Joint mission of the United Nations Interagency Task Force on the prevention and control of noncommunicable diseases: Philippines, 7-11 May 2018

Joint Mission of the United Nations Interagency Task Force on the Prevention and Control of Noncommunicable Diseases PHILIPPINES 7-11 MAY 2018 WHO/NMH/NMA/19.99 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-Non Commercial-Share Alike 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 l icence, 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 shou ld 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 l icense your work under the same or equivalent Creative Commons licence. 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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 l ies 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 Summary ….. Page iv Joint Mission ….. Page 1 Key Findings ….. Page 1 Recommendations ….. Page 5 Annex 1: Terms of Reference ….. Page 11 Annex 2: Members of the Joint Mission ….. Page 16 Annex 3: Joint Mission Programme ….. Page 19 Annex 4: More detailed findings ….. Page 21 Annex 5: WHO Progress Monitor Scorecard, 2017 for Philippines ….. Page 25 iv EXECUTIVE SUMMARY A Joint Mission of the United Nations Interagency Task Force on the Prevention and Control of Noncommunicable Diseases to Philippines was held on 7-11 May 2018 at the invitation of the Government of the Philippines. Ten United Nations system agencies participated. Philippines has shown outstanding action in the prevention and controlling NCDs in a number of areas. The third High-level Meeting on NCDs to be held on 27 September 2018 provides a significant opportunity for the country to share progress with the world. The Mission witnessed the achievements of the Government of the Philippines in developing national whole-of-government and whole-of-society responses to NCDs, including the recently updated Multisectoral NCD Action Plan 2015-2025, the FOURmula One Plus framework for health, the recently updated national tobacco control strategy, Philippine Package of Essential NCD Interventions for the management of hypertension and diabetes (PhilPEN), and tobacco and sugary sweetened beverage taxation. The Mission was also identified a number of examples of good policies on NCDs in the Manila Metro area and Valenzuela city. Despite efforts to halt the rise in NCDs, the Joint Mission was concerned that avoidable NCD risk factors are still a major problem. 43% of Filipino men are smokers. Prevalence of adult overweight and obesity has doubled in the last 20 years from 14.5% in 1993 to 31.1% in 2013. There has also been a dramatic increase in obesity among children and adolescents. About one quarter (23.9%) of the adult population is hypertensive and 5.4% have diabetes. To build on the progress that has been made so far, and to maintain its place as a global leader in combatting tobacco use, sugar-sweetened beverages, and other NCD risk factors, Philippines must maintain its attention on legislation, regulation, and its enforcement and consider how it creates more enabling environment for healthy choices. In order to increase physical activity in the population, the new WHO Global Physical Activity Initiative should be promoted and municipal governments should ensure that “healthy cities” and “age-friendly cities” policies are included in all urban planning and development, with the requirements to increase availability and access to public transport, public greenspace and sporting facilities. Opportunities to encourage healthy eating habits in the population were also identified. Rapid urbanization is a significant challenge for NCDs and greater leadership is needed to ensure that health is central to urban development. Strengthened cross government action to coordinate and incorporate healthy/age-friendly principles within all urban developments is a key recommendation of the Mission. A robust multi sectorial mechanism should be established for coordinating and driving forward the implementation of the Multi-Sectoral Action Plan (MSAP), especially in the area of tobacco control. In order to maximise the positive impact of the tobacco tax increase, it should be ensured that part of the Sin tax revenue is directed to health promotion and NCD prevention. A coordination mechanism for NCD-related initiatives across the UNCT and a clear cross UN action plan to support the Government of the Philippines implement the recommendations of this report should be developed very rapidly in order to drive forward action on the NCD-related SDGs in the Philippines. 1 THE JOINT MISSION A Joint Programming Mission of the United Nations Interagency Task Force (UNIATF) on the Prevention and Control of Non-Communicable Diseases (NCDs) to Philippines was conducted between 7-11 May 2018 at the invitation of the Government of Philippines (GoP). In alphabetical order, the following agencies participated in the mission: Food and Agriculture Organization (FAO), International Labour Organization (ILO), United Nations Development Programme (UNDP), United Nations Children’s Fund (UNICEF), United Nations Population Fund (UNFPA), the Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations System Standing Committee on Nutrition (UNSCN), World Food Programme (WFP), World Bank, and the World Health Organization (WHO), which led the mission. Public Health England also joined the mission. Members of the Joint Mission, Terms of Reference, and the programme are in Annexes 1-3. The Mission was conducted at the same time as the Joint Needs Assessment Mission for the Implementation of the WHO Framework Convention on Tobacco Control, and the data collection mission to develop an NCD Investment Case by WHO and UNDP Separate reports will be published for the Joint Needs Assessment Mission and NCD Investment Case mission. The Mission met with ministers and senior officials across government, including Departments of Health, Finance, Agriculture and Education as well as parliamentarians and local government representatives. The Mission also met with development partners, non-government organizations, selected private sector entities and academic institutions. The Mission also had discussions with the UN Country Team. The Joint Mission has framed its report in line with the Department of Health (DoH) FOURmula One Plus strategic framework for health: governance, financing, service delivery, regulation, and performance accountability. Philippines has shown outstanding action in the prevention and controlling NCDs in a number of areas. The third High-level Meeting on NCDs to be held on 27 September 2018 provides a significant opportunity for the country to share progress with the world. Nevertheless, unplanned urbanization is now becoming a massive challenge for NCDs. The urban environment in Philippines is providing the perfect storm for NCDs. Health must be at the centre of urban planning from now on. KEY FINDINGS NCDs remain the biggest killers in the Philippines accounting for over two-thirds (68%) of all deaths. The probability of dying between ages 30 and 70 years from one of the 4 main NCDs is 29%.1 Most premature deaths are associated with the main modifiable risk factors for NCDs, namely tobacco use, unhealthy diets, physical inactivity, and harmful use of alcohol. Mortality related to air pollution is also high in the Philippines.2 In spite of progress in implementing stronger tobacco control legislation, 1 There are an estimated 457,000 annual deaths from NCDs. http://apps.who.int/iris/bitstream/handle/10665/258940/9789241513029- eng.pdf;jsessionid=EA5DC408F834BCFEFC41EA166F663355?sequence=1. 2 Age-adjusted mortality rate of 47 per 100,000 population. WHO, Ambient air pollution: a global assessment of exposure and burden of disease (2016). http://apps.who.int/iris/bitstream/handle/10665/250141/9789241511353-eng.pdf?sequence=1 2 tobacco use remains high with 40% of adult Filipino men (and 22.5% of all adults) aged over 15 years currently smoking cigarettes.3 Of great concern is that 12% of school-based adolescents (13-15 years) are current smokers.4 The magnitude and rise in prevalence of the other NCD risk factors are equally alarming. Prevalence of adult overweight and obesity has doubled in the last 20 years from 14.5% in 1993 to 31.1% in 2013. 5 There has also been a dramatic increase in obesity among children and adolescents. About one quarter (23.9%) of the adult population is hypertensive and 5.4% have diabetes.6 Philippines faces the double-burden of undernutrition, overweight/obesity and diet-related NCDs. There is growing evidence of undernutrition and its links to developing overweight/obesity and NCDs in adulthood. A recent study from the United States Council on Foreign Relations demonstrates that NCDs are projected to increase in Philippines between 1990 and 2040, with an increase of around 80% over 1990 levels. 7 GOVERNANCE AND POLITICAL SUPPORT FOR THE PREVENTION AND CONTROL OF NCDS Within the Philippines, there is an increasing appreciation of the magnitude of the problem and the need for multisectoral action across government to ensure an effective response. There was significant concern from most ministries that the Joint Mission visited, about the impact of NCDs on the country’s economy 3 2015 Global Adult Tobacco Survey (GATS) 4 2015 Philippines Global School Health Survey (GSHS) and Global Youth Tobacco Survey (GYTS) 5 2013 National nutrition survey of the Food and Nutrition and Research Institute 6 Global health Observatory, WHO 2017, http://apps.who.int/gho/data/node.main.A875STANDARD?lang=en 7 Bollyky T et al. LICs that face the most rapid shift in NCD burden are also the least prepared. Health Affairs 36, NO. 11 (2017): 1866–1875. https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2017.0708 3 and productivity, with recognition of the importance of a multisectoral approach at the national and subnational levels to effectively tackling NCDs. In response to the growing NCD epidemic, the Philippine government and partners have undertaken a range of initiatives to strengthen health systems. The FOURmula One Plus framework has a whole-of- society, whole-of-government, and whole-of-system approach that recognises the underlying determinants of health. Further details on governance and political support are provided in Annex 4. HEALTH FINANCING Resources for the prevention and control of NCDs have significantly increased over the last couple of years, as a result of the ‘Sin Tax’ that uses revenue from tobacco and alcohol taxes for health sector. The budget of the Department of Health has tripled in recent years. The majority of these resources have been used to cover national health insurance premiums for poor families and benefit packages in both public and private facilities, as well as maintenance of healthcare facilities. While there has been an increase in resources for NCDs, the majority has gone towards treatment. An increase in resources for prevention is required: newly adopted policies need resources for implementation as well as monitoring and evaluation to enhance the policy evaluation cycle. Further details on health financing are provided in Annex 4. HEALTH REGULATION Regulations implemented over the years by the government and the Parliament of the Philippines demonstrate significant commitment to tackle NCDs, in particular through increasing taxes on tobacco and alcohol and using additional revenues to better fund the health sector. Further details are provided in Annex 4. HEALTH SERVICE DELIVERY The Philippines is committed to universal health coverage through the PhilHealth insurance scheme. Essential NCD services at the primary health care level through the Philippine Package of Essential NCD Interventions (PhilPEN) and outpatient benefit package on NCDs at primary health care level (Philhealth) are well implemented in the country. Provision of free NCD medicines at public health centres is done through the DOH Complete Treatment Pack (ComPack) Program. There is however the opportunity to strengthen preventive and early detection for NCDs into the health system response. ACCOUNTABILITY Accountability is an area where further action is required, particularly at the local level. While the Philippines has made notable achievements in adopting policies and regulations to prevent and control NCDs, there is an absence of a multi-sectoral mechanism for coordination, prioritization, monitoring of efforts and evaluation of impact, such that polices can be improved through learning. Moreover, there is a need to ensure that national level commitments are consistently operationalized at the local level, particularly given the decentralized governance structure. 4 UNITED NATIONS RESPONSE The UN Country Team (UNCT) is currently finalising the UN Partnership Framework for Sustainable Development (UNPFSD). It prioritizes three areas, all of which provide entry points for tackling NCDs: (i) people – including food security, nutrition, local governance and health; (ii) prosperity – focusing on the environment and economic development; and (iii) peace – with particular support for peace processes in Mindanao Province. While the UNCT recognises the linkages between NCDs and the 2030 Sustainable Development Agenda and the need to take collective action on the NCDs across the SDGs,8 there is no coordination mechanism for driving forward action on the NCD-related SDGs, nor a full appreciation on how different agencies should work towards delivering the above areas. RESPONSE OF DEVELOPMENT PARTNERS The DoH has robust mechanisms to engage with health partners. The Joint Mission met with a number of national non-governmental and professional organisations and international development partners committed to respond to NCDs and was impressed with their collective commitment to do even more. The Asian Development Bank convenes a regional forum on NCDs and includes NCDs in their work on health system strengthening in the Philippines. Others (e.g. World Bank) noted that they work on NCDs globally, but do not frame their support in the Philippines in the context of NCDs. However, they support work on undernutrition, such as funding of nutrition studies on stunting, supporting cash transfer programme (jointly with Asian Development Bank) to increase school attendance, use of health service check-up and the recent Korea Foundation for International Healthcare project. Urban settings/schools: Currently there appears to be little focus on healthy urban settings within development partner programmes in the Philippines. The World Bank, Asia Development Bank and certain bilateral donors, such as China9 and Japan,10 all have opportunities to incorporate health settings principles within their extensive infrastructure development projects in the Philippines. SITUATION AHEAD OF THE THIRD-HIGH LEVEL MEETING ON NCDS The Joint Mission reviewed the 2017 WHO Progress Monitor for Philippines with the Government, UNCT and international development partners. Philippines has fully achieved five of the 19 targets and partially achieved a further 7 (Annex 5). 8 e.g. SDG3 – ensure healthy lives and promote well-being for all at all ages; SDG2 – end hunger, achieve food security and improved nutrition and promote sustainable agriculture; and SDG 11 – Make cities and human settlements inclusive, safe, resilient and sustainable. 9 https://www.philstar.com/business/2018/02/21/1790030/pernia-sees-china- japan-rivalry-philippine-infrastructure-push; https://asia.nikkei.com/Spotlight/Cover-Story/Is-China-s-Belt-and-Road-working-A-progress-report-from-eight-countries; https://www.philstar.com/headlines/2018/04/17/1806807/chinas-silk-road-seen-fund-philippine-infrastructure-hits-snags-report 10 http://business.inquirer.net/246079/p753b-worth-infra-projects-japan-funding 5 RECOMMENDATIONS FOR ACTIONS GOVERNANCE AND POLITICAL SUPPORT FOR THE PREVENTION AND CONTROL OF NCDS i. Greater leadership to ensure that health is central to urban development. In the first instance, Philippines needs to: a) Review examples of best practice across the world. The UNCT should work across government on this. 11, 12 Strengthen cross government action to coordinate and incorporate healthy/age-friendly principles within all urban developments, e.g. Department of Transport, Department of Public Works and Highways, local government planning units (e.g. Metropolitan Manila Development Authority and other municipal development authorities). b) Explore public-private partnerships to ensure that Philippines has healthy urban and municipal planning (e.g. public transport, traffic control, public greenspace, walking tracks, cycle paths, other recreational/sporting facilities and vertical farming facilities for more local/urban fruit and vegetable production).13 Incentive schemes for Local Government Units (LGUs) developing healthy/age-friendly city/healthy island settings are important. c)) UNCT to work with National Economic and Development Authority (NEDA), Department of the Interior and Local Government (DILG), League of Governors and League of Mayors to review and develop actions in line with the WHO-UNDP NCD Brief for Local Government.14 d) Incorporate “healthy cities”/”age-friendly cities” and “health island” principles into the current Philippines “Build, Build, Build” infrastructure development programme. 15 It is critical for the DoH, NEDA and other relevant departments become more involved in shaping and guiding this current push to significantly expand infrastructure in the Philippines. Greater systems mapping will enable different sectors identify the opportunities for action. ii. Greater leadership for the Multi-Sectoral Action Plan (MSAP), especially in the area of tobacco control, e.g. Institutionalize a robust multi sectorial mechanism for coordinating and driving forward a coherent response and holding every party accountable. Ensure no interference from industry. 11 https://www.thelancet.com/series/urban-design 12 http://www.wpro.who.int/southpacific/programmes/pacific_ initiatives/healthy_isla nds/en/ 13 https://www.weforum.org/agenda/2017/04/this-futuristic-vertical-farm-could-feed-an-entire-african-town https://www.weforum.org/agenda/2017/05/farm-agriculture-on-roof-shipping-container/ 14 http://www.undp.org/content/dam/undp/libra ry/HIV-AIDS/NCDs/Local%20Government.pdf?download 15 https://www.forbes.com/sites/outofasia/2018/02/28/dutertes-ambitious-build-build-build-project-to-transform-the-philippines-could- become-his-legacy/#20bce0d61a7f 6 a) Establish a national tobacco control unit, with a full-time focal point. b) Undertake a rapid review of progress on the MSAP as an initial task towards clarifying roles and responsibilities of participating departments and partners and costing the plan. c) Prioritize and make clear on what the tasks are e.g. sustainable alternatives to tobacco growing (Department of Finance, Department of Agriculture, Department of Budget and Management); monitor & prosecute violations to Article 5.3 (Civil Service Commission and Office of the Ombudsman). d) Promote NCD champions from both within and outside the health sector, to ensure a focus on prevention and increase commitment to multi-sectoral action. e) Facilitate social contracting for provision of NCD prevention, management and support services by non-government and community-based providers. f) Engage private sector in workplace/worksite-based health promotion/NCD prevention and screening campaigns,16 whilst ensuring accountability, and ethical engagement and investment practices, under close monitoring and governance. g) Advocate for greater NCD prevention and management by highlighting how these contribute to the Philippines achieving a demographic dividend – translating NCD control into further socio-economic development and greater national prosperity.17 Finalise the NCD investment case to illustrate how reduction of NCD burden is central to maintaining economic development. h) Broaden the scope of the Multi-Sectoral Action Plan on NCDs, to include further government department inputs at national, subnational and local government levels to ensuring “healthy settings”, ”age-friendly cities” and “healthy islands” approaches within all further development work across the Philippines. HEALTH FINANCING iii. Reconsider the approach and mix for resource allocations (including human resources) within the DoH for prevention and control of NCDs, ensuring due resources are directed to health promotion and NCD prevention. iv. Develop an NCD investment case analysis to determine the return on investments from a range of NCD interventions. v. Finance safe drinking water in schools and their communities as part of promoting healthy diet and physical activity in schools. 16 http://www.who.int/occupational_health/healthy_workplaces/en/ 17 http://www.neda.gov.ph/2017/11/10/neda-reaping-demographic-dividend-to-spur-growth/ 7 vi. Invest in the strengthening of regulatory capacities to monitor compliance and enforcement of policies and regulations to prevent NCDs and address NCD risk factors and evaluate the impact of compliance and enforcement. HEALTH LEGISLATION AND REGULATION To build on the progress that has been made so far, and to maintain its place as a global leader in combatting tobacco use, sugar-sweetened beverages, and other NCD risk factors, Philippines must maintain its attention on legislation, regulation, and its enforcement. vii. Tobacco control a) Continue to increase tax on tobacco products. b) Enforce existing regulations regarding smoke free venues, cigarette sales to minors, marketing of tobacco products and sales of individual cigarettes. c) Introduce vaping legislation to prevent uptake by adolescents. viii. Healthy diet a) Strengthen legislative compliance and enforcement of the current nutrition labelling laws and their monitoring and increase Food and Drug Administration capacity to do this. b) strengthen the monitoring of levels and patterns of sugary sweetened beverages (SSB) consumption as well as the sugars contents in beverages and use SSB taxes for increasing the implementation and enforcement of action to promote healthy diets, including regulating sales and promoting of food and beverages in and around schools. c) Strengthen regulation on marketing and promotion of food and non-alcoholic beverages high in sugars, fats and sodium in and around schools. d) Identify market opportunities for fresh fruits and vegetables. At the moment there are limited opportunities for stalls for sale of fresh fruits and vegetables. e) Promote and expand integrated agriculture–aquaculture (IAA) food production systems in rural areas.18 f) Better understand the increase in fast food outlets, their influence on the diet transition and the policy options for improving the offer of healthier foods. 18 http://www.fao.org/docrep/005/Y1187E/y1187e00.htm#TopOfPage 8 ix. Harmful use of alcohol a) Implement alcohol unit pricing policy and legislation. b) Restrict alcohol marketing practices, especially marketing to young people. c) Restrict alcohol supply outlets/times and regulate serving practices (refusal of sale to intoxicated persons). x. Physical Activity Promote the new Global Physical Activity Initiative that was launched in June 2018) by developing local campaigns, including fun runs, triathlons, mass cycling events etc. xi. The urban environment a) Regulate to ensure “healthy cities” and “age-friendly cities” policies are included in all urban planning and development approval practices, especially for all proposed new city/barangay/LGU urban expansions and developments. b) Regulate requirements for regular LGU “healthy city” review/audits, with required follow-up actions, e.g. minimum municipal allocations to civic/green space, social amenity and public transport. 19 c) Regulate municipal governments planning of transport infrastructure, with requirements to increase availability and access to public transport, and to reduce reliance on private transport. ACCOUNTABILITY xii. Request UNCT responses on inclusion of NCD prevention and control initiatives within the new Philippines UNDAF/UNPFSD. Identify relevant indicator(s) of UN engagement and support for NCD programmes. Define/assign complementary, multi-agency roles in NCD interventions and programming. xiii. Engage ASEAN to counter industry interference regionally – in terms of guiding and limiting intervention by tobacco, alcohol, food and beverage manufacturing, restaurants/fast-food chain, retail sectors. xiv. Develop a consortium of technical partners to define enhanced NCD risk factor indices,20 implement enhanced NCD risk factor surveillance, with regular disaggregated reporting at Local 19 https://www.reuters.com/article/us-global-cities-walking/how-walkable-is-your-city-tool-aims-to-make-pedestrians-safer-and-happier- idUSKCN1FZ2CU 20 http://ncdrisc.org/ http://ncdrisc.org/multiple-factors.html 9 Government Units level, and support the building of public health capacity to analyse and use the surveillance data at a local level. xiv. Engage Philippines’ law enforcement/justice services in effectively policing tobacco regulations relating to control of sale and use. xv. Urban agenda a) Hold all levels of government accountable for their respective inputs and responsibilities concerning healthy urban design and development: • National: Fiscal allocation to urban greenspace projects, regulation of bilateral donor and private sector access/contributions • Provincial: Catchment planning, new urban sub-division planning, transportation infrastructure planning • Local Government: local healthy city planning and community-level infrastructure design and development incorporating public transportation, green spaces, cycle ways, traffic/pedestrian separation and other urban infrastructure, that enables physical activity and reduces exposure to air pollution. b) Enact community watchdog and whistleblower protection legislation to counter corruption and vested interest in urban development. c) Develop and foster government – civil society (CSO) partnerships, and collaborative planning and monitoring networks/frameworks, to progress health cities/islands initiatives. d) Increase surveillance of environment-related burden of disease (ERBD) (e.g. chronic respiratory disease, cancers and CVD related to air and water pollution). Publish ERBD statistics disaggregated by LGU. Award Red Orchid awards for top performing LGUs – that improve/maintain water/air quality. HEALTH SERVICE DELIVERY xvi. Strengthen linkages between reproductive health services, primary health care, in-patient and palliative care services. xvii. Create a “Community Movement” on NCDs – advocating for healthy settings/diets/behaviours. Engage civic leaders/CSOs in community-based NCD prevention, and care and support for people living with NCDs (social contracting). xviii. Develop linkages between DoH and other parts of government for incorporating healthy cities/health promoting LGU environments, and civil society engagement in NCD risk factor reduction and promotion of well-being. 10 xix. Strengthen cervical cancer services a) Roll-out cervical cancer screening at primary health care level, following WHO guidelines and incorporating appropriate diagnostic approaches (e.g. pap smear, visual inspection with acetic acid). b) Develop linked cervical cancer screening and HIV testing services – for early detection of abnormal cervical cytology in women living with HIV, and increased detection of HIV infection in women attending for cervical screening. c) Explore introduction of a national HPV vaccination programme, as part of the routine vaccination schedule, for all children 9–13 years of age. Engage technical support from the UN Joint Global Programme and HPV global leadership sub-team. d) Roll-out further prevention – treatment – care services aligned with the global goal for elimination of cervical cancer by 2050. UN SYSTEM xx. Establish coordination mechanism for NCD-related initiatives across the UNCT and include NCDs in to the UNPFSD, including including an NCD indicator into the M and E framework. xxi. Develop a clear cross UN action plan to support GoP implement the recommendations in this report.21 The UN system through the UN Country Team with the support of its regional and global offices need to provide catalytic technical support to the Government for the recommendations above, working with the Government and international development partners to identify the required resources. Support from UN agencies and development partners would further be refined once core activities related to NCDs are identified through the mapping exercise. oooOOOooo 21 Agencies should refer to the roles and responsibilities outlined on pages 38-41 of the guidance note on the integration of NCDs into the UNDAFhttp://www.who.int/nmh/ncd-task-force/guidance-note.pdf?ua=1 11 ANNEX 1 Terms of Reference for the Joint Mission of the United Nations Interagency Task Force on the Prevention and Control of Non-communicable Diseases to Philippines 1. Background and Rationale 1.1 NCDs and sustainable development Four types of Non-communicable diseases (NCDs), cardiovascular diseases, cancers, chronic respiratory diseases and diabetes, make the largest contribution to mortality across the world. Together these NCDs account for over 14 million premature deaths (defined as aged 30 to 70 years) each year, of which 85 percent occur in developing countries. Additionally, mental illness contributes to disability, suffering and premature death accounting, for 13% of the total global burden of disease (in 2000). Up to two-thirds of NCDs are linked to exposure to four main risk factors - namely, tobacco use, unhealthy diet and physical inactivity, and the harmful use of alcohol. Most of these premature deaths from NCDs can be prevented. NCDs are now exerting a drag on the socio- economic development of many countries. These include an increasing financial burden on the health system and loss of productivity among the workforce. The 2011 UN Political Declaration, the 2014 UN Outcome Document on NCDs and the WHO Global NCD Action Plan 2013-2020 highlight the need for a whole-of-government and whole-of-society response to NCDs. Member States have committed to: (i) developing national targets and indicators for NCDs based on national situations; (ii) developing, allocating and implementing budgets for national multi-sectoral NCD policies and plans; (iii) prioritizing the implementation of cost-effective and affordable interventions for the prevention and control of NCDs; and (iv) strengthening national surveillance systems for NCDs and measuring results. In 2015, NCDs and their related conditions were included in the 2030 Agenda for Sustainable Development. Target 3.4 is by 2030 to reduce by one third premature mortality from NCDs and promote mental health. Examples of other NCD SDG targets are shown below and examples of NCD-related SDG targets are shown in Annex 1. 12 Despite some successes in tackling NCDs, overall progress at the country level has remained insufficient and uneven and NCDs and mental health are still not a development priority across government and the development system in many countries. Despite the increase of national multisectoral plans and NCD units in many countries, a large number of developing countries still lack the capacity to move from commitment to action. Ministries of Health cannot tackle NCDs alone: they require political commitment right across government and action across sectors by encouraging multi-stakeholder engagement in order to meet their commitments on the prevention and control of NCDs. The same is so for WHO, as the specialised agency for health: a whole-of-UN response is required to provide effective support to Member States. 1.2 NCDs in Philippines According to the WHO NCD Country Profiles, NCDs are estimated to account for 67% of total deaths in the Philippines, and the probability of dying prematurely from one of the four main NCDs is 28%. 22 Tobacco use, unhealthy diet and insufficient physical activity are all increasing problems in the Philippines and the prevalence of overweight and obesity has been on the rise over recent years. Nearly one quarter of adults have raised blood pressure, and about 5% have diabetes. In addition, mental illness was found to be the third leading cause of disability as measured by census data (National Statistics Office, 2000). In workplaces employing 20 or more people, the number of cases of occupational diseases increased by 100% from 85,483 in 2011 to 171,787 in 2013. Additionally, occupational injuries increased by 3.8% from 49,118 in 2013 to 50,961 in 2015. (Philippine Statistics Authority, 2011-2015). The Philippines is committed to tackle NCDs and is already demonstrating significant commitment to action. Initiatives implemented over the years include the following: ▪ Passage and implementation of legislation on Tobacco Regulatory Act (RA 9211) and Sin tax (RA 10351); ▪ Issuance of policy (DOH administrative order) on nutrition labelling of pre-packaged food products; ▪ Taxation of sugar-sweetened beverages under the Tax Reform for Acceleration and Inclusion (Train) Legislation; ▪ Implementation of essential NCD services at the primary health care level though the Philippine Package of Essential NCD Interventions (PhilPEN); ▪ Implementation of Philhealth outpatient benefit package on NCDs at primary health care level; ▪ Provision of NCD medicines to indigent patients through the DOH Complete Treatment Pack (ComPack) Program; ▪ Implementation of health promotion activities such as: “Belly Gud”, Pilipinas Go4Health”, “HL to the Max”; Red Orchid Awards for Tobacco Control; and Outstanding Healthy Lifestyle Awards, etc. by the DOH; “10 Kumain-ments” and “Pinggang Pinoy” (healthy plate) by the National Nutrition 13 Council and Food and Nutrition Research Institute; and various health promotion events and activities by local government units (Zumba, community exercises, etc and other stakeholders; ▪ Health-promoting initiatives by non-health sectors such as: Civil Service Commission (CSC) memorandum circular on smoking prohibition on government premises, buildings and ground; CSC and DOH’s joint memorandum circular bans government officials and employees from interacting with the tobacco industry; Memorandum Circular on 100% Smoke-Free MMDA; and DepEd policy on banning unhealthy food (e.g softdrinks) in school canteens. ▪ Implementing NCD surveillance. NCD death reporting is done by the Philippine Statistics Authority. NCD risk factors surveys every 3-5 years are done by the Food and Nutrition Research Institute of the Department of Science and Technology (FNRI-DOST) and the DOH. Program monitoring and evaluation are done by DOH and other government agencies. ▪ NCD is included as a priority concern in the current Fourmula One Plus Health Agenda of the Department of Health. Another example of action to address tobacco use is the mHealth program for tobacco cessation, which supports users who want to quit tobacco use by sending evidence based text messages using behaviour change and communication techniques. The DoH is now planning to expand the initiative to include an mDiabetes program for better diabetes prevention and management. A bill for Philippine Mental Health Act of 2017 has been approved in Congress and Senate, and now awaiting signature by the President to become a law of the land. The bill proposes a mental health policy that aims to enhance integrated mental health services, the promotion of mental health services, protection of people who use these services, and the establishment of a Philippine mental health council. 1.3 Scaling up UN support for action on the NCD-related SDGs A UN Interagency Task Force on the Prevention and Control of NCDs was established by the UN Secretary- General in 2013 and reports to ECOSOC annually. The Task Force was established in recognition that Member States require concerted and coordinated action from UN agencies in tackling NCDs as part of the development agenda. The Secretariat for the Task Force is located in the WHO. The Task Force undertakes Joint Programming Missions to support UN Country Teams in their efforts to provide technical assistance to governments as they seek to develop and implement national NCD responses which contribute to the NCD-related targets in the SDGs. Joint Missions provide the opportunity for the UN System to engage with a range of government ministries and support them in adopting approaches to NCDs and mental health policy development which involve all government departments. This ensures that NCDs and mental health issues receive an appropriate, whole-of-government, multisectoral response. Joint Missions engage with other development partners, including NGOs, private sector entities, philanthropic foundations and academic institutions, thereby helping governments to promote a whole- of-society response to NCDs. To date, over 20 Joint Programming Missions have been conducted in different countries, with follow up action in many of those visited. 14 2. Overall approach of the Mission The planned Joint Programming Mission will identify entry points for scaling up action on the NCD-related SDGs across Government, parliament, the UN system and national and international development partners. The Joint Programming Mission will highlight the scale of the problem, learn from best practice in Philippines and describe examples of action being seen in other countries. The Joint Mission will highlight specific actions for individual ministries and their counterpart UN agency in mounting a whole- of-government response. The Joint Mission will meet with development agencies, civil society, selected private entities and the media to identify opportunities for collaboration between government and other partners. The mission, led by the WHO, is expected to include the following agencies: the Asian Development Bank, FAO, ILO, UNAIDS, UNDP, UNFPA, UNICEF, UNSCN and the World Bank. The Joint Mission will be coordinated by the WHO Country Office for Philippines and the WHO Western Pacific Regional Office in close collaboration with the Ministry of Health and the Office of the UN Resident Coordinator in Philippines. The joint UNIATF mission is intended to enhance the support of UN agencies, individually and through the UN Country Team, to the Government of Philippines to scale up the National Multisectoral Response to NCDs, in line with the WHO Global NCD Action Plan 2013-2020 and the Regional Action Plan. The Joint Mission will take as its starting point: • The 2011 UN Political Declaration and 2014 UN Outcome Document on NCDs, and the 2030 Agenda for Sustainable Development; • The 2015 WHO NCD Progress Monitor which tracks the extent to which WHO Member States are implementing the four timebound commitments for 2015 and 2016 included in the 2014 UN Outcome Document on NCDs; • The Terms of Reference for the UN Interagency Task Force, including a division of tasks and responsibilities between Task Force members. • The 2014 WHO NCD Country Profiles which provides an overview of the NCD situation in each country; • The 2014 WHO Atlas that provides data on country resources for mental health • The WHO Global NCD Action Plan 2013-2020, in particular the set of cost-effective and affordable interventions for all countries, and policy options to promote a whole-of-government and whole-of-society response to reducing risk factors and enabling heath systems to respond; • A key element of the mission will be to assess the state of national response to the challenge of NCDs in Philippines, including through exploring the role and potential of country and regional UN agencies and whole-of government and whole-of-society approaches in the implementation of the national NCD agenda; • Major areas of NCD intervention in the Philippines, including tobacco control, addressing harmful use of alcohol, promoting healthy diets and nutrition, health promotion relevant for NCDs and mental health and their risk factors, and NCDs management will be highlighted during the mission; • The mission will liaise with the UN Network for Scaling Up Nutrition (SUN), chaired by UNICEF to ensure good coordination among several joint UN initiatives 15 3. Purpose and objectives of the mission The purpose of the joint UNIATF mission to Philippines is to support UN agencies and the UN Country Team to: • Understand the relevance of addressing NCDs to their individual human development efforts in the country and support implementation of efforts on NCD prevention and control, accordingly; • Integrate actions to address NCDs and their determinants into their bilateral plans with the Government of the Philippines; • Strengthen a functional mechanism to coordinate support by the UNCT on NCDs to the Government's efforts to address NCDs; • Highlight progress made to date in laying the foundation for a strengthened national multisectoral response to NCDs through WHO support at country level; • Draw lessons from ongoing efforts by WHO and other UN Agencies working with the Government of Philippines in the area of NCD prevention and control, including implementation of the WHO Framework Convention on Tobacco Control (FCTC) in Philippines, in order to inform other countries in the region and beyond; • Position NCDs in the development agenda in the Philippines and advocate for NCDs investment as an investment for development; and • Explore policies, programmes and actions related to nutrition and diet, tobacco control, and promoting healthy and safe workplaces, and align them more effectively with the NCD agenda and vice versa Specific objectives of the joint mission are to support the Government of the Philippines: • Review progress on actions to achieve the NCD-related SDGs in the Philippines, assessing progress against national policies, plans and targets • Map existing policies, strategies and technical and financial support from the UN and other development agencies to support the Government in their efforts to address the NCD -related SDGs • Review the effectiveness of these strategies and assess opportunities for incorporating the NCD - related SDGs as a multisectoral development issue into the new UN Strategic Plan 2019-2023. • Advocate for effective multisectoral response and increased multi-sectoral investment for NCD prevention and control by: (i) positioning NCDs in the development agenda of the Philippines; (ii) highlighting approaches for effective coordination of national multisectoral responses to NCDs; (iii) identifying barriers which prevent effective coordination of the national multisectoral responses to NCDs, and provide relevant recommendations; (iv) identifying support needed by the Government from WHO, other UN agencies, the World Bank and international partners; and (v) advocating for health promoting policies across the Government; Collect the necessary economic data and undertake an institutional context assessment in the Philippines in order to develop the case for investing in NCDs. • Establish a roadmap for the next 12 months and beyond which will result in significant progress in ongoing national efforts contributing to the multisectoral response to NCDs , with clear entry points for government ministries, the UN system and other development partners. This mission was conducted at the same time as the Joint Needs Assessment Mission for the Implementation of the WHO Framework Convention on Tobacco Control in the Philippines and some of the activities will be conducted jointly. 16 ANNEX 2. Members of the Joint Mission (Agencies and individuals in alphabetical order) FAO Tamara PALIS-DURAN Assistant Representative (Programme), Philippines Country Office Maria Cecilia PASTORES Project Team Leader, Philippines Country Office Maria Ruzella QUILLA Project Development and Coordination Specialist, Philippines Country Office ILO Hassan KHALID Director, Philippines Country Office UNAIDS Louie OCAMPO Country Director, Philippines Country Office UNDP Fe CABRAL Programme Analyst, Philippines Country Office Nadia RASHEED Team Leader, Health and Development, Bangkok Regional Hub UNFPA Tim SLADDEN Senior Adviser, Sexual & Reproductive Health Branch, New York UNICEF Rene Gerard GALERA Nutrition Specialist, Philippines Country Office Wigdan MADANI Chief of Health and Nutrition, Philippines Country Office UNSCN Stineke OENEMA Coordinator, Rome World Bank Gabriel DEMOMBYNES Program Leader for Human Development, Philippines 17 Tomo MORIMOTO Senior Operations Officer, Health, Nutrition & Population Global Practice, Philippines WFP Corazon BARBA Nutrition Consultant, Philippines Country Office Martin PARRENO National Program Officer (Nutrition), Philippines Country Office WHO Geneva Maria Carmen AUDERA-LOPEZ Programme Manager, FCTC Secretariat Nick BANATVALA Head of UNIATF Secretariat, Geneva HQ Alexey KULIKOV External Relations Officer, UNIATF Secretariat Chizuru NISHIDA Coordinator, Department of Nutrition for Health and Development Robert Angelo TOTANES Technical Officer, Department of the Prevention of Noncommunicable Diseases Jason LIGOT Consultant, Department of the Prevention of Noncommunicable Diseases WHO Western Pacific Regional Office Ramon DE GUZMAN Consultant, Tobacco Free Initiative Ki-hyun HAHM Technical Officer, Health Law and Ethics Kathleen LANNAN Coordinator, Tobacco Free Initiative Rokho KIM Coordinator, Health and Environment Warrick Junsuk KIM Medical Officer, NCD and Health promotion Carmela MIJARES-MAJINI Consultant, NCD and Health promotion James SALISI Consultant, Nutrition Hai-Rim SHIN Acting Director, Division of NCD and Health through the Life-course Coordinator, NCD and Health promotion Juliawati UNTORO Technical Lead, Nutrition Martin VANDENDYCK Technical Lead, Mental Health and Substance abuse 18 WHO Philippines Country Office Gundo WEILER WHO Representative John Juliard GO National Professional Officer Other participants Tazeem BHATIA Public Health England (Observer) Yuliya YERMAKOVA Lead researcher, National research center for preventive medicine, Moscow (Economist) 19 ANNEX 3. Joint Mission Programme Monday, 7 May 2018 08:00-8:30 Introduction of Joint Mission Team to DOH Community 08:30-09:00 Meeting with Secretary of Health Office of the Secretary, Department of Health, Manila 09:00 - 10:00 Meeting with WHO Representative, Philippines WHO Philippines Office, Department of Health, Manila 10:00 - 12:00 Discussion with DOH and its attached agencies on Situation and Initiatives on NCD Prevention and Control in the Philippines WHO Philippines Office, Department of Health, Manila 14:00 - 16:00 Meeting with UN Resident Coordinator, UN Country Team, and UN Focal Points for UNIATF/ NCD Sheridan Tower, New Rockwell Business Center, Mandaluyong City Tuesday, 8 May 2018 9:00 – 12:00 Philippine Accomplishments and Current Initiatives on the Prevention and Control of NCDs ● National Perspective – Dr. Maria Elizabeth Caluag, DPCB, DOH ● Regional Perspective: Metro Manila – Dr. Corazon Flores, Director IV, DOH-NCR ● Local Perspective: Valenzuela – Dr. Michael Co, Medical NCD Coordinator, Valenzuela City Health Office Bayleaf Hotel, Intramuros, Manila 13:00 -17:00 Discussion on “Regulation of Marketing of Unhealthy Foods to Children and Nutrition Labelling” Global Updates on Diet and Nutrition to Prevent NCDs - Chizuru Nishida, Coordinator, HQ WPRO Initiatives on Marketing of Foods to Children and Nutrition Labelling – Juliawati Untoro, Technical Lead, Nutrition, WPRO Philippine Situation and Initiatives: Bayleaf Hotel, Intramuros, Manila 20 Marketing of Foods to Children – Ms Jovie Raval, National Nutrition Council Making Healthy Foods Available in Schools – Dr Ella Naliponguit, Department of Education Nutrition Labeling - Ms Hannah Margaret Rabaja , Food and Drug Administration Wednesday , 9 May 2018 09:00 -14:00 Bilateral Discussion with Government Agency Partners: Department of Finance/ Department of Agriculture Department of Education/ Food and Drug Administration Bayleaf Hotel, Intramuros, Manila 14:00 -16:00 Meeting with the Civil Society Organizations/ Civil Service Commission Thursday, 10 May 2018 8:30 – 9:30 Meeting with Development Partners Bayleaf Hotel, Intramuros, Manila 10:00 – 12:00 Meeting with Parliamentarians 10:00 – 12:00 Discussion on “Healthy Workplaces” 13:00 – 17:00 Food and Nutrition Research Institute Local Government Unit of Valenzuela FNRI Office, Bicutan, Taguig City Valenzuela City, Metro Manila 18:00 -20:00 Dinner meeting (UNIATF-FCTC Team with WHO, Internal Debrief) Bayleaf Hotel, Intramuros, Manila Friday , 11 May 2018 09:00 – 10:00 Debriefing with UNRC and UNCT Sheridan Tower, New Rockwell Business Center, Mandaluyong City 11:00 – 12:00 Debriefing with DOH Secretary of Health and DOH Officials Department of Health, Manila 21 ANNEX 4. MORE DETAILED FINDINGS GOVERNANCE AND POLITICAL SUPPORT FOR THE PREVENTION AND CONTROL OF NCDS A range of policies, plans and programs exist, for example: (i) national multisectoral plan and DOH strategic action plan for NCD prevention and control 2017-2025; (ii) national tobacco control strategy; (iii) Package of Essential NCD Interventions (PhilPEN); (iv) Philhealth primary care benefit package for NCDs; (v) provision of NCD Maintenance Medicines under the Medicines Access Program of the DOH; (vi) policies on cancer prevention and control, including palliative and hospice care; (vii) STOPSMOKE mobile health programme together with quit line and smoking cessation clinics; (viii) Philippine Plan of Action for Nutrition 2017-2022 which includes stunting, overweight and obesity; and (ix) guidelines for front-of-pack labelling in pre-packaged food. However, a number of these plans lack clarity on coordination mechanism, roles and responsibilities for the different sectors, costing, and operationalisation guidance. The Ministry of Agriculture, for example, is included in the multisectoral plan, but the plan does not highlight the opportunity that comes from promoting crops/products that contribute to a healthy diet. The National Nutrition Council is a good example of multi-sectoral collaboration and may be a model or starting point for a broader NCD prevention and control steering body. The Mission identified a number of examples of policies and plans relevant to combatting NCDs at municipal and city levels, in particular from the Metro Manila area:, for example (i) anti-smoking campaigns; (ii) implementation of the PhilPEN; (iii) diabetes and hypertension health clubs; and (iv) strengthening of monitoring and reporting systems. Efforts have been made to encourage physical activity, for example through the “Great Filipino Workout”, and some schools have access to sporting facilities. However, the lack of urban greenspace, parks, sidewalks, cycle paths and sporting facilities, severely limit urban residents’ opportunities to increase their levels of physical activity. Philippines has made steady progress in taxing tobacco products and has more recently introduced a tax on sugar-sweetened beverage. Policies are in place to reduce tobacco industry interference among government officials. A range of policies exist to discourage tobacco use and tobacco industry interference although mechanisms to monitor and coordinate such initiatives are often less than optimal. The Mission heard of interest among some parliamentarians to develop legislation to reduce marketing of unhealthy foods to children and remove transfats from all food. The Philippines has developed several policies and strategies on nutrition and diet-related health problems, including diet-related NCDs. A number of actions to promote healthy diet and prevent overweight/obesity and diet-related NCDs, including food-based dietary guidelines, nutrition labelling, media campaign, behavioral change communication and counselling exist. The challenge is however to strengthen coherence of existing policies and strategies in order to effectively address the growing double burden of malnutrition; undernutrition, overweight and obesity population-based, multi-sectoral, and multi-disciplinary actions. Civil society organizations are making an important contribution to NCD prevention and control in the Philippines. The Philippine Coalition for the Prevention and Control of NCDs, composed of around 40 organizations, has been supporting the DoH for over a decade in promoting healthy lifestyles and addressing the major NCD risk factors: tobacco and alcohol use, unhealthy diet, and physical inactivity. A handful of nongovernmental organizations, private sector, and health professional societies are also 22 contributing to various advocacy and health awareness campaigns against NCDs and malnutrition. In general, these activities have decreased over the years due to funding constraints. The NCD Coalition, with support from the DoH, previously organized biennial events such as public health conventions on NCDs and Outstanding Healthy Lifestyle Advocacy Awards, but budgetary support was removed by the DOH in recent years due to changes in program priorities. NCDs Surveillance: The Philippine Statistics Authority (PSA) collects and provides NCD mortality data. The Food and Nutrition Research Institute (FNRI) of the Department of Science and Technology (DOST) collects and provides data on NCD risk factors present in the population through a National Nutrition Survey, conducted every 5 years. The DOH also conducts the Global School Health Survey (GSHS) and Global Youth Tobacco Survey (GYTS) every two years, and has twice conducted the Global Adult Tobacco Survey (GATS). An electronic medical record system called iClinics has been introduced in recent years for use by primary health facilities, but many rural health units are still not using the system to date due to technical and logistical issues. In previous years, the conduction of surveys has been hampered by budgetary constraints, in certain instances, industry funding has been sought to remedy this problem, posing a conflict of interest issue. HEALTH FINANCING Coverage of the National Health Insurance Program (NHIP) has increased from 51% in 2010 to 91% in 2016 (Philhealth Stats and Charts, 2010 and 2016). However, protection from financial risk has continued to be inadequate with NHIP support value averaging 50%. Health promotion and measures to prevent NCDs are funded through the regular health department budget process. The budget for sustained health promotion and communication campaigns for NCD prevention and control is not sufficient and would benefit from direct allocation of Sin Tax revenues. Diet and nutrition: There was no specific review and assessment on the budget and resources for nutrition and diet-related actions and programmes during the Mission, although there was an indication by the Department of Education regarding the difficulties (due in part to limited availability of resources) in implementing school-based interventions to promote healthy diets and improve nutrition in and around schools. With the implementation of the sugar-sweetened beverage taxation, and earmarking and effective use of its revenues, required resources to support the activities to promote healthy diets could be made available to different sectors, with a strengthened focus on reduction of NCD risk factors and prevention of new cases of NCDs. Urban settings: There does not seem to be significant government budgeting or investment in promoting health in urban settings. In Valenzuela city, the Task Force team observed a holistic planning process for ensuring provision of health, education, transportation and other social services. However, a showcase example of a new medium-density community housing project appears to incorporate only very limited public space for exercise (see figure - including only one sports field and no other space included for physical activity). 23 Figure: Plans for Tampoy Housing Project, Valenzuela City HEALTH REGULATION Philippines has implemented a range of policies including nutrition labelling of pre-packaged food products (i.e. mandatory labelling of nutrient declarations), introduction of taxation on sweetened beverages, regulating food and beverages available in schools, implementation of a number of health promotion activities both at national level (e.g. “Belly Gud”, Pilipinas Go4Health”, “HL to the Max”) and local level (like Zumba community exercises). The Civil Service Commission (CSC) provides guidance for civil servants on how to avoid conflicting interests with the tobacco industry and develops policies for smoke-free offices and unhealthy food free canteens. Urban settings/schools: There appeared to be a lack of planning of health-promoting urban greenspace/settings within the Philippines fast-paced urban planning and development processes. Sporting facilities are planned within new educational facilities, although space is limited within urban environments. Strengthening the healthy cities23 approach and age-friendly cities24 programmes is important, building on existing urban health programmes, given the rapid urbanisation of the Philippines population. 23 http://www.who.int/healthy_settings/types/cities/en/ https://afhc2018.sarawak.gov.my/ 24 http://www.who.int/ageing/age-friendly-world/en/ https://extranet.who.int/agefriendlyworld/ 24 HEALTH SERVICE DELIVERY Essential NCD services at the primary health care level through the Philippine Package of Essential NCD Interventions (PhilPEN) and outpatient benefit package on NCDs at primary health care level (Philhealth) are well implemented in the country. Provision of free NCD medicines at public health centres is done through the DOH Complete Treatment Pack (ComPack) Program. There is however the opportunity to strengthen preventive and early detection for NCDs into the health system response. Community awareness raising exists mostly via mass media campaigns such as “cause awareness days/weeks” - focusing on specific health conditions such as diabetes, mental health, hypertension, breast cancer and other health issues. There have been previous efforts to increase physical activity in workplace settings. However raising awareness alone is insufficient to change behaviour. There are many opportunities for broader, combination prevention and multi-sectoral approaches for addressing NCDs. These “whole-of- government”, “whole-of-society approaches” are necessary to effect meaningful reduction of risk-related behaviours at community-level (i.e. to achieve significant and impactful positive/healthful behaviour changes). Combination prevention approaches need to incorporate a mix of bio-medical interventions (increased screening, clinical management and palliative care), multi-faceted behaviour change communication techniques and structural improvements that create more supportive settings and environments such as urban green spaces, cycle ways and sidewalks for increasing opportunities for exercise. Strengthening the focus on WHO “best buys” for reducing NCD risk factors will be necessary. Such combination approaches need to be applied across the life-course, starting with encouraging more healthy behaviours in mothers, fathers and young children, through promotion of healthy lifestyles in school-age children. Continued promotion of these healthful behaviours should be present through adult life within workplaces and other community settings, and support for maintaining functional ability through into old age. Supportive structural changes include continued and expanded legislation and taxation around NCD risk factors, focus on healthy settings including healthy urban and island environments, addressing poverty and other inequalities and universal health coverage processes to enable more people to access unaffordable health care. Community engagement must also be facilitated to enhance community uptake of health promoting behaviours, and to provide support mechanisms for persons diagnosed with NCDs, for example through social contracting out of prevention and care services to non-government allies and providers. 25 ANNEX 5. WHO Progress Monitor