Joint mission of the United Nations Interagency Task Force on the prevention and control of noncommunicable diseases: Mozambique, 2-6 November 2015

Joint Mission of the United Nations Interagency Task Force on the Prevention and Control of Noncommunicable Diseases Mozambique 2-6 November 2015 WHO/NMH/NMA/17.60 © World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization.. Suggested citation. United Nations Interagency Task Force on the Prevention and Control of Noncommunicable Diseases. Joint Mission, Mozambique, 2–6 November 2015. Geneva: World Health Organization; 2017 (WHO/NMH/NMA/17.60). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third- party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. This publication contains the collective views of the United Nations Interagency Task Force on the Prevention and Control of Noncommunicable Diseases and does not necessarily represent the decisions or the policies of WHO. iii Contents Page Summary 3 Key Observations of the Joint Programming Mission 4 Recommendations for Action 6 Annex 1. Background and Context of the Joint Mission 9 Annex 2. Members of the Joint Mission 12 Annex 3. Joint Mission Terms of Reference 13 Annex 4. Joint Mission Programme 17 Annex 5. Evidence-based cost-effective interventions for the prevention and control of NCDs 18 Annex 6. National commitments as set out in the Outcome Document of the High-Level Meeting of the General Assembly on the Review of the Progress Achieved in the Prevention and Control of NCDs 19 Annex 7. Commitment on Noncommunicable Diseases in Africa: Policies and Strategies to Address Risk Factors (AUC/WHO/2014/DOC.3, 17 April 2014) 22 iv Executive Summary Phase one of a two phased Joint Programming Mission of the United Nations Interagency Task Force on the Prevention and Control of Noncommunicable Diseases (UNIATF) to Mozambique was held in Maputo between 2–6 November 2015. Mozambique faces a growing burden of noncommunicable diseases (NCDs), particularly cardiovascular disease, cancers, diabetes and chronic respiratory diseases, which account for about 23% of deaths in the country. Worryingly, the probability of dying prematurely from NCDs is 17%. Mortality from cervical cancer is among the highest in Africa. More than 35% of Mozambicans have hypertension and access to the effective management of NCDs in primary health care facilities is inadequate in most parts of the country. The main risk factors for NCDs in Mozambique are tobacco use, the harmful use of alcohol, unhealthy diet and physical inactivity. Overall NCDs cause significant disability and are a growing drag on the country’s economy. The Government of Mozambique is now developing a national multisectoral action plan for the prevention and control of NCDs. This needs to be costed and focused on a small set of cost effective public health and primary care interventions (“best buys”) that are feasible to implement in Mozambique. Ahead of this, the joint mission recommends that the previous health sector NCD action plan 2008-2014, needs to be evaluated. In addition, a set of national targets for NCDs needs to be developed. Mozambique is only one of two countries in the WHO African Region that has yet to ratify the WHO Framework Convention on Tobacco Control (WHO FCTC). The Joint Mission encourages Parliament to ratify the WHO FCTC urgently and recommends that government solicits support from the UN system, donor agencies, civil society and the media to ensure that this is done. It was clear to the Joint Mission that the tobacco industry is very influential in Mozambique and promotes a range of policies that have great harm to the health and wellbeing of the citizens of Mozambique as well as wider economic and development progress. Levels of tobacco taxation, a highly cost-effective tobacco control measure, are significantly lower in Mozambique than in neighbouring countries. The UN system is well placed to provide technical assistance to Mozambique in preventing and controlling NCDs. The close to final draft of the 2017-2021 UN Development Assistance Framework (UNDAF) includes NCDs in a number of areas and provides a strong road map for action. As NCDs cuts across many of the UNDAF pillars, it is critical that there are strong coordination mechanisms for responding to NCDs across the UN Country Team. 1 Joint Mission of the United Nations Interagency Task Force on the Prevention and Control of Noncommunicable Diseases to Mozambique, 2– 6 November 2015 1. A initial Joint Programming Mission of the United Nations Interagency Task Force on the Prevention and Control of Noncommunicable Diseases (UNIATF) was conducted by WHO, UNDP and UNAIDS in Maputo, Mozambique between 2 and 6 October 2015. The background and context for the Joint Mission is in Annex 1. Terms of Reference, Members of the Joint Mission and the programme are in Annexes 2-4. It was agreed in advance of the Joint Programming Mission that this one would be exploratory and that a larger second Joint Programming Mission would take place next year. The Joint Mission is grateful to the Ministry of Health and other government ministries, the Parliament Commission on Social, Health, Gender and Technology Issues, and the United Nations Country Team (UNCT) that took time to meet with the Mission. The Mission also expresses its gratitude to other development partners that participated in discussions during the week. Key observations 2. Mozambique still faces a huge burden from communicable diseases as well as maternal and child health. At the same time NCDs – in the main, cardiovascular disease, cancers, diabetes and chronic respiratory diseases, is now a challenge and as a result, the country now faces a double burden of disease. This is placing ever greater stress on the economy and the health system. The ability of the health system to respond to the health needs of the population is limited and health coverage is far from universal. 3. The 2015 WHO NCD Progress Monitor 1 highlighted a number of areas with regards the prevention and control of NCDs where policies are not yet in place in Mozambique. These policies include those for the control of tobacco use, the harmful use of alcohol, unhealthy diet and physical inactivity as well as policies for tackling NCDs in primary care. The Joint Mission also considered that the lack of consistent NCD surveillance system is a significant issue and that investment in this area is urgently required: Mozambique has recently completed its second STEPS survey and it is important now that the results are speedily analyzed and disseminated. Clear advocacy for tackling NCDs among policy makers and the public is crucial. Overall awareness around NCDs and its risk factors is not well understood among the population. A Government in its early days of responding to the challenges of NCDs 4. Overall, the response from government is in its early days. The Ministry of Health is aware of the public health impact of NCDs with an NCD plan in place for several years. 2 The need now is to move this to a plan that is multisectoral and has ownership across the whole of government with clear actions for the different sectors, with coordination and accountability mechanisms. The Joint Mission therefore welcomes plans for developing a new multisectoral action plan as a successor to the 2008-2014 National Strategic Plan. The Joint Mission also welcomes the plans of the Ministry of Health to create a National commission on Social Determinants of Health. 5. Mozambique is one of two countries in Africa which has yet to ratify the WHO Framework Convention on Tobacco Control (WHO FCTC). Ratification of the WHO FCTC would be an important sign of commitment from the country to tackle tobacco use. The Joint Mission was informed that the WHO FCTC has been endorsed by Cabinet and now awaiting approval from Parliament, which the Joint Mission was told was expected to be in March 2016. The Parliamentary Commission on Social, Health, Gender and Technology Issues indicated to the Joint Mission its commitment to ratify the WHO FCTC but the Parliamentary Commission was not aware that the documentation had yet 1 http://www.who.int/nmh/publications/ncd-progress-monitor-2015/en/ 2 National Strategic Plan for prevention and control of NCDs 2008-2014. 2 reached Parliament. The Joint Mission was made aware of significant interference from the tobacco industry. The Joint Mission considers that ratification by Parliament is far from certain and that the Government needs to seek the support of the UN and other development partners to encourage Parliament to ratify the Convention. If ratification takes place, implementation of the Convention will remain a significant challenge, for example, increasing tobacco tax, which currently stands at 16%, which is significantly lower than in neighboring countries. Enforcement is an additional issue, for example, though the law says that tobacco products can only be sold in supermarkets, they are available in a large number of outlets including single sticks available on street corners. The Ministry of Finance in its discussions with the Joint Mission indicated any consideration to raising taxes on tobacco products should be left until Parliament had ratified the WHO FCTC. At the same time it is important that the UNCT is proactive in advocating for ratification of the WHO FCTC. 6. There are significant challenges for government to put in place effective policies for combatting the harmful use of alcohol. The mission heard that a significant obstacle to combatting the harmful use of alcohol is that as much alcohol is produced and distributed through informal networks. The Joint Mission learnt of the adverse effects of alcohol on the economy and impact on mental health, as well as violence and injuries, especially road traffic accidents. 7. At the moment, with all the competing challenges, such as chronic malnutrition and infectious diseases there has been little opportunity for the Government to prioritize actions to encourage a healthy diet among the population of Mozambique. It is now important that Mozambique develops policies that address the double burden of chronic malnutrition and overweight/obesity. 8. Urgent action is required during 2016 and 2017 biennium, to make progress in the prevention and control of NCDs, in preparation for the Third High-level Meeting on NCDs in 2018, when Mozambique, alongside all other countries will be required to demonstrate progress against a set of progress indicators described in Paragraph 3 above. 9. The Joint Mission also highlights the benefits of developing and enforcing strong policy in the area of tobacco use and the harmful use of alcohol on broader development issues such as education, HIV prevention and control, gender based violence as well as mental health and road traffic injuries. A UNCT that has recently included NCDs in the UNDAF and now needs to develop mechanisms for collective action to support Government. 10. The current Resident Coordinator has a strong understanding of the importance of NCDs as a development issue. The draft UN Development Assistance Framework 2017-2020 is being finalized. NCDs are well reflected under the Outcome, “People equitably access and use quality health, water and sanitation services.” 3 There are also a number of other outcomes which are relevant to NCDs in other sections of the UNDAF. The Joint Mission considered that 2016 provides an opportunity for the UNCT to develop a full understanding on roles and responsibilities, ways of working with government, developing effective coordination mechanisms and start taking forward some of the NCD-related actions identified in the UNDAF. 3 There are currently 4 outputs in this outcome: (i) FCTC ratification and implementation, (ii) enforcement of alcohol legislation and better regulation of commerce, (iii) guidelines for screening of main NCDs (diabetes, hypertension, asthma, cancer) approved and disseminated to all health facilities; and (iv) broader HPV vaccination against cervical cancer. 3 11. A number of UN agencies made the point that tackling NCDs will be a significant contribution to broader poverty reduction efforts that are being taken forward in the UNDAF. Other cross-cutting areas with strong links with health such as social protection and gender benefit from work on NCDs. 12. While WHO coordinates actions on NCDs across the UN system, the prevention and control of NCDs calls for engagement from all UN agencies. Relevant agencies in Mozambique that have comparative advantages in line with their respective mandates include FAO, UNAIDS, UNDP, UNESCO UNFPA, and UNICEF. Development partners at the onset of engaging with NCDs 13. The Joint Mission met with some of the donors and NGOs working in the health sector in Mozambique. Understandably, donors have not yet focused on NCDs. There are opportunities to develop interest in developing some early support from NCD through existing donor coordination platforms. While there was some interest in NCDs from NGOs, there is the need to develop this into coordinated support, especially with regards NCD risk factors. In addition it was clear to the Joint Mission that there are significant opportunities for development partners to include NCDs in their work on communicable disease control, sexual and reproductive health, and maternal and child health. Recommendations for Action 1. The WHO Framework Convention on Tobacco Control The Joint Mission recommends that: • the Parliament of Mozambique ratify as soon as possible, the WHO Framework Convention on Tobacco Control (FCTC); • the Government, through the MoH formally requests the support of WHO and the UNCT to provide the technical support and advocacy required to give every chance that Parliament ratifies the Convention. The Joint Mission considers that it is important that an explicit request comes from Government in order for this to be a truly country-owned process; • once a formal request for support has been received from Government by WHO and the UNCT, an 3-6 month action plan is developed by the UNCT and funds are identified (redeployed if required) to deliver the necessary actions to encourage Parliament to ratify the Convention. The UNCT should enlist the support of regional and HQ colleagues to provide additional support that is required; • the UNCT and Government work together to enlist the support of donors, NGOs, the media and other development partners to encourage Parliament to ratify the WHO FCTC. 2. Developing a National NCD Multisectoral Action Plan The Joint Mission recommends that: 4 • in preparation for the development of the government’s new NCD multisectoral action plan, an evaluation of the 2008-2014 National Strategic Plan is undertaken so that lessons learnt can be used in the design and execution of the new plan. This review should be undertaken between now and mid- January 2016; • between now and the end of 2015, the Government sets out a process for developing the new multisectoral action plan that engages with all relevant parties within government and outside government and that WHO provides the necessary technical support for developing the process; • the development of the new multisectoral action plan is completed by the end of April 2016 and includes a set of national targets in line with the Voluntary Global NCD Targets. • the Task Force’s follow up Joint Mission is timed to augment the UNCT’s support to Government in finalizing the plan; • the new multisectoral action plan focuses only on the most cost-effective and feasible interventions which are described in the WHO Global NCD Action Plan, 2013-2020 (Annex 5) and that the plan is costed; • the new multisectoral action plan is explicit in terms of the impact that action taken during 2016 and 2017 will have on the progress indicators that will be collated for the Third High- level Meeting in 2018; • the multisectoral action plan includes coordination and accountability mechanisms for government as well as other development partners. • that the Social Determinants of Health Commission that is under creation, includes NCDs and is headed at the level of Prime Minster or Deputy Prime Minister. 3. UN Development Assistance Framework, 2017-2020 A number of edits to the UNDAF 2017-2020 were made by the Joint Mission. The Joint Mission recommends that: • these edits are considered in finalizing the UNDAF; • WHO undertakes a review of those pillars that are relevant to NCDs to ensure that the appropriate UN agencies are included in coordination mechanisms; • UNDP and UNAIDS consider the inclusion of NCDs in the relevant UNDAF outputs, such as governance and youth/HIV. • Consider the inclusion of NCDs in other cross cutting areas such social protection and gender in order to maximize the impact of action in support of SDG 3. 4. Surveillance The Joint Mission recommends that: 5 • the WHO Country Office submits the Country Capacity Survey to WHO HQ as soon as possible; • the WHO Country Office recruits a consultant within next month to finalize the analysis of the results of the STEPS survey by the end of January 2016, with the results disseminated widely and being included in the discussions regarding priority actions for the new multisectoral action plan; • The MoH continues to integrate better NCD surveillance into broader health surveillance activities; • The MoH uses the results of the recent STEPs survey to develop a series of advocacy messages on NCDs ahead of Phase 2 of the mission. 5. Phase Two of the Joint Mission The Joint Mission recommends that the UNCT plans for a Phase 2 of Joint Mission for March 2016, working with regional and HQ counterparts. = = = 6 Annex 1. Background and Context A global United Nations Task Force to support countries respond to NCDs 1. The UNIATF was formed by the United Nations Economic and Social Council (ECOSOC) in 2013. In 2014, ECOSOC approved the UNIATF’s terms of reference. As part of this, a Division of Tasks and Responsibilities was adopted by UN agencies, funds and programmes to support implementing the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases, 2013- 2020. Activities identified in the UNIATF’s 2014-15 work-plan include a series of joint missions to selected countries to support governments and UNCTs scale up their response to NCDs. The mission to Sri Lanka was the ninth of these joint missions. Previous missions include Belarus, Democratic Republic of Congo, India, Kenya, Tonga, Barbados, Jordan, Turkmenistan, Mongolia and Sri Lanka. The need for UNCTs to prioritize the provision of support to governments around NCDs has been set out in two joint letters from the UNDP Administrator and the Director-General of WHO to UN Resident Coordinators and UN Country Teams in 2012 and 2014. At the global level there are clear frameworks to guide national action 2. The 2011 Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of NCDs called upon UN agencies and key international organizations to work together in a coordinated manner to support national efforts to prevent and control NCDs and mitigate their impacts. 4 The WHO Global Action Plan for the Prevention and Control of NCDs, 2013- 2020 also highlights the role of the UN system in supporting Member States and highlights cost- effective and very cost-effective interventions for the prevention and control of NCDs (Annex 4) in five key areas: (i) tobacco control; (ii) harmful use of alcohol; (iii) unhealthy diet; (iv) physical inactivity; and (v) household air pollution. 5 These interventions save lives. They also save individuals, communities and government money in both the short and long term. They are all evidence-based, high impact, cost effective, affordable and feasible to implement. Acting alone, ministries of health are limited to remedial action and treating the sick – a whole-of- government approach is required for the societal causes of NCDs to be addressed 3. Although these interventions are simple to execute, a number require political commitment and coordinated action across government. Acting alone, ministries of health are limited to remedial action, treating the sick; a whole-of-government approach is required for the societal causes of NCDs to be addressed. In parallel, a whole-of-UN approach must support a comprehensive national response. In addition, strategic engagement with civil society, academia, professional bodies and selected private entities are also important when it comes to tackling NCDs. 4. In July 2014, WHO Member States undertook a comprehensive review and assessment on the prevention and control of NCDs and progress since the 2011 Political Declaration on NCDs. 6 Key national commitments agreed at that meeting include: (i) setting national targets for NCDs for 2025; (ii) developing national multisectoral policies and plans to achieve the targets; (iii) considering establishing a national multisectoral mechanism for engaging policy coherence and mutual 4 Paragraph 51 of the Political Declaration “calls upon WHO, as the lead UN specialized agency for health, and all other relevant UN system agencies, funds and programmes, the international financial institutions, development banks and other key international organizations to work together in a coordinated manner to support national efforts to prevent and control NCDs and mitigate their impacts”. http://www.who.int/nmh/events/un_ncd_summit2011/political_declaration_en.pdf?ua=1 5 http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1 6 http://www.un.org/en/ga/68/resolutions.shtml 7 accountability of different spheres of policy-making that have a bearing on NCDs; (iv) reducing NCD risk factors by implementing interventions identified in the WHO NCD Global Action Plan, 2013-2020. The full set of national commitments is set out in Annex 5. At the regional level NCDs are accorded a high priority 5. In April 2011, the 47 member states of the WHO African Region adopted the Brazzaville Declaration which called for the development and implementation of strategies, policies, guidelines, legislation and regulatory framework for the prevention and control of NCDs. Member States were called upon to strengthen their health systems including health financing, training and retention of health workers. Member States were further urged to allocate resources commensurate with the burden of NCDs. In Resolution AFR/RC62/R7, the WHO Regional Committee for Africa in November 2012 endorsed the Brazzaville declaration and further urged member states to strengthen monitoring and surveillance systems for NCDs to generate reliable data and use evidence to raise awareness of NCDs and strengthen political commitment for effective national actions. 6. In April 2014, African Health Ministers attended a meeting jointly convened by the African Union Commission and WHO in Luanda, Angola. The meeting adopted the Luanda commitment on NCDs in Africa: policies and strategies to address risk factors. The commitments and undertakings made by minsters are included in Annex 7. Mozambique faces a growing burden of NCDs that cause premature mortality and disability 7. Despite of the Poverty Reduction Strategies that have contributed substantially to reducing the number of poor in Mozambique, more than half (54%) of the population still lived below the poverty line in 2014. Moreover, access to basic social services keeps remaining low. During recent years, there has been progress in some of the health-related MDGs including the decrease in neonatal and under-five mortality rates, but other health outcomes are still unsatisfactory including malaria, HIV/AIDS, and tuberculosis. The high maternal and child mortality reflects the inability of women and children to access essential services due to inadequate geographic coverage of health services, inadequate financing, shortage of health professionals and essential medicines. The health consequences of NCDs, neglected tropical diseases, road traffic injuries and the hidden tragedy of domestic violence are need to be addressed better through the public health system. (WHO CCS 2014.) 8. In Mozambique NCDs are one of the leading causes of morbidity and mortality. NCDs account for about 23% of deaths in the country. The probability of dying prematurely (between ages 30 and 70 years) from the four main NCDs is 17%. In 2005 7 , cardiovascular diseases were the 4 th leading cause of death in Mozambique. The national prevalence of diabetes is 3.8%. In 2011, 120 amputations were due to diabetes complications. Many patients with complications do not have access to surgery and die as a result. In 2012, Mozambique had the highest mortality from cervical cx in Africa at 5.23% (cumulative risk), and second only to Malawi in cervical cx incidence at 6.57% 8 . Obesity in Mozambique is estimated at 4.9% (2.3% among males and 7.2% among females) 9 . Injuries account for 11% of total mortality, major part of them due to road traffic accidents. (WHO Country Cooperation Strategy: Mozambique, 2014). The biggest NCD risk factor in the country is raised blood pressure, 40.9 % of males and 35.8% of females suffering from the condition in 2008. Total alcohol per capita consumption (in 2010, in litres of pure alcohol) in males was 3.5 and in females 1.1. Information on the prevalence of tobacco smoking is not available. (WHO NDC Country Profiles: 7 STEPS Survey 2005 8 http://globocan.iarc.fr/Default.aspx 9 Non-Communicable Diseases Country Profiles 2014 8 Mozambique, 2014.) Mozambique signed the WHO Framework Convention on Tobacco Control (FCTC) in 2003, is not yet ratified by the Mozambican Government. Data from the STEPS Survey conducted at the end of 2014 is currently being analysed and will provide more up-to-date information on the NCD situation in Mozambique. 9. There is currently greater understanding of the complex relationship between HIV and NCDs. The widespread availability of anti-retroviral treatment has made HIV a chronic disease. People with HIV and AIDS now live longer though they are at higher risk of developing non-communicable diseases. In addition, a recent study 10 shows that people living with HIV are more prone to develop cancers than those who are HIV-negative. Women living with HIV are at higher risk of HPV infection and thus at higher risk of cervical cancer 11 . Addressing NCD co-morbidity in people living with HIV has become important. In recognition of this, the Global Fund Board in April 2015, decided that countries can submit proposals for financing of co-morbidities provided there is sufficient evidence of the impact of the interventions. 10. The Ministry of Health of Mozambique has an operational unit that addresses NCDs with policies to control and prevent NCDs and their risk factors, including strategies to reduce the harmful use of alcohol, physical inactivity, and unhealthy diet. Mozambique also has evidence-based national guidelines for the management of major NCDs through a primary care approach. (WHO NDC Country Profiles: Mozambique, 2014.) However, the inter-sectorial cooperation/coordination among Government sectors is weak, and there is low implementation of measures for the prevention and control of NCD risk factors, and their linkages with HIV. 11. NCDs are one of the priorities in the recently approved Health Sector Strategy (2014-2019) and the Government five year plan. NCDs are integrated into UNDAF 2012-2015 and are one of the priorities in the new UNDAF which is being developed. Following the review of the National Strategy for the Prevention and Control of Non-Communicable Disease (2008-2014), a new national multi- sectoral NCD Strategy is under development. The new strategy will be aligned to the Global NCD Action Plan 2013-2020. To coordinate implementation of the NCD strategy, the Ministry of Health has created a Commission for coordination of the actions for the prevention and control of NCDs within the health sector. 10 http://annals.org/article.aspx?articleid=2450214 11 http://www.who.int/bulletin/volumes/91/9/12-109777.pdf, Eur J Cancer Prev. 2008 Nov;17(6):545-54. doi: 10.1097/CEJ.0b013e3282f75ea1, Lancet 2007;370:59–67. doi: http://dx.doi.org/10.1016/S0140-6736(07)61050-2 PMID:17617273, HIV Med. 2015 Aug 12. doi: 10.1111/hiv.12290. 9 Annex 2. Members of the Joint Mission (agencies and individuals in alphabetical order) UNDP Mrs Salmina Merique Health and HIV Focal Point, Mozambique UNAIDS Marta Bazima Community Mobilization and Networking Adviser, Mozambique WHO Country Office Hilde De Graeve HSS/WR a.i. WHO Mozambique Raquel Dulce Mahoque NCD/Violence Injury and Disabilities WHO Regional Office Prebo Barango Medical Officer, NCDs IST/ESA Steven Shongwe Medical Officer, NCDs, WHO Headquarters Dr Nick Banatvala Senior Adviser, Office of Assistant Director-General, NCDs & Mental Health Dr Alexey Kulikov External Relations Officer, UN Interagency Task Force on NCDs Secretariat 10 Annex 3. Joint Mission of the United Nations Interagency Task Force on the Prevention and Control of Non-communicable Diseases in the Republic of Mozambique Terms of Reference 1. Noncommunicable diseases (NCDs) are the leading causes of death globally. In 2012, 38 million deaths were caused by the four major NCDs namely cardiovascular diseases, cancer, chronic respiratory diseases and diabetes. The majority (85%) of deaths were from low and middle income countries and were largely preventable. 48% of NCD deaths in low and middle income countries occurred in people below the age of 70 years. The four main NCDs are linked to the four risk factors- tobacco use, harmful use of alcohol, unhealthy diets and lack of physical activity. 2. NCDs have adverse human, social and economic consequences in all countries particularly in low and middle income countries. NCDs act as a barrier to poverty alleviation and sustainable development. Goal 3 of the Sustainable Development Goals (SDGs) is Good health and well-being. Targets for Goal 3 include: (i) by 2030, reduce by one third premature mortality from NCDs through prevention and treatment and promote mental health and well-being; and (ii) strengthen the implementation of the WHO Framework Convention on Tobacco Control in all countries, as appropriate. There are other targets in Goal 3 and the other SDGs that if met will have a major impact on reducing premature mortality from NCDs. 3. The United Nations Political Declaration on NCDs which was endorsed by Heads of State and Government in September 2011 recognised that NCDs constitute one of the developmental challenges of the 21 st century and called for a “whole of government and a whole of society effort”. The WHO Global Action plan for the Prevention and Control of Noncommunicable Diseases 2013- 2020 which was endorsed by the 66 th World Health Assembly in May 2013 sets out a road map and policy options for member states and development partners which when implemented collectively between 2013 and 2020 will contribute towards a 25% reduction of premature mortality by 2025. 4. In July 2014 the United Nations General Assembly High Level meeting on NCDs conducted a comprehensive review and assessment of the progress made on NCDs since the Political Declaration of 2011. The High Level meeting noted that progress in developing countries had been slow and uneven. The major challenge was lack of capacity to address NCDs. At the High Level meeting, member states agreed to: (i) set national targets for 2025; (ii) develop multi-sectoral NCD policies and plans to achieve the targets and integrate NCDs into health planning and national development plans; (iii) implement the “best buys” to reduce exposure to the risk factors for NCDs; and (iv) strengthen health systems to respond. 5. A third UN High-level Meeting on NCDs will be held in 2018. The WHO Director-General will submit, by the end of 2017, a report on the progress achieved in the implementation of these commitments to the UN General Assembly, in preparation for a comprehensive review of the General Assembly in 2018. To promote accountability, WHO has defined 10 indicators which the WHO Director-General will use to report to the UN General Assembly towards the end of 2017 on the progress made by countries in implementing their 2011 and 2014 commitments to develop ambitious national NCD responses. The status of each of the 10 indicators was published in 2015 for each country, including Mozambique and provides a snap shot of achievements and challenges. 12 12 http://apps.who.int/iris/bitstream/10665/184688/1/9789241509459_eng.pdf 11 6. The United Nations Interagency Task Force on the Prevention and Control of NCDs was established by the United Nations Economic and Social Council (ECOSOC) in 2013 to coordinate the contribution of UN Agencies to the prevention and control of NCDs. Terms of reference were agreed in 2014. 13 Within the context of the Task Force’s 2014-2015 work plan 14 a series of joint programming missions have been held. To-date, the Task Force has conducted missions to Barbados, Belarus, the Democratic Republic of the Congo, India, Kenya, Tonga, and Sri Lanka. 7. In Mozambique NCDs are one of the leading causes of morbidity and mortality. In 2005 15 , cardiovascular diseases were the 4 th leading cause of death in Mozambique. The national prevalence of diabetes is 3.8%. In 2011, 120 amputations were due to diabetes complications. Many patients with complications do not have access to surgery and die as a result. In 2012, Mozambique had the highest mortality from cervical cx in Africa at 5.23% (cumulative risk), and second only to Malawi in cervical cx incidence at 6.57% 16 . Obesity in Mozambique is estimated at 4.9% (2.3% among males and 7.2% among females) 17 . Data from the STEPS Survey conducted at the end of 2014 is currently being analysed and will provide more up-to-date information on the NCD situation in Mozambique. 8. There is now greater understanding of the complex relationship between HIV and NCDs. The widespread availability of anti-retroviral treatment has made HIV a chronic disease. People with HIV and AIDS now live longer though they are at higher risk of developing non-communicable diseases. In addition, a recent study 18 shows that people living with HIV are more prone to develop cancers than those who are HIV-negative. Women living with HIV are at higher risk of HPV infection and thus at higher risk of cervical cancer 19 . Addressing NCD co-morbidity in people living with HIV has become important. In recognition of this, the Global Fund Board in April 2015, decided that countries can submit proposals for financing of co-morbidities provided there is sufficient evidence of the impact of the interventions. 9. NCDs are one of the priorities in the recently approved Health Sector Strategy (2014-2019) and the Government five year plan. NCDs are integrated into UNDAF 2012-2015 and are one of the priorities in the new UNDAF which is being developed. 10. Following the review of the National Strategy for the Prevention and Control of Non- Communicable Disease (2008-2014), a new national multi-sectoral NCD Strategy is under development. The new strategy will be aligned to the Global NCD Action Plan 2013-2020. To coordinate implementation of the NCD strategy, the Ministry of Health has created a Commission for coordination of the actions for the prevention and control of NCDs within the health sector. 11. Despite the progress made, challenges remain. The inter-sectorial cooperation/coordination among Government sectors is still weak associated. There is low implementation of measures for the prevention and control of NCD risk factors. The WHO Framework Convention on Tobacco Control is not yet ratified by the Mozambican Government. 12. The joint UNIATF mission to Mozambique will support the UN Country Team in their work with government to scale up national efforts to address the prevention and control of NCDs. A key 13 http://www.who.int/nmh/ncd-task-force/un-tf.PDF?ua=1 14 http://www.who.int/nmh/uniatf-workplan-2014-2015-20141023.pdf?ua=1 15 STEPS Survey 2005 16 http://globocan.iarc.fr/Default.aspx 17 Non-Communicable Diseases Country Profiles 2014 18 http://annals.org/article.aspx?articleid=2450214 19 http://www.who.int/bulletin/volumes/91/9/12-109777.pdf, Eur J Cancer Prev. 2008 Nov;17(6):545-54. doi: 10.1097/CEJ.0b013e3282f75ea1, Lancet 2007;370:59–67. doi: http://dx.doi.org/10.1016/S0140-6736(07)61050-2 PMID:17617273, HIV Med. 2015 Aug 12. doi: 10.1111/hiv.12290. 12 output of the mission will be the review and updating of the national multi-sectoral NCD Action Plan on NCDs, setting national targets and working with government to identify support for scaling up a set of prioritised interventions between 2015 and 2025 to contribute to a reduction of premature mortality from NCDs by 2025. By hosting a Task Force Mission, the UNCT in Mozambique agrees to follow up action on NCDs by putting in place a thematic group on NCDs or an equivalent mechanism to ensure that coordination action on NCDs is able to be taken forward by the UNCT. The agencies that will be invited to participate in the Joint Mission to Mozambique include the African Development Bank, FAO, UNAIDS, UNDP, UNFPA, UNICEF, UNODC, World Bank and WHO. Overall approach 13. The mission is intended to support the UN Country Team and the Government scale up the national multi-sectoral response to NCDs in line with the WHO Global NCD Action Plan 2013-2020 and relevant regional WHO action plans. This will enhance NCD prevention and control including tobacco use and harmful consumption of alcohol. The mission will advocate for the Ratification of the WHO Framework Convention on Tobacco Control and enforcement of measures for alcohol consumption control. 14. The mission will be carried out in line with the terms of reference of the UN Interagency Task Force. A key element of the mission will be to assess the current national response and support from the UN Country Team to the Government of Mozambique in the prevention and control of NCDs, including reviewing and assessing existing structures for coordinating the NCD response, the prevention and control of tobacco, alcohol and other risk factors, as well as the linkages between HIV and NCDs. The mission will also advocate for multi-sectoral coordination of interventions for prevention and control of NCDs. Purpose and objectives of the UNTIAF mission to Mozambique 15. The purpose of the Joint UNIATF mission to Mozambique is to support the UN Country Team:
Understand the relevance of NCDs to their individual human development efforts in Mozambique and how they can support NCD prevention and control;
Assess how NCDs and their determinants have been integrated into the Government of Mozambique development policies and plans and donor assistance; and review progress in the implementation of these policies and plans;
Ensure the United Nations Country Team has in place an effective mechanism for the coordination of technical assistance in the areas of NCD to the Government of Mozambique;
Assess progress made to-date in the national multisectoral response to NCDs;
Assess linkages between HIV and NCDs including financing of co-morbidities and;
Provide time bound recommendations for each of the above areas 16. The specific objectives of the joint mission are to: i. Map on-going government and development partner action to support the prevention and control of NCDs in Mozambique; ii. Organize meetings with key stakeholders including the Government, UN Agencies, NGOs, civil society, academia and research institutions to agree on the key elements of a national multi-sectoral NCD Action plan for Mozambique including national targets which are aligned with the Global NCD Action Plan 2013-2020; 13 iii. Work with the UNCT to review and update the national Multi-sectoral NCD Action plan for the Mozambique assist in setting national targets and objectives and selecting policy options for the prevention of and control of NCDs between 2015; iv. Make recommendations on the most effective governance mechanisms for coordinating the national response to NCDs in Mozambique; v. Advocate for effective multi-sectoral responses and increased multi-sectoral investment for NCDs in Mozambique; vi. Establish a roadmap over the next 12 months which will enable significant progress in the national multi-sectoral response to NCDs vii. Provide input into the UNDAF which is currently under development Proposed dates 17. The mission will be divided in two steps, in which the first step the Scope mission will take place in November from 02-05 November 2015 aiming to (1) Clearly define the role of each UN agency and partner on relevance of NCDs prevention and control to their individual human development efforts and (2) Draft the program for the Second phase of the mission expected to take place in early 2016. 14 Annex 4. Joint Mission Programme Day 1 08:30-10:00 Reunião técnica com a Equipe Nacional de ONU e MISAU (Technical meeting with National Team of UN and the MOH 10:30-11:30 Reunião com a Representante da OMS (Briefing meeting with WHO Representative) 13:30-14:30 Reunião com Director de Saúde Pública MISAU e equipe DNT (Meeting with Public Health directorate MOH and NCD team) 15:00-16:00 Reunião de cortesia com o Coordenador Residente da ONU (Courtesy Meeting with UN Resident Coordinator) 15:30-16:30 Reunião técnica interna (Internal technical meeting) Day 2 09:00-10:00 Reunião com Chefes das Agências da Nações Unidas (Meeting with UNCT members -Heads of Agencies) 10:30-16:30 Reuniões individuais com Agencias das Nações Unidas (UNFPA, UNICEF, FAO, UNAIDS, UNDP e WHO, Banco Mundial e Banco Africano de Desenvolvimento) (Individual meetings with UN agencies 16:30-17:00 Reunião técnica interna (Internal technical meeting) Day 3 09:00-11:30 Reunião de Revisão do Plano NCD (Multissectorial plan discussion with technical NCDs 12:00-13:30 Reflexão sobre DNTs no grupo técnico do UN (NCD Reflection during the UN brown bag lunch) 13:30-14:15 Reunião com a Ministra da Saúde (Meeting with Minister of Health) 14:30-15:30 Reunião com Parlamento (CASGTCS, direcção Deputada Conceita Sortane) (Meeting with Representatives of the Parliamentary Commission on Social, Health, Gender and Technology Issues) 16:30-17:00 Reunião técnica interna (Internal technical meeting) Day 4 08:00-09:00 Reunião com o CDC Director (Meeting with CDC/ US Government) 09:30-10:30 Reunião com o UNICEF (Meeting with CDC/ US Government) 11:00-12:30 Encontro com Organizações da Sociedade Civil ALCC, AMOCOR, AMODIA, Mchip, ICAP, FGH, CCS, CDC,MSF, e Comissão interna das NCD no MISAU (CSO’s stakeholders dialogue (ALCC, AMOCOR, AMODIA, Mchip, ICAP, FGH, CCS, CDC,MSF and internal commission of NCDs) 13:30-14:30 Reunião de Revisão do Plano NCD e Balanço com Ministério da Saúde (Multissectorial pan discussion and Debriefing with MOH) 15:00-16:30 Reunião com os doadores e Parceiros da Saúde (HPG, DFID, Irish Aid, USG…) (Meeting with Donors through Health partners Group (DFID, Irish Aid, USG) 16:30-17:30 Reuniao de balanco interna (Internal meeting to discuss preliminary outcomes and next steps) Annex 5. 15 Evidence-based cost-effective interventions for the prevention and control of NCDs 20 Tobacco use 21 • Reduce affordability of tobacco products by increasing tobacco excise taxes • Create by law completely smoke-free environments in all indoor workplaces, public places and public transport • Warn people of the dangers of tobacco and tobacco smoke through effective health warnings and mass media campaigns • Ban all forms of tobacco advertising, promotion and sponsorship Harmful use of alcohol • Regulating commercial and public availability of alcohol • Restricting or banning alcohol advertising and promotions • Using pricing policies such as excise tax increases on alcoholic beverages Unhealthy diet • Reduce salt intake (and adjust the iodine content of iodized salt, when relevant) • Replace trans fats with unsaturated fats • Implement public awareness programmes on diet and physical activity Cardiovascular disease and diabetes • 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 high risk (≥ 30%) of a fatal and nonfatal cardiovascular event in the next 10 years • Acetylsalicylic acid for acute myocardial infarction Cancer • Prevention of liver cancer through hepatitis B immunization • Prevention of cervical cancer through screening (visual inspection with acetic acid [VIA] (or Pap smear (cervical cytology), if very cost-effective), linked with timely treatment of pre- cancerous lesions 20 Taken from the WHO NCD Global Action plan 2013-2020 (http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1, pages 66 and 67).The measures listed are recognized as very cost-effective i.e. generate an extra year of healthy life for a cost that falls below the average annual income or gross domestic product per person. In addressing each risk factor, governments should not rely on one single intervention, but should have a comprehensive approach to achieve desired results. 21 These measures reflect one or more provisions of the WHO Framework Convention on Tobacco Control (WHO FCTC). The measures included are not intended to suggest a prioritization of obligations under the WHO FCTC. Rather, these measures have been proven to be feasible, affordable and cost-effective and are intended to fulfil the criteria for assisting countries to meet the agreed targets as quickly as possible. The WHO FCTC includes a number of other important provisions, including supply-reduction measures and those to support multisectoral actions, which are part of any comprehensive tobacco control programme. 16 Annex 6. National commitments as set out in the Outcome Document of the High-Level Meeting of the General Assembly on the Review of the Progress Achieved in the Prevention and Control of NCDs (a) Enhance governance: (i) By 2015, consider setting national targets for 2025 and process indicators based on national situations, taking into account the nine voluntary global targets for non- communicable diseases, building on guidance provided by the World Health Organization, to focus on efforts to address the impacts of non-communicable diseases and to assess the progress made in the prevention and control of non-communicable diseases and their risk factors and determinants; (ii) By 2015, consider developing or strengthening national multisectoral policies and plans to achieve these national targets by 2025, taking into account the WHO Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013-2020; (iii) Continue to develop, strengthen and implement, as appropriate, multisectoral public policies and action plans to promote health education and health literacy, with a particular focus on populations with low health awareness and/or literacy; (iv) Raise awareness about the national public health burden caused by non-communicable diseases and the relationship between non-communicable diseases, poverty, and social and economic development; (v) Integrate non-communicable diseases into health planning and national development plans and policies, including the United Nations Development Assistance Framework design processes and implementation; (vi) Consider establishing, as appropriate to the respective national context, a national multisectoral mechanism, such as a high-level commission, agency or task force for engagement, policy coherence and mutual accountability of different spheres of policy making that have a bearing on non-communicable diseases, in order to implement health-in- all-policies and whole-of-government and whole-of-society approaches, and to monitor and act on the determinants of non-communicable diseases, including social and environmental determinants; (vii) Enhance the capacity, mechanisms and mandates, as appropriate, of relevant authorities in facilitating and ensuring action across government sectors; (viii) Strengthen the capacity of Ministries of Health to exercise a strategic leadership and coordination role in policy development that engages all stakeholders across government, non-governmental organizations, civil society and the private sector, ensuring that non- communicable disease issues receive an appropriate, coordinated, comprehensive and integrated response; (ix) Align international cooperation on non-communicable diseases with national non- communicable diseases plans, in order to strengthen aid effectiveness and the development impact of external resources in support of non-communicable diseases; 17 (x) Develop and implement national policies and plans, as relevant, with financial and human resources allocated particularly to addressing non-communicable diseases, in which social determinants are included. (b) By 2016, as appropriate, reduce risk factors for non-communicable diseases and underlying social determinants through implementation of interventions and policy options to create health- promoting environments, building on guidance provided by Appendix 3 of the WHO Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013-2020. (c) By 2016, as appropriate, strengthen and orient health systems to address the prevention and control of non-communicable diseases and the underlying social determinants through people- centered primary health care and universal health coverage throughout the lifecycle, building on guidance provided by Appendix 3 of the WHO Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013-2020. (d) Consider the possible linkages between non-communicable diseases and some communicable diseases, such as HIV/AIDS, call for the integration, as appropriate, of responses to HIV/AIDS and non-communicable diseases, and in this regard call for attention to be given to people living with HIV/AIDS, especially in countries with a high prevalence of HIV/AIDS, in accordance with national priorities. (e) Continue to promote the inclusion of non-communicable disease prevention and control within programs for sexual and reproductive health and maternal and child health, especially at the primary health-care level, as well as communicable disease programs, such as TB, as appropriate. (f) Consider the synergies between major non-communicable diseases and other conditions as described in Appendix 1 of the WHO Global Action Plan for the Prevention and Control of Non- Communicable Diseases 2013-2020 in order to develop a comprehensive response for the prevention and control of non-communicable diseases that also recognizes the conditions in which people live and work. (g) Monitor the trends and determinants of non-communicable diseases and evaluate progress in their prevention and control: (i) Assess progress towards attaining the voluntary global targets and report on the results using the established indicators in the Global Monitoring Framework, according to the agreed timelines, and use results from surveillance of the twenty five indicators and nine voluntary targets and other data sources to inform and guide policy and programming, aiming to maximize the impact of interventions and investments on non-communicable disease outcomes; (ii) Contribute information on trends in non-communicable diseases to the World Health Organization, according to the agreed timelines on progress made in the implementation of national action plans and on the effectiveness of national policies and strategies, coordinating country reporting with global analyses; (iii) Develop or strengthen, as appropriate, surveillance systems to track social disparities in non-communicable diseases and their risk factors as a first step to addressing inequalities, and pursue and promote gender-based approaches for the prevention and control of non- communicable diseases founded on data disaggregated by sex and age and disabilities, in an effort to address the critical differences in the risks of morbidity and mortality from non- communicable diseases for women and men. 18 (h) Continue to strengthen international cooperation in support of national, regional and global plans for the prevention and control of non-communicable diseases, inter alia, through the exchange of best practices in the areas of health promotion, legislation, regulation and health systems strengthening, training of health personnel, development of appropriate health-care infrastructure and diagnostics, and by promoting the development and dissemination of appropriate, affordable and sustainable transfer of technology on mutually agreed terms for the production of affordable, safe, effective and quality medicines and vaccines, while recognizing the leading role of the World Health Organization as the primary specialized agency for health in that regard. 31. Continue to strengthen international cooperation through North-South, South-South and triangular cooperation, in the prevention and control of non-communicable diseases to promote at the national, regional and international levels an enabling environment to facilitate healthy lifestyles and choices, bearing in mind that South-South cooperation is not a substitute for, but rather a complement to, North-South cooperation. 32. Continue to explore the provision of adequate, predictable and sustained resources, through domestic, bilateral, regional and multilateral channels, including traditional and voluntary innovative financing mechanisms. 19 Annex 7. Commitment on Noncommunicable Diseases in Africa: Policies and Strategies to Address Risk Factors (AUC/WHO/2014/DOC.3, 17 April 2014) We, the African Ministers of Health attending the first meeting jointly convened by the African Union Commission and World Health Organization in Luanda, Angola; 1. Deeply concerned that Africa has been experiencing growing adverse health and social economic consequences due to the double burden of communicable and noncommunicable diseases; 2. Recalling the declaration on the outcome of the Sixth Session of the AU Conference of African Ministers of Health held under the theme “The Impact of Noncommunicable Diseases (NCDs) and Neglected Tropical Diseases (NTD) on Development in Africa;” which recognizes the alarming burden of both death and disability from NCDs in Africa; 3. Noting the Political Declaration of the High-level Meeting of the United Nations General Assembly on Prevention and Control of NCDs (resolution 66/2), and the WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020 (Document WHA 66/9); 4. Recognizing that inadequate numbers of health workers are an impediment to the full implementation of resolutions and declarations related to NCDs and their risk factors; Hereby collectively and individually: I. COMMIT to ensuring that prevention and control of NCDs and their risk factors are given the prominence they deserve and that the WHO global action plan for the prevention and control of NCDs 2013-2020 is fully implemented through the National NCD multisectoral plans, and mobilizing resources, both domestic and external, including the use of innovative financing; II. FURTHER COMMIT to protecting public health policies from interference by vested interests of the alcohol, tobacco and food industries through comprehensive legislation and enforcement of national laws and policies; III. UNDERTAKE to advocate to our governments for ministerial level representation at the 2014 United Nations General Assembly Comprehensive Review and Assessment of the progress achieved in the prevention and control of NCDs and to call for further action through a concise action-oriented outcome document; IV. REQUEST the AUC and WHO and relevant stakeholders to support resource mobilization efforts and strengthening of countries’ capacity for prevention and control of NCDs and their risk factors, as well as human resource development.