?ua=1 Responding to the Challenge of NCDs: UNHCR 3 On mental health specifically, UNHCR and WHO developed the mhGAP Humanitarian Intervention Guide6 for training non-specialized health workers in humanitarian settings to identify and respond to priority mental, neurological and substance use conditions.7 Since 2015, more than 1000 health and protection workers have been trained with this tool. In 2019, UNHCR introduced scalable psychological interventions (brief psychotherapies that can be conducted by non-specialized workers) into refugee operations.8 UNHCR has reviewed the recommended WHA-endorsed ‘Best buys’ and other recommendations for the prevention and control of non-communicable diseases to identify those linked to UNHCR’s work at global, regional and country level. UNHCR actions are highlighted in the table below. 6 World Health Organization, & United Nations High Commissioner for Refugees. (2015). mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies. Geneva: WHO. 7 Echeverri, C., Le Roy, J., Worku, B., & Ventevogel, P. (2018). Mental health capacity building in refugee primary health care settings in Sub-Saharan Africa: Impact, challenges and gaps. Global Mental Health, 5, e28. DOI: 10.1017/ gmh.2018.1019 8 Tay, A. K., Miah, M. A. A., Khan, S., Badrudduza, M., Alam, R., Balasundaram, S., & Silove, D. (2019). Implementing Integrative Adapt Therapy with Rohingya refugees in Malaysia: a training-implementation model involving lay counsellors. Intervention, 17(2), 267-277. BEST BUYS In 2017, the World Health Assembly endorsed a set of ‘best buys’ and other recommended interventions to address NCDs.9 Best buy interventions address four NCD risk factors (tobacco, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 9 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases, WHO 2017. Responding to the Challenge of NCDs: UNHCR Evidence-based interventions UNHCR actions Strengthen international cooperation for resource mobilization, capacity building, health workforce training, and exchange of information on lessons learned and best practices. Capacity building on NCD care for clinicians providing care to refugees and host communities through training, mentoring, support and monitoring. Allocation of resources for sufficient medicine supplies, diagnostic supplies and tools, and health infrastructure to better integrate NCD care at primary care level for refugees. Promote and support exclusive breastfeeding for the first 6 months of life, including promotion of breastfeeding. UNHCR and partners actively promote exclusive breastfeeding in health facilities as well as protecting refugees from donations/ marketing of breast milk substitutes. UNHCR has an Infant and Young Child Feeding framework for a multisectoral approach placing the infant at the center. Implement subsidies to increase the intake of fruits and vegetables. In some settings UNHCR and partners have implemented Fresh Food Vouchers as well as cash-based interventions, to increase dietary diversity to improve complementary feeding. Drug therapy (including glycaemic control for diabetes mellitus and control of hypertension using a total risk approach) and counselling to individuals who have had a heart attack or stroke and to persons with moderate to high risk (≥ 20%) of a fatal and non-fatal cardiovascular event in the next 10 years. UNHCR trains clinicians on diabetes, hypertension, cardiovascular disease and chronic respiratory diseases. This includes task shifting to nurses and use of risk assessment charts and standard clinical protocols. Treatment of asthma using low dose inhaled beclomethasone and short-acting beta agonist. As above. Vaccination against human papillomavirus (2 doses) of 9–13-year-old girls. Prevention of cervical cancer by screening women aged 49–30 and timely treatment of pre-cancerous lesions. UNHCR advocates with ministries of health and Gavi to ensure refugees are included in national HPV vaccination planning. UNHCR also advocates that refugees have access to national screening programmes and has supported such activities in refugee camps including for high risk groups such as women living with HIV. Prevention of liver cancer through hepatitis B immunization. UNHCR advocates with ministries of health to ensure refugees are included in the national Expanded Programme on Immunization (EPI) including access to hepatitis B immunization. In certain situations, including where refugees are residing in camps, UNHCR may support the staffing and infrastructure for the delivery of health services, including EPI. 4 Responding to the Challenge of NCDs: UNHCR UNHCR partners with multiple stakeholders on refugee health. At the national level, UNHCR works closely with government ministries, particularly ministries of health and refugee affairs, and NGO partners. Both at national and international level UNHCR partners with UN agencies including WFP, UNICEF, WHO, UNAIDS, UNFPA, UNDP, ILO, and IOM, as well as with civil society. UNHCR convenes an informal working group on NCDs in Humanitarian Settings at global level incorporating UN agencies, NGOs and academia. The group exchanges information on activities and initiatives and identifies collaboration opportunities to meet NCD care needs in humanitarian settings. Work is ongoing to develop operational and clinical guidance in such settings as well as to elaborate on the approach set out for NCDs in the Sphere handbook.10 This work builds upon ‘Non-communicable Diseases in Emergencies’, the brief for emergency planners, emergency care professionals and policymakers tasked with emergency response and preparedness.11 UNHCR published guidance on promoting treatment adherence for refugees in health care settings in 2019.12 UNHCR works closely with other international partners on the Inter-Agency Standing Committee Reference Group for Mental Health and Psychosocial Support in Emergency Settings. This includes working with WHO and UNICEF to develop a minimal service package for mental health and psychosocial support in humanitarian settings.13 10 The Sphere movement was started in 1997 to improve the quality of humanitarian work during disaster response. The 2018 Sphere Handbook provides a humanitarian charter and minimum standards in humanitarian responses. https:// spherestandards.org/wp-content/uploads/Sphere-Handbook-2018-EN.pdf 11 UNIATF on NCDs/WHO. (2016). Noncommunicable Diseases in Emergencies. http://apps.who.int/iris/bitstream/10665/204627/1/WHO_NMH_ NVI_16.2_eng.pdf?ua=1 12 UNHCR, Promoting treatment adherence for refugees and persons of concern in health care settings (2019). https://www.unhcr.org/5cd962bc7.pdf 13 IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings. https://interagencystandingcommittee.org/iasc-reference- group-on-mental-health-and-psychosocial-support-in-emergency-settings Due diligence is required to ensure that all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. 5 6The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the UNHCR as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. Responding to the Challenge of NCDs: UNHCR Sphere and NCDs The need to focus on NCDs in humanitarian crises reflects increased global life expectancy combined with behavioural risk factors such as tobacco smoking and unhealthy diets. About 80 per cent of deaths from NCDs occur in low- or middle- income countries, and emergencies exacerbate this. Within an average adult population of 10,000 people, there are likely to be 1,500–3,000 people with hypertension, 500–2,000 with diabetes, and 3–8 acute heart attacks over a normal 90- day period. Diseases will vary but often include diabetes, cardiovascular disease, chronic lung and cancer. Initial response should manage acute complications and avoid treatment interruption, followed by more comprehensive programmes. NCDs standard: People have access to preventive programmes, diagnostics and essential therapies for acute complications and long-term management of NCDs. Key actions: (i) identify the NCD health needs and analyze the availability of services pre-crisis; (ii) implement phased-approach programmes based on life-saving priorities and relief of suffering; (iii) integrate NCD care into the health system at all levels; (iv) establish national preparedness programmes for NCDs. Key indicators: (i) percentage of primary healthcare facilities providing care for priority NCDs; (ii) number of days essential medicines for NCDs were not available in the past 30 days; (iii) number of days for which basic equipment for NCDs was not available (or not functional) in the past 30 days; (iv) all healthcare workers providing NCD treatment are trained in NCD management. Adapted from the Sphere Handbook Section 2.6, pages 342–345 (mental health and palliative care are addressed in sections 2.5 and 2.7.10 4. Mobilizing resources to deliver UNHCR will continue to highlight the importance of NCDs as part of public health programmes, and seek improved NCD care for refugees within national health care systems, and fundraise with donors. Photo credits: page 3 (clockwise from bottom: © UNHCR; © UNDP; © UNHCR); page 5 © World Bank via Flickr 1 Responding to the Challenge of NCDs: UNICEF United Nations Children’s Fund Responding to the Challenge of Non-communicable Diseases 1. Many NCDs have their origins in early life NCDs undermine children and adolescents’ right to health, nutrition, education and play. Each year, about 1.2 million children and adolescents aged under 20 die from often treatable NCDs such as chronic respiratory diseases and cancers, accounting for 13% of overall NCD mortality. NCD risk factors, e.g. childhood overweight and obesity, have a negative impact on children’s mental and emotional well-being, peer relations, learning and opportunities to participate in education and recreation. Exposure to NCD risk factors is often established very early in life. Prenatal maternal undernutrition and/or low birthweight predispose an individual to obesity, high blood pressure, heart disease and diabetes later in life. Maternal obesity and gestational diabetes are associated with cardiovascular disease and diabetes in both mother and child. Childhood and adolescence are also periods when behaviours which lead to the onset of NCDs are adopted including tobacco use, alcohol use, unhealthy diets and physical inactivity as well as unsafe sex (which can result in the spread of HPV, a cause of cervical cancer). These behaviours contribute to an estimated 70% of premature deaths in adulthood. United Nations high-level meetings have highlighted the need for UN agencies, including UNICEF, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs account for 14.6% of all-cause mortality and 24.8% of disability-affected life years (DALYs) amongst children and adolescents. Exposure to NCD risk factors may begin before or during pregnancy and continue during infancy and childhood and adolescence, underlining the importance of action across these age groups Childhood and adolescence are periods where significant impact can be made in risk reduction through evidence-based interventions on diet, physical activity, tobacco and alcohol consumption Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. Children and adolescents are often targeted by companies producing, marketing and/ or selling unhealthy products (e.g. tobacco, alcohol and foods high in fat, sugar and/or salt). Many children and adolescents also grow up in built environments that are not conducive to healthy behaviours (e.g. urban areas that combine limited opportunities for physical activity, exposure to unsafe roads and high levels of air pollution). 2 Responding to the Challenge of NCDs: UNICEF Children and adolescents with NCDs, or those tasked to provide care for family members with NCDs, have lower educational attainments and less access to employment opportunities, leading to an increased risk of financial insecurity later in life. In addition to the psychological impact on offspring, NCD- linked adult illness and premature death are associated with household poverty, food insecurity, social stigma and an increased work burden on children. NCDs can contribute to gender inequality as they usually present a need for long- term caregiving which historically is disproportionately borne by female family members. NCD risk factors, such as alcohol and tobacco use, are also linked with child deprivation and violence against children, especially girls. The UNICEF Strategic Plan for 2018–2021 has strong links to NCD prevention and control, namely: • enhancing maternal, newborn and child health to reduce NCD risks; • improving immunisation, particularly against human papillomavirus (HPV); • preventing low birth weight, stunting, and other forms of malnutrition, including overweight and obesity; • preventing and treating HIV (HIV and its treatment increase the risks of NCDs and related problems); • investing in early childhood development (positive and responsive parenting); 2. UNICEF has a role to play in supporting countries in preventing and controlling NCDs • addressing adolescent health and nutrition (e.g. developing inclusive, multisectoral and gender-responsive national plans for adolescent health and well-being which included reducing behavioural risk factors for NCDs); and • adolescent mental health, suicide and road safety. Given its focus on childhood and adolescence and its cross-sectoral approach, UNICEF is well positioned to integrate early prevention of NCDs and their risk factors into its work. UNICEF has reviewed the recommended cost-effective NCD interventions endorsed by the WHA to identify those that are linked to UNICEF’s work at global, regional and country levels. Many of the recommended “best buy” interventions are already being implemented by UNICEF’s country offices (e.g. breastfeeding promotion), while some require the promotion of new activities (e.g. school-based policies and programmes, supportive infrastructure for active transportation in road safety programmes) and a focus on preconception health for females and males. Some areas of current and potential programming in relation to the “best buys” are highlighted in the table on page 3. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.1 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 1 WHO. 2017. ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf. 3 Responding to the Challenge of NCDs: UNICEF Evidence-based interventions UNICEF actions Advocate for legislation on food regulation and taxation. On the global platform, UNICEF has been at the forefront of breastmilk substitute regulation. UNICEF has been engaged with global level advocacy on the regulation of food composition and marketing and has promoted food labelling. UNICEF has also worked at global and country level to advocate for fiscal measures to control the consumption of sugar- sweetened beverages. Promote and support exclusive breastfeeding for the first 6 months of life, including promotion of breastfeeding. UNICEF’s Nutrition programme focuses on protection, promotion and support for exclusive breastfeeding for the first six months of life and continued breastfeeding with safe and adequate complementary feeding up to two years and beyond as well as promoting a healthy diet and addressing multiple micronutrient deficiencies among children aged 6–23 months. Implement nutrition education and counselling in different settings (e.g. preschools, schools, workplaces, health clinics and hospitals) to increase the intake of fruits and vegetables. To advance UNICEF’s Nutrition programme on NCDs and nutrition, guidance documents on the prevention of overweight and obesity, school nutrition and nutrition among adolescents are currently under development. Implement mass media campaign including social marketing on healthy diets to reduce the intake of total fat, saturated fats, sugars and salt, and to promote the intake of fruits and vegetables. UNICEF’s Communication for Development (C4D) programme can contribute to advocacy and community engagement efforts by creating an enabling policy and legislative environment for NCD prevention: this can engage communities, amplify the voices of affected children and adolescents, encourage participation particularly of adolescents and guarantee that governments and other stakeholders deliver on NCD prevention and control. Implement whole-of-school programmes that include quality physical education, availability of adequate facilities and programmes to support physical activity for all children. The UNICEF Education programme plays a significant role in NCD prevention through its preschool, primary and secondary school programmes for children over five years, and for adolescents. Developing and supporting whole-of-school policies and programmes that protect children and adolescents from harmful subsidies, encourage physical activity and address healthy diets are all potential entry points for UNICEF action. Implement community-wide public education and awareness campaign for physical activity which includes a mass media campaign combined with other community-based education, motivational and environmental programmes aimed at supporting behavioural change and physical activity levels. Through its Community Health programme, UNICEF is able provide support to mass media campaigns and targeted community-based health promotion activities via community health and social worker platforms. Primary prevention of rheumatic fever and rheumatic heart diseases by increasing appropriate treatment of streptococcal pharyngitis at the primary care level. UNICEF’s community and child health service delivery infrastructure, part of its Integrated Management of Childhood Illness programme, has the capacity to promote early detection and effective treatment of rheumatic fever as a preventive measure against rheumatic heart disease. Vaccination against HPV (2 doses) of 9- to 13-year-old girls. These campaigns are part of UNICEF’s Extended Programme on Immunization and delivered via in-country programmes. Prevention of liver cancer through hepatitis B immunisation. 4 Responding to the Challenge of NCDs: UNICEF Guidance on UNICEF’s approach on early life prevention of NCDs was issued in 2019. The UNICEF Strategy for Health 2016–2030 covers four areas that enable action at country level. Across these areas, there are many opportunities for UNICEF to strengthen its support to national NCD responses. Advocate for legislation on food regulation and taxation. Promote comprehensive laws that reduce the direct and indirect exposure of children and adolescents to tobacco, alcohol, illicit drugs, unhealthy foods and beverages, polluted air, water and soil (or polluted environment) and unsafe roads. Encourage school and community-based initiatives that enable healthy lifestyles and promote healthy food and physical activity. Reinforce health systems that, in coordination with education and social services, deliver NCD prevention, screening and care. Foster environmental initiatives that encourage physical activity and healthier diets (e.g. through sustainable transport and urban planning for health that prioritizes walkability and active mobility, in particular for school environments and safe and clean routes for schoolchildren). Target actions on environmental pollution monitoring, prevention and control. Integrate pollution control and NCD agenda. Pollution accounts for 22% of all deaths from cardiovascular disease, 53% of deaths from chronic obstructive pulmonary disease (COPD) and 40% of deaths from lung cancer). Identify data gaps and strengthen mechanisms for the collection and monitoring of NCD risk and related data across sectors. Influencing government policies. Provide technical support, convene stakeholders, facilitate knowledge exchange and mobilize resources to support governments in evidence-based policy-making and financing, including the adoption and implementation of laws, policies and programmes to protect children and adolescents from exposure to NCD risk factors. Make pollution prevention a core component of the intersectoral NCD agenda. Support the development of programmes for protective environments that discourage risk behaviours and support and protect health. Compile lessons learned, promote direct knowledge exchange between countries and foster South-South collaboration on effective strategies, policies and interventions. Strengthening service delivery Address NCDs more effectively across the lifecycle by leveraging existing platforms such as primary health care (PHC) facilities, community health platforms, schools and child protection systems,2 as well as guaranteeing clean and safe environments. Empowering communities Work with local civil society organizations (CSOs), governments and other local influencers to create demand for NCD prevention; use information and communication technologies (ICTs) to increase knowledge on healthy behavior patterns; and develop compelling and contextually appropriate messages to promote NCD prevention, delivered via communication-for- development (C4D) multimedia strategies. 2 UNICEF-supported maternal, newborn and child health programmes are well positioned to further integrate NCD prevention. 5 Responding to the Challenge of NCDs: UNICEF 3. Partnerships are critical for UNICEF in mobilizing an effective response to NCDs In addition to strengthening partnerships with governments, UNICEF can advance strategic partnerships with UN and multilateral partners. Examples include: • United Nations Population Fund (UNFPA), particularly programmes addressing antenatal care (ANC), HPV and risk factors during adolescence; • UN Women on gender policy; • Food and Agriculture Organisation (FAO) and World Food Programme (WFP) on nutrition and agriculture; • Gavi Alliance on HPV and hepatitis C; • World Bank and regional development banks on infrastructure programmes, financing and taxation; • United Nations Educational, Scientific and Cultural Organization (UNESCO) on health education and physical activity; • UN Environment Programme on clean, safe and healthy environments; • United Nations Development Programme (UNDP) on whole-of-government and whole- of-society NCD responses; • UN-Habitat on sustainable urban mobility; and • WHO on data/evidence/policy on prevention and control of pollution-related NCDs. UNICEF is also able to strengthen its collaboration with civil society on the prevention and control of NCDs, e.g. through NCD Child, NCD Alliance, Global Alliance for Improved Nutrition (GAIN), Child Health Initiative and EAT Foundation,3 including the EAT Food Forum. Engagement with the private sector can help leverage business data and expertise, e.g. to generate evidence, while business assets, technology, communications and outreach can be developed to deliver services or promote behaviour change on a large scale. 3 For example, UNICEF and EAT have initiated a collaboration, Children Eating Well (CHEW), to conduct research into and evaluate interventions related to food environments and children’s interactions with them, particularly in the urban context. Due diligence is required to ensure that desired results are obtained from private sector engagement, particularly as the activities of some businesses have an impact on children’s well-being through the marketing of tobacco, alcohol, and foods and beverages that are high in fat, sugar and/or salt. Partnerships with some pharmaceutical companies may also pose potential or real conflicts of interest. 6 Responding to the Challenge of NCDs: UNICEF The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the UNICEF as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr 4. Mobilizing resources to deliver Funding NCD prevention will enable UNICEF to protect children and adolescents from NCD risk factors and their impacts. However, while existing health, nutrition and education programmes can be adapted to include NCD prevention, it should not be assumed that this can be done easily, or at no cost. Nor should it be assumed that governments are always able to finance NCD prevention and control on their own, as many still require technical support to strengthen NCD-related services, policies, plans and programmes. Decision-makers must be made aware of the significant social and economic costs of NCD burdens. In addition to UNICEF’s traditional sources of funding for programmes and advocacy, private sector entities can be a potential source of funding provided they meet due diligence requirements. This technical brief is drawn from the UNICEF Programme Guidance on Early Life Prevention of Non-Communicable Diseases (2019).4 4 The full document can be accessed here: https://unicef-my.sharepoint.com/:b:/g/ personal/rbermejo_unicef_org1/EemhcUrpmFFLrDYURRM2uk8BmDV8IMjS_ LYcXbZOYWbgjg?e=V8frzU 1 Responding to the Challenge of NCDs: The World Bank The World Bank Responding to the Challenge of Non-communicable Diseases 1. The rising burden of NCDs poses a threat to health and development NCDs are a growing concern in all countries. NCDs are projected to rise in low- and middle- income countries (LMICs) by 2030 in line with changing lifestyles, ageing populations, urbanization and other factors. Many countries face a double burden of disease with an unfinished communicable disease burden and a rising NCD epidemic. Likewise, some LMICs face both a high prevalence of childhood stunting and the growing problem of obesity (the number of obese children and adolescents has grown more than tenfold over the past 40 years). NCDs result in increased health care spending and significant economic losses due to the often complex, costly and/or chronic nature of care, as well as to lost productivity. Between 2011 and 2025, NCDs are projected to cost LMICs more than US$7 trillion.1 Households bear the brunt of health care spending on NCDs and have limited financial protection in most LMICs. Considering the impoverishing effect of many NCDs, it will not be possible to attain the equity and financial protection goals of the UHC agenda if NCDs are not addressed. 1 Bloom, D. E., Chisholm, D., Jané-Llopis, E., Prettner, K., Stein, A., & Feigl, A. (2011). From burden to “best buys”: reducing the economic impact of non-communicable diseases in low-and middle-income countries (No. 7511). Available at: https:// www.who.int/nmh/publications/best_buys_summary.pdf. NCDs are defined as cardiovascular disease, cancers, diabetes and chronic respiratory diseases. United Nations high-level meetings have highlighted the need for UN agencies, including WB, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as unhealthy diet, tobacco use, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2 Responding to the Challenge of NCDs: The World Bank Regardless of their income levels, countries should not neglect the NCD burden given its implications for human capital development. Since NCDs are a major cause of premature death, disability and foregone wages, investments in the prevention and treatment of these conditions will improve adult health and economic growth. Investing in cost-effective NCD interventions in poorer countries will generate US$350 billion in economic benefits and save 8.2 million lives by 2030. This is a return of US$7 per person for every dollar invested.2 Financing of NCDs remains inadequate and out of line with the growing burden in LMICs. About 80% of the NCD burden is in LMICs, and NCDs overall represent over two thirds of the global disease burden; financing for NCDs is however concentrated in high- income countries and overseas development assistance for NCDs accounts for less than 3% of total assistance for health.3 NCD prevention requires a multisectoral, whole-of-government, whole-of-society approach which focuses on reducing population exposure to environmental and behavioural risk factors while increasing affordable access to basic services. Integrated care models which are patient-centered and leverage investments in infectious diseases and maternal, newborn and child health will be critical to managing both the rising burden of disease and spiralling costs. Despite several high-level NCD events since 2011, progress remains slow. The third UN High-Level Meeting on NCDs in September 2018 aimed to intensify political support in the context of the SDG agenda with a focus on “reducing premature mortality from NCDs by one third by 2030”, in line with SDG target 3.4. 2 WHO GCM/NCD Working Group on the Inclusion of NCDs in Other Programmatic Areas (2018). Final Report: Working Group on the Inclusion of NCDs in Other Programmatic Areas. Retrieved from https://www.who.int/global-coordination- mechanism/activities/working-groups/3-1-report.PDF?ua=1 3 Health Finance Institute. Addressing the economic burden of underinvestment in NCDs. Available at: http://healthfinanceinstitute.org/ Urgent action is needed to accelerate progress in health service coverage and financial protection, and to address the broader socioeconomic determinants of NCDs. 3 Responding to the Challenge of NCDs: The World Bank The World Bank’s health sector strategy supports countries to accelerate progress towards UHC. Its three main pillars include: (a) expanding financial protection so that no one is tipped into poverty because of catastrophic health spending; (b) increasing coverage of quality health services for the poorest 40% of the population; and (c) fostering a healthy society, including investments that reduce risk factors for NCDs. The prevention and control of NCDs cut across the three pillars. The World Bank responds to client demand to prevent and control NCDs by providing financial support, policy advice and technical assistance to strengthen the health system response and address key risk factors for NCDs. The World Bank has produced analytic work to understand the nature and magnitude of the NCD problem, identify risk factors and propose mitigation measures. It has also conducted expenditure analyses to determine the efficiency of public spending and identify strategies to expand domestic resource mobilization (including through taxation of health-harming products) in order to increase those available for primary health care (PHC). The World Bank plays an important knowledge-sharing role by producing a wide range of knowledge products and sharing experiences and lessons across countries. The Bank has brokered various partnerships to leverage technical and financial support, working in close collaboration with technical agencies, the private sector and UN agencies. 2. The World Bank has a role to play in supporting countries in preventing and controlling NCDs Investment lending is effective for scaling up domestic action on the prevention and control of NCDs The Bank has a diversified portfolio of investment operations in health systems and health services in support of NCDs, totaling about US$1.5 billion (2019): this represents about 12% of the Bank’s overall health, nutrition and population (HNP) lending. Projects include: (a) strengthening early detection and screening for NCDs; (b) promoting NCD risk reduction; and (c) revamping health systems and facilitating transformational reforms to shift attention from costly secondary care to primary health care. Over a half of all NCD health investments are on integrated projects with both disease prevention and chronic disease management activities. Other projects use communicable disease investments to support NCD prevention and treatment. The Bank portfolio also includes roughly US$0.2 billion of non-health investment operations that directly or indirectly contribute to NCD prevention. Examples include: (a) promoting environmental health; (b) expanding the use of safe and efficient cookstoves; (c) enhancing awareness and knowledge; (d) promoting fiscal and regulatory reforms; and (e) reducing the risk of road injuries. 4 Responding to the Challenge of NCDs: The World Bank Protecting Vulnerable People against NCDs in Argentina. NCDs generate a heavy health and economic burden. The US$350 million project (2015–2020) in Argentina aims to improve the readiness of public health facilities to deliver higher quality NCD services for vulnerable population groups and expand the scope of selected services, as well as to protect vulnerable population groups against prevalent NCD risk factors. Regional Programme of Cancer Registries in East Africa. In 2012, sub-Saharan Africa had about 850,000 new cancer cases and 600,000 deaths. The World Bank is supporting Burundi, Kenya, Rwanda, Tanzania and Uganda to strengthen their capacity for collecting, analysing and sharing data on cancers. Access to timely information on the rising cancer disease burden is critical to develop financial protection mechanisms to ensure that households are not impoverished by catastrophic health spending, provide quality services in a timely manner in order to facilitate early detection and treatment, and address risk factors associated with cancers. Leveraging Investments in Infectious Diseases to combat NCDs in Egypt. The World Bank supported a combined national hepatitis C and NCD risk factor (hypertension, high blood sugar and body mass index) screening campaign, with high-level political support from the President. Individuals with hepatitis C and/or at risk of NCDs were enrolled in structured treatment programmes. To date, 49.8 million adults aged of 18 or over have been screened. This innovative initiative demonstrates the potential for leveraging existing infectious disease platforms to address NCDs. Examples of World Bank-funded NCD Interventions Towards Population-Based Screening and Community-Level Outreach for NCDs in India. Tamil Nadu is India’s sixth most populous state and is dealing with a double burden of communicable and non-communicable diseases. Cardiovascular disease, diabetes, and cancer are the leading causes of death for people aged above 40. The World Bank has provided a US$287 million loan to strengthen management of NCDs, with a focus on health promotion and NCD prevention, population- based screening of NCDs among the eligible population, treatment and follow- up, and improvement of NCD monitoring and evaluation. The project aims to support a move from opportunistic screening to population-based screening. Establishment of Health Lifestyle Centres (HLCs) for NCD Screening and Referral in Sri Lanka and Turkey. The World Bank has supported the establishment of Healthy Life Centres at the PHC level for the detection and management of patients with a high NCD risk. In Sri Lanka this is being done by strengthening PHC capacity, population screening and better treatment and follow-up. Performance-Based Financing for NCDs in Tajikistan. Ischaemic heart disease is one of the leading causes of death in Tajikistan. The World Bank is supporting the government’s performance-based financing scheme to improve the coverage and quality of basic primary health services in rural health facilities in 10 districts. Under this supply-side project, the Ministry of Health contracts rural health centers to enhance both the quantity and quality of NCD services, providing coverage in about 450 health facilities to approximately 15 percent of the country’s total population. 5 Responding to the Challenge of NCDs: The World Bank Analytic work and knowledge management: Linking evidence to operations The Bank undertakes a wide range of country, regional and global studies to better understand and address the risk factors associated with NCDs, as well as to provide an analytic underpinning for investment lending and inform public policy. Examples are given in the box. The World Bank Group’s Global Tobacco Control Programme supports knowledge exchange among selected countries on the economics of tobacco control. Experts in health, governance and macroeconomic and financial management, poverty and equity, agriculture and trade engage actively in this programme, which is a win-win for both public health and domestic resource mobilization.4 The programme assists countries to design tobacco tax policy reforms and increase tobacco tax rates in order to: (a) achieve public health goals by increasing prices, reducing smoking, and preventing initiation among youth; (b) raise domestic resources for investments that benefit the entire population; and (c) enhance equity by reducing the health risks associated with tobacco-attributable diseases and the risk of impoverishment due to high out-of-pocket expenditure among the lowest income population groups. Achievements include providing support for tobacco tax policy reforms in several countries and the launch of the World Bank Group report “Tobacco Tax Reform: At the Crossroads of Health and Development”. 4 The World Bank. Global Tobacco control. https://www.worldbank.org/en/topic/ tobacco Impact of NCDs on Human Capital (2019). The WB is collaborating with several partners to produce a report that describes how human capital and productivity can be enhanced by tackling NCDs, with recommendations for action. This work is part of the World Bank’s Human Capital Project to improve human capital at the country level through investing in health and education. Obesity: A Ticking Time Bomb – What can the World Bank do to Defuse It? (2019). This report highlights the growing epidemic of obesity in both low- and high-income countries, and its health and economic costs. The report lays out the drivers of obesity, lessons learned from obesity-prevention efforts across the globe, and the policy and investment tools that the World Bank can deploy across different sectors to address obesity. How to Improve the Use of Fiscal Policy to Address the NCD Crisis: Lesson Learned from Tonga (2019). Tonga has a very high burden of NCDs. This study generates policy-relevant findings and insights on the implementation of taxation policy on tobacco, alcohol, food and behaviours, pricing, government revenues and the country’s response to the rising NCD burden. The Challenge of NCDs and Road Traffic Injuries in sub-Saharan Africa (2013). This is a comprehensive review of the literature with input from policy-makers, researchers and practitioners. It describes how resource- constrained governments can prevent and control NCDs and increase road safety. The Challenge of NCDs and Road Traffic Injuries in sub-Saharan Africa (2013). This is a comprehensive review of the literature with input from policy-makers, researchers and practitioners. It describes how resource- constrained governments can prevent and control NCDs and increase road safety. 6 Responding to the Challenge of NCDs: The World Bank The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the World Bank as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr 3. Partnerships are critical for the World Bank in mobilizing an effective response to NCDs The Bank has been an active member of several key partnerships and/or leader in key initiatives (e.g. tobacco control and mental health) to prevent and control NCDs. Examples include: • Access Accelerated. The Bank brokered this partnership with the private sector to leverage funding for pilot projects that aim to support early screening, detection and initial treatment for NCDs in countries such as Kenya and El Salvador. • Union for International Cancer Control (UICC) — City Cancer Challenge. The Bank participated in the UICC-led City Cancer Challenge initiative which supports cities to design, plan and implement cancer treatment solutions to reduce cancer mortality by 2025. • World Bank Umbrella Facility for Gender Equality (UFGE). The UFGE is a multidonor trust fund that aims to strengthen awareness, knowledge and capacity for gender-informed policy-making; it also explores new approaches to improve human capital, such as through the control of NCDs. 1 Responding to the Challenge of NCDs: WFP World Food Programme Responding to the Challenge of Non-communicable Diseases 1. The nutrition and food security sectors are central to an effective response to NCDs WFP is the food-assistance branch of the United Nations (UN), delivering food assistance in developing and emergency contexts, and working with communities to improve nutrition and build resilience. Unhealthy diets1 are a leading risk factor for NCDs. Diet-related NCDs include cancers, diabetes and cardiovascular disease. The right to food must not be reduced to “the right to not starve.”2 Ensuring access to diverse, safe and nutritious foods can prevent NCDs and their impacts on sustainable development. The triple burden of malnutrition— undernutrition and hunger, overweight and obesity, and micronutrient deficiencies— remains unacceptable. Children under five face large and multiple burdens: 149 million are stunted, 49.5 million are affected by wasting, and 40.1 million are overweight.3 1 Unhealthy diets include energy-dense and highly processed foods that are high in refined starches, sugar, fats and/or salt, accompanied by an insufficient intake of fresh fruits and vegetables, wholegrains, pulses, nuts and seeds. FAO (2017). The State of Food and Agriculture 2017: Leveraging Food Systems for Inclusive Rural Transformation. Available at: www.fao.org/3/a-I7658e.pdf. 2 A/HRC/19/59. Report submitted by the Special Rapporteur on the right to food, Olivier De Schutter. Available at: https://www.ohchr.org/Documents/HRBodies/ HRCouncil/RegularSession/Session19/A-HRC-19-59_en.pdf 3 United Nations Children’s Fund (UNICEF), World Health Organization, International Bank for Reconstruction and Development/The World Bank. Levels and trends in child malnutrition: key findings of the 2019 Edition of the Joint Child Malnutrition Estimates. Geneva: World Health Organization; 2019 Licence: CC BY-NC-SA 3.0 IGO. United Nations high-level meetings have highlighted the need for UN agencies, including WFP to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. An approach to the prevention of NCDs requires food system transformation and policies that address aspects of the wider food system, encompassing nutrition, food culture and identity, public food and meals, food loss and waste and sustainable diets. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2 Responding to the Challenge of NCDs: WFP The world is now experiencing record levels of overweight and obesity among adults (38.9%), with trends increasing, particularly among adolescents.4 Supporting good nutrition during the first 1,000 days of life and adopting healthy dietary habits during adolescence can reduce the risk of NCDs later in life. Supporting prematernal and gestational nutrition can reduce NCD risks for both mother and child. WFP supports governments to implement a comprehensive multisectoral package of actions that address the triple burden of malnutrition and the prevention of diet-related NCDs. Through its core work on nutrition and food security, and in collaboration with various stakeholders, WFP is uniquely positioned to contribute to global efforts to address NCDs.5 WFP’s nutrition policy (2017–2021) articulates its role in addressing NCDs and supporting governments to achieve the NCD-related targets in the 2030 Agenda for Sustainable Development. WFP works with government counterparts and partners to develop five-year country strategic plans, which are subsequently endorsed by WFP Executive Board members. A review of the cost-effective interventions endorsed by the WHA identified relevant WFP interventions at the global, regional and country level. Six examples are shown in the table. 4 United Nations Children’s Fund (UNICEF), World Health Organization, International Bank for Reconstruction and Development/The World Bank. Levels and trends in child malnutrition: key findings of the 2019 Edition of the Joint Child Malnutrition Estimates. Geneva: World Health Organization; 2019 Licence: CC BY-NC-SA 3.0 IGO. 5 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf. 2. WFP has a role to play in supporting countries in preventing and controlling NCDs Evidence-based interventions WFP actions Implement mass media campaign on healthy diets including social marketing to reduce the intake of total fat, saturated fats, sugars and salt, and promote the intake of fruits. Work with governments on strategies and programming for social and behavioural change and communication (SBCC), nutrition education and messaging across a variety of electronic and traditional media platforms including social media and press/radio. Related activities have been rolled out in countries, e.g. Sudan, Madagascar and Mozambique. Promote and support exclusive breastfeeding for the first six months of life. Promote infant and young child feeding through existing platforms such as community management of acute malnutrition and food assistance programmes. Implement nutrition education and counselling in different settings (e.g. in pre- schools, schools, workplaces and hospitals) to increase the intake of fruits and vegetables. Support governments to ensure that school meals programmes are nutritious. Support governments to develop policies and programmes in schools to encourage healthy diets. Implement nutrition labelling to reduce total energy intake (kcal), sugars, sodium and unhealthy fats. Work through the SUN Business Network to support governments in encouraging the private sector to strengthen nutrition labelling to inform consumers about total energy intake, sugars, sodium and unhealthy fats. Access to improved stoves and cleaner fuels to reduce indoor air pollution. Country-level implementation of the initiatives contained in the WFP Handbook on Safe Access to Firewood and Alternative Energy. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.5 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 3 Responding to the Challenge of NCDs: WFP WFP collaborates with a range of partners including the UN and the private sector to address malnutrition in all its forms. Partnerships are aimed at strengthening coordination, developing multisectoral policy, enhancing research and development, strengthening logistics and supply chain, and promoting digital technology and education. WFP ensures that partnerships are in the interest of public health. The Scaling Up Nutrition (SUN) Business Network. WFP and GAIN co-convene the SUN Business Network which, at the global and country levels, provides a platform to advance the dialogue on nutrition between the private sector, governments and other stakeholders. Depending on national nutrition priorities and the local private sector setting, efforts of the SUN Business Network may focus on reducing undernutrition, overnutrition or micronutrient deficiencies. Committee on World Food Security (CFS). The CFS is the foremost international and intergovernmental platform to promote food security and nutrition for all. In 2017, CFS started developing a set of voluntary guidelines on food systems and nutrition. Scaling Up Nutrition (SUN) United Nations Network (UNN)/REACH. ‘The SUN UNN/ REACH initiative’ is a partnership between WFP, Food and Agriculture Organisation (FAO), United Nations Children’s Fund (UNICEF), the World Health Organization (WHO) and the International Fund for Agricultural Development (IFAD). Its mandate is to accelerate the scaling up of food and nutrition actions in countries experiencing a high burden of child malnutrition. 3. Partnerships are critical for WFP in mobilizing an effective response to NCDs The UNN was established in 2013 by WFP, Food and Agriculture Organisation (FAO), United Nations Children’s Fund (UNICEF), the World Health Organization (WHO) and the International Fund for Agricultural Development (IFAD). The UNN works in countries to elevate national nutrition dialogue through its senior leadership and helps to leverage the collective strengths of the UN agencies, to foster innovations, find efficiencies and enhance complementarity across agencies and with government and SUN networks. Global Fund. WFP partners with organizations and companies to ensure that food and nutrition assistance is available to communities in some of the world’s hardest- to-reach areas. WFP’s partnership with the Global Fund is addressing logistics and supply chain issues around health and nutrition commodities in countries such as the Central African Republic and Burundi. IASC Humanitarian Cluster Mechanism. WFP is the lead agency in the Logistics Cluster6 (a coordination mechanism to ensure an efficient and effective emergency response, including the provision of NCD-related medicines during emergencies). WFP and FAO co-lead the Food Security Cluster7 (a coordination mechanism for food security response in humanitarian crises). 6 World Food Programme. Logistic cluster. https://www.wfp.org/logistics-cluster 7 Food Security Cluster. Coordinating the food security response in humanitarian crises. https://fscluster.org/ 4 Responding to the Challenge of NCDs: WFP P ho to c re di ts : © W or ld B an k vi a Fl ic kr The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by WFP as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. Due diligence is required to ensure that all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. 4. Mobilizing resources to deliver WFP leverages existing programmes to drive actions against undernutrition and hunger, overweight and obesity, and micronutrient deficiencies. Priorities include: • Fill the Nutrient Gap (FNG). This tool analyses the nutrition situation in a country and identifies the barriers faced by the most vulnerable in accessing and consuming healthy and nutritious foods; the FNG tool is used to inform government policies and WFP programming. In Madagascar, FNG helped to make the school meal food basket more nutritious. • School meals. Schools can encourage healthy eating among students, their families and communities. WFP’s Regional Bureau in Latin America and the Caribbean (LAC) is currently at the forefront of efforts to address overweight and obesity in schools in the LAC region. As part of the Latin American Network for School Meals initiative, WFP recently published an analysis on how nutrition-sensitive national school meals programmes can address malnutrition (undernutrition, overweight and obesity and micronutrient deficiencies), as well as accelerate progress towards achieving the SDGs (particularly SDG 2 and 3). • Social protection systems. WFP supports governments in the design of nutrition- sensitive social policies, mainstreaming nutrition education and supporting the design of shock-responsive social protection systems. • Social and behaviour change communication. This aims to improve behaviour around access to, selection, preparation and consumption of nutritious foods, to strengthen nutrition education and behaviour change communication in nutrition-specific programmes and to mainstream nutrition education aligned with national food-based dietary guidelines. • Food environments. WFP works to ensure balanced food baskets through diversification and micronutrient fortification, advocates for regulatory policies that improve the availability of safe, nutritious food and work environments, and negotiates with the private sector to increase the availability and marketing of age-appropriate and nutritious food.

RESPONDING TO THE CHALLENGE OF NON-COMMUNICABLE DISEASES United Nations Agency Briefs This set of briefs provides policy advisors and decision-makers across different United Nations agencies, Member States and development partners with information on how the UN system is responding to the challenge of non-communicable diseases (NCDs). The briefs were brought together by the WHO-led United Nations Inter-Agency Task Force on the Prevention and Control of NCDs. Heads of State and Government and representatives of States and Governments… … call upon WHO to continue to exercise its leadership, as the directing and coordinating authority on international health, in order to contribute to Member States’ efforts to prevent and control NCDs by continuing and strengthening its normative and standard-setting work and its capacity to develop and provide technical cooperation, assistance and policy advice to Member States, as well as to enhance its multi-stakeholder engagement and dialogue, including through … the United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases. Paragraph 47, Political declaration of the Third High-level Meeting of the General Assembly on the prevention and control of NCDs.1 Heads of State and Government and representatives of States and Governments… …call upon WHO to continue to promote and monitor enhanced global action to prevent and control NCDs by coordinating work with other UN agencies, development banks and other regional and international organizations.1 Paragraph 48, Political declaration of the Third High-level Meeting of the General Assembly on the prevention and control of NCDs.1 These briefs describe: • the role of the different UN system agency in making an effective contribution to the prevention and control of NCDs;1 • current and potential actions for different agencies to support the World Health Assembly-endorsed “best buys” and other recommended interventions to address NCDs;2 • the importance of partnerships for ensuring that agencies mobilize an effective response to NCDs; • the importance of partnerships in agencies’ response to NCDs; and • how agencies are mobilizing resources to deliver support to Member States. 1 Time to deliver: accelerating our response to address non-communicable diseases for the health and well-being of present and future generations. Political declaration of the Third High-level Meeting of the General Assembly on the prevention and control of NCDs, 2018. http://www.un.org/en/ga/search/view_doc.asp?symbol=A/ RES/73/2 2 WHO. “Best buys” and other recommended interventions for the prevention and control of noncommunicable diseases. 2017. www.who.int/ncds/management/best-buys/en/ The Task Force reports to the Economic and Social Council of the United Nations (ECOSOC) annually. Since 2014, ECOSOC has adopted a resolution each year on the Task Force: 2014: endorses the Task Force’s terms of reference 2015: encourages the Task Force to scale up action in countries 2016: expands the work of the Task Force to the NCD-related SDGs 2017: calls for greater financing for the work of the Task Force 2018: calls for development of partnerships to achieve public health goals 2019: encourages bilateral and multilateral donors, as well as other relevant stakeholders, to mobilize resources to support Member States, to catalyse sustainable domestic responses to NCDs and mental health conditions, including through a dedicated multi-donor trust fund. In the 2030 Agenda for Sustainable Development, adopted in September 2015, Member States recognize NCDs as a leading sustainable development issue. Agenda 2030 provides an enabling framework for identifying and implementing win-win approaches for NCDs and other development priorities. NCDs, principally cardiovascular disease, diabetes, cancer and chronic respiratory disease, are now the world’s biggest killers. Urgent and whole-of-government action is needed to prevent the annual toll of 41 million people dying from NCDs, including 15 million dying prematurely between the ages of 30 and 69 years. Often misconstrued as a problem of high- income countries only, NCDs place an equal—if not greater—burden on low- and middle-income countries (LMICs). Over 85 percent of premature NCD deaths occur in LMICs. Most premature NCD deaths are preventable by taking cost-effective action to tackle four main behavioural risk factors —tobacco use, harmful use of alcohol, physical inactivity and unhealthy diet. Also critical are ensuring affordable access to basic health services, including for mental health, and addressing environmental risks such as air pollution. Tackling NCDs and their risk factors requires a response from government. Sustainable Development Goal 3 on health and well-being includes a specific target relating to the prevention and control of NCDs and several other targets that are NCD-relevant. Achieving the NCD targets will advance the 2030 Agenda broadly, given the strong links between NCDs and poverty, social inequities, lack of access to affordable basic services, economic growth and climate action. 2018 NCD Political Declaration:1 10 takeaways for the UN system 1. 4 x 43 is expanded to 5 x 5 by including mental health conditions and air pollution. 2. Every year, over 15 million people aged 30–70 die from NCDs. Most of these premature deaths could have been avoided. 86% of these deaths occur in developing countries. NCDs will cost developing countries US$ 7 trillion over the next 15 years. 3. While the probability of dying from a major NCD between the ages of 30 and 70 continues to decline (22% in 2000 to 18% in 2016), the rate is insufficient to meet SDG target 3.4.4 4. Cost-effective, affordable and evidence-based interventions exist and need to be scaled up. 5. National NCD investment cases need to be developed to inform countries about the costs of NCDs, the return on investment from prevention and treatment, and links to poverty and socio- economic development. 6. The primary role and responsibility for combating NCDs lies with presidents and prime ministers. 7. Governments need to mobilize civil society and the private sector, where appropriate, to implement national NCDs responses, while giving due regard to managing conflicts of interest. 8. Mechanisms for national multi-stakeholder dialogue and accountability are critical. 9. There is a need to mobilize and allocate adequate, predictable and sustained resources for national NCD responses through domestic, bilateral and multilateral channels, as well as through public-private partnerships. 10. The UN system needs to step up its efforts to meet the requests for technical cooperation from Member States. WHO must continue to lead the UN Inter-Agency Task Force and explore options for innovative financing to support national NCD control efforts. 3 Four diseases (cardiovascular disease, cancer, diabetes and chronic lung disease) and four risk factors (tobacco use, harmful use of alcohol, unhealthy diets and physical inactivity). 4 By 2030, reduce by one third premature mortality from NCDs through prevention and treatment and promote mental health and well-being. WHO/UNIATF/19.98 Publication date: September 2019. © World Health Organization 2019. World Health Organization 2019. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. Photo credits (clockwise): © Nicholas Banatvala © UNDP (2) © Asian Development Bank © UNDP © AMISOM © World Bank © FMSC 1 Responding to the Challenge of NCDs: FAO Food and Agriculture Organization of the United Nations Responding to the Challenge of Non-communicable Diseases 1. The food and agriculture sector is crucial for an effective response to NCDs The food and agriculture sector plays a major role in nourishing people by increasing the availability of and access to diverse, safe and nutritious food, which meets dietary recommendations and principles relating to environmental sustainability.1 Most of today’s food systems need to be re-aligned from the production of high- yielding staple food crops such as cereals to sustainable provision of non-staple foods such as fruits and vegetables that will enhance dietary diversity. Improved food systems need to address all forms of malnutrition, such as overweight and obesity as well as wasting, stunting and micronutrient deficiencies. In today’s food systems, the nutritious foods that make up a healthy diet are not always available or affordable for many people.2 Various UN instruments have re-affirmed several fundamental nutrition- related rights, namely the right to have access to safe, sufficient and nutritious food, as well as the right to be free from hunger.3 The rise in obesity and NCDs is associated with a shift towards energy-dense diets, which are characterized by highly processed foods 1 FAO. 2018. Strengthening sector policies for better food security and nutrition results: food systems for healthy diets. Available at: www.fao.org/3/CA2797EN/ ca2797en.pdf. 2 FAO. 2013. The State of Food and Agriculture 2013: food systems for better nutrition. Available at: www.fao.org/docrep/018/i3300e/i3300e.pdf. 3 FAO & WHO. 2014. Second International Conference on Nutrition, Rome, 19-21 November 2014. Conference Outcome Document: Rome Declaration on Nutrition. Available at: http://www.fao.org/3/a-ml542e.pdf. high in refined starches, sugar, fats, and/or salt, accompanied by an insufficient intake of fresh fruits and vegetables, wholegrains, pulses, nuts and seeds.4 This shift is also coupled with sedentary lifestyles and low levels of physical activity. Most of the world's population now lives in countries where overweight and obesity kill more people than underweight.5 The way we produce, process, store and bring our food to markets is changing rapidly. Food production and supply chains have intensified, 4 FAO. 2017. The State of Food and Agriculture 2017: leveraging food systems for inclusive rural transformation. Available at: www.fao.org/3/a-I7658e.pdf. 5 WHO. 2019. Obesity and overweight [website]. Available at: https://www.who.int/ en/news-room/fact-sheets/detail/obesity-and-overweight. United Nations high-level meetings have highlighted the need for UN agencies, including FAO, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries (LMICs). Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as unhealthy diet, tobacco use, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. becoming industrialized and globalized, with people eating more purchased, processed and packaged food. Large-scale production has led to the use of a narrow range of high-yielding food crop and animal varieties, which has contributed to a reduction in agro-biodiversity. In addition, harmful chemicals used in food production are known to cause cancer. Widespread marketing of foods high in fat, sugar and/or salt, particularly those targeted at children, is a source of concern. This development is related to the steady growth and increasing influence of the private sector, including large-scale international food and agri-businesses and retailers. FAO is uniquely positioned to contribute to global efforts to reduce the prevalence of overweight, obesity and NCDs through the support it provides to countries in reforming their food systems and its work with line ministries responsible for agriculture, trade, environment and rural development, as well as with other UN agencies and development partners. Key areas for FAO engagement include: Situation analyses and awareness raising on how food systems and dietary changes drive overweight, obesity and NCDs. Engaging food systems stakeholders in policy analysis and dialogue, and encouraging them to implement public policy and regulations in order to create an appropriate set of incentives and disincentives to drive change in food systems. Political economy analysis to identify how different sectors impact on food systems and changes required to prevent and control NCDs. 2. FAO has a role to play in supporting countries in the prevention and control of NCDs For the first time FAO’s Medium-Term Plan 2018–2021 and Programme of Work and Budget 2018–2019 explicitly mention the issues of overweight, obesity and NCDs, and refer to the related targets under Sustainable Development Goals (SDGs) 2 and 3.6 FAO has reviewed the recommended cost- effective interventions endorsed by the World Health Assembly (WHA) to identify those linked to FAO’s work at global, regional and country levels. Examples are included in the table. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.7 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 6 FAO. 2017. The Director-General’s Medium-term Plan 2018-21 and Programme of Work and Budget 2018-19. Available at: www.fao.org/3/a-ms278e.pdf. 7 WHO. 2017. ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf. Responding to the Challenge of NCDs: FAO 2 Evidence-based interventions FAO actions Implement mass media campaign on healthy diets, including social marketing to reduce the intake of total fat, saturated fats, sugars and salt, and promote the intake of fruits. FAO supports countries to form action networks to promote healthy diets, nutrition labelling and food reformulation as part of the UN Decade of Action on Nutrition. Limiting portion and package size to reduce energy intake and the risk of overweight/ obesity. FAO supports countries to develop food-based dietary guidelines addressing overweight, obesity and undernutrition.8 Implement nutrition education and counselling in different settings (e.g. preschools, schools, workplaces, hospitals) to increase the intake of fruits and vegetables. FAO implements school- based food and nutrition education programmes, and supports governments to develop policies and programmes in schools to encourage healthy diets. Raise public and political awareness, understanding and practice about prevention and control of NCDs. FAO supports countries to raise awareness on NCDs and their risk factors, including obesity and steps that can be taken to prevent NCDs. Integrate NCDs into the social and development agenda and poverty alleviation strategies. FAO ensures that nutrition- sensitive social protection interventions also tackle the problem of diet-related NCDs. FAO integrates nutrition objectives into food and agriculture policy, programme design and implementation to enhance nutrition-sensitive agriculture, ensure food security and enable healthy diets for the prevention of overweight, obesity and NCDs. FAO supports countries in the development of easy-to-understand labels contributing to sustainable food systems. 8 Food-based dietary guidelines (also known as dietary guidelines) establish a basis for public food and nutrition, health and agricultural policies and nutrition education programmes to foster healthy eating habits and lifestyles. They provide advice on foods, food groups and dietary patterns to provide the required nutrients to the general public to promote overall health and prevent NCDs. See: www.fao.org/ nutrition/education/food-dietary-guidelines/en/. UN Decade of Action on Nutrition (2016–2025). In 2016, the UN General Assembly mandated FAO and the World Health Organization (WHO) to lead implementation of the Nutrition Decade with the aim to achieve the global nutrition and diet-related NCD targets by 20259 as well as the nutrition- and NCD-related targets in the 2030 Agenda for Sustainable Development (General Assembly resolution 70/1). It also called on FAO and WHO to accelerate the implementation of commitments made at the 2014 Second International Conference on Nutrition.10 Global Individual Food consumption data Tool (GIFT). FAO/WHO GIFT is an online platform providing individual dietary data that enables policy-makers to answer the question “What are people eating?” and to create better informed public policies for healthy diets.11 Kyoto University. This collaboration includes knowledge exchange, the provision of technical expertise, and awareness raising about urban food policy, food waste, and agriculture modelling, and study of the linkages between climate change and sustainable food and agriculture systems. The Rockefeller Foundation. Established in 2016, this partnership supports food security and seeks to reduce food losses by expanding the capacity of small-scale producers in sub- Saharan Africa. UN Habitat. This collaboration involves building resilient food systems by improving rural-urban food supply chains, e.g. in Kenya. 9 UN. 2019. UN Decade of Action on Nutrition [website]. Available at: www.un.org/ nutrition/. 10 FAO. 2014. The Second International Conference on Nutrition (ICN2) [website]. Available at: www.fao.org/about/meetings/icn2/en/. 11 More information on this tool is available at: www.fao.org/gift-individual-food- consumption. 3. Partnerships are critical for FAO in mobilizing an effective response to NCDs Responding to the Challenge of NCDs: FAO 3 Consumers International. This partnership aims to enhance Consumer International’s (CI) access to FAO’s wealth of knowledge and information while allowing FAO to work more closely with the network of CI membership organizations across the world which liaise with and advocate for individual consumers. In Latin America and the Caribbean, for example, both organizations cooperate to support the development of public policies for improved access to nutritious food and nutritional information. World Obesity Federation. This partnership, recently formalized in a memorandum of understanding, will increase awareness of the agriculture and food systems-related policy measures that have led to the current overweight and obesity situation and related disease burdens. FAO has developed a portfolio of programme priorities12 and invited partners to increase their investment in food and agriculture to improve health and achieve the SDGs. Among the NCD-related priorities are: • Tackling obesity through sustainable food systems: transforming food systems for health and well-being. • Food and green environments for healthy cities: improving the accessibility of nutritious food and green spaces for all. 12 FAO. 2019. Business development portfolio: opportunities to invest in sustainable development, 2019–2020 cycle. Available at: http://www.fao.org/3/ca4265en/ ca4265en.pdf. 4. Mobilizing resources to deliver Due diligence is required to ensure that all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by FAO as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. Responding to the Challenge of NCDs: FAO 4 1 Responding to the Challenge of NCDs: FCTC Secretariat of the WHO Framework Convention on Tobacco Control and Protocol to Eliminate Illicit Trade in Tobacco Products Responding to the Challenge of Non-communicable Diseases 1. WHO FCTC and its Protocol are essential legal instruments to ensure the attainment of global NCD targets Tobacco use is responsible for one in six deaths from NCDs. While gains have been made by many countries on tobacco control, the fact remains that approximately 80% of the world’s one billion smokers live in low- and middle-income countries: the tobacco industry is constantly looking for new markets in these countries and blocking tobacco control efforts.1 Governments negotiated and adopted the WHO FCTC in 2003. This evidence-based treaty entered into force in 2005, becoming one of the most rapidly embraced conventions of the United Nations system. Currently there are 181 Parties to the WHO FCTC, representing 90% of the world’s population. The Protocol to Eliminate Illicit Trade in Tobacco Products was adopted in 2014, entered into force in 2018 and currently has 56 Parties. The Meeting of the Parties (MOP) was established in 2018 and has put into motion the mechanisms for implementing the Protocol.2 1 UNGA, Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, A/RES/66/2 (2011); UNGA, Political Declaration of the Third High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (2018); United Nations, Economic and Social Council, United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases, E/RES/2018/13 (2018). 2 WHO FCTC Secretariat, Protocol to Eliminate Illicit Trade in Tobacco Products (2013). Available at: https://www.who.int/fctc/protocol/illicit_trade/protocol- publication/en/ United Nations high-level meetings have highlighted the need for the UN to scale up its work on NCDs as part of the 2030 Agenda for Sustainable Development.1 NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in developing countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioral risk factors, such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2 Responding to the Challenge of NCDs: FCTC Two MOP working groups have been established: one on tracking and tracing systems and another on assistance and cooperation.3 The Convention Secretariat (CS) is also the Secretariat of the Protocol. The political declarations of the high-level meetings of the General Assembly on the prevention and control of NCDs called on full implementation of the WHO FCTC while continuing to implement tobacco control measures without any tobacco industry interference; it urged Member States who have yet to ratify the WHO FCTC to accelerate the ratification process. Target 3.a of the Sustainable Development Goals (SDG2030) calls for strengthening the implementation of the WHO FCTC, which also contributes directly to Target 3.4 on prevention and control of the NCDs. Tobacco control can accelerate sustainable development in all its social, economic and environmental dimensions,4 and contributes to other health issues beyond those relating solely to NCDs, e.g. by addressing HIV and tuberculosis co-morbidities,5 maternal and child health, reproductive health and universal health coverage. Target 5 of the WHO Global NCD Action Plan 2013–2020 is a 30% relative reduction in the prevalence of current tobacco use in persons aged 15 years and over. 3 WHO FCTC Secretariat, Establishment of Expert and Working Groups to advance global tobacco control (2019). Available at: https://www.who.int/fctc/mediacentre/ news/2019/expert-working-groups-cop-mop-advance-tobacco-control/en/ 4 WHO FCTC Secretariat and UNDP, The WHO Framework Convention on Tobacco Control an Accelerator for Sustainable Development (2017). Available at: https:// www.who.int/fctc/implementation/publications/who-fctc-accelerator-for- sustainable-development/en/ 5 WHO FCTC Secretariat, Issue Brief: Integrating Tobacco Control into Tuberculosis and HIV Responses (2018). Available at: https://www.who.int/fctc/publications/ WHO-FCTC-HIV-TB.pdf?ua=1 As a legally binding instrument, the WHO FCTC is a powerful mechanism that reaffirms the right of all people to the highest standard of health. In 2018, the Conference of the Parties (COP)6 adopted the Global Strategy to Accelerate Tobacco Control: Advancing Sustainable Development through the Implementation of the WHO FCTC 2019–2025 (GS2025). The Strategy seeks to make a meaningful contribution to reaching the overall health goal of SDG 3 and target 3.4 on NCDs. Furthermore, the Strategy adopted the voluntary global target of “a 30% reduction in the age-standardized prevalence of current tobacco use in persons aged 15 years and over by 2025” as its own overall target, thus harmonizing WHO FCTC implementation with global NCD efforts. The COP has recognized the strong contribution it can make to achieving the global NCD target on the reduction of tobacco use. Subsequently, the COP has called upon Parties to integrate WHO FCTC implementation with national multisectoral NCD policies. It also requested the Convention Secretariat to promote WHO FCTC implementation as an essential and high-impact strategy for achieving SDG target 3.4, and report on the efforts taken in the next COP sessions. Protecting public health policies from the commercial and vested interests of the tobacco industry and establishing measures7 to protect the integrity of the decisions adopted by the governing bodies of WHO FCTC and its Protocol is at the core of the Parties’ obligations under the Convention and its protocols. 6 The Conference of the Parties (COP) is the governing body of the WHO FCTC and is comprised of all Parties to the Convention. The work of the COP is governed by its Rules of Procedure and keeps under regular review the implementation of the Convention: it takes decisions necessary to promote its effective implementation and may also adopt protocols, annexes and amendments to the Convention. For more information: https://www.who.int/fctc/cop/governance/en/ 7 See decisions FCTC/COP8(4), (12), (18) at https://www.who.int/fctc/cop/sessions/ cop8/decisions/en/ 3 Responding to the Challenge of NCDs: FCTC 2. The Convention Secretariat has a role to play in supporting countries in preventing and controlling NCDs The Convention Secretariat is a global authority overseeing implementation of the WHO FCTC. It promotes multisectoral, comprehensive tobacco-control policies and legislation at country level through strengthened coordination and planning. Over the years, the Convention Secretariat has supported close to 60 Parties, mostly developing country Parties and Parties with economies in transition by conducting needs assessments8 in the light of their obligations under the Convention. Parties have also received further support in development assistance including South- South and triangular cooperation with emphasis on the FCTC2030 project implemented in 15 Parties. Capacity- building initiatives at global, regional and country levels, sharing of best practices and dissemination of information, statements and position papers through the regular use of formal and informal communications with governments are part of the core attributions of the Convention Secretariat. The Convention Secretariat has also a network of CS-Knowledge Hubs with expertise in different areas of Convention implementation which provide technical support to the Parties in various fields, e.g. research, legal, economic, surveillance and policy-making. 8 WHO FCTC Secretariat, Needs assessments (2019). Available at: https://www.who. int/fctc/implementation/needs/en/ As part of the synergy framework promoted through COP decisions and resolutions of the World Health Assembly (WHA),9 the Convention Secretariat has reviewed the recommended cost-effective interventions endorsed by the WHA in order to identify those that are linked to its work at global, regional and country levels: specific examples are given in the table. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.10 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 9 Seventh Session of the Conference of the Parties to the WHO FCTC, Strengthening synergy between the Conference of the Parties and the World Health Assembly: Report of the Convention Secretariat, FCTC/COP/7/32 (2016). Available at https:// www.who.int/fctc/cop/cop7/FCTC_COP_7_32_EN.pdf and Seventh Session of the Conference of the Parties to the WHO FCTC, Strengthening synergy between the Conference of the Parties and the World Health Assembly, FCTC/COP7(18) (2016). Available at: https://www.who.int/fctc/cop/cop7/FCTC_COP7_18_EN.pdf?ua=1 10 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf 4 Responding to the Challenge of NCDs: FCTC Evidence-based interventions Convention Secretariat actions Increase excise taxes and prices on tobacco products. This is one of the specific objectives of the GS2025. Article 6 of the WHO FCTC is therefore a priority in the core work of the CS and includes development assistance projects such as the FCTC2030. Its application is supported by the Guidelines to implement Article 6 adopted by COP. Additionally, the CS-Knowledge Hub on taxation supports the CS in assisting Parties to implement Article 6 of the WHO FCTC.11 Implement plain/standardized packaging and/or large graphic health warnings on all tobacco packages. This is one of the specific objectives of the GS2025 and bears on Article 11 of the WHO FCTC. Its application is supported by the Guidelines to implement Article 11 adopted by COP. As one of the time-bound measures under the Convention, country development assistance projects coordinated by the CS frequently cover pictorial health warning legislation. The CS also encourages granting licences for pictorial health warnings to promote large-scale and effective pictorial health warnings. The CS-Knowledge Hub on international cooperation also supports the CS in assisting Parties to implement Article 11 of the WHO FCTC. Enact and enforce comprehensive bans on tobacco advertising, promotion and sponsorship (TAPS). Ban cross-border advertising, including using modern means of communication. TAPS bans are one of the specific objectives of the GS2025 and bears on Article 13 of the WHO FCTC as one of the time-bound measures under the Convention. Country development assistance projects frequently cover tobacco advertising, promotion and sponsorship legislation supported by the Guidelines to implement Article 13 adopted by COP. Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public places public transport. Guidelines on cross-border TAPS will be further elaborated. In decision FCTC/COP8(17), the COP established an intersessional working group to develop specific guidelines to address cross-border TAPS and the depiction of tobacco in the entertainment media under Article 13 of the WHO FCTC in the light of technological advances over the past decade such as the Internet and mobile communications.12 Implement effective mass media campaigns that educate the public about the harms of smoking/tobacco use and second-hand smoke. This is one of the specific time-bound objectives of the GS2025. Its implementation is supported by the Guidelines to implement Article 8 adopted by COP. As one of the time-bound measures under the Convention, country development assistance projects frequently cover smoke-free legislation. The CS-Knowledge Hub on international cooperation also supports the CS in assisting Parties to implement Article 8 of the WHO FCTC.13 Provide cost-covered, effective and population-wide support (including brief advice, national toll-free quit line services) for tobacco cessation to all those who want to quit. As one of the demand reduction measures under the Convention, country development assistance projects frequently cover education campaigns including mass media campaigns in line with Guidelines to implement article 12 adopted by COP. Provide mobile phone-based tobacco cessation services for all those who want to quit. As one of the demand reduction measures under the Convention, country development assistance projects frequently promote as broad a range of interventions as possible in order to support cessation in line with the Guidelines to implement Article 14 adopted by COP. The Convention Secretariat also works to promote targeted cessation initiatives when addressing co-morbidities such as HIV and tuberculosis.14 Additionally, the CS- Knowledge Hub on international cooperation promotes implementation of Article 14 of the Convention.15 Implement measures to minimize illicit trade in tobacco products. The Convention Secretariat has promoted the legal adoption of the Protocol and continues to endorse awareness-raising initiatives to encourage Parties to the Convention to become Parties to the Protocol and to begin its implementation. The CS is working to bring its development assistance initiatives in line with MOP guidance and decisions. 11 WHO FCTC Secretariat, WHO FCTC Knowledge Hub on Taxation (2019). Available at: https://untobaccocontrol.org/kh/taxation/ 12 Eighth Session of the Conference of the Parties to the WHO FCTC, Tobacco advertising, promotion and sponsorship: depiction of tobacco in entertainment media, FCTC/COP8(17) (2018). Available at: https://www.who.int/fctc/cop/sessions/cop8/FCTC__COP8(17).pdf?ua=1 13 WHO FCTC Secretariat, WHO FCTC Knowledge Hub on International Cooperation (2019). Available at: https://untobaccocontrol.org/kh/int-cooperation/ 14 WHO FCTC Secretariat, Issue Brief: Integrating Tobacco Control into Tuberculosis and HIV Responses (2018). Available at: https://www.who.int/fctc/publications/WHO-FCTC-HIV- TB.pdf?ua=1 15 ibid 5 Responding to the Challenge of NCDs: FCTC Twenty-eight international intergovernmental organizations and 21 nongovernmental organizations are accredited to the COP as observers. The Convention Secretariat cooperates with all observers in providing support to all Parties of both the WHO FCTC and its Protocol. The UK- and Australia-funded FCTC2030 project16 has enabled the Convention Secretariat to work with UNDP and WHO to support 15 low- and middle-income countries (LMICs) in promoting and supporting governments to accelerate implementation of the WHO FCTC. The Convention Secretariat leads the UNIATF Thematic Group on Tobacco Control under which several initiatives are taking place: • The Convention Secretariat takes the lead in developing and promoting the Model Policy on preventing tobacco industry interference among the UN agencies.17 After it was adopted by the seventh meeting of the UNIATF, it was endorsed by the UN Economic and Social Council (ECOSOC) meeting in 201718 and reiterated again in 2018.19 16 WHO FCTC Secretariat, FCTC 2030 (2019). Available at: https://www.who.int/fctc/ implementation/fctc2030/ 17 The purpose of this policy is to ensure that efforts to protect tobacco control from commercial and other vested interests of the tobacco industry are comprehensive, effective and consistent across the United Nations system including the UN itself and its funds, programmes, specialized agencies, other entities and related organizations. To download the model policy: https://www.who.int/ncds/un-task- force/events/model-policy-agencies-united-nations1.pdf 18 United Nations, Economic and Social Council, United Nations Inter-Agency Task Force on the Prevention and Control of Non-Communicable Diseases, E/ RES/2017/L.21 (2017). Available at: http://www.un.org/ga/search/view_doc. asp?symbol=E/2017/L.21 19 United Nations, Economic and Social Council, United Nations Inter-Agency Task Force on the Prevention and Control of Non-Communicable Diseases, E/ RES/2018/13 (2018). Available at: https://undocs.org/E/RES/2018/13 3. Partnerships are critical for the Convention Secretariat to mobilize and implement the WHO FCTC and its Protocol and provide an effective response to NCDs • The Convention Secretariat and WHO joined forces with FAO and ILO to support their Governing Body decision to stop funding from the tobacco industry for child labour in tobacco growing areas. • The Convention Secretariat is working with several UN agencies to develop a new joint programme to support low- and middle- income countries in developing economically sustainable alternatives to livelihoods based on tobacco growing. • The Convention Secretariat promotes a smoke-free UN campus in the UNIATF and has joined forces with WHO to develop tools and guides. Due diligence is required to ensure all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens for example by working to increase or preserve the availability, accessibility and/ or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. 6 Responding to the Challenge of NCDs: FCTC 4. Mobilizing resources to deliver COP8 has developed a fundraising strategy for implementing the WHO FCTC in line with GS2025, including the concept of an Investment Fund as a regular and sustainable fundraising mechanism.20 The Convention Secretariat has been actively mobilizing funds to support developing country Parties and Parties with economies in transition to strengthen their implementation of the WHO FCTC.21 20 Eighth Session of the Conference of the Parties to the WHO FCTC, Convention Secretariat’s fundraising strategies: Investment fund concept, FCTC/COP8(5) (2018). Available at: https://www.who.int/fctc/cop/sessions/cop8/FCTC__COP8(5). pdf?ua=1 21 WHO FCTC Secretariat, Donors and partners from 2018 (2019). Available at: https:// www.who.int/fctc/about/donorspartners/en/ The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the Convention Secretariat as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr 1 Responding to the Challenge of NCDs: IAEA International Atomic Energy Agency Responding to the Challenge of Non-communicable Diseases 1. Nuclear techniques assist in the prevention, early detection, diagnosis and treatment of NCDs1 Nuclear techniques play an integral role in the management of non-communicable diseases (NCDs)1 such as cancer, cardiovascular diseases, and neurological conditions, and can be used to design and evaluate interventions to address malnutrition in all its forms. Cancer. Cancer causes 9 million deaths each year.2 Medical imaging, including X-rays, and nuclear medicine techniques are critical in cancer care, in terms of: early and accurate diagnosis, including assessment of the location and spread of the disease (staging); follow-up of the patient to detect relapses; prognostic evaluation; and appropriate therapeutic decisions and follow-up of the response to treatment.3 Radiotherapy is a key element of cancer treatment for every second cancer patient worldwide. Modern radiotherapy allows automated delivery of a precise dose to the tumour and avoids the surrounding critical structures, giving the patient a chance to recover with minimal side- effects. 1 This UNIATF brief draws from the IAEA Brief for policymakers, “Prevention, Early Diagnosis and Treatment of Non-Communicable Diseases: The Role of Nuclear Techniques.” Available at: https://www.iaea.org/sites/default/files/18/10/ prevention-early-diagnosis-and-treatment-of-non-communicable-diseases.pdf 2 WHO. Key facts. NCDs. https://www.who.int/news-room/fact-sheets/detail/ noncommunicable-diseases 3 For more information, see: https://www.iaea.org/topics/cancer-diagnosis United Nations high-level meetings have highlighted the need for UN agencies, including IAEA, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as unhealthy diet, tobacco use, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2 Responding to the Challenge of NCDs: IAEA Cardiovascular disease. Cardiovascular diseases account for most NCD deaths, claiming the lives of 17.9 million people annually.4 Cardiac imaging using nuclear techniques is an important diagnostic tool, enabling earlier diagnosis and the planning of more effective treatment, as well as follow- up of patient response. Neurological conditions. Worldwide, around 50 million people have dementia, and there are nearly 10 million new cases every year. Alzheimer’s disease is the most common form of dementia and may contribute to 60– 70% of cases.5 Molecular imaging, including brain perfusion techniques, is helpful in the diagnosis of Alzheimer’s and other forms of dementia.6 Malnutrition. The effects of poor nutrition add to the burdens on health-care systems. In 2018, globally 149 million children under 5 years of age were stunted, 49 million wasted and 40 million overweight.7 Nuclear and stable isotope techniques provide important accurate data on body composition, breastfeeding practices, total daily energy expenditure, micronutrient bioavailability and vitamin A status, all of which directly relate to the prevention of diet-related NCDs. 4 WHO. Key facts. NCDs. https://www.who.int/news-room/fact-sheets/detail/ noncommunicable-diseases 5 WHO. Dementia: Key facts. https://www.who.int/news-room/fact-sheets/detail/ dementia 6 Torosyan N, Silverman S. (2012). Neuronuclear Imaging in the Evaluation of Dementia and Mild Decline in Cognition. Semin Nucl Med; 42(6): 415–422. 7 Global Health Observatory: Child malnutrition https://www.who.int/gho/child- malnutrition/en/ 2. IAEA has a role to play in preventing and controlling NCDs Working with governments, research and health institutions and development partners, IAEA provides technical assistance to Members States to strengthen their capacity in cancer diagnostics and treatment, and to evaluate preventive interventions for diet-related NCDs using stable isotope techniques.8 This support consists of developing, adopting and strengthening practices, providing technical advice and training, engaging in coordinated research projects, provision of equipment, preparation of technical publications and public information, and resource mobilization activities. IAEA also strengthens the evaluation of a range of nutrition interventions to prevent and support treatment of NCDs such as those that increase physical activity, promote breastfeeding and assess body composition and energy expenditure. IAEA has supported more than 110 low- and middle-income countries (LMICs) to address issues related to NCDs. IAEA has established a dedicated service (imPACT Review)9 to assess national capacities in cancer control and subsequently support Member States in evidence-based planning of cancer control resources. This service is delivered in cooperation with the World Health Organization (WHO) and International Agency for Research on Cancer (IARC). 8 IAEA Brief on Human Health for Policy Makers. https://www.iaea.org/sites/default/ files/18/10/prevention-early-diagnosis-and-treatment-of-non-communicable- diseases.pdf 9 https://www.sciencedirect.com/science/article/abs/pii/S1470204517303728 Abdel-Wahab M, Lahoupe B, Polo A, et al. (2017). Assessment of Cancer Control Capacity and Readiness: The Role of the International Atomic Energy Ageny. Lancet Oncol; 18(10): 587-594. 3 Responding to the Challenge of NCDs: IAEA IAEA’s Quality Management Audit for Nuclear Medicine Practice aims to support facilities to improve the quality of their clinical practice. Since 2009, IAEA has conducted 72 audits in 38 countries.10, 11, 12 IAEA has compiled the first comprehensive database on global energy expenditure data. Between 1981 and 2017, over 6600 measurements from 23 countries were collected using the Doubly Labelled Water method. These data help countries develop better health policies to combat the growing obesity epidemic. IAEA has reviewed the recommended cost- effective interventions endorsed by the WHA for NCDs to identify those that can be advanced through IAEA’s work at global, regional and country levels. Examples are provided in the table below. 10 Dondi M, Paez D, Torres L, et al. (2018). Implementation of Quality Systems in Nuclear Medicine: Why It Matters. An Outcome Analysis (Quality Management Audits in Nuclear Medicine Part III). Semin Nucl Med; 48(3):299-306. 11 Dondi M, Torres L, Marengo M, et al. (2017). Comprehensive Auditing in Nuclear Medicine Through the International Atomic Energy Agency Quality Management Audits in Nuclear Medicine Program. Part 2: Analysis of Results. Semin Nucl Med;47(6):687-693. 12 Dondi M, Torres L, Marengo M, et al. (2017). Comprehensive Auditing in Nuclear Medicine Through the International Atomic Energy Agency Quality Management Audits in Nuclear Medicine (QUANUM) Program. Part 1: the QUANUM Program and Methodology. Semin Nucl Med;47(6):680-686. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.13 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 13 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. http://apps.who.int/iris/bitstream/ handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf 4 Responding to the Challenge of NCDs: IAEA Evidence-based interventions IAEA actions Treatment of heart attacks. Building capacity in appropriate and safe use of medical imaging, including nuclear medicine (SPECT and PET) and radiology. Establishing sustainable medical imaging facilities for evaluation of patients with CVD. Treatment of heart failure. Breast screening using mammography with timely diagnosis and treatment of breast cancer. Ensuring quality control, image quality and dose optimization of mammography units. Assisting in the development of national diagnostic reference levels. Building capacity for the appropriate and safe use of mammography. Establishing sustainable mammography facilities. Treatment of colorectal cancer stages I and II and basic palliative care for cancer. Planning, establishing and sustaining radiotherapy services. Supporting radiotherapy quality assurance programmes. Provision of training in radiotherapy. Raising public and political awareness, understanding and practice relating to the prevention and control of NCDs. Highlighting NCD issues through media including social media. Strengthening international cooperation for resource mobilization, capacity-building, health workforce training, and exchange of information on lessons learned and best practices. Supporting education and training activities for health practitioners. Supporting the development of national resource mobilization strategies, technical documents and targeted funding proposals. Assessing national capacity for the prevention and control of NCDs. Supporting the development of national cancer control plans and strategies. Providing recommendations on national treatment and palliative care programmes. Conducting national assessments to strengthen national cancer control programmes. Strengthening human resources and institutional capacity for research. Supporting countries to train healthcare staff. Supporting countries to build clinical research capacity. Strengthening research capacity through cooperation with domestic and foreign research institutes. Partnering with joint research programmes. Supporting clinical research protocols in LMICs. Promoting and supporting exclusive breastfeeding for the first six months of life. Evaluating breastfeeding practices using stable isotope techniques. 5 Responding to the Challenge of NCDs: IAEA The IAEA collaborates with a number of partners in response to NCD burdens. Examples include: • IAEA/WHO (Network of Secondary Standards Dosimetry Laboratories) which provides calibrations for dosimetry equipment that are used to determine radiation dose levels for patients, staff or the public; • UN Joint Global Programme on Cervical Cancer Prevention and Control, which supports countries to reduce the burden of cervical cancer – IAEA has a key role in supporting Member States in the diagnosis and treatment of cervical cancer, including radiotherapy and palliative treatment; • International Union of Nutritional Sciences’ Task Force on Nutrition and Cancer which, at national, regional and global levels, catalyses capacity and collaboration across nutrition and cancer; • International Organization for Medical Physics in the development of guidelines and American Association of Physicists in Medicine in the development of dosimetry codes of practice; and • International Centre for Theoretical Physics, European Society for Radiotherapy and Oncology and a range of other professional organizations in building capacity through training courses, conferences and workshops. 3. Partnerships are critical for IAEA in mobilizing an effective response to NCDs A formal mechanism for due diligence, which also addresses conflicts of interest in safeguarding the reputational risk to the organization, should be in place to ensure that all partnerships advance health and development outcomes. 6 Responding to the Challenge of NCDs: IAEA 4. Mobilizing resources to deliver As Member States struggle with inadequate resources to tackle their increasing cancer burden, IAEA has adopted a new resource mobilization approach, joining forces with the private sector and international financial institutions to support low- and middle-income countries in order to secure financial and non- financial resources: in 2012, for instance, IAEA launched a focused partnership effort with the Organization of Islamic Cooperation and the Islamic Development Bank to expand access to effective, safe and sustainable cancer care in common Member States. The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the IAEA as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. Photo credits: © IAEA © World Bank (p.3, top) © UNICEF (p.3, bottom) 1Responding to the Challenge of NCDs: ILO International Labour Organization Responding to the Challenge of Non-communicable Diseases 1. Non-communicable diseases (NCDs) in the world of work United Nations high-level meetings have highlighted the need for UN agencies, including the ILO, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low and middle- income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. A comprehensive and effective prevention strategy for NCDs requires engagement of the world of work. Workers in all sectors are at risk of NCDs. NCDs arise from risk factors at work and affect worker productivity. They can be prevented by improving working conditions and through workplace health promotion programmes. The International Labour Organization (ILO) was founded on the mandate of guaranteeing adequate protection for the life and health of workers in all occupations. The workplace is where people spend more than one-third of their lives and is therefore an important platform for health promotion among workers, their families and communities.1 Most occupational diseases are non- communicable and from workplace exposures such as exposure to hazardous substances including chemicals, dusts and fumes.2 These exposures can increase the risk of negative health outcomes such as respiratory diseases and cancer.3 1 WHO. 1994. Global strategy on occupational health for all: The way to health at work. Available at: https://bit.ly/2UrgMen 2 ILO. 2010. ILO List of Occupational Diseases (revised 2010). Available at: https://bit. ly/3f3kmDq 3 ILO. 2020. Harmful Chemical and Biological agents/substances. Available at: https://bit.ly/37gpkKA It is estimated that cardiovascular diseases (31 per cent), cancers (26 per cent) and respiratory diseases (17 per cent) account for almost three-quarters of work-related mortality worldwide.4 Certain working practices can also lead to NCDs, for example sedentary habits are a risk for cardiovascular diseases and diabetes. Addressing modifiable risk factors and using the workplace as a platform for health promotion is critical to addressing NCDs. 4 Hämäläinen, P.; Takala, J.; Boon Kiat, T. 2017. Global Estimates of Occupational Accidents and Workrelated Illnesses 2017 (XXI World Congress on Safety and Health at Work, Singapore, Workplace Safety and Health Institute). 2• Tobacco control: Tobacco use in the workplace can affect workers through primary exposure as well as second-hand smoke from other workers. Smoking breaks can also result in reduced productivity from workers. Smoking in the workplace also has the potential to cause fires or explosions, further posing a risk to safety and health. Providing workers with education, cessation support and regulations concerning smoking on workplace premises can protect workers from the harmful effects of smoking; • Healthy sleep: Working schedules, long hours, stress and other factors can impact healthy sleep, increasing the risk of workplace injury and NCDs; • Physical activity: Depending on the tasks at a specific workplace, workers may be either sedentary for extended periods of time or physically active. Workplace health promotion initiatives can ensure physical activity opportunities to reduce the risk of NCDs. Promoting good health benefits both employers and workers by improving well- being, productivity and performance. A foundation of good health in the world of work reduces pressure on the health, welfare and social security systems while supporting economic growth. This can be done by developing national and workplace level policies, technical guidance, and awareness raising including on the following5: • Workplace nutrition: Healthy diets reduce the risk of NCDs and other diseases, workplace injury and productivity loss. As workers often spend a large proportion of their time at work, access to healthy food options and education about nutrition in the workplace can have a large impact on their diets and overall health; • Mental health, stress and psychosocial risks: Mental health can be affected in the workplace when workers experience an imbalance between perceived responsibilities and their abilities and resources, underutilization of talent, bullying, harassment, repetitive tasks, economic stress, precarious work and other factors and situations. In addition, mental health conditions can affect workers’ productivity and their ability to complete tasks safely. Workplaces can provide education and support for workers in the area of mental health; • Violence and harassment: Violence and harassment in the workplace can be horizontal (between co-workers), vertical (between supervisor and worker) or external (between worker and the public, customers or vendors). Violence and harassment can affect the mental and physical health of workers as well as their productivity and safety on the job. Workplaces should have training, clear policies and procedures in place to protect workers; • Alcohol and drug abuse: Alcohol and drug use, occurring both during working hours or outside of the workplace, can affect workers’ ability to safely complete tasks and can increase the risk of diseases and injuries. Workplaces can provide cessation support and education about these substances as part of their health promotion strategies. Regulations concerning consumption of alcohol and drugs in the workplace can also protect workers’ health and safety; 5 ILO. 2012. The SOLVE training package: Integrating health promotion into workplace OSH policies. Available at: https://bit.ly/3dSY0UU Responding to the Challenge of NCDs: ILO 32. The ILO has an important role to play in supporting countries to prevent and control NCDs Working with governments, employers and workers through its tripartite governance structure, the ILO has developed International Labour Standards focused on fundamental principles of occupational safety and health (OSH) as well as risk-specific and sector- specific Conventions6 and Recommendations. Risk-specific Conventions relevant to NCDs include those on radiation,7 benzene,8 cancer,9 the working environment,10 asbestos11 and chemicals.12 Sector-specific Conventions relevant to NCDs include those on construction,13 mining14 and agriculture.15 The ILO published SOLVE: Integrating Health Promotion into Workplace Occupational Safety and Health (OSH) Policies in 2012.16 This comprehensive training package focuses on both prevention of psychosocial risks and promotion of health and well-being at work through policy design and action. It covers stress, alcohol and drugs, violence, HIV & AIDS, tobacco, nutrition, physical activity, healthy sleep and economic stress in the world of work. 6 ILO. International Labour Standards on Occupational Safety and Health. Available at: https://bit.ly/3izwrSK 7 ILO. 1960. C115 - Radiation Protection Convention, 1960 (No. 115). Available at: https://bit.ly/3h5MaJn 8 ILO. 1971. C136 - Benzene Convention, 1971 (No. 136). Available at: https://bit. ly/37fXcHk 9 ILO. 1974. C139 - Occupational Cancer Convention, 1974 (No. 139). Available at: https://bit.ly/3cNI991 10 ILO. 1977. C148 - Working Environment (Air Pollution, Noise and Vibration) Convention, 1977 (No. 148). Available at: https://bit.ly/3cOq4rj 11 ILO. 1986. C162 - Asbestos Convention, 1986 (No. 162). Available at: https://bit. ly/3f6uds9 12 ILO. 1990. C170 - Chemicals Convention, 1990 (No. 170). Available at: https://bit. ly/2XMgpxh 13 ILO. 1988. C167 - Safety and Health in Construction Convention, 1988 (No. 167). Available at: https://bit.ly/2XOaGah 14 ILO 1995. C176 - Safety and Health in Mines Convention, 1995 (No. 176). Available at: https://bit.ly/3hcmx9u 15 ILO. 2001. C184 - Safety and Health in Agriculture Convention, 2001 (No. 184). Available at: https://bit.ly/2zfS9dh 16 ILO. 2012. SOLVE: Integrating Health Promotion into Workplace OSH Policies. Available at: https://bit.ly/3h2WLVc BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs. Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. Responding to the Challenge of NCDs: ILO 4Responding to the Challenge of NCDs: ILO Evidence-based interventions ILO actions Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public places and public transport. Implement effective mass media campaigns that educate the public about the harms of smoking/tobacco use and second- hand smoke. Provide support for tobacco cessation to all those who want to quit. Promotion and implementation of a smoke-free work environment fall under the ILO’s mandate to create healthy and safe workplaces. The ILO has produced a number of Conventions and Recommendations related to smoking at the workplace and provides assistance to countries and employers in their implementation. Reduce salt intake through the establishment of a supportive environment in public institutions such as hospitals, schools, workplaces and nursing homes, to enable lower sodium options to be provided. Implement nutrition education and counselling in different settings (for example, in preschools, schools, workplaces and hospitals) to increase the intake of fruits and vegetables. The ILO works with partners to ensure that workers have access to nutritious, safe and affordable food, an adequate meal break and decent conditions for eating. Implement multi-component workplace physical activity programmes. The ILO is working with employers on encouraging physical activity of workers, including through wider campaigns on health promotion at the workplace, with information, education and other measures to create a social environment which is conducive to physical activity and exercise. Cost-effective interventions to prevent occupational lung diseases, for example, from exposure to silica or asbestos. The ILO works with countries on laws and regulations, enforcement of occupational exposure limits and technical standards, and on national action programmes involving governmental agencies, industry and trade unions, to create infrastructure which is needed to prevent silicosis. Develop and implement a national multi-sectoral policy and plan for the prevention and control of NCDs through multi- stakeholder engagement. Raise public and political awareness, understanding and practice about prevention and control of NCDs. The ILO engages with multi-sectoral partners to encourage policies that prevent and control NCDs, including health promotion and well-being at work programmes. In addition, the ILO has developed a large number of codes of practice and other publications to support countries in workplace settings. Risk specific publications include a Code of Practice on alcohol and drugs,17 multiple publications and resources on psychosocial risk and stress in the world of work18, 19, 20, 21and training on stress prevention at work.22 The ILO also produced the International Classification of Radiographs of Pneumoconioses.23 17 ILO. 1999. Management of alcohol and drug-related issues in the workplace. Code of practice. Available at: https://bit.ly/37gDATe 18 ILO. 2020. Managing work-related psychosocial risks during the COVID-19 pandemic. Available at: https://bit.ly/2PIDCvt 19 ILO. 2020. Safe and healthy working environments free from violence and harassment. Available at: https://bit.ly/3fRTvdq 20 ILO. Stress Prevention at Work Checkpoints app. Available at: https://bit.ly/2AQ8VQH 21 ILO. 2016. Workplace Stress: a collective challenge. Available at: https://bit.ly/3hdA8xw 22 ILO. 2012. Stress Prevention at Work Checkpoints. Practical improvements for stress prevention in the workplace. Available at: https://bit.ly/2BOIgEs 23 ILO. 2020. ILO International Classification of Radiographs of Pneumoconiosis. Available at: https://bit.ly/2BPzFkT 5Responding to the Challenge of NCDs: ILO 3. Partnerships are critical for ILO in mobilizing an effective response to NCDs In addition to strengthening partnerships with governments, employers and workers within its tripartite structure, the ILO can advance strategic partnerships with multilateral stakeholders. The ILO and World Health Organization (WHO) have collaborated on producing a methodology for estimating the global burden of work-related disease and injury.24 This methodology builds on existing work to estimate burdens of disease for 39 pairs of occupational risk factors and health outcomes. The updated methodology will include an estimated 13 additional risk factor and outcome pairs including the following: • Occupational exposure to solar ultra violet radiation and skin cancers, cataracts; • Occupational noise and cardiovascular diseases; and • Long working hours and ischemic disease, stroke, depression and alcohol use disorders. Jointly, the ILO and WHO have created the International Chemical Safety Cards Project that includes over 1700 data sheets in more than 10 languages and using a recognizable, clear and concise format to promote the safe use of chemicals in the workplace. The Inter-Organization Programme for the Sound Management of Chemicals (IOMC) and the Globally Harmonised System for Classification and Labelling of Chemicals (GHS) are two ILO partnerships on chemical safety. The ILO is also providing technical support to WHO in the development of guidelines on mental health in the workplace. 25 24 ILO. 2016. The WHO/ILO joint methodology for estimating the work-related burden of disease and injury. Available at: https://bit.ly/30mJNM2 25 ILO & WHO. International Chemical Safety Cards (ICSCs). Available at: https://bit. ly/37cC2d0 6The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the ILO as part of a set of United Nations system agency briefs under the Task Force. Ph ot o cr ed its : © IL O 4. Mobilizing resources to deliver Responding to the Challenge of NCDs: ILO The ILO will continue to address NCDs as an important issue in the world of work through technical support and partnerships on NCD prevention and care. The Global Occupational Safety and Health Coalition includes the WHO, the ILO and other founding partners. The coalition’s priorities include the prevention and control of NCDs in support of paragraph 44 of the 2018 Political declaration of the 3rd High Level Meeting of the General Assembly on the Prevention and Control of Non-Communicable diseases.26 Each year, the ILO leads the World Day for Safety and Health at Work with a different theme.27 Often these themes address safety and health issues related to NCDs. The ILO also organizes, along with other partners, the World Congress on Safety and Health, which occurs every three years.28 26 United Nations. 2018. Political declaration of the 3rd High-Level Meeting of the General Assembly on the Prevention and Control of Non-Communicable diseases. Available at: https://bit.ly/2UsZvBL 27 ILO. World Day for Safety and Health at Work. Available at: https://bit.ly/2UozbZk 28 ILO. 2020. World Congress on Safety and Health. Available at: https://bit.ly/3h9hh6y International Organization for Migration Responding to the Challenge of Non-communicable Diseases Migration is an important determinant of health. It can challenge physical, mental and social well-being. Throughout the migration process, migrants experience difficulties in accessing health services and face increased exposure and vulnerability to NCDs and their risk factors as well as mental ill-health and injuries. In their community of origin, migrants may face poverty, violence and social conflict, as well as limited access to health care. For families left behind, the social cost is considerable, and has significant mental health implications. Remittances that could be used for accessing long-term health protection schemes are often used for out-of-pocket health expenditure. During transit, stressful and unsafe travel conditions and discontinued care can exacerbate migrants’ risk of developing NCDs or worsen pre-existing conditions. At destination, potential challenges in continuity of care, coupled with difficulty adapting to a new culture, may lead to the adoption of unhealthy lifestyle behaviors which further increase the burden of NCDs on migrant communities. United Nations high-level meetings have highlighted the need for UN agencies, including IOM, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. Stigma, discrimination and restrictive policies also expose migrants to NCD risk factors. In addition, migrant workers are reported to have a higher risk of work-related injuries and chronic illnesses than native workers. During return, especially after crisis situations, their access to health services may be limited. Migrants and mobile populations can face many obstacles in accessing essential health care services due to, among other factors, their irregular immigration status, language barriers, the absence of migrant-inclusive health policies and inaccessible services. 1. Migrants are at increased risk of NCDs and mental health conditions 1 Responding to the Challenge of NCDs: IOM 2. IOM has a role to play in supporting countries in preventing and controlling NCDs “Life Is Better”—psychoactive substances abuse primary prevention campaign, Georgia (2016–2017) IOM Georgia implemented a multisectoral approach involving local authorities in seven public schools. The “Life is Better” school-based campaign used an innovative and interactive two-pronged educational approach combining information dissemination on the risks of drug use and skill-building which targeted youth and their families in migrant communities and among ethnic minorities. The campaign reached 4,067 school children who were shown to be comparatively more aware of drug-related risks and better equipped to face social pressures relating to drug use. The “Life is Better” campaign acts as a primary prevention method to combat NCDs since substance abuse can lead to mental health problems such as depression and anxiety. Substance abuse can also increase the risk of developing cancer, diabetes and other NCDs. The campaign was adopted by the Ministry of Education and Science of Georgia and has been expanded nationwide. IOM, as the UN migration agency, is committed to the inclusion of migrant and mobile populations in all relevant policies and programmes to reduce NCDs. This commitment is reflected in IOM’s support for implementation of the Global Compact for Safe, Orderly and Regular Migration,1 as well as World Health Assembly (WHA) Resolution 70.15 and the related Global Action Plan on promoting the health of refugees and migrants. IOM serves as the Coordinator and hosts the Secretariat of the UN Network on Migration, which was established to ensure effective, timely and coordinated system-wide support to Member States in the implementation of the GCM. The Network working groups, especially related to improving access to services, can provide a further platform to promote NCDs related activities to promote health of migrants. IOM is committed to supporting partnerships to ensure the inclusion of migrants and mobile populations in national and regional plans including Universal Health Coverage (UHC). Migrants should be afforded equitable access to high-quality health services including to prevent, treat and manage NCDs. Continuity of care should be guaranteed, especially at the point of destination where they can receive more comprehensive treatment for diseases developed during the migration process, specifically NCDs. To ensure that migrants are not excluded from accessing healthcare regardless of their race, gender, or legal status, it is important to develop migrant-inclusive policies and develop migration-sensitive and culturally appropriate health systems able to deal with NCD risk factors associated with population movements. 1 Global Compact for Safe, Orderly and Regular Migration, endorsed by the United Nations General Assembly in resolution 73/195 (2018). 2 Responding to the Challenge of NCDs: IOM MANAGEMENT OF NCDS WITHIN THE IOM HEALTH ASSESSMENT PROGRAMME (HAP) IOM provides comprehensive pre-departure health assessment services for immigrants and refugees; these services generally include medical history-taking, physical examination, laboratory tests and radiology, through which the presence of NCDs may be disclosed or diagnosed. If an NCD is detected or suspected based on health assessment findings, the refugee or immigrant is provided with counselling and is referred for follow-up care or further investigations. If the beneficiary is a refugee for resettlement and will be traveling under the auspices of the Organization, IOM takes responsibility for the management of the refugee’s medical condition, including pre- departure stabilization and care, travel health assistance, such as medical escorts, post- arrival follow-up care, and confidential transfer of medical information to the receiving entity to ensure the continuity of care. 3. Partnerships are critical for IOM in mobilizing an effective response to NCDs IOM has partnerships with multiple stakeholders on issues relating to international health and migration. At the national level, IOM works closely with relevant government ministries, particularly ministries of health and immigration, NGOs and private sector entities (e.g. employment agencies). At the regional and global levels, key partners include UN agencies such as WHO, UNAIDS, UNHCR and ILO, as well as civil society partners such as migrants’ associations and academia. 3 Responding to the Challenge of NCDs: IOM BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.2 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. IOM has reviewed the recommended WHA- endorsed cost-effective interventions and recommended policy actions to identify those that are linked to IOM’s work at the global, regional and country level. Evidence-based interventions IOM actions Raise public and political awareness, understanding and practice in relation to the prevention and control of NCDs. Include NCDs in the tools used to monitor the health of migrant populations, and enhance IOM’s knowledge- base to inform evidence- based programming and policy development. Strengthen community-based surveillance (CBS) systems to monitor NCD trends and identify the health priorities of migrants. Integrate NCDs into the social and development agenda and poverty alleviation strategies. Implement NCD-focused interventions for migrants and displaced populations in transit and destination communities. Provide clinicians and public health planners in host countries with adequate knowledge of NCD profiles in migrants’ countries of origin. Advocate for psychosocial support to be provided to migrant and mobile populations. Strengthen international cooperation for resource mobilization, capacity building, health workforce training and exchange of information on lessons learned and best practices. Raise awareness of NCDs in national and regional capacity development activities. Foster multisectoral dialogues to address migrants’ structural vulnerabilities to NCDs. 2 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. Available at: http://apps.who. int/iris/bitstream/handle/259232/10665/WHO-NMH-NVI-17.9-eng.pdf Ph ot o cr ed its : © IO M The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by IOM as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. 4 Responding to the Challenge of NCDs: IOM 4. Mobilizing resources to deliver IOM will continue to highlight NCDs as an important issue with donors, and ensure that IOM country and regional offices include NCDs in project development and implementation. 1Responding to the Challenge of NCDs: OECD Organization for Economic Co-operation and Development (OECD) Responding to the Challenge of Non-communicable Diseases 1. NCDs negatively impact societies and the economy United Nations high-level meetings have highlighted the need to scale up work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in developing countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action, both nationally and internationally, within a broader whole-of-society response. Changes in population structure, environments and behaviours have led to rapid growth in non-communicable diseases (NCDs). NCDs include heart disease, cancer, diabetes and chronic respiratory diseases. They share the same risk factors, namely tobacco use, harmful use of alcohol, unhealthy diet, physical inactivity and air pollution. NCDs cause approximately 70% of deaths worldwide.1 This figure increases to just under 90% when analysing OECD member countries only.2 NCDs are also a key cause of disability, and have been the main driver of disability growth over the last 20 years. As of 2017, 80% of disabilities were related to NCDs.3 Not only are NCDs a significant health burden, they are also an economic burden. The costs of NCDs are both health and non-health related. Regarding health, NCDs lead to higher service delivery costs, such as increased hospital admissions and more complex medical treatment. Treating diseases related to overweight and obesity, for example, is expected to cost OECD countries, on average, USD 200 per person per year, which equates to 8.4% of total health spending.4 1 Jan S, Laba TL, Essue BM, Gheorghe A, Muhunthan J, Engelgau M, et al. Action to address the household economic burden of non-communicable diseases. Vol. 391, The Lancet. Lancet Publishing Group; 2018. p. 2 2 World Bank. Cause of death, by non-communicable diseases (% of total) [Internet]. 2019. Available from: https://data.worldbank.org/indicator/SH.DTH.NCOM.ZS 3 Institute for Health Metrics and Evaluation (IHME). Findings from the Global Burden of Disease Study 2017. Seattle, WA; 2018. 4 OECD. The Heavy Burden of Obesity: The Economics of Prevention. OECD Publishing, Paris; 2019. Non-health care costs from NCDs are also significant and include lower levels of productivity due to absenteeism (being out of work sick), presenteeism (working less effectively) and a reduced labour supply due to premature death. For example, OECD analyses found that individuals with diabetes are 15% less likely to be employed and nearly 10% more likely to intend on retiring early. Similar figures were recorded for patients with cancer and heart diseases.5 5 Feigl AB, Goryakin Y, Devaux M, Lerouge A, Vuik S, Cecchini M. The short-term effect of BMI, alcohol use, and related chronic conditions on labour market outcomes: A time-lag panel analysis utilizing European SHARE dataset. Chen S, editor. PLoS One [Internet]. 2019 Mar 11 [cited 2020 Feb 6];14(3):e0211940. Available from: http:// dx.plos.org/10.1371/journal.pone.0211940 2Responding to the Challenge of NCDs: OECD Thirdly, an evaluation of the intervention is necessary to identify facilitators and barriers to success, which can then be mapped against those identified in other contexts. Finally, the intervention should incorporate learnings from the evaluation as well as continually evolve to account for changes such as demographics and epidemiology. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.9 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 9 WHO. 2017. ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf. These figures may increase with worsening air pollution. OECD estimates premature deaths from air pollution will grow by 21% between 2010-2060 in G7 countries if no effective action is taken, with associated costs amounting to 3.8% of their annual GDP.6 The United Nation’s Sustainable Development Goals (SDGs) highlight the importance of tackling NCDs to ensure health and prosperity. Specifically, the SDGs include a target to reduce premature mortality from NCDs by one-third by 2030 through prevention, treatment, and the promotion of good health and well-being. Achieving this SDG target will improve population health, save households and governments significant resources and contribute to economic growth. In France, for instance, OECD modelling estimated that meeting risk factor reduction targets (e.g. for tobacco, harmful use of alcohol, and obesity) by 2025 would add 25 300 healthy life years and reduce health spending by EUR 660 million per year.7 Another analysis of key policy interventions for addressing obesity revealed positive returns on investments. For example, for every USD 1 invested in advertising regulation, nearly USD 6 in GDP growth is returned.8 Given the economic costs associated with NCDs, it is important that policy-makers use limited resources effectively. This is a 360° process beginning with the selection of interventions with a robust evidence base, such as the WHO NCD Best Buys. Selected interventions must also be adapted to the local context to meet population needs and avoid duplication of efforts to optimise cost- effectiveness. 6 OECD. Healthy people, healthy planet [Internet]. 2017. Available from: https://www. oecd.org/health/health-systems/Healthy-people-healthy-planet.pdf 7 Devaux M, Lerouge A, Ventelou B, Goryakin Y, Feigl A, Vuik S, et al. Assessing the potential outcomes of achieving the World Health Organization global non- communicable diseases targets for risk factors by 2025: is there also an economic dividend? Public Health. 2019 Apr 1;169:173–9. 8 OECD. The Heavy Burden of Obesity: The Economics of Prevention. OECD Publishing, Paris; 2019. 3Responding to the Challenge of NCDs: OECD 2. OECD plays a leading role in supporting countries achieve ambitious global and national NCD targets Given OECD’s expertise in policy evaluation and advice, the organisation plays a leading role in supporting countries achieve their NCD targets. OECD’s work on health helps countries achieve high-performing health systems by measuring health outcomes and health system resource use, as well as by analysing policies to improve access, efficiency, and quality of care. OECD’s work on public health focuses on key risk factors driving NCDs such as obesity, unhealthy diet, physical inactivity and sedentary lifestyles, environmental risks, and the harmful use of alcohol and tobacco use. OECD’s policy advice on NCDs is derived from three complementary work streams: 1) evidence generation, 2) strategic advice and 3) implementation support. Evidence generation Policy-makers are faced with growing healthcare needs and tightening budgets. Therefore, it has become increasingly important to ensure there is robust evidence supporting whether an investment represents good ‘value for money’. OECD plays a key role in this area as a global leader in undertaking sophisticated cost-effectiveness analysis using an in-house microsimulation model – OECD’s Strategic Public Health Planning for NCDs (OECD SPHeP-NCDs). The model is used to measure the economic burden of risk factors and diseases affecting population health as well as the impact of policy interventions targeted at preventing and controlling NCDs. The model does this by projecting the impact of policy interventions on population health outcomes and the associated health, non-health (e.g. labour productivity) and programme implementation costs up until 2050. Results from the model provide policy- makers with a clear understanding of the impact the intervention will have on the productivity of the labour force, GDP and ultimately long-term fiscal sustainability. Currently, the model can produce results for 52 countries, however, it is capable of extending to nearly all countries. In 2019, OECD released a health policy study pertaining to obesity – ‘The Heavy Burden of Obesity: the economics of prevention’. In the study, ten policy actions, including several WHO Best Buys, were analysed such as food and menu labelling, mass media campaigns promoting physical activity, workplace wellness programs, and the prescription of physical activity in primary care (as well as the combination of these policies). In 2021, OECD will release a second health policy study on alcohol, which will analyse the impact of policies to reduce harmful use of alcohol. G D P 4Responding to the Challenge of NCDs: OECD Analyses for other risk factors such as air pollution and tobacco use are under discussion and will likely be included in OECD’s future work. Strategic advice OECD provides strategic advice through country-specific Public Health Reviews. These offer in-depth analysis and policy recommendations to strengthen priority areas within a country’s public health system, highlighting best practices that allow learning from shared experiences and the spreading of innovative approaches. The OECD Public Health Reviews appraise the public health capacity in the country, then focus on specific high priority topics. OECD’s Public Health Review of Chile, for example, analysed policies related to diet and obesity and provided advice for implementing a monitoring system to evaluate the country’s food labelling scheme. The OECD have also carried out Public Health Reviews for Japan and South Korea. Others are in preparation. Implementation support The OECD assists countries by using robust methodological techniques to systematically identify, transfer, implement and monitor best practice interventions. Regarding identification, OECD is developing a multi-criteria decision analysis (MCDA) framework incorporating criteria to assess whether an intervention can be considered a best practice. The OECD Framework will be applied to all forms of NCD interventions, including actions to prevent and manage NCDs and, potentially, other areas of public health such as communicable diseases. 3. OECD has formed key partnerships to more effectively address NCDs To assist countries with transferring and implementing best practice interventions, OECD provides advice on how to adapt the intervention to local context, for example to account for specific population health needs as well as health system infrastructure and financing arrangements. To determine whether the intervention should be expanded, amended or removed, OECD assists countries by outlining the necessary steps for undertaking a comprehensive evaluation. Addressing NCDs is complex and requires multi-sectoral support from national and international stakeholders. OECD has formed key partnerships allowing it to more effectively address NCDs. Examples include: • World Health Organization and its Regional Offices: OECD and WHO formally entered into a co-operative working relationship in 1999, which was later revised in 2005. Together, OECD and WHO aim to strengthen their co- operation in key areas of work including the measurement, monitoring and assessment of health systems, which covers public health. OECD and WHO continue to collaborate on projects related to NCDs. 5Responding to the Challenge of NCDs: OECD Analytic work and knowledge management: OECD produces high-quality evidence to inform policy-making: The Heavy Burden of Obesity: The Economics of Prevention (2019). In 2019, OECD released a report detailing the economic impact overweight and obesity will have on population health, health budgets and the overall economy. Based on OECD analysis, between 2020 and 2050, overweight and related diseases will reduce life expectancy by three years across OECD, EU28 and G20 countries, and will cost USD 425 billion per year to the healthcare systems of this group of countries. Upcoming report on harmful alcohol consumption (expected release in 2021). OECD is finalizing an analogous report to the Heavy Burden of Obesity, which examines the health and economic impact of harmful alcohol consumption and of policy options to address this key risk factor to population health. Identification, transfer and monitoring of NCD best practice (BP) interventions (2019-2022). OECD is supporting countries to promote the implementation of BP NCD interventions. OECD is also developing a guidebook to assist countries transfer BP interventions to their local context. Stemming the Superbug Tide: Just a Few Dollars More (2018). This report analysed the health and economic impact of anti-microbial resistance (AMR), including one of the first empirical analyses of the potential effect of AMR on the risk of infection and death associated with surgical procedures and blood cancer chemotherapy. Healthy People, healthy planet (2017). This report for the G7 Ministers of Health outlined the key policy issues and associated policy actions to improve population health while concurrently reducing human footprint on the environment. Public health reviews (ongoing). OECD’s Reviews of Public Health provide in-depth analyses and recommendations to strengthen key public health priority areas, often with a focus on NCDs. The reviews also highlight best practice examples thereby spreading innovative practices which countries can learn from. • World Bank: the World Bank is a key partner for OECD’s co-operation with non-member countries. A Joint Statement on Co-operation between the two organisations highlights the growing importance of working together on issues related to health. • European Commission: OECD provides the European Commission with technical and strategic advice on a range public health issues, including NCDs. OECD’s collaboration with the Commission supports efforts by EU Member States to achieve the voluntary global targets on NCDs of the United Nations and World Health Organization, as well as the relevant SDGs. • EU Joint Actions: OECD is a frequent member of EU Joint Actions, which represent a collaboration between the European Commission and Member States. OECD provides participating countries with technical support to achieve the objective of the Joint Action. For example, as part of the CHRODIS+ Joint Action on Chronic Diseases, OECD is undertaking cost-effectiveness analyses of interventions targeted at reducing the chronic disease burden. 6The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the OECD as part of a set of United Nations system agency briefs under the Task Force. Ph ot o cr ed its : © F re ep ik (p .2 , 3 ; p .4 ra w pi xe l; p. 5 W H O ; p . 6 U N DP (t op ), W H O (b ot to m ) Responding to the Challenge of NCDs: OECD 4. Mobilizing resources to deliver Evaluating the economic burden of NCDs and analysing the economic benefit of best practice interventions is a key work stream for OECD’s team working on health. Findings from the analysis provide governments with robust evidence to ‘make the case’ for investing in interventions which prevent, manage and control NCDs and help mobilise resources across the different parts of the government. 1 Responding to the Challenge of NCDs: UNAIDS Joint United Nations Programme on HIV/AIDS Responding to the Challenge of Non-communicable Diseases 1. NCDs among people living with HIV is an increasing global public health issue Many countries with HIV epidemics are now experiencing growing rates of NCDs.1 Death rates from NCDs are nearly twice as high in low- and middle-income countries (LMICs) compared to high-income countries. Antiretroviral therapy (ART) for HIV enables people living with HIV to lead long and productive lives. However, they are now becoming susceptible to NCDs in later life. The four NCDs that account for the greatest number of comorbidities among people living with HIV in LMICs are cardiovascular diseases (CVD), cervical cancer, depression and diabetes.2 The risk of cervical cancer among women living with HIV compared to women without HIV is increased up to fivefold.3 HIV-hepatitis C virus coinfection is associated with CVD, diabetes and/or death in people living with HIV.4, 5 1 General Assembly Resolution 66/2, Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, A/RES/66/2 (19 December 2011), available from https://undocs.org/A/ RES/66/2 2 Patel P, Rose C, Collins P, Nuche-Berenguer B, Sahasrabuddhe V, Peprah et al. (2018). Non-communicable diseases among HIV-infected persons in low-income and middle-income countries. AIDS, 32:S5-S20. doi: 10.1097/ QAD.0000000000001888. 3 HPV, HIV and cervical cancer: leveraging synergies to save women’s lives. Geneva: UNAIDS; 2016 (UNAIDS/JC2851E; https://www.unaids.org/en/resources/ documents/2016/HPV-HIV-cervical-cancer). 4 Jenny-Avita ER. (2003). HCV-Coinfection Is Associated with Diabetes and CD4 Decline. AIDS Clinical Care 3:1(12). 5 Kakinami L, Block R, Adams M, Cohn S, Maliakkal B and Fisher S. (2012). Risk of cardiovascular disease in HIV, hepatitis C, or HIV/hepatitis C patients compared to the general population. International Journal of Clinical Practice, 67(1):6-13 doi: 10.1111/j.1742-1241.2012.02953.x HIV, cervical cancer and NCDs are all diseases associated with gender and socioeconomic inequalities, and health disparities across and within countries. HIV infection may increase the risk of NCDs due to stimulation of inflammatory markers and adverse events associated with some antiretroviral medicines for HIV treatment. This risk is compounded by NCD risk factors, e.g. tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity. United Nations high-level meetings have highlighted the need for the UN, including UNAIDS, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development.1 NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in developing countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2Smoking is associated with a twofold increase in mortality among people living with HIV mainly due to lung cancer. In LMICs, tobacco use among people living with HIV is higher than among those without HIV.6 Smoking is predicted to produce an excess of 18 million cases and 40 million deaths related to tuberculosis (TB) between 2010 and 2050, increasing TB cases and deaths by 7 percent and 66 percent respectively over this period.7 Given the HIV-TB syndemic, smoking, thus, constitutes a major exacerbating factor for HIV, TB and HIV-TB co-infections. Harmful use of alcohol is associated with: risky sexual behaviour with an increased risk of acquiring HIV, resulting in an estimated 33,000 new cases of HIV each year;8 reduced adherence to ART; alcohol-drug interactions and toxicities; and an increased risk of antiretroviral resistance. Harmful use of alcohol also increases the risk of TB infection9 and is associated with delays in seeking TB care.10 Alcohol increases the risk for HIV-related comorbidities, including liver disease, CVD, cerebrovascular disease, pulmonary disease, bone disease and cancer. Alcohol dependence further impacts the progression of HIV infection, as well as associated TB and viral hepatitis. People with mental health and substance use conditions are often at greater risk of HIV infection and are less likely to access education, prevention, testing and treatment services. People living with HIV are at an increased risk of developing mental health conditions, such as depression and anxiety. Key populations, people living with HIV and people with mental health conditions experience multifaceted stigma and the effects of interlocking systems of discrimination.11, 12 Stigma associated with HIV and marginalized identities have been linked to anxiety, depression, poor self-esteem and poor adherence to HIV care.13 Stigma also remains a barrier to accessing drug dependence treatment, mental health care and HIV services. 14, 15 6 Mdege N, Shah S, Ayo-Yusuf O, Hakim J and Siddiqi K. (2017). Tobacco use among people living with HIV: analysis of data from Demographic and Health Surveys from 28 low- income and middle-income countries. The Lancet Global Health, 5(6):e578-e592. 7 Basu S, Stuckler D, Bitton A, and Glantz SA. (2011). Projected effects of tobacco smoking on worldwide tuberculosis control: mathematical modelling analysis. BMJ, (343): doi: https://doi.org/10.1136/bmj.d5506 8 Global status report on alcohol and health 2018. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO. 9 Imtiaz S, Shield KD, Roerecke M, et al. (2017). Alcohol consumption as a risk factor for tuberculosis: meta-analyses and burden of disease. European Respiratory Journal, (50) : doi: 10.1183/13993003.00216-2017 10 Van Ness SE, Chandra A, Sarkar S et al. (2017). Predictors of delayed care seeking for tuberculosis in southern India: an observational study. BMC Infect Dis, (17):567: doi: 10.1186/ s12879-017-2629-9 11 Collins PY, Unger Hv, Armbrister A. Church ladies, good girls, and locas: Stigma and the intersection of gender, ethnicity, mental illness, and sexuality in relation to HIV risk. Social Science & Medicine. 2008;67(3):389-97. 12 Earnshaw VA, Bogart LM, Dovidio JF, Williams DR. Stigma and racial/ethnic HIV disparities: moving toward resilience. The American psychologist. 2013;68(4):225-36. 13 Patton GC, Sawyer SM, Santelli JS, Ross DA, Afifi R, Allen NB, et al. Our future: a Lancet commission on adolescent health and wellbeing. Lancet. 2016;387(10036):2423-78 14 Global Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. Geneva: World Health Organization; 2017. 15 Bundy DAP, de Silva N, Horton S, Patton GC, Schultz L, Jamison DT. Investment in child and adolescent health and development: key messages from Disease Control Priorities, 3rd Edition. Lancet. 2018;391(10121):687-99. Responding to the Challenge of NCDs: UNAIDS 3In partnership with the United Nations Interagency Task Force on NCDs, UNAIDS focuses on developing policies for integration of HIV and NCDs, and HIV and mental health strategies. This approach is aligned with the 2016 UN Political Declaration on Ending AIDS by 2030 and the 2016–2021 UNAIDS Strategy: On the Fast-Track to End AIDS.16 The UNAIDS Global Strategy for 2016–2021 supports multisectoral, integrated, people- centred, human rights and evidence-based services for HIV and HPV/cervical cancer, HIV and NCDs, HIV and mental health as well as for tuberculosis, sexual and reproductive health, maternal, newborn and child health with the active engagement of communities and civil society. 16 UNAIDS 2016–2021 Strategy. Geneva: UNAIDS; 2015 (https://www.unaids.org/ sites/default/files/media_asset/20151027_UNAIDS_PCB37_15_18_EN_rev1.pdf) 2. UNAIDS has a role to play in supporting countries in NCD prevention and control The Thematic Segment of the 43rd UNAIDS Programme Coordinating Board (PCB) meeting was dedicated to mental health and HIV: promoting human rights, an integrated and person-centred approach to improving ART adherence, well-being and quality of life.17 In follow up to the Thematic Segment, at its 44th meeting,18 UNAIDS PCB called on: • Member States to implement evidence- based, people-centred, human rights and community-based policies and programmes to promote mental health and quality of life with a focus on addressing stigma and discrimination related to both HIV and mental health conditions as part of HIV prevention, treatment and care services. • Member States to address social determinants of mental health and HIV by adopting and implementing social protection policies and programmes to reduce stigma and discrimination. • the UNAIDS Joint Programme to review and revise existing practices and guidelines in order to ensure integration of mental health and substance use services into HIV service delivery platforms, and HIV services into mental health and substance use prevention and treatment programmes, and to provide respective implementation guidance. • the UNAIDS Joint Programme to take into account the intersection between mental health and HIV, and the importance of improving psychosocial wellbeing and upholding the quality of life of people affected and living with HIV, as part of a person-centred and human rights approach when developing the next UNAIDS strategy for 2021–2030. 17 The 43rd UNAIDS Programme Coordinating Board (11–13 December 2018), available from https://www.unaids.org/sites/default/files/media_asset/20181214_ UNAIDS_PCB43_Decisions_EN.pdf 18 The 44th UNAIDS Programme Coordinating Board (27 June 2019), available from https://www.unaids.org/en/resources/documents/2019/PCB44_Decisions Responding to the Challenge of NCDs: UNAIDS 4UNAIDS has reviewed the recommended cost-effective interventions endorsed by the WHA—”best buys”—to identify those that are linked to its work at global, regional and country levels. These interventions address the synergies between HIV and HPV/ cervical cancer, HIV and NCDs, and HIV and mental health. UNAIDS plays an advocacy and facilitating role for global, regional and country level multisectoral partnerships as well as resource mobilization efforts to support countrywide responses to cervical cancer, NCDs and mental health issues. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.19 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 19 “Best buys” and other recommended interventions for the prevention and control of non-communicable diseases, Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO. Available at: http://apps.who.int/iris/bitstream/ handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf Evidence-based interventions UNAIDS actions Vaccination against human papillomavirus (2 doses) of 9–13-year-old girls. Prevention of cervical cancer by screening women aged 30–49 years. UNAIDS advocates for an HIV-cervical cancer policy, services and partnerships, along with community engagement; it also supports a focus on HPV vaccination for HIV-positive girls, and cervical pre-cancer and cancer screening, treatment and care for women living with and at risk of HIV. UNAIDS collects, analyses and tracks country reports on the Global AIDS Monitoring and National Composite Policy Index indicators for cervical cancer screening among women living with HIV, and integrated cervical cancer- HIV policies and services. Raise public and political awareness, understanding and practice about prevention and control of NCDs. UNAIDS raises political and public awareness at global and country levels for integrating NCDs and mental health into HIV strategies, policies and programmes with a focus on people living with and at risk of HIV, HIV-NCDs and HIV-mental health comorbidities; emphasis is also put on addressing human rights issues, stigma and discrimination, and health, social and gender inequalities which are common across HIV, NCDs and mental health issues. Integrate NCDs into the social and development agenda and poverty alleviation strategies. UNAIDS advocates for tackling the social determinants of mental health and HIV by means of social protection policies and other programmes to reduce stigma and discrimination. Responding to the Challenge of NCDs: UNAIDS 5UNAIDS actively seeks to strengthen partnerships to address NCDs: some of them are listed below. • UNAIDS is a co-founding partner of the PEPFAR-G.W. Bush Institute-UNAIDS-Merck public-private partnership to end AIDS and cervical cancer among HIV-positive women in Africa. This initiative enables UNAIDS to support policy advocacy and reforms, resource mobilization and community engagement. • In partnership with WHO, United Nations Population Fund (UNFPA) and other partners, UNAIDS is supporting national governments in fast-track countries to develop cervical cancer indicators and targets in their respective national health plans, and advocates for the realization of the WHO Global Call to Action towards the elimination of cervical cancer at the country level and development of the WHO Global Strategy towards the Elimination of Cervical Cancer. • UNAIDS is supporting the H6 partnership for the health of women, children and adolescents (currently under WHO chairmanship) at the global and country level by enhancing the centrality of sexual, reproductive, maternal, newborn, child and adolescent (RMNCAH) health: this programme prioritizes HPV- cervical cancer prevention, screening and treatment for girls and young women and engages communities and mobilizes resources to enable these services to be scaled up. • UNAIDS and WHO are in the process of developing an implementation guidance for integrating mental health and substance use services into HIV service delivery programmes. 3. Partnerships are critical for UNAIDS in mobilizing an effective response to NCDs Due diligence is required to ensure all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. Responding to the Challenge of NCDs: UNAIDS 6The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the UNAIDS as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr 4. Mobilizing resources to deliver UNAIDS advocates and supports countries to mobilize domestic and donor resources for integrating HIV and cervical cancer prevention and care in countries with a high burden of HIV and cervical cancer. UNAIDS has also mobilized resources for the integration of mental health and HIV services and for addressing human rights and quality of life issues. Responding to the Challenge of NCDs: UNAIDS 1 Responding to the Challenge of NCDs: UNDP United Nations Development Programme Responding to the Challenge of Non-communicable Diseases 1. NCDs are a development issue1 NCDs, such as cardiovascular disease, cancer, diabetes and chronic respiratory disease, are the greatest source of preventable illness, disability and mortality worldwide. NCDs place a significant burden on health systems, presenting a challenge to universal health coverage and other development aims.1 Out-of-pocket healthcare expenditures in response to NCDs can be financially ‘catastrophic’ for those affected. NCDs can also force household earners out of the labour market. Children may drop out of school to care for a sick relative or to make up for lost wages. Women and girls particularly sacrifice their time and opportunities.2 At the national level, NCDs sap public resources and impede economic growth. Between 2011 and 2030, NCDs including mental illnesses project to cost low- and middle-income countries (LMICs) US$ 21.3 trillion in healthcare costs and lost productive capacities.3 1 For in-depth information on UNDP’s response to NCDs, please see ‘UNDP Issue Brief: Preventing and Controlling Noncommunicable Diseases’: https://www.undp. org/content/undp/en/home/librarypage/hiv-aids/preventing-and-controlling-non- communicable-diseases0.html 2 See UNDP’s Discussion Paper on Addressing the Social Determinants of NCDs; and the World Bank’s Thwarting a Disease Crisis in the Pacific. 3 HSPH and WEF. 2011. ‘The Global Economic Burden of Non-communicable Diseases’. http://www3.weforum.org/docs/WEF_Harvard_HE_ GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf United Nations high-level meetings have highlighted the need for UN agencies, including UNDP, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development.4 NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as unhealthy diet, tobacco use, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. NCDs are linked to ageing, rapid unplanned urbanization, changing consumption patterns and environmental degradation. Many NCD risks are enmeshed with commercial interests which may conflict with public health objectives. Underlying social exclusion, marginalization, discrimination and inequities across different dimensions shape exposure to behavioural and environmental NCD risks, as well as access to basic services. 4 Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (2011); Political Declaration of the Third High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (2018); E/RES/13/2018 United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases. 2The Sustainable Development Goals include a specific target (3.4) to reduce premature mortality from NCDs. Shared gains across the 2030 Agenda for Sustainable Development are possible given the strong relationship between NCDs and priorities such as poverty and inequality reduction, economic growth, climate action and financing for development. Reducing the nine million premature deaths caused by pollution each year5 would, for instance, improve health while protecting the planet. 5 Landrigan, PJ, et al. The Lancet Commission on pollution and health. Lancet 2018; 391(10119); 462-512. The health sector cannot address NCDs on its own: whole-of-government and whole-of- society responses are essential. Differential exposures to behavioural and environmental risk factors for NCDs are often rooted in public policy choices that span sectors beyond health. Achieving coherence across sectors and ministries means confronting conflicts and countering vested interests which may act against public health objectives. UNDP is uniquely positioned to support integrated health and development solutions, building on its development portfolio, partnerships and networks, and country-level presence.6 In line with the SDG 3 ‘Global Action Plan for Healthy Lives and Well-Being for All’, UNDP, in cooperation with WHO, the Secretariat of the WHO Framework Convention on Tobacco Control (WHO FCTC), the broader UN Inter-Agency Task Force on NCDs and other partners, supports governments in all regions to implement or strengthen whole- of-government NCD responses. This support centres on strengthening national capacity, leadership, governance, multisectoral action and partnerships to accelerate country responses. UNDP leverages its core competencies in areas that intersect with NCD prevention and control, including access to basic services, poverty and inequality reduction, environment and energy, good governance, sustainable financing, gender, and south-south and triangular cooperation. 6 UNDP’s Discussion Paper on Addressing the Social Determinants of NCDs outlines entry points for development actors. https://www.undp.org/content/dam/undp/ library/hivaids/English/Discussion_Paper_Addressing_the_Social_Determinants_ of_NCDs_UNDP_2013.pdf 2. UNDP has a role to play in supporting countries to prevent and control NCDs Responding to the Challenge of NCDs: UNDP 3UNDP’s work on NCDs promotes effective and inclusive governance for health, a priority of its ‘HIV, Health and Development Strategy 2016–2021’.7 It aligns with its ‘Strategic Plan 2018–2021’,8 which recognizes the direct relationship between health, poverty eradication and other development aims. UNDP has reviewed the recommended World Health Assembly-endorsed policy options to identify those that are linked to UNDP’s work at global, regional and country level. Five indicative examples are given in the table. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.9 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 7 UNDP (2016). HIV, Health and Development Strategy 2016-2021. http://www.undp. org/content/undp/en/home/librarypage/hiv-aids/hiv--health-and-development- strategy-2016-2021.html 8 UNDP Strategic Plan, 2018-2021. http://undocs.org/DP/2017/38 9 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. http://apps.who.int/iris/bitstream/ handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf Evidence-based interventions UNDP actions Raise public and political awareness, understanding and practice about prevention and control of NCDs. Support non-health ministries to understand how NCDs impact their sector, and how they can support the national response.10 Work with parliamentary unions/associations to highlight the role for parliamentarians in NCD advocacy and in ensuring NCD-sensitive legal environments. Integrate NCDs into the social and development agenda and poverty alleviation strategies. Support countries to establish NCD prevention and control and tobacco control as development priorities within their national planning instruments/SDG action plans and corresponding UN Sustainable Development Frameworks.11 Prioritize and increase, as needed, budgetary allocations for prevention and control of NCDs, without prejudice to the sovereign right of nations to determine taxation and other policies. Work with partners to support ministries of health to develop national investment cases for scaled-up action. Analyse institutions and contexts to advance policy coherence, financing opportunities, and institutional roles and accountabilities. Develop and implement a national multisectoral policy and plan for the prevention and control of NCDs through multi-stakeholder engagement. Work with partners to support the drafting, costing and adoption of ambitious national NCD and tobacco control strategies, establishment of functional national and/ or subnational coordination mechanisms, and the passing, enforcement and monitoring of effective NCD-related legislation. Engage and mobilize civil society and the private sector as appropriate and strengthen international cooperation to support implementation of the action plan at global, regional and national levels. Strengthen the capacity of civil society organizations to advocate for multisectoral NCD action including through community mobilization and by linking with HIV/AIDS, TB and environment and climate communities. 10 UNDP and WHO have jointly produced a series of briefs on ‘What Government Ministries Need to Know about Non-communicable Diseases’. https://www.undp. org/content/undp/en/home/librarypage/hiv-aids/what-government-ministries- need-to-know-about-non-communicable-diseases.html 11 UNDP and WHO have developed a Guidance Note for UN Country Teams and governments on how to integrate NCDs into UN Development Assistance Frameworks. https://www.undp.org/content/undp/en/home/librarypage/hiv-aids/ guidance-note-NCDs-UNDAF.html; With the Convention Secretariat of the WHO FCTC, UNDP has developed guidance on integrating the WHO FCTC into UN and national development planning instruments. https://www.undp.org/content/ undp/en/home/librarypage/hiv-aids/development-planning-and-tobacco-control-- integrating-the-who-fr.html Responding to the Challenge of NCDs: UNDP 4UNDP and WHO are implementing a Global Joint Programme (GJP) on NCD Governance, with support from the Russian Federation. For LMICs, the GJP aims to support the development of national NCD investment cases, strengthen national coordinating mechanisms and municipal action, and integrate NCDs into domestic SDG frameworks. GJP assesses and seeks to expand fiscal space for universal access to NCD-related health services, while driving legislation, policies and targeted interventions for prevention. Through the FCTC 2030 project, conducted with the assistance of the UK and Australian Governments, UNDP is working with the Convention Secretariat of the WHO FCTC and WHO to support 15 LMICs in developing investment cases for accelerated implementation of the WHO FCTC. UNDP supports national coordination, the development and implementation of country-specific tobacco control plans, integrating tobacco control into broader SDG implementation efforts, and capacity building including for parliamentarians. UNDP supports national governments in the procurement of health products for NCDs, for example medicines for diabetes and cancer. In 2017 this procurement totaled approximately US$ 94 million. With the Global Environment Facility, UNDP manages over 800 projects across 141 countries on environmental challenges. Many projects support the NCD response. Examples include projects which reduce use of and people’s exposure to hazardous chemicals, and sustainable transport projects which support the construction of lanes for cycling (this promotes physical activity while reducing air pollution from vehicle emissions).12 12 UNDP (2018). Annual Performance Report 2017 – UNDP Global Environmental Finance Unit. https://www.undp.org/content/undp/en/home/librarypage/poverty- reduction/global-environmental-finance/2017-undp-gef-annual-performance-report. html 3. Partnerships are critical for UNDP in mobilizing an effective response to NCDs Due diligence is required to ensure that all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. Responding to the Challenge of NCDs: UNDP Responding to the Challenge of NCDs: UNDP 5 UNDP, other UN agencies and partners are supporting the implementation of the National Clean Air Programme of the Government of India. This work aims to tackle air pollution, a major cause of premature death from NCDs, through a systematic and coordinated multi-sector approach involving government departments and agencies, the corporate sector, academic institutions, civil society and local institutions. UNDP has extensive expertise in implementing large-scale health programmes, for example through its partnership with the Global Fund to Fight AIDS, Tuberculosis and Malaria. UNDP is working to ensure that Global Fund grants, where appropriate, address interactions between infectious diseases and NCDs and their risk factors.13 In the Pacific region, UNDP is managing a multicountry Global Fund programme to ensure that national tuberculosis guidelines include elements of the WHO ‘Collaborative Framework for Care and Control of Tuberculosis and Diabetes’.14 13 In 2015, the Global Fund approved a framework for financing interventions that respond to co-infections or co-morbidities that can exacerbate HIV, TB or malaria. https://www.theglobalfund.org/media/4167/bm33_11-co-infectionsandco- morbidities_report_en.pdf 14 UNDP and the Convention Secretariat of the WHO FCTC have produced an Issue Brief to support Global Fund applicants in integrating tobacco cessation into Global Fund HIV and TB grants. http://www.undp.org/content/undp/en/home/librarypage/ hiv-aids/integrating-tobacco-control-into-tuberculosis-and-hiv-responses.html UNDP plays a role in driving investments and efficiencies related to NCD prevention and control. Actions include but are not limited to: • supporting partners to advocate for the establishment of a multidonor trust fund to enable countries to catalyse financing on NCDs and mental health while strengthening policy coherence at the country level;15 • providing targeted technical support to countries to analyze the return on investment (ROI) in select NCD and tobacco control interventions, and to consider ROI in allocating resources to the national response; • strengthening partnerships and programmes oriented around “best buys” (e.g. the SAFER initiative to support countries to tackle harmful use of alcohol) as well as emerging relevant programmatic areas (e.g. air pollution); • supporting domestic financing for NCD responses including through innovative taxation measures for tobacco, alcohol, sugar-sweetened beverages and other health- harming products. Globally, increased taxes on tobacco, alcohol and sugary beverages could avert 50 million premature deaths and raise US$ 20.5 trillion in revenue over the next 20 years,16 while delivering benefits across the SDGs;17 and • collaborating with development banks to ensure that NCD loans seek to strengthen public health legislation and regulations to prevent NCDs, in addition to focusing on health system strengthening. 15 In line with ‘Time to Deliver’, the Report of the WHO Independent High-level Commission on Noncommunicable diseases. https://apps.who.int/iris/bitstream/ handle/10665/272710/9789241514163-eng.pdf?ua=1 16 Task Force on Fiscal Policy for Health. 2019. Health Taxes to Save Lives: Employing Effective Excise Taxes on Tobacco, Alcohol, and Sugary Beverages. https://www. bbhub.io/dotorg/sites/2/2019/04/Health-Taxes-to-Save-Lives.pdf 17 Sugar, Tobacco, and Alcohol Taxes (STAX) Group. Sugar, tobacco, and alcohol taxes to achieve the SDGs. Lancet 2018, 391(10138): 2400-2401. https://www.thelancet. com/journals/lancet/article/PIIS0140-6736(18)31219-4/fulltext 4. Mobilizing resources to deliver Responding to the Challenge of NCDs: UNDP 6 The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the UNDP as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. Photo credits: © World Bank via Flickr; page 5 © Omer Sadaat via The Global Fund 1 Responding to the Challenge of NCDs: UNFPA United Nations Population Fund Responding to the Challenge of Non-communicable Diseases 1.There are strong links between protecting and promoting sexual and reproductive health and rights, and preventing and controlling non-communicable diseases NCDs have a significant impact on the sexual and reproductive health of both men and women.1 • Obesity, hypertension and diabetes during pregnancy lead to poorer maternal and neonatal outcomes. • Tobacco use, by both pregnant women and other family members, adversely affects the foetus, newborn and children, as does maternal alcohol consumption. • Lack of breastfeeding increases the risk of NCDs in later life. • Poor diet, tobacco, alcohol and exposure to chemicals also affect fertility, reducing sperm viability and increasing erectile dysfunction in men. • Harmful use of alcohol increases the risk of unprotected sex, unintended pregnancies, HIV and other STIs including human papilloma virus (HPV), as well as the risk of domestic and gender-based violence. 1 Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (2011); Political Declaration of the Third High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable diseases (2018); E/RES/2018/13 United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases. United Nations high-level meetings have highlighted the need for UN agencies, including UNFPA, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development.1 NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in developing countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. Premature deaths from NCDs are largely preventable by encouraging women, men and young people to reduce their use of tobacco and consumption of harmful amounts of alcohol, adopt a healthy diet and step up their levels of physical activity. Cervical cancer is a global public health issue and can largely be prevented by vaccinating 9 to 13-year-old girls and boys against HPV. Penile and oropharyngeal cancers can also be prevented through HPV vaccination. Mental health is now an integral part of the NCD agenda and post-natal depression is considered a major public health issue. 2 Responding to the Challenge of NCDs: UNFPA NCDs are an increasing priority for UNFPA. By expanding its activities to include the prevention and control of NCDs, UNFPA will have a significant impact on reducing the current and future NCD burden. By tackling NCDs, UNFPA contributes to a direct improvement in maternal and neonatal health outcomes. UNFPA can support sexual and reproductive health and rights (SRHR) policy-makers and service providers to help young people and women of childbearing age reduce their exposure to, and use of tobacco and alcohol, and promote healthy diets and physical activity. Ante- and postnatal care also provide significant opportunities for the detection, prevention and management of diabetes and high blood pressure in women. UNFPA promotes exclusive breastfeeding for at least the first six months of life. Breastfeeding has long-term benefits for mothers and children in reducing the risk of NCDs. Several UNFPA programmes strengthen services which provide support to women with postpartum depression and other psychosocial conditions that impact them and their families. UNFPA is making a significant contribution to the elimination of cervical cancer globally by supporting countries in their efforts to scale up HPV vaccination, as well as through cervical cancer screening and early diagnosis activities as part of comprehensive cervical cancer control programmes. 2. UNFPA has a role to play in supporting countries to prevent and control NCDs in line with UNFPA’s commitment to improve public health throughout the lifecycle. UNFPA works with men and boys to reduce gender-based violence: this includes reducing the exposure to, and harmful use of alcohol by men in order to lessen alcohol-related violence. UNFPA is also committed to raising awareness about the socioeconomic impact of an ageing population, including the impact of NCDs in this group. In relation to this activity, UNFPA supports national censuses and demographic health surveys in order to improve population projections and strengthen policy and planning, including NCD programming. UNFPA has reviewed the cost-effective interventions endorsed by the World Health Assembly in order to identify those that are linked to UNFPA’s work at global, regional and country level: specific examples are given in the table. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.2 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 2 WHO. 2017. ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf. 3 Responding to the Challenge of NCDs: UNFPA Evidence-based interventions UNFPA actions Promote and support exclusive breastfeeding for the first six months of life. Exclusive breastfeeding is promoted by midwives as part of their comprehensive antenatal and postnatal care interventions and services. Preconception care among women of reproductive age who have impaired glucose tolerance or diabetes, including patient education and intensive glucose management. Midwives and other antenatal care providers include diabetic screening and management, specifically for expectant women in antenatal clinic settings, and via outreach services where possible. Human papillomavirus vaccination (2 doses) for 9 to 13-year-old girls and boys. UNFPA supports delivery of HPV vaccination through primary health care services and school vaccination programmes. Prevention of cervical cancer by screening women aged 30–49 years. UNFPA is assisting countries to strengthen cervical cancer screening and referral for treatment from family planning, HIV and primary health care services. Screening with mammography (once every two years for women aged 50–69 years) linked with timely diagnosis and treatment of breast cancer. Breast cancer screening services are being supported by a limited number of UNFPA country offices. Comprehensive sexuality education (CSE). Governments are supported in implementing “in and out-of-school” CSE programmes: these promote healthy behaviour patterns, reduce NCD risk factors and endeavour to lessen unprotected sex in order to lower the incidence of unplanned pregnancies and STIs including HPV. Promote tobacco avoidance and cessation in young people. Through adolescent CSE and SRH services, youth community centres and peer outreach programmes, young people are supported in making healthier life choices that reduce their exposure to NCD risk factors. Implement nutrition education and counselling in order to increase the intake of fruit and vegetables and reduce salt intake. Promote physical activity. UNFPA is a member of the UN Joint Global Programme on Cervical Cancer Prevention and Control, which assists countries to reduce the burden of cervical cancer via the WHO-led Global Cervical Cancer Elimination Initiative. UNFPA is an adviser to GAVI and a number of countries in rolling out HPV vaccination as part of adolescent health, screening and treatment programmes. At the regional level, UNFPA is working to strengthen the capacity of service providers, especially in delivering cervical cancer screening and treatment programmes. For example, in Eastern Europe and Central Asia, UNFPA has developed a training programme for health care providers in cervical cancer screening and treatment. UNFPA is supporting the rolling out of HPV vaccination in the Arab States and is currently contributing to regional training programmes, as well as to assessments of NCD prevention and control needs, including opportunities for scaling up the “best buys”. UNFPA country programmes provide backing for the strengthening of safe motherhood programmes in all countries, as well as for developing partnerships with youth and women’s organizations to include activities in favour of NCD prevention. 3. Partnerships with UN and other development agencies are critical for UNFPA in mobilizing an effective response to NCDs Due diligence is required to ensure all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. 4 Responding to the Challenge of NCDs: UNFPA While UNFPA’s focus is on improving sexual and reproductive health and rights, it is increasingly looking to identify opportunities to mobilize resources for incorporating NCD prevention and control into its programmes, in the expectation that these efforts will have a direct impact on improving sexual and reproductive health for all. 4. Mobilizing resources to deliver Photo credits (from top clockwise): © UNFPA ©World Bank via Flickr (also page 2) © UNV The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by UNFPA as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. 1 Responding to the Challenge of NCDs: UNHCR United Nations High Commissioner for Refugees Responding to the Challenge of Non-communicable Diseases 1. Refugees and asylum seekers are particularly vulnerable to NCDs including mental health conditions and may face barriers to adequate health care. NCDs, such as cardiovascular disease, cancers, diabetes, chronic respiratory disease and mental health conditions, are the greatest source of preventable illness, disability and mortality worldwide. In the country of origin, prior to flight, refugees may have limited access to health care, including due to a disrupted health care system. Consequently, they may have undiagnosed or poorly controlled NCDs. During flight, refugees may face harsh conditions and lack of continuity of care which may exacerbate NCDs. Apart from the health risks associated with the forced migration, access to comprehensive healthcare may be limited for refugees. Key barriers to healthcare access may include language and cultural differences; protection issues resulting from a lack of legal status; and an inability to afford healthcare due to inadequate livelihoods.1 1 The health needs and access barriers among refugees and asylum- seekers in Malaysia: a qualitative study. Int J Equity Health. 2018. https:// equityhealthj.biomedcentral.com/articles/10.1186/s12939-018-0833-x United Nations high-level meetings have highlighted the need for UN agencies, including UNHCR, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. Multiple stressors (experiences of violence, disrupted social support systems and marginalization) in the country of origin, during flight and country of asylum, may lead to mental health conditions. Displacement and lack of livelihood opportunities may increase unhealthy behaviors, such as tobacco and alcohol use as well as unhealthy diet. During return, returnees may be returning to a country with a disrupted health system and lack access to quality health services, further threatening continuity of care. 2 Responding to the Challenge of NCDs: UNHCR 2. UNHCR has a key role to play in supporting countries to prevent and control NCDs UNHCR, as the UN refugee agency, is committed to the inclusion of refugees and asylum seekers in all relevant policies and programmes to reduce NCDs. This commitment is reflected in UNHCR’s support to the implementation of the Global Compact for Refugees,2 as well as World Health Assembly (WHA) Resolution 70.15 on promoting the health of refugees and migrants.3, 4 UNHCR facilitates the integration of refugee NCD programmes into national systems. UNHCR’s aim is to reduce morbidity and mortality amongst refugees from NCDs by improving the quality, accessibility and affordability of preventive and treatment services, ensuring the rational use of medicines, and strengthening the clinical and community-based management of NCDs. Improved NCD care improves quality of life, reduces premature death and disability, and, if provided early, significantly reduces financial strains on health systems due to the costs associated with disease progression and complications. 2 Report of the United Nations High Commissioner for Refugees Part II Global compact on refugees. General Assembly Official Records Seventy-third Session Supplement No. 12 (A/73/12 (Part II)) https://www.unhcr.org/gcr/GCR_ English.pdf 3 https://www.iom.int/sites/default/files/our_work/DMM/Migration-Health/ WHA_RES_70.15-Promoting-the-health-of-refugees-and-migrants.pdf 4 https://www.who.int/migrants/about/framework_refugees-migrants.pdf In 2014, UNHCR expanded the support of NCD programmes for refugees through a dedicated capacity building programme ‘Caring for Refugees with NCDs’ in Algeria, Bangladesh, Burkina Faso, Burundi, Chad, Democratic Republic of the Congo, Ethiopia, Jordan, Kenya, Rwanda, Tanzania and Uganda. Key activities of the project are: • Training of Trainers, including learning material in clinical- and system-level NCD management for UNHCR and partners’ public health staff (medical doctors, clinical officers) at regional and country level. This includes group workshops, individual coaching, diagnostic tool application, action learning, remote learning, dissemination of online resources, and case study discussions contributing towards a community of practice. • Development of adapted screening and clinical management protocols based on country protocols and discussions with ministries of health including the community- based management approach for follow up of persons with NCDs. • Development of a system of continuous professional development for local and regional trainers which might include e-portfolios, online forums and access to a specific library of material. • Ensuring that the UNHCR Essential Medicines List (based on the WHO Model List of Essential Medicines5) includes evidence-based cost- effective medication to provide care for NCDs in line with national protocols. • Strengthening data collection and monitoring tools for NCD care. 5 World Health Organization Model List of Essential Medicines (2019). https://apps.who.int/iris/bitstream/handle/10665/325771/WHO-MVP-EMP-IAU- 2019.06-eng.pdf?ua=1 Responding to the Challenge of NCDs: UNHCR 3 On mental health specifically, UNHCR and WHO developed the mhGAP Humanitarian Intervention Guide6 for training non-specialized health workers in humanitarian settings to identify and respond to priority mental, neurological and substance use conditions.7 Since 2015, more than 1000 health and protection workers have been trained with this tool. In 2019, UNHCR introduced scalable psychological interventions (brief psychotherapies that can be conducted by non-specialized workers) into refugee operations.8 UNHCR has reviewed the recommended WHA-endorsed ‘Best buys’ and other recommendations for the prevention and control of non-communicable diseases to identify those linked to UNHCR’s work at global, regional and country level. UNHCR actions are highlighted in the table below. 6 World Health Organization, & United Nations High Commissioner for Refugees. (2015). mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies. Geneva: WHO. 7 Echeverri, C., Le Roy, J., Worku, B., & Ventevogel, P. (2018). Mental health capacity building in refugee primary health care settings in Sub-Saharan Africa: Impact, challenges and gaps. Global Mental Health, 5, e28. DOI: 10.1017/ gmh.2018.1019 8 Tay, A. K., Miah, M. A. A., Khan, S., Badrudduza, M., Alam, R., Balasundaram, S., & Silove, D. (2019). Implementing Integrative Adapt Therapy with Rohingya refugees in Malaysia: a training-implementation model involving lay counsellors. Intervention, 17(2), 267-277. BEST BUYS In 2017, the World Health Assembly endorsed a set of ‘best buys’ and other recommended interventions to address NCDs.9 Best buy interventions address four NCD risk factors (tobacco, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 9 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases, WHO 2017. Responding to the Challenge of NCDs: UNHCR Evidence-based interventions UNHCR actions Strengthen international cooperation for resource mobilization, capacity building, health workforce training, and exchange of information on lessons learned and best practices. Capacity building on NCD care for clinicians providing care to refugees and host communities through training, mentoring, support and monitoring. Allocation of resources for sufficient medicine supplies, diagnostic supplies and tools, and health infrastructure to better integrate NCD care at primary care level for refugees. Promote and support exclusive breastfeeding for the first 6 months of life, including promotion of breastfeeding. UNHCR and partners actively promote exclusive breastfeeding in health facilities as well as protecting refugees from donations/ marketing of breast milk substitutes. UNHCR has an Infant and Young Child Feeding framework for a multisectoral approach placing the infant at the center. Implement subsidies to increase the intake of fruits and vegetables. In some settings UNHCR and partners have implemented Fresh Food Vouchers as well as cash-based interventions, to increase dietary diversity to improve complementary feeding. Drug therapy (including glycaemic control for diabetes mellitus and control of hypertension using a total risk approach) and counselling to individuals who have had a heart attack or stroke and to persons with moderate to high risk (≥ 20%) of a fatal and non-fatal cardiovascular event in the next 10 years. UNHCR trains clinicians on diabetes, hypertension, cardiovascular disease and chronic respiratory diseases. This includes task shifting to nurses and use of risk assessment charts and standard clinical protocols. Treatment of asthma using low dose inhaled beclomethasone and short-acting beta agonist. As above. Vaccination against human papillomavirus (2 doses) of 9–13-year-old girls. Prevention of cervical cancer by screening women aged 49–30 and timely treatment of pre-cancerous lesions. UNHCR advocates with ministries of health and Gavi to ensure refugees are included in national HPV vaccination planning. UNHCR also advocates that refugees have access to national screening programmes and has supported such activities in refugee camps including for high risk groups such as women living with HIV. Prevention of liver cancer through hepatitis B immunization. UNHCR advocates with ministries of health to ensure refugees are included in the national Expanded Programme on Immunization (EPI) including access to hepatitis B immunization. In certain situations, including where refugees are residing in camps, UNHCR may support the staffing and infrastructure for the delivery of health services, including EPI. 4 Responding to the Challenge of NCDs: UNHCR UNHCR partners with multiple stakeholders on refugee health. At the national level, UNHCR works closely with government ministries, particularly ministries of health and refugee affairs, and NGO partners. Both at national and international level UNHCR partners with UN agencies including WFP, UNICEF, WHO, UNAIDS, UNFPA, UNDP, ILO, and IOM, as well as with civil society. UNHCR convenes an informal working group on NCDs in Humanitarian Settings at global level incorporating UN agencies, NGOs and academia. The group exchanges information on activities and initiatives and identifies collaboration opportunities to meet NCD care needs in humanitarian settings. Work is ongoing to develop operational and clinical guidance in such settings as well as to elaborate on the approach set out for NCDs in the Sphere handbook.10 This work builds upon ‘Non-communicable Diseases in Emergencies’, the brief for emergency planners, emergency care professionals and policymakers tasked with emergency response and preparedness.11 UNHCR published guidance on promoting treatment adherence for refugees in health care settings in 2019.12 UNHCR works closely with other international partners on the Inter-Agency Standing Committee Reference Group for Mental Health and Psychosocial Support in Emergency Settings. This includes working with WHO and UNICEF to develop a minimal service package for mental health and psychosocial support in humanitarian settings.13 10 The Sphere movement was started in 1997 to improve the quality of humanitarian work during disaster response. The 2018 Sphere Handbook provides a humanitarian charter and minimum standards in humanitarian responses. https:// spherestandards.org/wp-content/uploads/Sphere-Handbook-2018-EN.pdf 11 UNIATF on NCDs/WHO. (2016). Noncommunicable Diseases in Emergencies. http://apps.who.int/iris/bitstream/10665/204627/1/WHO_NMH_ NVI_16.2_eng.pdf?ua=1 12 UNHCR, Promoting treatment adherence for refugees and persons of concern in health care settings (2019). https://www.unhcr.org/5cd962bc7.pdf 13 IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings. https://interagencystandingcommittee.org/iasc-reference- group-on-mental-health-and-psychosocial-support-in-emergency-settings Due diligence is required to ensure that all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. 5 6The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the UNHCR as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. Responding to the Challenge of NCDs: UNHCR Sphere and NCDs The need to focus on NCDs in humanitarian crises reflects increased global life expectancy combined with behavioural risk factors such as tobacco smoking and unhealthy diets. About 80 per cent of deaths from NCDs occur in low- or middle- income countries, and emergencies exacerbate this. Within an average adult population of 10,000 people, there are likely to be 1,500–3,000 people with hypertension, 500–2,000 with diabetes, and 3–8 acute heart attacks over a normal 90- day period. Diseases will vary but often include diabetes, cardiovascular disease, chronic lung and cancer. Initial response should manage acute complications and avoid treatment interruption, followed by more comprehensive programmes. NCDs standard: People have access to preventive programmes, diagnostics and essential therapies for acute complications and long-term management of NCDs. Key actions: (i) identify the NCD health needs and analyze the availability of services pre-crisis; (ii) implement phased-approach programmes based on life-saving priorities and relief of suffering; (iii) integrate NCD care into the health system at all levels; (iv) establish national preparedness programmes for NCDs. Key indicators: (i) percentage of primary healthcare facilities providing care for priority NCDs; (ii) number of days essential medicines for NCDs were not available in the past 30 days; (iii) number of days for which basic equipment for NCDs was not available (or not functional) in the past 30 days; (iv) all healthcare workers providing NCD treatment are trained in NCD management. Adapted from the Sphere Handbook Section 2.6, pages 342–345 (mental health and palliative care are addressed in sections 2.5 and 2.7.10 4. Mobilizing resources to deliver UNHCR will continue to highlight the importance of NCDs as part of public health programmes, and seek improved NCD care for refugees within national health care systems, and fundraise with donors. Photo credits: page 3 (clockwise from bottom: © UNHCR; © UNDP; © UNHCR); page 5 © World Bank via Flickr 1 Responding to the Challenge of NCDs: UNICEF United Nations Children’s Fund Responding to the Challenge of Non-communicable Diseases 1. Many NCDs have their origins in early life NCDs undermine children and adolescents’ right to health, nutrition, education and play. Each year, about 1.2 million children and adolescents aged under 20 die from often treatable NCDs such as chronic respiratory diseases and cancers, accounting for 13% of overall NCD mortality. NCD risk factors, e.g. childhood overweight and obesity, have a negative impact on children’s mental and emotional well-being, peer relations, learning and opportunities to participate in education and recreation. Exposure to NCD risk factors is often established very early in life. Prenatal maternal undernutrition and/or low birthweight predispose an individual to obesity, high blood pressure, heart disease and diabetes later in life. Maternal obesity and gestational diabetes are associated with cardiovascular disease and diabetes in both mother and child. Childhood and adolescence are also periods when behaviours which lead to the onset of NCDs are adopted including tobacco use, alcohol use, unhealthy diets and physical inactivity as well as unsafe sex (which can result in the spread of HPV, a cause of cervical cancer). These behaviours contribute to an estimated 70% of premature deaths in adulthood. United Nations high-level meetings have highlighted the need for UN agencies, including UNICEF, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs account for 14.6% of all-cause mortality and 24.8% of disability-affected life years (DALYs) amongst children and adolescents. Exposure to NCD risk factors may begin before or during pregnancy and continue during infancy and childhood and adolescence, underlining the importance of action across these age groups Childhood and adolescence are periods where significant impact can be made in risk reduction through evidence-based interventions on diet, physical activity, tobacco and alcohol consumption Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. Children and adolescents are often targeted by companies producing, marketing and/ or selling unhealthy products (e.g. tobacco, alcohol and foods high in fat, sugar and/or salt). Many children and adolescents also grow up in built environments that are not conducive to healthy behaviours (e.g. urban areas that combine limited opportunities for physical activity, exposure to unsafe roads and high levels of air pollution). 2 Responding to the Challenge of NCDs: UNICEF Children and adolescents with NCDs, or those tasked to provide care for family members with NCDs, have lower educational attainments and less access to employment opportunities, leading to an increased risk of financial insecurity later in life. In addition to the psychological impact on offspring, NCD- linked adult illness and premature death are associated with household poverty, food insecurity, social stigma and an increased work burden on children. NCDs can contribute to gender inequality as they usually present a need for long- term caregiving which historically is disproportionately borne by female family members. NCD risk factors, such as alcohol and tobacco use, are also linked with child deprivation and violence against children, especially girls. The UNICEF Strategic Plan for 2018–2021 has strong links to NCD prevention and control, namely: • enhancing maternal, newborn and child health to reduce NCD risks; • improving immunisation, particularly against human papillomavirus (HPV); • preventing low birth weight, stunting, and other forms of malnutrition, including overweight and obesity; • preventing and treating HIV (HIV and its treatment increase the risks of NCDs and related problems); • investing in early childhood development (positive and responsive parenting); 2. UNICEF has a role to play in supporting countries in preventing and controlling NCDs • addressing adolescent health and nutrition (e.g. developing inclusive, multisectoral and gender-responsive national plans for adolescent health and well-being which included reducing behavioural risk factors for NCDs); and • adolescent mental health, suicide and road safety. Given its focus on childhood and adolescence and its cross-sectoral approach, UNICEF is well positioned to integrate early prevention of NCDs and their risk factors into its work. UNICEF has reviewed the recommended cost-effective NCD interventions endorsed by the WHA to identify those that are linked to UNICEF’s work at global, regional and country levels. Many of the recommended “best buy” interventions are already being implemented by UNICEF’s country offices (e.g. breastfeeding promotion), while some require the promotion of new activities (e.g. school-based policies and programmes, supportive infrastructure for active transportation in road safety programmes) and a focus on preconception health for females and males. Some areas of current and potential programming in relation to the “best buys” are highlighted in the table on page 3. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.1 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 1 WHO. 2017. ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf. 3 Responding to the Challenge of NCDs: UNICEF Evidence-based interventions UNICEF actions Advocate for legislation on food regulation and taxation. On the global platform, UNICEF has been at the forefront of breastmilk substitute regulation. UNICEF has been engaged with global level advocacy on the regulation of food composition and marketing and has promoted food labelling. UNICEF has also worked at global and country level to advocate for fiscal measures to control the consumption of sugar- sweetened beverages. Promote and support exclusive breastfeeding for the first 6 months of life, including promotion of breastfeeding. UNICEF’s Nutrition programme focuses on protection, promotion and support for exclusive breastfeeding for the first six months of life and continued breastfeeding with safe and adequate complementary feeding up to two years and beyond as well as promoting a healthy diet and addressing multiple micronutrient deficiencies among children aged 6–23 months. Implement nutrition education and counselling in different settings (e.g. preschools, schools, workplaces, health clinics and hospitals) to increase the intake of fruits and vegetables. To advance UNICEF’s Nutrition programme on NCDs and nutrition, guidance documents on the prevention of overweight and obesity, school nutrition and nutrition among adolescents are currently under development. Implement mass media campaign including social marketing on healthy diets to reduce the intake of total fat, saturated fats, sugars and salt, and to promote the intake of fruits and vegetables. UNICEF’s Communication for Development (C4D) programme can contribute to advocacy and community engagement efforts by creating an enabling policy and legislative environment for NCD prevention: this can engage communities, amplify the voices of affected children and adolescents, encourage participation particularly of adolescents and guarantee that governments and other stakeholders deliver on NCD prevention and control. Implement whole-of-school programmes that include quality physical education, availability of adequate facilities and programmes to support physical activity for all children. The UNICEF Education programme plays a significant role in NCD prevention through its preschool, primary and secondary school programmes for children over five years, and for adolescents. Developing and supporting whole-of-school policies and programmes that protect children and adolescents from harmful subsidies, encourage physical activity and address healthy diets are all potential entry points for UNICEF action. Implement community-wide public education and awareness campaign for physical activity which includes a mass media campaign combined with other community-based education, motivational and environmental programmes aimed at supporting behavioural change and physical activity levels. Through its Community Health programme, UNICEF is able provide support to mass media campaigns and targeted community-based health promotion activities via community health and social worker platforms. Primary prevention of rheumatic fever and rheumatic heart diseases by increasing appropriate treatment of streptococcal pharyngitis at the primary care level. UNICEF’s community and child health service delivery infrastructure, part of its Integrated Management of Childhood Illness programme, has the capacity to promote early detection and effective treatment of rheumatic fever as a preventive measure against rheumatic heart disease. Vaccination against HPV (2 doses) of 9- to 13-year-old girls. These campaigns are part of UNICEF’s Extended Programme on Immunization and delivered via in-country programmes. Prevention of liver cancer through hepatitis B immunisation. 4 Responding to the Challenge of NCDs: UNICEF Guidance on UNICEF’s approach on early life prevention of NCDs was issued in 2019. The UNICEF Strategy for Health 2016–2030 covers four areas that enable action at country level. Across these areas, there are many opportunities for UNICEF to strengthen its support to national NCD responses. Advocate for legislation on food regulation and taxation. Promote comprehensive laws that reduce the direct and indirect exposure of children and adolescents to tobacco, alcohol, illicit drugs, unhealthy foods and beverages, polluted air, water and soil (or polluted environment) and unsafe roads. Encourage school and community-based initiatives that enable healthy lifestyles and promote healthy food and physical activity. Reinforce health systems that, in coordination with education and social services, deliver NCD prevention, screening and care. Foster environmental initiatives that encourage physical activity and healthier diets (e.g. through sustainable transport and urban planning for health that prioritizes walkability and active mobility, in particular for school environments and safe and clean routes for schoolchildren). Target actions on environmental pollution monitoring, prevention and control. Integrate pollution control and NCD agenda. Pollution accounts for 22% of all deaths from cardiovascular disease, 53% of deaths from chronic obstructive pulmonary disease (COPD) and 40% of deaths from lung cancer). Identify data gaps and strengthen mechanisms for the collection and monitoring of NCD risk and related data across sectors. Influencing government policies. Provide technical support, convene stakeholders, facilitate knowledge exchange and mobilize resources to support governments in evidence-based policy-making and financing, including the adoption and implementation of laws, policies and programmes to protect children and adolescents from exposure to NCD risk factors. Make pollution prevention a core component of the intersectoral NCD agenda. Support the development of programmes for protective environments that discourage risk behaviours and support and protect health. Compile lessons learned, promote direct knowledge exchange between countries and foster South-South collaboration on effective strategies, policies and interventions. Strengthening service delivery Address NCDs more effectively across the lifecycle by leveraging existing platforms such as primary health care (PHC) facilities, community health platforms, schools and child protection systems,2 as well as guaranteeing clean and safe environments. Empowering communities Work with local civil society organizations (CSOs), governments and other local influencers to create demand for NCD prevention; use information and communication technologies (ICTs) to increase knowledge on healthy behavior patterns; and develop compelling and contextually appropriate messages to promote NCD prevention, delivered via communication-for- development (C4D) multimedia strategies. 2 UNICEF-supported maternal, newborn and child health programmes are well positioned to further integrate NCD prevention. 5 Responding to the Challenge of NCDs: UNICEF 3. Partnerships are critical for UNICEF in mobilizing an effective response to NCDs In addition to strengthening partnerships with governments, UNICEF can advance strategic partnerships with UN and multilateral partners. Examples include: • United Nations Population Fund (UNFPA), particularly programmes addressing antenatal care (ANC), HPV and risk factors during adolescence; • UN Women on gender policy; • Food and Agriculture Organisation (FAO) and World Food Programme (WFP) on nutrition and agriculture; • Gavi Alliance on HPV and hepatitis C; • World Bank and regional development banks on infrastructure programmes, financing and taxation; • United Nations Educational, Scientific and Cultural Organization (UNESCO) on health education and physical activity; • UN Environment Programme on clean, safe and healthy environments; • United Nations Development Programme (UNDP) on whole-of-government and whole- of-society NCD responses; • UN-Habitat on sustainable urban mobility; and • WHO on data/evidence/policy on prevention and control of pollution-related NCDs. UNICEF is also able to strengthen its collaboration with civil society on the prevention and control of NCDs, e.g. through NCD Child, NCD Alliance, Global Alliance for Improved Nutrition (GAIN), Child Health Initiative and EAT Foundation,3 including the EAT Food Forum. Engagement with the private sector can help leverage business data and expertise, e.g. to generate evidence, while business assets, technology, communications and outreach can be developed to deliver services or promote behaviour change on a large scale. 3 For example, UNICEF and EAT have initiated a collaboration, Children Eating Well (CHEW), to conduct research into and evaluate interventions related to food environments and children’s interactions with them, particularly in the urban context. Due diligence is required to ensure that desired results are obtained from private sector engagement, particularly as the activities of some businesses have an impact on children’s well-being through the marketing of tobacco, alcohol, and foods and beverages that are high in fat, sugar and/or salt. Partnerships with some pharmaceutical companies may also pose potential or real conflicts of interest. 6 Responding to the Challenge of NCDs: UNICEF The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the UNICEF as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr 4. Mobilizing resources to deliver Funding NCD prevention will enable UNICEF to protect children and adolescents from NCD risk factors and their impacts. However, while existing health, nutrition and education programmes can be adapted to include NCD prevention, it should not be assumed that this can be done easily, or at no cost. Nor should it be assumed that governments are always able to finance NCD prevention and control on their own, as many still require technical support to strengthen NCD-related services, policies, plans and programmes. Decision-makers must be made aware of the significant social and economic costs of NCD burdens. In addition to UNICEF’s traditional sources of funding for programmes and advocacy, private sector entities can be a potential source of funding provided they meet due diligence requirements. This technical brief is drawn from the UNICEF Programme Guidance on Early Life Prevention of Non-Communicable Diseases (2019).4 4 The full document can be accessed here: https://unicef-my.sharepoint.com/:b:/g/ personal/rbermejo_unicef_org1/EemhcUrpmFFLrDYURRM2uk8BmDV8IMjS_ LYcXbZOYWbgjg?e=V8frzU 1 Responding to the Challenge of NCDs: The World Bank The World Bank Responding to the Challenge of Non-communicable Diseases 1. The rising burden of NCDs poses a threat to health and development NCDs are a growing concern in all countries. NCDs are projected to rise in low- and middle- income countries (LMICs) by 2030 in line with changing lifestyles, ageing populations, urbanization and other factors. Many countries face a double burden of disease with an unfinished communicable disease burden and a rising NCD epidemic. Likewise, some LMICs face both a high prevalence of childhood stunting and the growing problem of obesity (the number of obese children and adolescents has grown more than tenfold over the past 40 years). NCDs result in increased health care spending and significant economic losses due to the often complex, costly and/or chronic nature of care, as well as to lost productivity. Between 2011 and 2025, NCDs are projected to cost LMICs more than US$7 trillion.1 Households bear the brunt of health care spending on NCDs and have limited financial protection in most LMICs. Considering the impoverishing effect of many NCDs, it will not be possible to attain the equity and financial protection goals of the UHC agenda if NCDs are not addressed. 1 Bloom, D. E., Chisholm, D., Jané-Llopis, E., Prettner, K., Stein, A., & Feigl, A. (2011). From burden to “best buys”: reducing the economic impact of non-communicable diseases in low-and middle-income countries (No. 7511). Available at: https:// www.who.int/nmh/publications/best_buys_summary.pdf. NCDs are defined as cardiovascular disease, cancers, diabetes and chronic respiratory diseases. United Nations high-level meetings have highlighted the need for UN agencies, including WB, to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors, such as unhealthy diet, tobacco use, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2 Responding to the Challenge of NCDs: The World Bank Regardless of their income levels, countries should not neglect the NCD burden given its implications for human capital development. Since NCDs are a major cause of premature death, disability and foregone wages, investments in the prevention and treatment of these conditions will improve adult health and economic growth. Investing in cost-effective NCD interventions in poorer countries will generate US$350 billion in economic benefits and save 8.2 million lives by 2030. This is a return of US$7 per person for every dollar invested.2 Financing of NCDs remains inadequate and out of line with the growing burden in LMICs. About 80% of the NCD burden is in LMICs, and NCDs overall represent over two thirds of the global disease burden; financing for NCDs is however concentrated in high- income countries and overseas development assistance for NCDs accounts for less than 3% of total assistance for health.3 NCD prevention requires a multisectoral, whole-of-government, whole-of-society approach which focuses on reducing population exposure to environmental and behavioural risk factors while increasing affordable access to basic services. Integrated care models which are patient-centered and leverage investments in infectious diseases and maternal, newborn and child health will be critical to managing both the rising burden of disease and spiralling costs. Despite several high-level NCD events since 2011, progress remains slow. The third UN High-Level Meeting on NCDs in September 2018 aimed to intensify political support in the context of the SDG agenda with a focus on “reducing premature mortality from NCDs by one third by 2030”, in line with SDG target 3.4. 2 WHO GCM/NCD Working Group on the Inclusion of NCDs in Other Programmatic Areas (2018). Final Report: Working Group on the Inclusion of NCDs in Other Programmatic Areas. Retrieved from https://www.who.int/global-coordination- mechanism/activities/working-groups/3-1-report.PDF?ua=1 3 Health Finance Institute. Addressing the economic burden of underinvestment in NCDs. Available at: http://healthfinanceinstitute.org/ Urgent action is needed to accelerate progress in health service coverage and financial protection, and to address the broader socioeconomic determinants of NCDs. 3 Responding to the Challenge of NCDs: The World Bank The World Bank’s health sector strategy supports countries to accelerate progress towards UHC. Its three main pillars include: (a) expanding financial protection so that no one is tipped into poverty because of catastrophic health spending; (b) increasing coverage of quality health services for the poorest 40% of the population; and (c) fostering a healthy society, including investments that reduce risk factors for NCDs. The prevention and control of NCDs cut across the three pillars. The World Bank responds to client demand to prevent and control NCDs by providing financial support, policy advice and technical assistance to strengthen the health system response and address key risk factors for NCDs. The World Bank has produced analytic work to understand the nature and magnitude of the NCD problem, identify risk factors and propose mitigation measures. It has also conducted expenditure analyses to determine the efficiency of public spending and identify strategies to expand domestic resource mobilization (including through taxation of health-harming products) in order to increase those available for primary health care (PHC). The World Bank plays an important knowledge-sharing role by producing a wide range of knowledge products and sharing experiences and lessons across countries. The Bank has brokered various partnerships to leverage technical and financial support, working in close collaboration with technical agencies, the private sector and UN agencies. 2. The World Bank has a role to play in supporting countries in preventing and controlling NCDs Investment lending is effective for scaling up domestic action on the prevention and control of NCDs The Bank has a diversified portfolio of investment operations in health systems and health services in support of NCDs, totaling about US$1.5 billion (2019): this represents about 12% of the Bank’s overall health, nutrition and population (HNP) lending. Projects include: (a) strengthening early detection and screening for NCDs; (b) promoting NCD risk reduction; and (c) revamping health systems and facilitating transformational reforms to shift attention from costly secondary care to primary health care. Over a half of all NCD health investments are on integrated projects with both disease prevention and chronic disease management activities. Other projects use communicable disease investments to support NCD prevention and treatment. The Bank portfolio also includes roughly US$0.2 billion of non-health investment operations that directly or indirectly contribute to NCD prevention. Examples include: (a) promoting environmental health; (b) expanding the use of safe and efficient cookstoves; (c) enhancing awareness and knowledge; (d) promoting fiscal and regulatory reforms; and (e) reducing the risk of road injuries. 4 Responding to the Challenge of NCDs: The World Bank Protecting Vulnerable People against NCDs in Argentina. NCDs generate a heavy health and economic burden. The US$350 million project (2015–2020) in Argentina aims to improve the readiness of public health facilities to deliver higher quality NCD services for vulnerable population groups and expand the scope of selected services, as well as to protect vulnerable population groups against prevalent NCD risk factors. Regional Programme of Cancer Registries in East Africa. In 2012, sub-Saharan Africa had about 850,000 new cancer cases and 600,000 deaths. The World Bank is supporting Burundi, Kenya, Rwanda, Tanzania and Uganda to strengthen their capacity for collecting, analysing and sharing data on cancers. Access to timely information on the rising cancer disease burden is critical to develop financial protection mechanisms to ensure that households are not impoverished by catastrophic health spending, provide quality services in a timely manner in order to facilitate early detection and treatment, and address risk factors associated with cancers. Leveraging Investments in Infectious Diseases to combat NCDs in Egypt. The World Bank supported a combined national hepatitis C and NCD risk factor (hypertension, high blood sugar and body mass index) screening campaign, with high-level political support from the President. Individuals with hepatitis C and/or at risk of NCDs were enrolled in structured treatment programmes. To date, 49.8 million adults aged of 18 or over have been screened. This innovative initiative demonstrates the potential for leveraging existing infectious disease platforms to address NCDs. Examples of World Bank-funded NCD Interventions Towards Population-Based Screening and Community-Level Outreach for NCDs in India. Tamil Nadu is India’s sixth most populous state and is dealing with a double burden of communicable and non-communicable diseases. Cardiovascular disease, diabetes, and cancer are the leading causes of death for people aged above 40. The World Bank has provided a US$287 million loan to strengthen management of NCDs, with a focus on health promotion and NCD prevention, population- based screening of NCDs among the eligible population, treatment and follow- up, and improvement of NCD monitoring and evaluation. The project aims to support a move from opportunistic screening to population-based screening. Establishment of Health Lifestyle Centres (HLCs) for NCD Screening and Referral in Sri Lanka and Turkey. The World Bank has supported the establishment of Healthy Life Centres at the PHC level for the detection and management of patients with a high NCD risk. In Sri Lanka this is being done by strengthening PHC capacity, population screening and better treatment and follow-up. Performance-Based Financing for NCDs in Tajikistan. Ischaemic heart disease is one of the leading causes of death in Tajikistan. The World Bank is supporting the government’s performance-based financing scheme to improve the coverage and quality of basic primary health services in rural health facilities in 10 districts. Under this supply-side project, the Ministry of Health contracts rural health centers to enhance both the quantity and quality of NCD services, providing coverage in about 450 health facilities to approximately 15 percent of the country’s total population. 5 Responding to the Challenge of NCDs: The World Bank Analytic work and knowledge management: Linking evidence to operations The Bank undertakes a wide range of country, regional and global studies to better understand and address the risk factors associated with NCDs, as well as to provide an analytic underpinning for investment lending and inform public policy. Examples are given in the box. The World Bank Group’s Global Tobacco Control Programme supports knowledge exchange among selected countries on the economics of tobacco control. Experts in health, governance and macroeconomic and financial management, poverty and equity, agriculture and trade engage actively in this programme, which is a win-win for both public health and domestic resource mobilization.4 The programme assists countries to design tobacco tax policy reforms and increase tobacco tax rates in order to: (a) achieve public health goals by increasing prices, reducing smoking, and preventing initiation among youth; (b) raise domestic resources for investments that benefit the entire population; and (c) enhance equity by reducing the health risks associated with tobacco-attributable diseases and the risk of impoverishment due to high out-of-pocket expenditure among the lowest income population groups. Achievements include providing support for tobacco tax policy reforms in several countries and the launch of the World Bank Group report “Tobacco Tax Reform: At the Crossroads of Health and Development”. 4 The World Bank. Global Tobacco control. https://www.worldbank.org/en/topic/ tobacco Impact of NCDs on Human Capital (2019). The WB is collaborating with several partners to produce a report that describes how human capital and productivity can be enhanced by tackling NCDs, with recommendations for action. This work is part of the World Bank’s Human Capital Project to improve human capital at the country level through investing in health and education. Obesity: A Ticking Time Bomb – What can the World Bank do to Defuse It? (2019). This report highlights the growing epidemic of obesity in both low- and high-income countries, and its health and economic costs. The report lays out the drivers of obesity, lessons learned from obesity-prevention efforts across the globe, and the policy and investment tools that the World Bank can deploy across different sectors to address obesity. How to Improve the Use of Fiscal Policy to Address the NCD Crisis: Lesson Learned from Tonga (2019). Tonga has a very high burden of NCDs. This study generates policy-relevant findings and insights on the implementation of taxation policy on tobacco, alcohol, food and behaviours, pricing, government revenues and the country’s response to the rising NCD burden. The Challenge of NCDs and Road Traffic Injuries in sub-Saharan Africa (2013). This is a comprehensive review of the literature with input from policy-makers, researchers and practitioners. It describes how resource- constrained governments can prevent and control NCDs and increase road safety. The Challenge of NCDs and Road Traffic Injuries in sub-Saharan Africa (2013). This is a comprehensive review of the literature with input from policy-makers, researchers and practitioners. It describes how resource- constrained governments can prevent and control NCDs and increase road safety. 6 Responding to the Challenge of NCDs: The World Bank The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the World Bank as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. Ph ot o cr ed its : © W or ld B an k vi a Fl ic kr 3. Partnerships are critical for the World Bank in mobilizing an effective response to NCDs The Bank has been an active member of several key partnerships and/or leader in key initiatives (e.g. tobacco control and mental health) to prevent and control NCDs. Examples include: • Access Accelerated. The Bank brokered this partnership with the private sector to leverage funding for pilot projects that aim to support early screening, detection and initial treatment for NCDs in countries such as Kenya and El Salvador. • Union for International Cancer Control (UICC) — City Cancer Challenge. The Bank participated in the UICC-led City Cancer Challenge initiative which supports cities to design, plan and implement cancer treatment solutions to reduce cancer mortality by 2025. • World Bank Umbrella Facility for Gender Equality (UFGE). The UFGE is a multidonor trust fund that aims to strengthen awareness, knowledge and capacity for gender-informed policy-making; it also explores new approaches to improve human capital, such as through the control of NCDs. 1 Responding to the Challenge of NCDs: WFP World Food Programme Responding to the Challenge of Non-communicable Diseases 1. The nutrition and food security sectors are central to an effective response to NCDs WFP is the food-assistance branch of the United Nations (UN), delivering food assistance in developing and emergency contexts, and working with communities to improve nutrition and build resilience. Unhealthy diets1 are a leading risk factor for NCDs. Diet-related NCDs include cancers, diabetes and cardiovascular disease. The right to food must not be reduced to “the right to not starve.”2 Ensuring access to diverse, safe and nutritious foods can prevent NCDs and their impacts on sustainable development. The triple burden of malnutrition— undernutrition and hunger, overweight and obesity, and micronutrient deficiencies— remains unacceptable. Children under five face large and multiple burdens: 149 million are stunted, 49.5 million are affected by wasting, and 40.1 million are overweight.3 1 Unhealthy diets include energy-dense and highly processed foods that are high in refined starches, sugar, fats and/or salt, accompanied by an insufficient intake of fresh fruits and vegetables, wholegrains, pulses, nuts and seeds. FAO (2017). The State of Food and Agriculture 2017: Leveraging Food Systems for Inclusive Rural Transformation. Available at: www.fao.org/3/a-I7658e.pdf. 2 A/HRC/19/59. Report submitted by the Special Rapporteur on the right to food, Olivier De Schutter. Available at: https://www.ohchr.org/Documents/HRBodies/ HRCouncil/RegularSession/Session19/A-HRC-19-59_en.pdf 3 United Nations Children’s Fund (UNICEF), World Health Organization, International Bank for Reconstruction and Development/The World Bank. Levels and trends in child malnutrition: key findings of the 2019 Edition of the Joint Child Malnutrition Estimates. Geneva: World Health Organization; 2019 Licence: CC BY-NC-SA 3.0 IGO. United Nations high-level meetings have highlighted the need for UN agencies, including WFP to scale up their work on NCDs as part of the 2030 Agenda for Sustainable Development. NCDs contribute to ill-health, poverty and inequities and slow the development of countries. Every year 15 million people die before age 70 from NCDs, with 86% of these premature deaths occurring in low- and middle-income countries. Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by modifiable behavioural risk factors such as tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Environmental risks (e.g. air pollution) and constrained access to basic services also contribute significantly to NCDs. An approach to the prevention of NCDs requires food system transformation and policies that address aspects of the wider food system, encompassing nutrition, food culture and identity, public food and meals, food loss and waste and sustainable diets. Addressing NCDs requires coordinated action from all UN agencies within a broader whole-of- society response. 2 Responding to the Challenge of NCDs: WFP The world is now experiencing record levels of overweight and obesity among adults (38.9%), with trends increasing, particularly among adolescents.4 Supporting good nutrition during the first 1,000 days of life and adopting healthy dietary habits during adolescence can reduce the risk of NCDs later in life. Supporting prematernal and gestational nutrition can reduce NCD risks for both mother and child. WFP supports governments to implement a comprehensive multisectoral package of actions that address the triple burden of malnutrition and the prevention of diet-related NCDs. Through its core work on nutrition and food security, and in collaboration with various stakeholders, WFP is uniquely positioned to contribute to global efforts to address NCDs.5 WFP’s nutrition policy (2017–2021) articulates its role in addressing NCDs and supporting governments to achieve the NCD-related targets in the 2030 Agenda for Sustainable Development. WFP works with government counterparts and partners to develop five-year country strategic plans, which are subsequently endorsed by WFP Executive Board members. A review of the cost-effective interventions endorsed by the WHA identified relevant WFP interventions at the global, regional and country level. Six examples are shown in the table. 4 United Nations Children’s Fund (UNICEF), World Health Organization, International Bank for Reconstruction and Development/The World Bank. Levels and trends in child malnutrition: key findings of the 2019 Edition of the Joint Child Malnutrition Estimates. Geneva: World Health Organization; 2019 Licence: CC BY-NC-SA 3.0 IGO. 5 ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. WHO. 2017. Available at: http://apps.who.int/iris/ bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf. 2. WFP has a role to play in supporting countries in preventing and controlling NCDs Evidence-based interventions WFP actions Implement mass media campaign on healthy diets including social marketing to reduce the intake of total fat, saturated fats, sugars and salt, and promote the intake of fruits. Work with governments on strategies and programming for social and behavioural change and communication (SBCC), nutrition education and messaging across a variety of electronic and traditional media platforms including social media and press/radio. Related activities have been rolled out in countries, e.g. Sudan, Madagascar and Mozambique. Promote and support exclusive breastfeeding for the first six months of life. Promote infant and young child feeding through existing platforms such as community management of acute malnutrition and food assistance programmes. Implement nutrition education and counselling in different settings (e.g. in pre- schools, schools, workplaces and hospitals) to increase the intake of fruits and vegetables. Support governments to ensure that school meals programmes are nutritious. Support governments to develop policies and programmes in schools to encourage healthy diets. Implement nutrition labelling to reduce total energy intake (kcal), sugars, sodium and unhealthy fats. Work through the SUN Business Network to support governments in encouraging the private sector to strengthen nutrition labelling to inform consumers about total energy intake, sugars, sodium and unhealthy fats. Access to improved stoves and cleaner fuels to reduce indoor air pollution. Country-level implementation of the initiatives contained in the WFP Handbook on Safe Access to Firewood and Alternative Energy. BEST BUYS In 2017, the World Health Assembly endorsed a set of “best buys” and other recommended interventions to address NCDs.5 Best buy interventions address four NCD risk factors (tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and four disease areas (cardiovascular disease, diabetes, cancer and chronic respiratory disease). There are 88 recommended interventions, including overarching/enabling policy actions. 3 Responding to the Challenge of NCDs: WFP WFP collaborates with a range of partners including the UN and the private sector to address malnutrition in all its forms. Partnerships are aimed at strengthening coordination, developing multisectoral policy, enhancing research and development, strengthening logistics and supply chain, and promoting digital technology and education. WFP ensures that partnerships are in the interest of public health. The Scaling Up Nutrition (SUN) Business Network. WFP and GAIN co-convene the SUN Business Network which, at the global and country levels, provides a platform to advance the dialogue on nutrition between the private sector, governments and other stakeholders. Depending on national nutrition priorities and the local private sector setting, efforts of the SUN Business Network may focus on reducing undernutrition, overnutrition or micronutrient deficiencies. Committee on World Food Security (CFS). The CFS is the foremost international and intergovernmental platform to promote food security and nutrition for all. In 2017, CFS started developing a set of voluntary guidelines on food systems and nutrition. Scaling Up Nutrition (SUN) United Nations Network (UNN)/REACH. ‘The SUN UNN/ REACH initiative’ is a partnership between WFP, Food and Agriculture Organisation (FAO), United Nations Children’s Fund (UNICEF), the World Health Organization (WHO) and the International Fund for Agricultural Development (IFAD). Its mandate is to accelerate the scaling up of food and nutrition actions in countries experiencing a high burden of child malnutrition. 3. Partnerships are critical for WFP in mobilizing an effective response to NCDs The UNN was established in 2013 by WFP, Food and Agriculture Organisation (FAO), United Nations Children’s Fund (UNICEF), the World Health Organization (WHO) and the International Fund for Agricultural Development (IFAD). The UNN works in countries to elevate national nutrition dialogue through its senior leadership and helps to leverage the collective strengths of the UN agencies, to foster innovations, find efficiencies and enhance complementarity across agencies and with government and SUN networks. Global Fund. WFP partners with organizations and companies to ensure that food and nutrition assistance is available to communities in some of the world’s hardest- to-reach areas. WFP’s partnership with the Global Fund is addressing logistics and supply chain issues around health and nutrition commodities in countries such as the Central African Republic and Burundi. IASC Humanitarian Cluster Mechanism. WFP is the lead agency in the Logistics Cluster6 (a coordination mechanism to ensure an efficient and effective emergency response, including the provision of NCD-related medicines during emergencies). WFP and FAO co-lead the Food Security Cluster7 (a coordination mechanism for food security response in humanitarian crises). 6 World Food Programme. Logistic cluster. https://www.wfp.org/logistics-cluster 7 Food Security Cluster. Coordinating the food security response in humanitarian crises. https://fscluster.org/ 4 Responding to the Challenge of NCDs: WFP P ho to c re di ts : © W or ld B an k vi a Fl ic kr The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by WFP as part of a set of United Nations system agency briefs under the Task Force. Publication date: September 2019. Due diligence is required to ensure that all partnerships advance health and development outcomes. Some private sector activities are beneficial for public health, while others contribute to NCD burdens by working to increase or preserve the availability, accessibility and/or desirability of health-harming products. An example is the fundamental conflict of interest between the tobacco industry and public health. Partnerships with some pharmaceutical companies may pose apparent or real conflicts of interest. 4. Mobilizing resources to deliver WFP leverages existing programmes to drive actions against undernutrition and hunger, overweight and obesity, and micronutrient deficiencies. Priorities include: • Fill the Nutrient Gap (FNG). This tool analyses the nutrition situation in a country and identifies the barriers faced by the most vulnerable in accessing and consuming healthy and nutritious foods; the FNG tool is used to inform government policies and WFP programming. In Madagascar, FNG helped to make the school meal food basket more nutritious. • School meals. Schools can encourage healthy eating among students, their families and communities. WFP’s Regional Bureau in Latin America and the Caribbean (LAC) is currently at the forefront of efforts to address overweight and obesity in schools in the LAC region. As part of the Latin American Network for School Meals initiative, WFP recently published an analysis on how nutrition-sensitive national school meals programmes can address malnutrition (undernutrition, overweight and obesity and micronutrient deficiencies), as well as accelerate progress towards achieving the SDGs (particularly SDG 2 and 3). • Social protection systems. WFP supports governments in the design of nutrition- sensitive social policies, mainstreaming nutrition education and supporting the design of shock-responsive social protection systems. • Social and behaviour change communication. This aims to improve behaviour around access to, selection, preparation and consumption of nutritious foods, to strengthen nutrition education and behaviour change communication in nutrition-specific programmes and to mainstream nutrition education aligned with national food-based dietary guidelines. • Food environments. WFP works to ensure balanced food baskets through diversification and micronutrient fortification, advocates for regulatory policies that improve the availability of safe, nutritious food and work environments, and negotiates with the private sector to increase the availability and marketing of age-appropriate and nutritious food.