Sixty-eighth Regional Committee for Europe: Rome, 17–20 September 2018: progress report on implementation of the Action Plan for the Prevention and Control of Noncommunicable Diseases in the WHO European Region 2016–2025

W ORL D H E A LT H O RG A N I Z AT IO N R EG I ON A L O F F I C E FO R EU R O P E UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Telephone: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eugovernance@who.int Web: http://www.euro.who.int/en/who-we-are/governance Regional Committee for Europe EUR/RC68/8(D) 68th session Rome, Italy, 17–20 September 2018 6 August 2018 180460 Provisional agenda item 5(o) ORIGINAL: ENGLISH Progress report on implementation of the Action Plan for the Prevention and Control of Noncommunicable Diseases in the WHO European Region 2016–2025 This report provides an overview of implementation of the Action Plan for the Prevention and Control of Noncommunicable Diseases in the WHO European Region 2016–2025, in line with resolution EUR/RC66/R11. It is submitted to the 68th session of the WHO Regional Committee for Europe in 2018. EUR/RC68/8(D) page 2 Introduction and background 1. Resolution EUR/RC66/R11, adopted in 2016 by the WHO Regional Committee for Europe at its 66th session (RC66), urged Member States1 to continue to strengthen their efforts, as appropriate, in achieving the time-bound commitments included in the Outcome document of the high-level meeting of the General Assembly on the comprehensive review and assessment of the progress achieved in the prevention and control of non-communicable diseases,2 held in 2014. It further urged Member States to apply the priority and supporting actions presented in the Action Plan for the Prevention and Control of Noncommunicable Diseases in the WHO European Region. The same resolution requested the Regional Director for Europe to monitor the implementation of the Action Plan and report to RC68 in 2018. 2. The goal of the Action Plan is to avoid premature death and significantly reduce the disease burden from noncommunicable diseases (NCDs) by taking integrated action, improving quality of life and making healthy life expectancy more equitable within and between Member States. In general, the WHO European Region has good news to report. For practically all countries where robust mortality data are available, there has been a clear decline in premature deaths from NCDs in the past decade. This decline has been fastest in the countries with the highest mortality, and the Region is converging at a steady rate, leading to a reduction in east–west differences. The regional average rate of decline for men is 2.2% annually, compared with 2.1% for women. Almost all countries in the Region have comfortably achieved the original bold goal of a 2% annual reduction over the decade 2007–2017. The targets on relative reduction of premature mortality from four NCDs in Health 2020 (1.5% annually by 2020), the global NCD monitoring framework (25% by 2025) and the Sustainable Development Goals (SDGs) (one third by 2030) are well on their way to being achieved, and even exceeded, in the coming years. WHO’s Thirteenth General Programme of Work, 2019–2023,3 sets great store by impact measurement, and the reduction of premature mortality in Europe is a prime example of the progress that is possible in public health worldwide. 3. Furthermore, data from the WHO Global NCD Progress Monitor and the WHO NCD country capacity assessment surveys conducted in 2015 (baseline for the Action Plan) and 2017 indicate that the implementation of priority actions is improving fast, as shown by an overall increase in the achievement of the 19 progress monitoring indicators (PMIs). While 34% of Member States had fully achieved the PMIs in 2015, this share increased to 42% by 2017. Simultaneously, partial achievement increased from 69% to 76%. However, achievements and progress are uneven between different indicators and Member States. 1 And regional economic integration organizations, where applicable. 2 United Nations General Assembly resolution 68/300. 3 The Thirteenth General Programme of Work is available at: http://www.who.int/about/what-we-do/gpw- thirteen-consultation/en/. EUR/RC68/8(D) page 3 Action on NCD prevention and control in the European Region since 2016 Priority action areas 4. A key PMI on governance is whether Member States have an operational, multisectoral national strategy or action plan that integrates the major NCDs and their shared risk factors. The proportion of Member States that fully achieved this target in 2017 was 66% (up from 43% in 2015), with another 8% having partly achieved it. The development and implementation of a set of national targets and indicators is another important instrument and target for governance and accountability of NCD policies and programmes. In 2017, 30% of Member States had established a full set of targets and indicators (up from 23% in 2015), while 19% had established a partial set. The Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases4 called for governments to integrate NCDs into health planning processes and the national development agenda, and the United Nations Development Programme (UNDP) and WHO agreed to integrate NCDs into the United Nations Development Assistance Framework (UNDAF) design processes and implementation in support of that call. By November 2017, 11 WHO Member States in the European Region had UNDAFs that included NCDs. 5. During the biennium 2016–2017, the WHO Regional Office for Europe actively supported Member States in developing NCD policies and action plans. The Regional Office provided technical support for the development, implementation and evaluation of NCD plans, including convening multisectoral dialogues, in 19 countries. The European Meeting of National NCD Directors and Programme Managers held on 8–9 June 2017 in Moscow, Russian Federation, reviewed the progress made and, based on the available evidence, discussed the feasibility of European WHO Member States exceeding the global target and reducing premature mortality from NCD-related causes by 45%, rather than 30%, as provided in SDG target 3.4, by 2030. 6. Progress in surveillance, monitoring and evaluation is measured on the basis of whether Member States have a functioning system for generating reliable cause-specific mortality data on a routine basis, and whether a WHO STEPwise approach to Surveillance (STEPS) survey or a comprehensive health examination survey is conducted every five years. In general, the systems for generating cause-specific mortality data in Member States of the European Region are among the most advanced in the world, with 81% (up from 77% in 2015) of Member States achieving the target fully, and another 19% partially, in 2017. Although most Member States in the Region conduct surveys on at least one NCD, surveys integrating the main four risk factors at once are less common. In 2015, 40% of Member States reported having achieved the target fully, and 49% that they had partly achieved it. By 2017, the proportion of Member States having achieved the target partly had increased to 74%, but the proportion of those having achieved the target fully had dropped to 19%. A training course on cancer registration methods and strengthening cancer registries was held in Bishkek, Kyrgyzstan, from 28 November to 2 December 2016, which was attended by 26 participants from eight countries of the Commonwealth of Independent States (CIS). Two additional courses were held in Moscow, Russian Federation, on 20–23 September 2016 and 4 United Nations General Assembly resolution 66/2. EUR/RC68/8(D) page 4 26–29 September 2017. Tailored assistance in the form of expert missions was provided to four Member States. Under the leadership of the WHO geographically dispersed office (GDO) on noncommunicable diseases in Moscow, Russian Federation, WHO has supported several countries in carrying out NCD risk factor surveys for adults during the period 2016–2017: WHO STEPS surveys (11 countries) and the Global Adult Tobacco Survey (three countries). Regarding children and adolescents, Health Behaviour in School-age Children studies have been conducted in 43 countries, global youth tobacco surveys in eight countries, and child obesity surveillance initiative surveys in 41 countries, to date. These efforts have significantly extended the coverage and scope of NCD risk factor data collection in the European Region. 7. Addressing and reducing exposure to the main behavioural NCD risk factors (such as alcohol consumption, tobacco use, unhealthy diet and physical inactivity) is a fundamental aspect of prevention and health promotion aimed at reducing the impact of these diseases. These areas of work are described in more detail in the sections on priority and supporting interventions. 8. In order to address NCDs, people-centred health systems need to be strengthened to enable the provision of quality, comprehensive and coordinated services. Early diagnosis, treatment and health-care management are crucial for addressing individual needs. During 2016–2017, in the context of cross-divisional work on health systems strengthening for better NCD outcomes, five countries received support through multidisciplinary country assessments, reports and/or launches. A combined review of assessments from 12 countries was undertaken and was considered at the high-level regional meeting, Health Systems Respond to NCDs: Experience in the European Region, held on 16–18 April 2018 in Sitges, Spain. This event brought together evidence and experience on ways in which governments can adapt their health systems to meet the growing challenge of NCDs effectively. Priority interventions: population-level 9. In relation to fiscal and marketing policies for tobacco, alcohol and food, there has been mixed progress. The affordability of tobacco products has been significantly reduced by increasing tobacco excise taxes (PMI 5a): while only 2% of Member States had fully achieved this indicator in 2015, the proportion increased to 47% by 2017. Nevertheless, nine Member States of the Region have yet to achieve taxes above 50% of the retail price of a packet of cigarettes, and 28 Member States are still to achieve recommended tax rates. For alcohol, only 13% of Member States fully implemented pricing policies, such as excise tax increases, on alcoholic beverages in 2017 (PMI 6c). Two thirds of Member States have implemented the WHO set of recommendations on the marketing of foods and non-alcoholic beverages to children (PMI 7c), which represents an increase of 24 percentage points. Many countries in the Region have taken steps to limit the marketing of products high in fat, sugar and salt to children, but too many (46%) still report no action. Self-regulatory measures seem to be preferred, and the focus is on television rather than other media, such as digital social media platforms. Within countries, formal monitoring of marketing to children is not yet widespread. 10. Three quarters (77%) of countries in the European Region reported in 2017 activities to encourage reformulation of food products, many concentrating on salt (55%) rather than on other relevant nutrients such as saturated fat (27%) and sugar (37%). Overall, reformulation is least prevalent in the countries of eastern Europe and central Asia. National policies that limit EUR/RC68/8(D) page 5 saturated fatty acids and virtually eliminate industrially produced trans-fatty acids in the food supply (PMI 7b) had been adopted by 62% of countries by 2017, which represents an increase of 20 percentage points since 2015. 11. Most European Member States have introduced some measures for salt reduction and encourage reformulation to reduce salt content. National policies to reduce population salt/sodium consumption (PMI 7a) are at least partly available in 68% of Member States, which represents an increase of four percentage points since 2015. However, full implementation has been achieved in less than half of Member States (47%). This is potentially a concern, as recent WHO data for six countries in the European Region indicate extremely high levels of salt and trans-fat in commonly available foods. Furthermore, it is still the case that only one quarter of Member States in the Region have carried out measurements of 24-hour urinary sodium excretion (the gold standard for salt evaluation). 12. The proportion of countries having implemented at least one recent national public awareness programme for physical activity (PMI 8) decreased slightly, from 75% in 2015 to 70% in 2017. Progress on implementing the Physical Activity Strategy for the WHO European Region 2016–2025 is reported separately. 13. The contribution of air pollution (both outdoor and indoor) to the burden of NCDs has gained prominence during the last biennium. Promoting clean air is increasingly recognized as a significant means of preventing NCDs. The issue was discussed in depth at the Sixth Ministerial Conference on Environment and Health held in Ostrava, Czech Republic, on 13–15 June 2017. In the Declaration emanating from that meeting, Member States committed to a range of interventions to combat air pollution and other environmental threats to health. Priority interventions: individual-level 14. Coverage of cardio-metabolic risk assessment and management is monitored through PMI 10, which measures provision of drug therapy, including glycaemic control, and counselling for eligible persons at high risk to prevent heart attacks and strokes, with emphasis on the primary care level. Three workshops on implementation of a WHO package of essential NCD interventions for primary health care in eastern Europe and central Asia have been held since October 2015. Evidence shows that at least five out of the 11 CIS countries receiving support have achieved target 8 of the NCD Global Monitoring Framework, and that achievement of PMI 10 increased from 30% of countries in 2015 to 58% of countries in 2017. 15. By 2017, 68% of Member States had fully implemented evidence-based national guidelines/protocols/standards for the management of major NCDs through a primary care approach recognized or approved by government or competent authorities (PMI 9), which represents a significant increase from 45% in 2015. During 2016–2017, WHO support for early detection and effective treatment of major NCDs largely focused on cancer, cardiovascular disease and diabetes. In the follow-up to the International Conference on Cardiovascular Diseases, held on 19–20 November 2015 in Saint Petersburg, Russian Federation, WHO has engaged with countries in activities such as reviewing acute and rehabilitative services for heart attack and/or stroke (in three countries) and supporting work on hypertension and diabetes management. Eight countries participated in a workshop on cancer screening and early diagnosis hosted by the Regional Office on 12–14 December 2016 in Turin, Italy. WHO has also supported countries in strengthening implementation of EUR/RC68/8(D) page 6 essential NCD interventions in primary health care. Tailored technical assistance for cancer screening and early diagnosis was provided in six countries; four countries received support in the field of cancer treatment and/or palliative care. 16. Vaccination against human papillomavirus has been promoted within the context of comprehensive cervical cancer control, with two countries benefiting from expert missions and recommendations. The Global Ministerial Conference on Ending Tuberculosis in the Sustainable Development Era held in Moscow, Russian Federation, on 16–17 November 2017, highlighted synergies and areas for joint action to combat tuberculosis and NCDs and their respective risk factors. Supporting interventions 17. There has been limited progress in the promotion of oral health and musculoskeletal health. A manual on how to incorporate oral health in schools has been developed in line with the WHO health promoting schools concept. Oral health fact sheets on tobacco use and sugar intake have been prepared by the Regional Office in line with the common risk factors approach of the Action Plan. During 2017 the Regional Office strengthened its engagement with relevant stakeholder organizations in Europe and contributed to the following meetings: the 6th Fragility Fracture Network Global Congress held in Malmö, Sweden, on 24–26 August 2017; the European League Against Rheumatism conference on the future of research and innovation after Horizon 2020, held on 17 October 2017; and the WHO consultation jointly hosted by WHO, the German Federal Ministry of Health, and the Japanese Ministry of Health, Labour and Welfare, Integrated Care for Older People – the Path to Universal Health Coverage, which took place during the annual general meeting of the Global Alliance for Musculoskeletal Health of the Bone and Joint Decade held on 22–23 October 2017 in Berlin, Germany. 18. Detailed information on promoting mental health was provided in the progress report on the implementation of the European Mental Health Action Plan contained in document EUR/RC67/8, which was considered by RC67 in 2017. A background technical report on addressing comorbidity between mental disorders and major NCDs was published in 2017 to support implementation of the European Mental Health Action Plan 2013–2020 and the WHO European Action Plan for the Prevention and Control of NCDs 2016–2025. 19. WHO continues to support countries in promoting health in specific settings. A WHO intercountry meeting on school health in the prevention of NCDs was held in Bishkek, Kyrgyzstan on 23–25 August 2016; as a result of which 12 countries developed school health approaches for health promotion and NCDs. An international meeting on prison health was organized in Lisbon, Portugal, on 11–12 December 2017. The meeting focused on drug use and drug-related harm, treatment and prevention, as well as data monitoring, and was attended by 114 participants, including representatives of 11 Member States of the European Region. The Health in Prisons European Database was launched in early 2018 and includes data collected in 41 Member States through a national questionnaire for the minimum public health dataset for prisons in the European Region in 2016–2017. The new handbook, Age- friendly environments in Europe. A handbook of domains for policy action (2017), is now used by age-friendly cities in over 20 European countries. It promotes measures to ensure accessibility of neighbourhoods, public transport and housing in order to foster physical activity and prevent falls and other injuries. It also promotes accessibility of services and EUR/RC68/8(D) page 7 infrastructure, in such areas as healthy nutrition. The WHO European Healthy Cities Network continues to support health promotion and disease prevention. Five cities in the Region participate in the Partnership for Healthy Cities, a global network of cities supported by Bloomberg Philanthropies in partnership with WHO, which is committed to saving lives by preventing NCDs and injuries. Role of the WHO Regional Office 20. The WHO European Office and Member States have shared the success stories of the Region in global forums such as the WHO Global Conference on NCDs that took place in Montevideo, Uruguay, on 18–20 October 2017. The latest publication on progress achieved, Monitoring noncommunicable disease commitments in Europe (2017), provided useful input for the Conference. Preceding this, the European Meeting of National NCD Directors and Programme Managers, held on 8–9 June 2017 in Moscow, Russian Federation, provided valuable input. The meeting was an opportunity to review progress on NCDs in the Region, highlight areas for further work, including closing the gender gap in premature mortality, and identify ways to accelerate outcomes. The Regional Office has continued its close collaboration with the European Commission on several joint projects, including CHRODIS PLUS,5 physical activity and prison health. The Regional Office has also addressed the Eurasian Economic Union on NCD prevention. There has been close collaboration with the United Nations Interagency Task Force on NCDs, UNDP and other United Nations agencies on the development of NCD investment cases for four countries in the Region and the development of a methodology and expertise to support this work globally, among others. Other agencies, such as the International Atomic Energy Agency and the International Agency for Research on Cancer, have been close collaborators in supporting cancer control. 21. Numerous capacity-building events on NCD prevention and control were held at the regional, subregional and national levels. These include annual capacity building on issues such as NCDs and law for national NCD directors from CIS countries, and training for primary health care workers on NCD treatment and risk factors. This work has received much support from WHO collaborating centres, international experts, and institutions and experts identified by the WHO European Office for the Prevention and Control of NCDs in Moscow, Russian Federation. 22. The work on NCDs within the Region has been generously supported by several countries, including the Russian Federation (funding the GDO in Moscow), Turkmenistan (supporting the work on tobacco), the European Commission (supporting the work on nutrition and alcohol), and development partners such as the Swiss Agency for Development and Cooperation (providing essential support to NCD projects in Bosnia and Herzegovina, Kyrgyzstan, Republic of Moldova and Ukraine), Bloomberg Philanthropy (contributing to tobacco surveillance and policy) and the Borrow Foundation (supporting work on oral health in the Region). 5 Information on CHRODIS PLUS, an initiative funded by the European Commission and participating organizations to combat chronic diseases, is available at: http://www.chrodis.eu. EUR/RC68/8(D) page 8 Innovation 23. This progress report has mirrored the structure of the Action Plan for the Prevention and Control of Noncommunicable Diseases in the WHO European Region. Cutting across the Action Plan is the work carried out in the Region to innovate and develop new tools and cutting-edge techniques, including those described below. (a) FEEDCities: a method for assessing the nutrient composition of foods sold in local markets in low- and middle-income countries. (b) Investment cases: the initial methodology for the investment case project that is now being implemented worldwide by the United Nations Interagency Task Force on NCDs was developed in Europe. It is used to help policy-makers in countries in all regions assess the potential return on investment of multisectoral interventions that have an impact on NCDs. (c) The Tobacco Control Playbook:6 public health practitioners in low- and middle-income countries face the same opposition that high-income countries faced in the past when they tried to implement effective tobacco-control interventions. The Region has developed a website with a summary of the health counter-arguments to those put forward by the tobacco industry. These arguments are used to support the many new tobacco-control initiatives in the Region. (d) The Childhood Obesity Surveillance Initiative: although this protocol was originally developed with European Union support, the GDO in Moscow, Russian Federation, has also facilitated its application in the Member States of eastern Europe and central Asia. It is the only data source worldwide that has measured trends in overweight and obesity among primary school children. (e) Health Systems Response to NCDs: in many countries, health system planners work separately from NCD policy-makers. A collaboration between the WHO Office for Health Systems Strengthening in Barcelona, Spain, the WHO Regional Office in Copenhagen, Denmark, and the WHO European Office for the Prevention and Control of NCDs in Moscow, Russian Federation, has led to the development of a tool for assessing health systems and strengthening the evidence-based NCD component. This has been implemented in many countries of eastern Europe and central Asia and has included assessment of the primary health care level and emergency and hospital services in several countries. This work is described in separate products such as country assessments and good practice briefs.7 Conclusions and plans for the future 24. This report gives a brief overview of progress and achievements in the Region over the last two years. More detailed reports submitted to RC67 and RC68 provide a comprehensive picture of the work carried out and progress made regarding the main NCDs and their risk factors. Some key lessons, as described below, can be extracted. 6 The Playbook is available at: http://www.euro.who.int/en/health-topics/disease- prevention/tobacco/policy/tobacco-control-playbook. 7 These products are available at: http://www.euro.who.int/en/media-centre/events/events/2018/04/high-level- regional-meeting-health-systems-respond-to-ncds-experience-in-the-european-region/documentation. EUR/RC68/8(D) page 9 (a) The decline in premature mortality from NCDs in Europe is unequalled in any other WHO region. At the same time, there is strong evidence that European Member States do not take sufficient advantage of cost-effective interventions available for the prevention and control of NCDs. The SDG targets should therefore be regarded as a minimum standard for the European Region; collectively, the Region can do even more. (b) The decline in mortality is distributed unevenly and insufficient attention is paid to the problems of disproportionate mortality in young males and higher morbidity rates in women. In future, European NCD programmes must have a greater focus on gender and other social determinants. (c) While much has been achieved over the past two years and data from the Global NCD Progress Monitor shows that progress in the Region has been greater than in many other regions, this cannot hide the shortcomings. The European Region is a long way from full implementation of the “best buys” in the prevention and management of NCDs. (d) The work of the WHO European Office for the Prevention and Control of NCDs in Moscow, Russian Federation, has been of immeasurable value for the Region and will be described in detail in a separate progress report. By providing secure salaries for an expanded number of staff, the Regional Office has been able to step up technical support to countries and fuel the spirit of transformation and innovation that has characterized the last three years. (e) The power of joint action is considerable. The implementation of the Tobacco Products Directive (2014/40/EU) in European Union Member States was an important development in tobacco control. Recent presidencies of the Council of the European Union have considered taking action on childhood obesity and cross-border issues of alcohol control. The Eurasian Economic Union is considering taking action on trans- fatty acids. Such broad agreements have potential to rapidly advance public health across large populations and help overcome cross-border determinants of NCDs. = = =