Non-communicable diseases and mental health: case studies from across the United Nations system

CASE STUDIES FROM ACROSS THE UNITED NATIONS SYSTEM NON-COMMUNICABLE DISEASES AND MENTAL HEALTH WHO/UHC/CD-NCD/19.88 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-Non Commercial- 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). 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CASE STUDIES FROM ACROSS THE UNITED NATIONS SYSTEM NON-COMMUNICABLE DISEASES AND MENTAL HEALTH 1CASE STUDIES 2 3 4 Safeguarding the quality of cancer care in low- and middle-income countries Promoting healthy diets and physical activity Improving the health and well-being of workers Unleashing the power of digital technology to combat NCDs Strengthening NCD care in humanitarian settings Sugar tax in Malaysia Trade and public health: the importance of policy coherence for NCDs Tobacco control Opioid overdose: community-based management National investment cases for stronger NCD action Cervical cancer training in Eastern Europe and Central Asia Integrating mental health and psychosocial support into primary care Integration of HIV services and cervical cancer screening in Zambia 5 6 7 8 9 10 11 12 13 1 Under a “business as usual” scenario where intervention efforts remain static and rates of NCDs continue to increase as populations grow and age, cumulative economic losses in low- and middle-income countries (LMICs) from the four diseases (cardiovascular diseases, cancers, chronic respiratory diseases and diabetes) are estimated to surpass US$ 7 trillion over the period 2011–2025 (an average of nearly US$ 500 billion per year).1 Countries look to the United Nations (UN) system and other multilateral agencies for support. The World Health Organization acts as the lead UN agency in supporting national responses to the NCDs epidemic. However, the work of other UN and multilateral agencies is critical. The case studies in this brochure provide examples on how UN and multilateral agencies beyond WHO are stepping up their action to support countries in their efforts to meet the NCD-related Sustainable Development Goal targets. 1 WHO/WEF (2011). From Burden to “Best Buys”: Reducing the Economic Impact of NCDs in Low- and Middle-Income Countries https://www.who.int/nmh/publications/best_buys_summary.pdf The impact of non-communicable diseases (NCDs) and mental health conditions on the social and economic development of countries is enormous and growing rapidly. NCDs currently kill nearly 41 million people each year, and many of these people die prematurely (under the age of 70 years). 32 Integrating cervical cancer screening into HIV services in Zambia In 2016, the Global Fund began supporting Zambia’s efforts to integrate national HIV services and cervical cancer prevention. With this support, Zambia has been able to screen more than 100,000 women for cervical cancer over the last 5 years by integrating screening into the existing HIV programmes. In conjunction with HIV and TB programmes in the country as well as bilateral partners, the Zambian government has opened 58 cervical cancer screening clinics in 41 districts, targeting women living with HIV. These cervical cancer screening clinics employ a “See and Treat” approach, treating women who screen positive in the same visit, if eligible. Women with complex cervical lesions are referred to one of the 25 cervical cancer referral clinics in the country. Lessons learnt from the integration of HIV care and cervical cancer prevention show that linking these services is a cost-effective way of improving health outcomes of women living with HIV. The programme has shown to reduce loss to follow-up in women needing treatment for pre-cancerous lesions and to reduce time between screening and treatment. This adaptive approach has leveraged resources from multiple partners while enhancing coordination of the HIV and cervical cancer care. Most notably, the programme is estimated to reduce the incidence and mortality from cervical cancer in Zambia by 25% by 2025, particularly among women living with HIV. 1 54 For more information, please see: https://www.iaea.org/services/laboratory-services/dosimetry-auditing http://www-naweb.iaea.org/nahu/portfolio/dmrp-getting-the-dose-right.html http://www-naweb.iaea.org/nahu/DMRP/tld.html Safeguarding the quality of cancer care in low- and middle-income countries Radiation beams generated by the radiotherapy machines used in cancer clinics need to be periodically calibrated using precise dose measurements (the process is known as dosimetry). Incorrect radiotherapy beam calibrations can result in inadequate radiation doses being administered to patients. This can potentially lead to ineffective treatments, radiation injuries, and can have fatal consequences. To verify the accuracy of radiation beam calibration, cancer clinics in LMICs are being offered a dosimetry audit service by IAEA/WHO which supports radiation oncologists to protect patients from the unintended consequences of a dosage discrepancy. Since its beginnings in 1969, over 2,300 clinics in 134 countries have used the IAEA/ WHO dosimetry audit service. Over the years, the participating clinics have reported a systematic increase in accurate beam calibrations reaching over 95% acceptable results in 2018. 2 76 For more information, please see: https://www.idlo.int/what-we-do/initiatives/global-recap-capacity-building-prevent-ncds The Global Regulatory and Fiscal Capacity Building Programme (RECAP) is implemented jointly by WHO and the International Development Law Organization (IDLO), in collaboration with Canada’s International Development Research Centre (IDRC). RECAP aims to strengthen national regulatory and fiscal environments to promote healthy diets and physical activity. RECAP builds human and institutional capacity to promote healthier diets and active living through evidence-informed, cost-effective, coherent, and equitable public policies and government interventions. Five East African and South Asian countries (Bangladesh, Kenya, Sri Lanka, Tanzania, Uganda and the United Republic of Tanzania) have agreed to participate in the first phase of the programme. Key interventions include: restrictions on the marketing of foods and non-alcoholic beverages to children; fiscal policies on diets, including taxation of sugar-sweetened beverages; nutrition labelling, including front-of-pack labelling; reformulation of products to contain less salt, sugar and fats; and promotion of physical activity. Promoting healthy diets and physical activity 3 98 For more information, please see: http://www.ilo.org/safework/info/instr/WCMS_178438/lang--en/index.htm ILO’s SOLVE training package focuses on the prevention of psychosocial risks and the promotion of health and well-being at work through policy design and action. The package is delivered through a training of trainers methodology, and covers areas such as nutrition, stress, substance abuse, sleep, physical activity, and violence in the world of work. The training package is intended to be used by HR managers, trade unions, employers’ associations, occupational safety and health (OSH) professionals, and national institutions responsible for the health and well-being of workers. A network of 300 trainers are now delivering the SOLVE package in over 80 countries. The experience of ILO Member States and social partners shows that workplace health promotion programmes can improve the quality of working life if they are integrated into OSH policies and systematically implemented. These policies have been shown to: benefit both workers and employers by improving the long-term mental health and well-being of workers and their families; increase productivity and performance; and reduce pressure on health, welfare and social security systems. Furthermore, integrating health promotion measures into workplace OSH management systems enhances occupational health practices, and contributes to promoting a global preventive safety and health culture. Improving the health and well-being of workers4 1110 For more information, please see: https://www.itu.int/en/ITU-D/ICT-Applications/Pages/mhealth-for-ncd-behealthy-bemobile.aspx Be He@lthy, Be Mobile is a joint International Telecommunication Union/WHO initiative which provides evidence-based content and technical support to Member States wishing to implement national mHealth programmes on NCDs. Since its launch in 2013, the initiative has provided support to 15 programmes in 11 countries and improved the capacity of Member States to implement sustainable mHealth programmes at scale. Toolkits on various NCDs and related risk factors provide guidance and best practices, and build on existing technical assistance offered to countries for the planning, implementation and evaluation of each national mHealth programme. Results from independent evaluations of the Be He@lthy, Be Mobile programmes show a 19% quit rate among a sample of mTobaccoCessation participants, improved glycemic control among mDiabetes users, and an increase in cervical cancer screenings among mCervicalCancer users. To date, over 800,000 users from five countries (India, Egypt, Tunisia, Senegal and Sudan) have followed the mDiabetes programme, and 2.1 million users for the mTobaccoCessation programme. Moving forward, the Be He@lthy, Be Mobile initiative aims to contribute further to SDG 3.4 by expanding the number of national mHealth programmes it supports, and exploring new, innovative ways to deliver its health content. Unleashing the power of digital technology to combat NCDs5 1312 The UNDP/WHO Global Joint Programme (GJP) on NCD Governance supports multisectoral action by Member States to achieve the NCD-related SDG targets. In low- and middle-income countries, the GJP supports: the development of national NCD investment cases; strengthened national coordinating mechanisms and municipal actions; and the integration of NCDs into domestic SDG frameworks. This work is possible largely thanks to a contribution from the Russian Federation. As of June 2019, UNDP, WHO and partners have finalized NCD investment cases—the GJP’s foundational activity—in ten countries and initiated investment cases in nine others. The investment cases generate evidence to secure buy-in and ownership of the NCD response across government and society. The impact of GJP actions include an expanded fiscal space for universal access to treatment and care, as well as legislation, policies and targeted interventions for the prevention of NCDs. Selected examples of the impact of investment cases include: Barbados: Implemented an innovative excise tax on sugar-sweetened beverages. Belarus: Implemented smoke-free legislation. Jamaica: Reactivated its national multisectoral coordination mechanism on NCDs. Kyrgyzstan: Integrated NCDs into government and UN strategies and programmes. Mongolia: Initiated a 2-year campaign to reduce sodium in local food production. Turkey: Released a new tobacco control programme and plan of action. Over 50 countries have requested an NCD investment case. Many Member States have requested the development and application of new methodologies on air pollution and mental health in line with high disease burdens and associated costs. Investment cases completed: Armenia, Barbados, Belarus, Fiji, Jamaica, Kyrgyzstan, Mongolia, Saudi Arabia, Turkey and Uzbekistan. Investment cases initiated: Cambodia, Ethiopia, Iran, Kazakhstan, Peru, Philippines, Russia, Viet Nam and Zambia. National investment cases for stronger NCD action6 For more information, please see: https://www.who.int/ncds/un-task-force/flyer-ncds2030.pdf?ua=1 https://www.youtube.com/watch?v=u_LtBeyOA_E 1514 Cervical cancer training in Eastern Europe and Central Asia 7 United Nations Population Fund is supporting a growing number of countries to tackle cervical cancer and reduce this preventable cause of mortality in women in Eastern European and Central Asian countries. These countries have experienced a limited success in implementing cervical cancer prevention programmes due to unresolved capacity gaps. To bridge these gaps, UNFPA, in partnership with the International Federation of Cervical Pathology and Colposcopy (IFCPC) and the International Agency for Research on Cancer (IARC), has created a certified online training course for service providers in colposcopy and cervical cancer prevention. The 12‐month programme, available in English and Russian, incorporates an online course and a clinical component supervised by accredited colposcopy master trainers. At the end of the programme, students complete a clinical examination, and successful trainees receive a certificate from IFCPC‐IARC. In January 2017, 150 participants from 17 Eastern Europe and Central Asian countries attended the first training programme. Twenty‐two trainees successfully completed the theoretical and clinical components of the course following an objective structured clinical examination in colposcopy and case management of cervical cancer. In addition, 20 master/clinical trainers from 13 countries attended two trainings of trainers, and are now qualified to support and coordinate national capacity‐building efforts, incorporating the regional cervical cancer training within national action plans on sexual and reproductive health. Among the new initiatives that have been launched are: the development of the National Cervical Screening Registry in Georgia; clinical guidelines for cervical cancer prevention in the Republic of North Macedonia; and the procurement of colposcopy equipment by the Government of Uzbekistan to increase access to cervical cancer screening in primary health facilities. For more information, please see: https://eeca.unfpa.org/en/publications/certified-colposcopy-and-cervical-cancer-prevention-course https://eeca.unfpa.org/en/news/helping-medical-professionals-step-challenge-preventing-cervical- cancer 1716 The conventional approach to providing health services to conflict-affected populations during humanitarian emergencies has been to focus on saving lives and treating acute communicable diseases, such as measles, malaria, diarrhea and respiratory infections. In such cases, patients presenting with NCDs and requiring specialist medical care are referred to secondary or tertiary care facilities or specialists. This has cost implications for the humanitarian partners providing quality primary health care in refugee camps. UNHCR decided to address this problem through targeted clinical training to address the most commonly found NCDs within PHC settings in refugee camps. This entailed: the roll-out of simplified clinical protocols; the inclusion of all basic essential medicines found in the WHO Model List of Essential Medicines; and targeted capacity building for clinicians, nurses and community health workers, as task shifting required everyone to play a key role in the management and follow- up care of NCD patients. UNHCR leads the informal working group on NCDs in humanitarian settings, and is currently developing operational guidance, indicators for improved monitoring of NCDs, and improved clinical management through targeted capacity building interventions. The group brings together the technical and operational expertise of many partners, including CDC, HelpAge, ICRC, IFRC, IMC, IOM, IRC, MSF, Save the Children and WHO, as well as subject-matter expertise from academia and research institutes. Strengthening NCD care in humanitarian settings8 1918 Sugar tax in Malaysia 9 Malaysia has one of the highest burdens of obesity in Asia and, according to the Economist Intelligence Unit, obesity accounts for 10–19% of Malaysia’s total healthcare expenditure. Nearly half of adults are overweight or obese, and children are increasingly affected. In 2006, 7.7% of children and adolescents aged 5–19 were obese; a decade later, obesity had risen to an alarming 26.5% among this age group. In November 2018, the Minister of Finance of Malaysia announced that the government would impose a sugar tax of 40 cents per litre on beverages starting in mid-2019, including drinks containing more than 5 grams per 100 ml of added sugar/sweeteners, and fruit and vegetable juice drinks that contain more than 12 grams of sugar per 100 ml. Malaysia is now, along with Brunei, the Philippines and Thailand, one of four countries in South-East Asia to impose a sugar tax. UNICEF Malaysia, with support from UNICEF’s East Asia and the Pacific Regional Office played a significant role in advocating and lobbying for this important measure. To promote the imposition of the new tax, UNICEF conducted joint advocacy with WHO and supported the MoH in Malaysia to host an ASEAN meeting to develop a regional framework on fiscal measures (“sugar taxes”) for sugar sweetened beverages. The results of a UNICEF-MoH landscape analysis on child nutrition also contributed to generating momentum and shining a spotlight on the double burden of malnutrition in Malaysia, revealing burgeoning obesity levels and persisting significant rates of stunting and wasting. 2120 For more information, please see: https://www.unodc.org/unodc/en/drug-prevention-and-treatment/index.html. In industrialized and developing countries alike, drug use and drug use disorders are a public health and developmental issue, associated with poverty, violence, criminal behaviour and social exclusion. UNODC estimates the number of opioid users at 53 million (in 2019) and opioids were responsible for two thirds of the 585,000 drug use-related deaths in 2017. Prevention and treatment of drug use disorders is an essential strategy in addressing the burden of NCDs. The UNODC/WHO S-O-S initiative to stop overdose safely mobilizes and supports people likely to witness an overdose in the community, including people who use drugs, peers and family members. The initiative, which forms part of the UNODC-WHO Programme on Drug Dependence Treatment and Care, aims to reduce deaths from preventable opioid overdoses through effective emergency management of opioid overdose, including the use of naloxone. Naloxone has been used in opioid overdose management for over 40 years, with minimal adverse effects. If provided rapidly, Naloxone displaces opioids from opioid receptors and thus can revert an overdose. Different formulations exist and especially the intramuscular and intranasal formulations have been used for community management of opioid overdoses. Naloxone is on the WHO Model List of Essential Medicines but is often not registered at country level or not available on site when most needed. Opioid overdose: community-based management 10 2322 UNRWA’s MHPSS programme seeks to protect and promote the right of Palestine refugees to enjoy the best possible state of mental health and psychosocial well-being. The MHPSS programme was launched to serve a population experiencing psychological distress and living in a context where there are a limited number of mental health professionals available. MHPSS interventions aim to enhance the psychological and social well-being of individuals and their communities by empowering community and individual resilience. These interventions are not limited to emergency situations or other problems, but rather aim to support psychosocial well-being and empowerment processes. These processes are beneficial to both Palestine refugees and the health professionals supporting them. The integration of mental health and psychosocial support into UNRWA’s Family Health Team model was initiated in July 2017 in all areas of operations. The process is part of a three-year integration plan supported by the Government of Japan. The integration plan is being implemented in 88 of 143 (61.5%) of UNRWA’s health centres by 1,825 staff members that have received comprehensive training on psychosocial support and WHO’s Mental Health Gap Action Programme (mhGAP) by certified WHO trainers. Integrating mental health and psychosocial support into primary care 11 2524 For more information, please see: Policy Brief, July 2018, published by the United Nations University-International Institute for Global Health (UNU-IIGH): https://i.unu.edu/media/iigh.unu.edu/publication/6533/Policy-Coherence-for- NCDs-July-2018.pdf Trade and health objectives need not be mutually exclusive. However, the challenge lies in developing strategies to ensure that trade and health mutually reinforce one another through coherent policy actions, and to achieve agreed objectives across government departments and agencies. One of the adverse outcomes of trade liberalization through the WTO’s rules-based international trading system has been the globalization of unhealthy lifestyles and marketing of tobacco, alcohol, and unsafe food—all risk factors for NCDs. In many cases, international trade and investment agreements trump national health policies by restricting the regulatory space for countries to implement policies for the prevention and control of NCDs. A policy brief developed by the United Nations University (UNU) addresses the policy pathways that countries can use to pursue international trade objectives without undermining national policies on the prevention and control of NCDs. The health ministers and officials from Cambodia, Myanmar, and Laos, the less developed countries in Southeast Asia, requested capacity building and training to address the incoherence of trade and health policies in their countries. UNU-IIGH is working with relevant stakeholders, based on its current strategic plan, to convene policy dialogues bringing together experts from the academia, civil society, and policy makers to generate policy recommendations that would build coherence between trade and health Trade and public health: the importance of policy coherence for NCDs 12 2726 For more information and global, regional and country reports, please visit: https://www.worldbank.org/en/topic/tobacco The World Bank Group’s (WBG) Global Tobacco Control Programme assists countries in designing tobacco tax policy reforms and increasing tobacco tax rates as a policy measure to: achieve public health goals by hiking prices, reducing smoking, and preventing initiation among youth; raise domestic resources for investments that benefit the entire population; and enhance equity by reducing health risks associated with tobacco-attributable diseases, and the risk impoverishment due to out-of-pocket medical care expenditures among the lowest income population quintiles, who tend to be more responsive in reducing consumption when facing higher tobacco prices. In addition, the programme supports countries in addressing illicit tobacco trade by strengthening Customs’ systems. WBG experts in fields as diverse as health, governance, macro-economic and financial management, poverty and equity, agriculture, and trade are engaged in this multisectoral programme. Notable achievements include providing support for the enactment of tobacco tax policy reforms in more than 30 countries across the world, as well as through the launch of WBG global reports on “Tobacco Tax Reform: At the Crossroads of Health and Development” at the WBG-IMF Annual Meetings in October 2017; the report on “Confronting Illicit Tobacco Trade: A Global Review of Country Experiences” at the 2019 PMAC in Bangkok; and the report “Is Tobacco Taxation Regressive? Evidence on Public Health, Domestic Resource Mobilization, and Equity Improvements” released at the WBG-IMF Spring Meetings in April 2019. In addition, global knowledge exchange events have been organized to disseminate accumulated evidence. 13 Tobacco Control 28 Established in 2013 by the UN Secretary-General, the United Nations Interagency Task Force on the Prevention and Control of Non communicable Diseases supports governments in tackling NCDs and mental health conditions. The Task Force provides a platform for cooperation across the United Nations, governments and non-state actors, e.g. non governmental organizations, private sector entities, academia and philanthropic bodies. Over 40 UN agencies, including multilateral development banks and other intergovernmental organizations, are members of the Task Force, and collectively promote whole-of-government and whole-of society action to achieve the NCD-related Sustainable Development Goals, including Target 3.4 (by 2030 reduce by one-third premature mortality from NCDs through prevention and treatment, and promote mental health and well-being). Through its work, the Task Force seeks to bring countries a step closer towards achieving the goals of the 2030 Agenda for Sustainable Development. All images are Copyright to World Bank Photo Collection via Flickr with the exception of : Heifer Lyell via Flickr (p.2), UNDP via Flickr (p.6), David Khizanishvili/UNDP via Flickr (p.11), Eddie Welker via Flickr (p.18), Jeff Anderson via Flickr (p.20), Shareef Sarhan/UN via Flickr (p.22), Simone.Brunozzi via Flickr (p.26)