Western Pacific Regional acton plan for noncommunicable diseases : a region free of avoidable NCD deaths and disability

WESTERN PACIFIC REGIONAL ACTION PLAN FOR NONCOMMUNICABLE DISEASES

A Region free of avoidable

NCD deaths and disability

WESTERN PACIFIC REGIONAL ACTION PLAN FOR NONCOMMUNICABLE DISEASES

A Region free of avoidable NCD deaths and disability

WHO Library Cataloguing in PublicaƟon Data Western Pacific Regional AcƟon Plan for Noncommunicable Diseases.

1. Chronic diseases – prevenƟon and control. 2. Noncommunicable diseases. 3. Western Pacific.

ISBN 978 92 9061 428 9

(NLM ClassificaƟon: WT 500)

© World Health OrganizaƟon 2009 All rights reserved. The designaƟons employed and the presentaƟon of the material in this publicaƟon do not imply the expression of any opinion whatsoever on the part of the World Health OrganizaƟon concerning the legal status of any country, territory, city or area or of its authoriƟes, or concerning the delimitaƟon of its fronƟers or boundaries. DoƩed lines on maps represent approximate border lines for which there may not yet be full agreement. The menƟon of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health OrganizaƟon in preference to others of a similar nature that are not menƟoned. Errors and omissions excepted, the names of proprietary products are disƟnguished by iniƟal capital leƩers. The World Health OrganizaƟon does not warrant that the informaƟon contained in this publicaƟon is complete and correct and shall not be liable for any damages incurred as a result of its use. PublicaƟons of the World Health OrganizaƟon can be obtained from WHO Press, World Health OrganizaƟon, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce WHO publicaƟons, in part or in whole, or to translate them – whether for sale or for noncommercial distribuƟon – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). For WHO Western Pacific Regional PublicaƟons, request for permission to reproduce should be addressed to PublicaƟons Office, World Health OrganizaƟon, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, fax: +632 521 1036, e-mail: publicaƟons@wpro.who.int

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KEY MESSAGE

NONCOMMUNICABLE DISEASES (NCD) are a criƟcal health and development issue for the Western Pacific Region. Government leadership and poliƟcal commitment are essenƟal to coordinate the necessary mulƟsectoral response to the regional NCD burden. Cost-effecƟve intervenƟons exist and need to be prioriƟzed for scaling up in countries. To achieve this, health systems need to strengthen prevenƟon and to ensure NCD control is integrated into primary health care, using the Chronic Care model. Resources for noncommunicable diseases need to be enhanced and sustained to achieve measurable improvements in the health of the Region’s people.

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TABLE OF CONTENTS FOREWORD 1 2 INTRODUCTION THE PUBLIC HEALTH IMPACT OF NONCOMMUNICABLE DISEASES IN THE WESTERN PACIFIC 2.1 2.2 2.3 2.4 Changing epidemiology Increasing prevalence of NCD risk factors Rising health care costs related to noncommunicable diseases The call for acƟon

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3 3 4 5 5

3 THE WESTERN PACIFIC REGIONAL ACTION PLAN FOR NONCOMMUNICABLE DISEASES 3.1 3.2 3.3 3.4 3.5 Vision and focus Key principles Strategic approach Scope and consideraƟons ObjecƟves and AcƟons

7 7 8 10 12 12

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FINAL WORD

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ANNEXES Annex A Annex B Annex C Annex D Annex E Annex F A conceptual framework for noncommunicable disease prevenƟon and control: basis for the Western Pacific Regional AcƟon Plan Official WHO documents that guided the development of this Regional AcƟon Plan Process for operaƟonalizing the global acƟon plan for NCD prevenƟon and control Current WHO and other selected tools and resources for NCD prevenƟon and control Affordability of selected intervenƟons Regional CommiƩee ResoluƟon WPR/RC59.R5: Noncommunicable disease prevenƟon and control 40 42 44 46 52 54

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FOREWORD

Chronic diseases, mainly cardiovascular diseases, cancers, diabetes and chronic respiratory diseases, have overtaken communicable diseases as the leading health burden in the Western Pacific Region. Up to 80% of heart disease, stroke, type 2 diabetes and over a third of cancers could be prevented by eliminaƟng shared risk factors, mainly tobacco use, unhealthy diet, physical inacƟvity and the harmful use of alcohol. WHO has proposed a global goal for the prevenƟon and control of chronic noncommunicable diseases that calls for an addiƟonal 2% reducƟon in chronic disease death rates every year from 2005 to 2015. The goal focuses on an achievable level of prevenƟon that may be targeted for individual countries depending on the current state of the epidemic. An addiƟonal 2% reducƟon in chronic disease deaths every year over the next 10 years would mean 36 million lives saved worldwide by 2015. Close to 10 million of these lives would be saved in the Western Pacific. Member States and other partners in the Western Pacific Region recognized the urgent need to stem the overwhelming health and economic burden from noncommunicable diseases (NCDs). Various acƟon plans related to NCD prevenƟon and control were developed over successive meeƟngs in the Region, sharing a focus on prevenƟon and health promoƟon through healthy policies, environments and lifestyles.

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The Western Pacific Regional AcƟon Plan for PrevenƟon and Control of Noncommunicable Diseases, adopted at the fiŌy-ninth session of the Regional CommiƩee for the Western Pacific in Manila in September 2008, is aligned with the global acƟon plan for the WHO global NCD strategy. The focus of the acƟon plan is on pracƟcal, cost-effecƟve and evidencebased intervenƟons that Member States can adopt to achieve a reducƟon in NCD risk-factor prevalence and NCD mortality and morbidity. The key principles on which the plan was developed were “people-centred approach; culturally relevant; focused on reducing inequiƟes; encompassing the enƟre care conƟnuum; involving the whole of society; integral to health systems strengthening; consistent with the global acƟon plan, and supporƟve of exisƟng, related regional strategies and acƟon plans, flexible, using a phased approach”. The acƟon plan emphasizes on the need for a whole-of-government approach required for addressing NCD risk factors. The acƟon plan provides a step-by-step approach for the development of a comprehensive and integrated naƟonal plan to prevent and control noncommunicable diseases. This acƟon plan will help Member States enhance resources for NCD prevenƟon and control and to maximize the investments in this area. WHO remains commiƩed to working closely with its partners to apply the acƟons contained in the Regional AcƟon Plan to reduce morbidity and mortality from noncommunicable diseases through a people-centred approach.

Shin S hin Young-soo, MD, Ph.D. Regional Director

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1

INTRODUCTION

NONCOMMUNICABLE DISEASES (NCD) represent a major public health threat in the Western Pacific Region. Currently, about 26 500 people die every day from noncommunicable diseases in the Region, with over 20 000 of these deaths occurring in the Region’s developing countries.1 Close to half of NCD deaths occur in individuals under the age of 70.2 Already, noncommunicable diseases, notably cardiovascular disease (coronary heart disease and cerebrovascular disease), diabetes, cancer, and chronic pulmonary diseases, account for almost 8 out of every 10 deaths in the Western Pacific Region3 —and the situaƟon is expected to worsen in countries and areas in economic transiƟon if urgent measures are not taken. Ironically, most risk factors for these diseases (e.g. tobacco use, unhealthy diet, physical inacƟvity, harmful use of alcohol, and indoor and outdoor air polluƟon) are preventable. The evidence base for effecƟve intervenƟons is growing. Yet, the prevalence of these risk factors in the Western Pacific Region remains unacceptably high, and in many countries conƟnues to increase. WHO’s global strategy for the prevenƟon and control of chronic noncommunicable diseases was endorsed by the World Health Assembly in 2000 (resoluƟon WHA53.17). Various strategies, frameworks and acƟon plans addressing diverse NCD risk factors were developed from 2000 to 2007, including the internaƟonal WHO Framework ConvenƟon on Tobacco Control (FCTC) and the Global Strategy for Diet, Physical AcƟvity and Health (DPAS), which provided the basis for a global acƟon plan for the global strategy. At the recently concluded Sixty-first World Health Assembly, in resoluƟon WHA61.14,

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Member States endorsed the AcƟon Plan for the Global Strategy for the PrevenƟon and Control of Noncommunicable Diseases. The Global Strategy and AcƟon Plan represent the culminaƟon of diverse efforts by WHO and its Member States to definiƟvely address, in solidarity, the challenge of chronic diseases. Recognizing that chronic diseases are the major contributor to preventable death and disability in the Western Pacific Region, Member States have been working collaboraƟvely to determine how best to respond to the regional burden of noncommunicable diseases. This document contains a Regional AcƟon Plan to operaƟonalize the Global AcƟon Plan for the prevenƟon and control of noncommunicable diseases, envisioning “a Region free of avoidable NCD deaths and disability”.

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THE PUBLIC HEALTH IMPACT OF NONCOMMUNICABLE DISEASES IN THE WESTERN PACIFIC

2.1 Changing epidemiology PopulaƟon ageing has altered the nature of death and disease. Success in increasing life expectancy has ensured that a significant proporƟon of the populaƟon manage to survive the risks of dying during the perinatal period and early childhood, and has allowed chronic noncommunicable diseases to overtake communicable diseases as the major cause of mortality and morbidity. While not discounƟng the inevitability of death, the evidence indicates that noncommunicable diseases oŌen cause death prematurely, usually aŌer years of increasing disability and ill-health. In the Western Pacific Region, home to over 26% of the world’s populaƟon,4 noncommunicable diseases represent 92% of the burden of disease in disability-adjusted life years (DALYs) in high-income countries and approximately 63% in middle- and low-income countries and areas. Moreover, middleand low-income countries and areas in the Region have more than a quarter of the global total burden of disease in DALYs for malignant neoplasms, and close to a third of the global total in respiratory disorders. They also have a fiŌh of the global total burden of disease in DALYs for diabetes and cardiovascular disease.5 Over three fourths of deaths in the Region are aƩributable to noncommunicable diseases, compared to 14% of deaths caused by communicable diseases. Cardiovascular disease (coronary heart disease and cerebrovascular disease) and malignant neoplasms cause more deaths in middle- and lowincome countries and areas in the Western Pacific Region than all communicable diseases combined.6

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Cardiovascular disease alone causes no less than 3 million deaths in the Region annually.7 Pacific island countries and areas consistently have the highest rates of death from coronary heart disease, cerebrovascular disease and diabetes.8

2.2 Increasing prevalence of NCD risk factors9 Common risk factors underlie noncommunicable diseases. An esƟmated 80% of premature heart disease, stroke and type 2 diabetes, and 40% of cancer, could be avoided through healthy diet, regular physical acƟvity, and avoidance of tobacco use. GlobalizaƟon and urbanizaƟon, while contribuƟng to countries’ economic growth and development, have also created environments for the promoƟon of unhealthy lifestyles (e.g. tobacco use, unhealthy diet, physical inacƟvity and harmful use of alcohol) and environmental changes (e.g. indoor and outdoor air polluƟon). These common risk factors give rise to intermediate risk factors such as raised blood pressure, raised blood glucose, unhealthy lipid profiles, obesity and impaired lung funcƟon. In turn, the intermediate risk factors predispose individuals to the “fatal four” – cardiovascular disease (heart disease and stroke), cancer, chronic respiratory disease and diabetes etes (Figure 1). Figure 1. The causaƟon pathway for chronic diseases

UNDERLYING DETERMINANTS GlobalizaƟon UrbanizaƟon PopulaƟon ageing Social determinants

COMMON RISK FACTOR Unhealthy diet Physical inacƟvity Tobacco and alcohol use Air polluƟon Age (non-modifiable) Heredity (non-modifiable)

INTERMEDIATE RISK FACTOR Raised blood sugar Raised blood pressure Abnormal blood lipids Overweight/obesity Abnormal lung funcƟon

DISEASES Cardiovascular disease (Heart disease and stroke) Cancer Diabetes Chronic respiratory disease

Source: Adapted from PrevenƟng Chronic Disease: a Vital Investment. Geneva, World Health OrganizaƟon, 2005.

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In the Western Pacific Region, major common and intermediate risk factors for noncommunicable diseases are prevalent and increasing in many countries and territories. As a result, cardiovascular diseases, cancer, chronic respiratory diseases and diabetes account for the majority of the deaths in the Region.

2.3 Rising health care costs related to noncommunicable diseases The health care costs related to noncommunicable diseases are significant. For the socioeconomically disadvantaged, the out-of-pocket expenditure for noncommunicable diseases can be catastrophic. On top of the direct health care costs, the economic impact of early death and disability, i.e. before age 60, is potenƟally devastaƟng. For example, lost producƟvity due to noncommunicable diseases between 2005 and 2015 will cost China over US$ 550 billion.10 Given that in the Western Pacific Region, 75% of diabetes cases and 90% of cancer cases are diagnosed in developing countries,11 noncommunicable diseases contribute to the Region’s burden of poverty, retard naƟonal development and can widen the health inequiƟes within and across countries. Unfortunately, investment in NCD prevenƟon and control remains inadequate despite the growing burden and evidence for effecƟve intervenƟons.

2.4 The call for acƟon At the global level, WHO’s Member States adopted a global strategy in 2000 for the prevenƟon and control of noncommunicable diseases during the FiŌy-third World Health Assembly.12 The Global Strategy on Diet, Physical AcƟvity and Health was endorsed in 2002. In 2003, the WHO Framework ConvenƟon on Tobacco Control, developed from 1999 to 2003, was opened for signature. The treaty came into force in 2005. Member States endorsed the AcƟon Plan for the Global Strategy for the PrevenƟon and Control of Noncommunicable Diseases at the Sixty-first World Health Assembly13 in May 2008.

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At the regional level, the Regional CommiƩee for the Western Pacific called for acƟon to combat noncommunicable diseases and their related risk factors in two specific resoluƟons (WPR51.R5 in 2000 and WPR/RC57.R4 in 2006). Various regional acƟon plans related to NCD prevenƟon and control (e.g. Regional Plan for Integrated PrevenƟon and Control of Cardiovascular Diseases and Diabetes for the Western Pacific Region 1998–2003, Tobacco Free IniƟaƟve Regional AcƟon Plans 2000–2004 and 2005–2009, Plan of AcƟon 2006–2010 for the Western Pacific DeclaraƟon on Diabetes, and the Regional Strategy to Reduce Alcohol-related Harm) were developed over the past decade, sharing a focus on policy and planning, surveillance, health promoƟon and clinical prevenƟon. WHO developed a Pacific Framework for the PrevenƟon and Control of Noncommunicable Diseases in 2007 to serve as a guide in addressing noncommunicable diseases among Pacific island countries and areas, and this framework was adopted by the Secretariat of the Pacific Community (SPC). AugmenƟng these acƟon plans and frameworks is a Region-wide interest and commitment to fostering health systems change, parƟcularly in relaƟon to the prevenƟon and control of noncommunicable diseases. In November 2007, the WHO-supported meeƟng on “Strengthening Health Systems to Improve Chronic Disease PrevenƟon and Control” culminated in a set of recommendaƟons for reducing the health burden from noncommunicable diseases through health systems improvements. The Western Pacific Regional AcƟon Plan for Noncommunicable Diseases is a collaboraƟve effort by the WHO Regional Office for the Western Pacific and Member States to establish a shared vision and strategic acƟons to reduce the NCD burden. Recognizing that countries have varying capaciƟes and are at different stages of progress in the fight against noncommunicable diseases, and building on previous work within the Region and globally, this document seeks to guide Member States as they fulfil their commitment to implement the Global Strategy. The Regional AcƟon Plan aims to operaƟonalize the objecƟves of the Global AcƟon Plan within the Western Pacific context, thereby adding value through concrete and relevant guidance for Member States.

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THE WESTERN PACIFIC REGIONAL ACTION PLAN FOR NONCOMMUNICABLE DISEASES

3.1 Vision and focus

VISION A Region free of avoidable NCD deaths and disability

FOCUS The Western Pacific Regional AcƟon Plan is focused on pracƟcal, cost-effecƟve and evidence-based intervenƟons that Member States can adopt to achieve a reducƟon in NCD risk factor prevalence, and NCD mortality and morbidity. 7

3.2 Key principles The Western Pacific Regional AcƟon Plan is built around eight key principles: 1 People-centred health care – IntervenƟons and iniƟaƟves must adhere to the principles and values outlined in the People-centred Health Care policy framework of the Western Pacific Region (hƩp://www.wpro.who.int/sites/pci/).14 2 Cultural relevance – Policies, programmes and services must respect and take into consideraƟon the specific cultures and the diversity of populaƟons within the Region. 3 Focused on reducing inequiƟes – The Regional AcƟon Plan recognizes that the burden of chronic diseases is disproporƟonately borne within countries, by the poorer and less advantaged sectors, and across countries, by those at the lower stages of economic development. Other social determinants of health, such as race and gender, can also influence differenƟal health outcomes from noncommunicable diseases. Thus, intervenƟons must address the need to reduce inequiƟes across and within countries by considering the social determinants of health to enable the aƩainment of healthy outcomes by all. 4 Encompassing the enƟre care conƟnuum – The Regional AcƟon Plan affirms the importance of a balanced approach to noncommunicable diseases, beginning with prevenƟon and health promoƟon, lifestyle intervenƟons to modify risk factors, screening, clinical intervenƟons for high-risk individuals and groups, all the way through to chronic care, rehabilitaƟon and palliaƟon. This implies that the acƟve parƟcipaƟon of the enƟre health system is fundamental to creaƟng impacts on populaƟon health. 5 Involving the whole of society – Many of the criƟcal intervenƟons to prevent and control chronic diseases lie outside of the direct sphere of influence of the health sector. Thus, mulƟsectoral partnerships are essenƟal to successful NCD prevenƟon and control.

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6 Integral to health systems strengthening – Noncommunicable diseases impact on the health care system not only in terms of increased service uƟlizaƟon and the associated costs, but also in the nature of the demands on service delivery to meet the needs of paƟents requiring long-term care. Health systems, in general, are designed to provide acute illness care, not chronic care.15 As such, most health systems fall short in the following areas: a. the paƟent’s responsibility and role in disease management are not emphasized; b. follow-up is sporadic; c. community services tend to be ignored; and d. prevenƟon is underuƟlized and underemphasized. As the NCD burden grows, ensuring that health systems can adequately address noncommunicable diseases becomes integral to augmenƟng the capacity of health systems to meet evolving health challenges. For this to occur, integraƟng NCD prevenƟon and management into primary health care is essenƟal. 7 Consistent with the Global AcƟon Plan, and supporƟve of exisƟng regional strategies and acƟon plans – Recommended acƟons are in line with the objecƟves of the Global AcƟon Plan, and with the strategies and principles of previous regional plans. This plan uƟlizes the best available science in selecƟng strategic acƟons while acknowledging the current limitaƟons of research into the effecƟveness of NCD intervenƟons. 8 Flexibility through a phased approach – Recognizing that countries and areas are at different stages of capacity for NCD prevenƟon and control, the Regional AcƟon Plan aligns its strategic acƟons along a conƟnuum consistent with the NCD causaƟon pathway. This phased approach allows countries to intervene at different points along the conƟnuum depending on their local situaƟon, capacity and resources.

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3.3 Strategic approach The Western Pacific Regional AcƟon Plan for Noncommunicable Diseases uƟlizes a comprehensive approach that simultaneously seeks to effect change at three levels: 1 2 at the environmental level, through policy and regulatory intervenƟons; at the level of common and intermediate risk factors, through populaƟon-based lifestyle intervenƟons; and at the level of early and established disease, through clinical intervenƟons targeted at the enƟre populaƟon (screening), high-risk individuals (risk factor modificaƟon) and persons with established disease (clinical management).

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To support change in these three levels, addiƟonal acƟons are needed in the following areas: 1 advocacy; 2 research, surveillance and evaluaƟon; 3 leadership, mulƟsectoral partnerships and community mobilizaƟon; and 4 health systems strengthening. In summary, the approach recognizes seven strategic acƟon areas (Figure 2) along an intervenƟon pathway that corresponds to the NCD causaƟon pathway (see Annex A for a fuller descripƟon of the intervenƟon pathway). Specific regional acƟons under each of these acƟon areas were mapped to the Global AcƟon Plan. Where appropriate, specific acƟons from established regional and global frameworks and plans of acƟon are included, demonstraƟng that these various disease and risk factor-specific acƟon plans can be systemaƟcally integrated into one comprehensive strategy. Indeed, these various frameworks should be considered as “pieces of a puzzle”, which, when assembled, provide components of a coherent and organized response to the challenge of chronic diseases (see Annex B).

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Figure 2. Strategic approach and acƟon areas in the Western Pacific Regional AcƟon Plan for Noncommunicable Diseases

1.

ENVIRONMENTAL INTERVENTIONS (macroeconomic and policy change) • Governance • Policy and legislaƟon • CreaƟng supporƟve environments

2. • • • •

LIFESTYLE INTERVENTIONS Behavioural intervenƟons Health promoƟon InformaƟon and educaƟon Improving the ‘built’ environment 4. ADVOCACY

3.

CLINICAL INTERVENTIONS • Clinical prevenƟve services • Risk factor detecƟon (screening) and control • Acute care • Chronic care and rehabilitaƟon • PalliaƟve care

5. RESEARCH, SURVEILLANCE AND EVALUATION 7. HEALTH SECTOR RESPONSE • Primary health care • Chronic care management • Health systems strengthening

6.

“WHOLE ͳOFͳGOVERNMENT” AND WHOLEͳOFͳSOCIETY RESPONSE • Leadership • MulƟsectoral partnership • Community mobilizaƟon

The process to operaƟonalize these acƟons is described in Annex C. The process consists of four major steps: (1) profiling; (2) planning and priority seƫng; (3) puƫng into pracƟce (implementaƟon); and (4) evaluaƟon. Using an iteraƟve process, countries move from their baseline situaƟon in relaƟon to noncommunicable diseases to progressively higher levels of capacity and acƟon.

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3.4 Scope and consideraƟons Research indicates that four noncommunicable diseases are responsible for the majority of mortality and disease burden in developing countries. These four are cardiovascular disease (coronary heart disease and stroke), cancer, chronic respiratory disease and diabetes. Because these four diseases, and their shared risk factors, make the largest contribuƟon to the Region’s mortality, they are the major focus of this Regional AcƟon Plan. However, other noncommunicable diseases, including blindness, deafness, oral diseases, certain geneƟc diseases and a number of infecƟous diseases that have a chronic nature, such as HIV/AIDS and tuberculosis, remain priority health problems in the Western Pacific Region. Noncommunicable diseases also include injuries that have an acute onset but are followed by prolonged convalescence and impaired funcƟon, as well as chronic mental diseases and substance abuse disorders. This Regional AcƟon Plan recognizes that Member States must assess, and health systems must respond to, the health burden specific to each country’s situaƟon, realizing that many of the intervenƟons specified in this strategy have broad applicaƟon and uƟlity.

3.5 ObjecƟves and acƟons Consistency with the Global AcƟon Plan This Regional AcƟon Plan is intended to fully support the Global AcƟon Plan. The objecƟves and major strategic acƟons are, therefore, taken directly from the Global AcƟon Plan. Specific regional acƟons are listed as subsets of the major strategic acƟons, and are indicated in italics. Global acƟons that have lesser relevance or applicability at the regional level are indicated accordingly. Where addiƟonal regional acƟons have been idenƟfied, these are listed in a separate secƟon following the global acƟons. Discussion in the Western Pacific Region strongly emphasized the importance of health system strengthening as a fundamental aspect of an effecƟve approach to noncommunicable diseases in the Region. However, for consistency, recommended strategic acƟons for health systems strengthening are situated under ObjecƟve 2 of the Global AcƟon Plan. 12

OBJECTIVE 1

Recommended acƟons for Member States It is proposed that, in accordance with their legislaƟon and as appropriate in view of their specific circumstances, Member States consider undertaking the acƟons set out below. 1 Assess and monitor the public health burden imposed by noncommunicable diseases and their determinants, with special reference to poor and marginalized populaƟons. 2 Incorporate the prevenƟon and control of Noncommunicable diseases in poverty-reducƟon strategies and in relevant social and economic policies. • Increase awareness among regional, naƟonal and community leaders and other partners of the magnitude of the NCD burden, and the wider societal benefits of addressing it in terms of economic and social development, and advocate for their commitment to whole-of-government and whole-of-society approaches to control noncommunicable diseases and their risk factors. Engage with other Member States and relevant regional and internaƟonal bodies to address NCD risk factors and disease issues that cross naƟonal borders. As examples, consider the public health impact on respiratory health during cross-country discussions on haze control, and incorporate health impacts of unhealthy products in trade agreements, such as those arising from the AssociaƟon of South East Asian NaƟons (ASEAN) and the Pacific Island Countries Trade Agreement (PICTA).

To raise the priority accorded to noncommunicable disease in development work at global and national levels, and to integrate prevention and control of such diseases into policies across all government departments

•

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3 Adopt approaches to policy development that involve all government departments, ensuring that public health issues receive an appropriate cross-sectoral response. 4 Implement programmes that tackle the social determinants of noncommunicable diseases with parƟcular reference to the following: health in early childhood, the health of the urban poor, fair financing and equitable access to primary health care services. • IdenƟfy and uƟlize opportuniƟes to merge NCD prevenƟon and control into related health and non-health policy areas relevant to the Western Pacific Region, such as those that address urban development (e.g. Healthy CiƟes), poverty alleviaƟon, gender and health, workers’ health (e.g. Healthy Workplaces) and sustainable development (e.g. Healthy Islands).

Recommended acƟons for WHO 1 Raise the priority given to the prevenƟon and control of noncommunicable diseases on the agendas of relevant high-level forums and meeƟngs of naƟonal and internaƟonal leaders. • AcƟvely advocate for governments and other regional stakeholders to support efforts to integrate NCD prevenƟon and control into the global development agenda, and to allocate resources for the expansion of the implementaƟon of chronic disease prevenƟon and control strategies regionally at forums such as the Pacific Islands Forum and the annual meeƟng of ASEAN heads of state and government. Coordinate and expedite efforts by Member States to reduce the burden of noncommunicable diseases in the Region. Develop regional leadership programmes to support country-level leadership iniƟaƟves that promote poliƟcal champions for NCD prevenƟon and control, building on exisƟng models such as Pro-Leadi, and using exisƟng venues such as the annual Saitama NCD training course.

• •

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Pro-Lead (hƩp://www.prolead.org)is a leadership development programme that focuses on applied leadership and management in health promoƟon intended for advocates, pracƟƟoners and partners in the health sector, government and private sector and civil society, for the promoƟon of health.

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2 Work with countries in building and disseminaƟng informaƟon about the necessary evidencebased and surveillance data in order to inform policy-makers, with special emphasis on the relaƟonship between noncommunicable diseases, poverty and development. • Facilitate dialogue among relevant stakeholders at the regional level to ensure that regional, mulƟlateral and bilateral policies and other regulatory agreements are consistent with the evidence base for NCD prevenƟon and control.

3 Develop and disseminate tools that enable decision-makers to assess the impact of policies on the determinants of, risk factors for, and consequences of noncommunicable diseases; and provide models of effecƟve, evidence-based policy-making. • Provide countries with technical assistance in the development, implementaƟon and assessment of effecƟve advocacy campaigns for the prevenƟon and control of noncommunicable diseases. Work with Member States, collaboraƟng centres, and other partner insƟtuƟons and agencies to establish and maintain a repository or clearinghouse of best pracƟces and successful strategies for policies to reduce prevalence of NCD risk factors and to promote the adopƟon of healthier lifestyles. Provide technical guidance to countries in formulaƟng and implemenƟng policy and regulatory intervenƟons designed to create supporƟve environments for NCD prevenƟon and control based on exisƟng guidance documents.

•

•

4 Draw up a document in support of policy coherence, poinƟng out connecƟons between the findings of the Commission on Social Determinants of Health and the prevenƟon and control of noncommunicable diseases; and take forward the work on social determinants of health as it relates to noncommunicable diseases.

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Recommended acƟons for internaƟonal partners and WHO collaboraƟng centres 1 Include the prevenƟon and control of noncommunicable diseases as an integral part of work on global development and in related investment decisions. • Work with WHO to facilitate regional collaboraƟve partnerships among countries, WHO collaboraƟng centres and relevant partners to advocate for investments in regional NCD prevenƟon and control iniƟaƟves as part of the regional development agenda. For example, consider the model used by the Western Pacific DeclaraƟon on Diabetes as a partnership model for WHO, InternaƟonal Diabetes FederaƟon Western Pacific Region, Secretariat of the Pacific Community (SPC) and Member States.

2 As appropriate, work with WHO to involve all stakeholders in advocacy in order to raise awareness of the increasing magnitude of the public health problems posed by noncommunicable diseases, and of the fact that tackling the determinants of and risk factors for such diseases has the potenƟal to be a significant method of prevenƟon. • Provide technical assistance to countries and areas through a regional clearinghouse of best pracƟces and successful strategies for NCD advocacy.

3 Support WHO in creaƟng forums where key stakeholders – including nongovernmental organizaƟons, professional associaƟons, academia, research insƟtuƟons and the private sector – can contribute and take concerted acƟon against noncommunicable diseases.

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OBJECTIVE 2

Recommended acƟons for Member States It is proposed that, in accordance with their legislaƟon and as appropriate in view of their specific circumstances, Member States consider undertaking the acƟons set out below. NaƟonal mulƟsectoral framework for the prevenƟon and control of noncommunicable diseases 1 Develop and implement a comprehensive policy and plan for the prevenƟon and control of major noncommunicable diseases, and for the reducƟon of modifiable risk factors. • Design and implement an advocacy campaign to mobilize poliƟcal and grassroots support for the naƟonal acƟon plan for NCD prevenƟon and control. Support the integrated approach to NCD prevenƟon and control through policy statements and official guidelines. As an example, consider Japan’s “People’s Health PromoƟon Campaign for the 21st Century (Health Japan 21),” which endorses a comprehensive approach to NCD as a core element of Japan’s naƟonal public health agenda.

To establish and strengthen national policies and plans for the prevention and control of noncommunicable diseases

•

2 Establish a high-level naƟonal mulƟsectoral mechanism for planning, guiding, monitoring and evaluaƟng enactment of the naƟonal policy with the effecƟve involvement of sectors outside health. 3 Conduct a comprehensive assessment of the characterisƟcs of noncommunicable diseases and the scale of the problems they pose, including an analysis of the impact on such diseases of the policies of the different government sectors. 17

4 Review and strengthen, when necessary, evidence-based legislaƟon, together with fiscal and other relevant policies, which are effecƟve in reducing modifiable risk factors and their determinants. • • Consider fiscal policies that reinforce healthy lifestyle choices through pricing, taxaƟon, subsidies and other market incenƟves. Prepare and put in place, as appropriate and with all relevant stakeholders, a framework and/or mechanisms to promote a social and media environment that is supporƟve of healthy lifestyles and encourages responsible markeƟng. Regulate the built environment to promote physical acƟvity and social interacƟon and to protect people from hazardous exposures such as second-hand smoke.

•

IntegraƟon of the prevenƟon and control of noncommunicable diseases into the naƟonal health development plan 1 Establish an adequately staffed and funded noncommunicable disease and health promoƟon unit within the ministry of health or other comparable government health authority. 2 Establish a high-quality surveillance and monitoring system that should provide, as minimum standards, reliable populaƟon-based mortality staƟsƟcs and standardized data on noncommunicable diseases, key risk factors and behavioural paƩerns, based on the WHO STEPwise approach to risk factor surveillance. 3 Incorporate evidence-based, cost-effecƟve primary and secondary prevenƟon intervenƟons into the health system with emphasis on primary health care. ReorientaƟon and strengthening of health systems 1 Ensure that provision of health care for chronic diseases is dealt within the context of overall health system strengthening and that the infrastructure of the system, in both the public and private sectors, has the elements necessary for the effecƟve management of and care for chronic condiƟons. Such elements include appropriate policies, trained human resources, adequate access to essenƟal medicines and basic technologies, standards for primary health care, and well-funcƟoning referral mechanisms. 18

•

Reorient and reinforce health systems, using the six “building blocks”,16 to enhance responsiveness and capacity to address the challenges of NCD prevenƟon and control, guided by the recommendaƟons of the 2007 WHO Regional MeeƟng on Strengthening Health Systems to Improve Chronic Disease PrevenƟon and Control. One example is Mongolia’s “Master Plan for Health System Development 2006–2015”, which uses an integrated approach to NCD prevenƟon and control as an anchor for health systems strengthening. Another is the Republic of Korea’s “Comprehensive PrevenƟve NaƟonal Health Management System”, which incorporates lifecycle-specific services for health promoƟon and NCD prevenƟon into the naƟonal health-service delivery system. Strengthen primary health care to respond to all chronic diseases regardless of aeƟology, using the Chronic Care model. Explore innovaƟve service delivery models that encompass both populaƟon-based prevenƟve and behavioural services and clinical services for chronic disease management. For example, consider the Sentrong Siglaii model of the Philippines.

• •

2 Adopt, implement and monitor the use of evidence-based guidelines and establish standards of health care for common condiƟons like cardiovascular diseases, cancers, diabetes and chronic respiratory diseases, integraƟng, whenever feasible, their management into primary health care. • Disseminate health service frameworks, clinical pracƟce guidelines and evidence-based decision-making support tools to health care providers to ensure Ɵmely screening, diagnosis, and treatment of noncommunicable diseases, consistent with country-specific burden and taking into account the health infrastructure and capacity. Implement and scale up proven cost-effecƟve NCD intervenƟons, beginning with: • • • ii

•

tobacco control, salt reducƟon, mulƟdrug treatment for individuals with high risk for cardiovascular disease.

Sentrong Sigla is a quality improvement programme of the Philippines Department of Health that confers recogniƟon to health centres and hospitals for excellence in health service delivery, including the use of an integrated approach to disease management.

19

•

Promote clinical pracƟce guidelines that use the integrated disease model, such as those issued by the InternaƟonal Diabetes FederaƟon (IDF) Western Pacific Region.

3 Implement and monitor cost-effecƟve approaches for the early detecƟon of breast and cervical cancers, diabetes, hypertension and other cardiovascular risk factors. 4 Strengthen human resources capacity, improve training of physicians, nurses and other health personnel and establish a conƟnuing educaƟon programme at all levels of the health care system, with a special focus on primary health care. • Use innovaƟve approaches to health workforce development to equip health care providers with the necessary skills, knowledge and aƩributes to deliver effecƟve, people-centred care for chronic diseases regardless of aeƟology. Foster leadership for noncommunicable diseases within the health care sector by building on exisƟng models such as Pro-Lead, and using exisƟng venues such as the annual Saitama NCD training course.

•

5 Take acƟon to help people with noncommunicable diseases to manage their own condiƟons beƩer, and provide educaƟon, incenƟves and tools for self-management and care. • Promote the people-centred approach to health care, as outlined in the recent WHO publicaƟon, People at the Centre of Health Care: Harmonizing Body and Mind, People and Systems.17 Establish programmes to empower individuals and communiƟes to develop health literacy, to take on self-care responsibiliƟes and to become resources for themselves and others in disease management and prevenƟon. Adopt intervenƟons to improve the quality of life of individuals with noncommunicable diseases.

•

•

20

6 Develop mechanisms for sustainable health financing in order to reduce inequiƟes in accessing health care. • Establish financing mechanisms to channel sustainable funding to NCD prevenƟon and control iniƟaƟves, such as through earmarking tobacco and alcohol taxes for health promoƟon, as was done in Australia by the Victorian Health PromoƟon FoundaƟon (VicHealth) and in the Republic of Korea, and was iniƟated in Malaysia, Mongolia and Tonga. Promote equitable access to and raƟonal use of cost-effecƟve medical products and commodiƟes related to NCD disease management.

•

Recommended acƟons for WHO NaƟonal mulƟsectoral framework for the prevenƟon and control of noncommunicable diseases 1 Conduct a review of internaƟonal experience in the prevenƟon and control of noncommunicable diseases, including community-based programmes, and idenƟfy and disseminate lessons learnt. [AcƟon to be led by WHO Headquarters.] 2 Recommend, based on a review of internaƟonal experience, successful approaches for intersectoral acƟon against noncommunicable diseases. • Build on previous intersectoral iniƟaƟves in the Region, such as the WHO/FAO MeeƟng on Food Standards to Promote Health and Fair Trade in the Pacific (December 2007) and the WHO Healthy CiƟes and Healthy Islands IniƟaƟve. Highlight successful naƟonal examples of intersectoral strategies that address noncommunicable diseases and their risk factors, such as New Zealand’s “Healthy EaƟng – Healthy AcƟon”.iii

•

iii

“Healthy EaƟng – Healthy AcƟon” is the New Zealand Ministry of Health’s strategic approach to improving nutriƟon, increasing physical acƟvity and achieving healthy weight for all New Zealanders. It uses a "whole-of-society" approach to address NCD risk factors in the populaƟon (www.moh.govt.nz/healthyeaƟnghealthyacƟon).

21

3 Provide guidance for the development of naƟonal policy frameworks, including evidence-based public health policies for the reducƟon of risk factors, and provide technical support to countries in adapƟng these policies to their naƟonal context. IntegraƟon of the prevenƟon and control of noncommunicable diseases into the naƟonal health development plan 1 Expand, over the Ɵme frame of this plan, the technical capacity of WHO’s regional and country offices and develop networks of experts and collaboraƟng or reference centres for the prevenƟon and control of noncommunicable diseases in support of naƟonal programmes. 2 Develop norms for surveillance and guidelines for primary and secondary prevenƟon, based on the best available scienƟfic knowledge, public health principles and exisƟng WHO tools. [AcƟon to be led by WHO Headquarters.] • Disseminate to Member States exisƟng surveillance standards and clinical pracƟce guidelines, such as WHO’s “PrevenƟon of Cardiovascular Disease: Guidelines for Assessment and Management of Cardiovascular Risk” and the InternaƟonal Agency for Research on Cancer’s “Handbooks of Cancer PrevenƟon”.

3 Review and update diagnosƟc criteria, classificaƟons and, where needed, management guidelines for common noncommunicable diseases. [AcƟon to be led by WHO Headquarters.] 4 Provide support to countries, in collaboraƟon with internaƟonal partners, in strengthening opportuniƟes for training and capacity-building with regard to the public health aspects of the major noncommunicable diseases. • Support countries and areas with periodic technical assistance and training at the naƟonal and regional level, including training in the selecƟon of appropriate clinical intervenƟons that are feasible to implement even within a developing country seƫng, and in the peoplecentred approach to noncommunicable diseases.

22

ReorientaƟon and strengthening of health systems 1 Ensure that the response to noncommunicable diseases is placed at the forefront of efforts to strengthen health systems. • Promote a regional framework for health systems strengthening in relaƟon to noncommunicable diseases (building on the Chronic Care model and similar concepts) that is relevant to and adaptable for the Region. Support Member States in their efforts to strengthen their health systems and re-orient their systems of care to address chronic diseases, as guided by the “Strategic Plan for Strengthening Health Systems in the WHO Western Pacific Region”. Reinforce the integrated approach to noncommunicable diseases by arƟculaƟng this in policy statements and guidelines.

•

•

2 Provide technical guidance to countries in integraƟng cost-effecƟve intervenƟons against major noncommunicable diseases into their health systems. • Provide countries with technical assistance regarding service delivery models for chronic disease, with an emphasis on integraƟng NCD prevenƟon and control intervenƟons into primary health care. For example, consider integraƟon of brief intervenƟons for tobacco cessaƟon into all clinical encounters. Encourage and assist Member States to develop appropriate naƟonal health care guidelines that incorporate noncommunicable diseases and other chronic disease care into the overall health care package.

•

3 Provide support to countries in enhancing access to essenƟal medicines and affordable medical technology, building on the conƟnuing WHO programmes promoƟng both good-quality generic products, and the improvement of procurement, efficiency and management of medicine supplies. • Disseminate guidelines for raƟonal use of medicines and technology for NCD prevenƟon and control, as an integral part of health systems.

23

4 Assess exisƟng models for self-examinaƟon and self-care, and design improved affordable versions where necessary, with a special focus on populaƟons with low health awareness and/or literacy.

Recommended acƟons for internaƟonal partners and WHO collaboraƟng centres 1 Support the development and strengthening of internaƟonal, regional, and naƟonal alliances, networks and partnerships in order to support countries in mobilizing resources, building effecƟve naƟonal programmes and strengthening health systems so that they can meet the growing challenges posed by noncommunicable diseases. • Expand and build upon regional (e.g. Western Pacific DeclaraƟon on Diabetes, Framework Convention Alliance Asia-Pacific) and national alliances for NCD capacity-building (e.g. Singapore’s Civic CommiƩee on Healthy Lifestyle). Disseminate technical resources relevant to noncommunicable diseases to countries and areas. For example, ensure that all countries and areas have the publicaƟon, “AcƟng on Noncommunicable Diseases: An Advocacy Guide for the Western Pacific”, developed by La Trobe University, Australia.

•

2 Support implementaƟon of intervenƟon projects, exchange of experience among stakeholders, and regional and internaƟonal capacity-building programmes.

24

OBJECTIVE 3

Recommended acƟons for Member States It is proposed that, in accordance with their legislaƟon and as appropriate in view of their specific circumstances, Member States consider undertaking the acƟons set out below. Tobacco control 1 Strengthen the implementaƟon of the Framework ConvenƟon on Tobacco Control 2 Implement the following package of six cost-effecƟve policy intervenƟons (the MPOWER package), which builds on the measures for reducing demand contained in the WHO Framework ConvenƟon for Tobacco Control: • • • • • • • monitor tobacco use and tobacco prevenƟon policies; protect people from tobacco smoke in public places and workplaces; offer help to people who want to stop using tobacco; warn people about the dangers of tobacco; enforce bans on tobacco adverƟsing, promoƟon and sponsorship; and raise tobacco taxes and prices. Delineate and implement intervenƟons to reduce the demand for and limit the supply of tobacco, including chewing tobacco with betel nut. Introduce intervenƟons to facilitate and increase access to smoke-free faciliƟes.

To promote interventions to reduce the main shared modifiable risk factors for noncommunicable diseases: tobacco use, unhealthy diets, physical inactivity and harmful use of alcohol

In parƟcular:

•

25

PromoƟng healthy diet 1 Implement the acƟons recommended in, but not limited to, the Global Strategy on Diet, Physical AcƟvity and Health. In parƟcular: • • Delineate and implement intervenƟons to reduce the demand for unhealthy foods and increase the availability of healthy foods. Promote the consumpƟon of healthy local foods, as is happening in some Pacific island countries (e.g. promoƟon of local bananas rich in vitamin A in the Federated States of Micronesia).

PromoƟng physical acƟvity 1 Implement the acƟons recommended in, but not limited to, the Global Strategy on Diet, Physical AcƟvity and Health. • Increase access of communiƟes to exercise faciliƟes (e.g. Tonga’s “Walking Path”, Malaysia’s “ProAcƟve Scheme” ).iv

Reducing the harmful use of alcohol 1 Respond effecƟvely to the public health challenges posed by harmful use of alcohol – in accordance with exisƟng regional strategies and guided by the outcome of current and future WHO global acƟviƟes to reduce harmful use of alcohol. • Adopt and begin implementaƟon of the Western Pacific Regional Strategy to Reduce Alcoholrelated Harm.

iv

Malaysia’s ProAcƟve scheme engages sports organizaƟons and communiƟes to develop community-based physical acƟviƟes and acƟve recreaƟonal projects, making physical acƟviƟes aƩracƟve and accessible to community members who do not normally parƟcipate or are currently inacƟve (www.healthpromo.gov.my/healthpromo.asp?val=scheme2).

26

AddiƟonal recommended regional acƟons 1 UƟlize media and social markeƟng to promote healthy choices and to increase knowledge and awareness of NCD risk factors. Apply lessons learnt from previous iniƟaƟves, such as the WHO Regional Office’s “It’s OK to Say You Mind” campaign on second-hand smoke, using culturally relevant messages. 2 Incorporate NCD prevenƟon and control intervenƟons into the “Healthy Seƫngs” approach. As an example, consider Papua New Guinea’s pilot obesity and physical acƟvity programme for workplaces, conducted jointly by the Ministry of Health and the Papua New Guinea’s Sports FederaƟon.

Recommended acƟons for WHO 1 Use exisƟng strategies such as the WHO Framework ConvenƟon on Tobacco Control, the Global Strategy on Diet, Physical AcƟvity and Health, the Global Strategy for Infant and Young Child Feeding, and other relevant strategies that have been the subject of resoluƟons adopted by the World Health Assembly, in order to provide technical support to countries in implemenƟng or strengthening naƟonwide acƟon to reduce risk factors for noncommunicable diseases and their determinants. • Develop and disseminate appropriate technical guidelines on populaƟon-based strategies to moƟvate behaviour change, when none currently exist.

2 Guide the development of pilot or demonstraƟon community-based programmes of intervenƟon. • • Consider support to countries for pilot or demonstraƟon projects for promising intervenƟons that have not been extensively studied for applicability and relevance to the Region. Document and disseminate lessons learnt and assist countries to replicate and scale up proven intervenƟons. For example, share lessons learnt from community-based intervenƟons for salt reducƟon as implemented in the Tianjin Study, China with other Member States.

3 Support the development of networks of community-based programmes at the regional and global levels.

27

4 Provide support to countries in implemenƟng the MPOWER package and provide technical support to implement other measures contained in the WHO Framework ConvenƟon on Tobacco Control in response to specific naƟonal needs. • Support countries and areas with periodic technical assistance and training at the naƟonal and regional level, including training in the use of evidence to guide the selecƟon, development and implementaƟon of populaƟon-based lifestyle intervenƟons.

5 Ensure synergy with the work of the ConvenƟon Secretariat and the implementaƟon of the WHO Framework ConvenƟon on Tobacco Control in applying the tobacco-control component of this plan. [AcƟon to be led by WHO Headquarters.]

Recommended acƟons for internaƟonal partners and WHO collaboraƟng centres 1 Provide support for and parƟcipate in the development and implementaƟon of technical guidance and tools in order to reduce the main shared modifiable risk factors for noncommunicable diseases. • Invest in naƟonal programmes to reduce modifiable risk factors, such as what Bloomberg Philanthropies is undertaking with tobacco control in China, the Philippines and Viet Nam.

28

OBJECTIVE 4

Recommended acƟons for Member States It is proposed that, in accordance with their legislaƟon and as appropriate in view of their specific circumstances, Member States consider undertaking the acƟons set out below. 1 Invest in epidemiological, behavioural, and health system research as part of naƟonal programmes for the prevenƟon of noncommunicable diseases and develop – jointly with academic and research insƟtuƟons – a shared agenda for research, based on naƟonal prioriƟes. • Establish or strengthen and expand naƟonal research infrastructure and capacity to enable robust data collecƟon for NCD prevenƟon and control. Consider designaƟng a lead agency or designated lead within the ministry or department of health to oversee and manage naƟonal research iniƟaƟves for noncommunicable diseases. Work with partners and academic insƟtuƟons to prioriƟze implementaƟon research for noncommunicable diseases. Consider innovaƟve approaches to behavioural research, such as community-based parƟcipatory research methods, for shiŌing populaƟon behaviour towards healthier choices.

To promote research for the prevention and control of noncommunicable diseases

•

•

•

2 Encourage the establishment of naƟonal reference centres and networks to conduct research on socioeconomic determinants, gender, cost-effecƟveness of intervenƟons, affordable technology, health system reorientaƟon and workforce development. 29

AddiƟonal recommended regional acƟon 1 Disseminate research findings through parƟcipaƟon in exisƟng informaƟon disseminaƟon venues such as the MobilizaƟon of Allies on Noncommunicable Disease AcƟon (MOANA)v and ProCOR.vi

Recommended acƟons for WHO 1 Develop a research agenda for noncommunicable diseases in line with WHO’s global research strategy, collaborate with partners and the research community and involve major relevant consƟtuencies in prioriƟzing, implemenƟng, and funding research projects. A prioriƟzed research agenda for noncommunicable diseases should generate knowledge and help to translate knowledge into acƟon through innovaƟve approaches in the context of low- and middle-income countries. [AcƟon to be led by WHO Headquarters.] • Assist Member States to develop relevant and pracƟcal research agendas to support NCD prevenƟon and control.

2 Encourage WHO collaboraƟng centres to incorporate the research agenda into their plans and facilitate collaboraƟve research through bilateral and mulƟlateral collaboraƟon and mulƟcentre projects.

v

MOANA is an NCD network in the Western Pacific Region, with an acƟve web-based informaƟon disseminaƟon and discussion group. ProCOR (www.procor.org), a programme of the Lown Cardiovascular Research FoundaƟon, is an ongoing, e-mail and webbased electronic conference aimed at addressing the epidemic of cardiovascular diseases in the developing world.

vi

30

Recommended acƟons for internaƟonal partners and WHO collaboraƟng centres 1 Support low- and middle-income countries in building capacity for epidemiological and health systems research, including the analyƟcal and operaƟonal research required for programme implementaƟon and evaluaƟon in the area of noncommunicable diseases. 2 Support, and work jointly on, priority research on noncommunicable diseases at the global, regional and subregional levels, parƟcularly research on socio-economic determinants, lifestyle and behaviour modificaƟon, community-based intervenƟons, equity, reorientaƟon of health systems and primary health care, together with research that explores models of care that are applicable to resource-poor seƫngs. 3 Strengthen and support WHO collaboraƟng centres and naƟonal reference centres and monitor iniƟaƟves and partnerships involved in research related to the prevenƟon and control of noncommunicable diseases.

31

OBJECTIVE 5

Recommended acƟons for Member States It is proposed that, in accordance with their legislaƟon and as appropriate in view of their specific circumstances, Member States consider undertaking the acƟons set out below. 1 ParƟcipate acƟvely in regional and subregional networks for the prevenƟon and control of noncommunicable diseases. 2 Establish effecƟve partnerships for the prevenƟon and control of noncommunicable diseases, and develop collaboraƟve networks, involving key stakeholders, as appropriate. • Encourage and promote community parƟcipaƟon and grassroots mobilizaƟon to establish a broad base of support for the prevenƟon and control of chronic diseases and to ensure acceptability and effecƟveness of policy and populaƟon-based intervenƟons. For example, promote the growth of community coaliƟons for noncommunicable diseases, such as the Philippine CoaliƟon for the PrevenƟon and Control of NCD. Explore working with appropriate partners, such as the food industry, to establish public health intervenƟons for NCD prevention and control. For example, consider Singapore’s Nutrition Labelling programmevii and New Zealand’s Food Industry Group (FIG).viii

To promote partnerships for the prevention and control of noncommunicable diseases

•

vii

Singapore's NutriƟon Labelling Programme (www.hpb.gov.sg/hpb) is a programme whereby the Ministry of Health works with the food industry to provide nutriƟon informaƟon on food packaging at the point of sale.

viii The Food Industry Group of New Zealand (www.fig.org.nz) was formed to encourage food companies to work with the Government and the community to solve the problem of obesity.

32

Recommended acƟons for WHO 1 Establish an advisory group in 2008 in order to provide strategic and technical input and conduct external reviews of the progress made by WHO and its partners in the prevenƟon and control of noncommunicable diseases. [AcƟon to be led by WHO Headquarters.] 2 Encourage the acƟve involvement of exisƟng regional and global iniƟaƟves in the implementaƟon and monitoring of the global strategy for the prevenƟon and control of noncommunicable diseases, and of related strategies. • AcƟvely promote collaboraƟve relaƟonships with internaƟonal stakeholders and regional funders of health programmes to support the work in NCD prevenƟon and control within the Region, commensurate with the burden. Assist Member States to establish and use cross-country alliances, networks and partnerships for NCD capacity-building, advocacy, research and surveillance (e.g. Alliance for Healthy CiƟes, MOANA). Cross-country alliances can also facilitate unified responses to transnaƟonal issues that affect noncommunicable diseases, such as trade issues and global markeƟng of unhealthy lifestyles. For example, follow-up on the conclusions of the MeeƟng of the Ministers of Health of the Pacific Island Countries in Vanuatu, which call for engagement with the food and trade sectors to ensure that the health impact of trade agreements on diet is minimized.

•

3 Support and strengthen the role of WHO collaboraƟng centres by linking their plans to the implementaƟon of specific intervenƟons in the global strategy. 4 Facilitate and support, in collaboraƟon with internaƟonal partners, a global network of naƟonal, regional, and internaƟonal networks and programmes such as the WHO regional networks for noncommunicable disease prevenƟon and control. [AcƟon to be led by WHO Headquarters.]

33

AddiƟonal recommended regional acƟons for WHO 1 Advise Member States on ways of engaging construcƟvely with appropriate industries. 2 Provide technical assistance and other support to countries to promote social mobilizaƟon and community parƟcipaƟon in NCD prevenƟon and control.

Recommended acƟons for internaƟonal partners and WHO collaboraƟng centres 1 Collaborate closely with and provide support to Member States and the Secretariat in implemenƟng the various components of the global strategy for the prevenƟon and control of noncommunicable diseases. • AcƟvely encourage internaƟonal and appropriate private partners to support NCD prevenƟon and control in the Region.

2 Give priority to noncommunicable diseases in internaƟonal and regional iniƟaƟves to strengthen health systems based on primary health care. 3 Support the establishment and strengthening of coordinated global, regional and subregional networks for the prevenƟon and control of noncommunicable diseases.

34

OBJECTIVE 6

Recommended acƟons for Member States It is proposed that, in accordance with their legislaƟon and as appropriate in view of their specific circumstances, Member States consider undertaking the acƟons set out below. 1 Strengthen surveillance systems and standardized data collecƟon on risk factors, disease incidence and mortality by cause, using exisƟng WHO tools. • Regularly parƟcipate and implement standard global and regional surveys, such as the WHO STEPS survey and the various surveys comprising the Global Tobacco Surveillance System, and use the data to guide NCD policy and programme development.

To monitor noncommunicable diseases and their determinants, and evaluate progress at the national, regional and global levels

2 Contribute, on a rouƟne basis, data and informaƟon on trends in respect of noncommunicable diseases and their risk factors disaggregated by age, gender, and socioeconomic groups; and provide informaƟon on progress made in implementaƟon of naƟonal strategies and plans.

Recommended acƟons for WHO 1 Develop and maintain an informaƟon system to collect, analyse and disseminate data and informaƟon on trends in respect of mortality, disease burden, risk factors, policies, plans and programmes using currently available data sources like the WHO Global InfoBase and other exisƟng global informaƟon systems. This database will be expanded to handle new informaƟon on subjects such as health services coverage, related costs, and quality of care. [AcƟon to be led by WHO Headquarters.] 35

• •

At the regional level, maintain a STEPS survey database, including use of STEPS data for policy. Make use of exisƟng global databases and inform Member States of the availability of these databases. For example, promote the global cancer database of the InternaƟonal Agency for Research on Cancer (IARC).

2 Establish a reference group for noncommunicable diseases and risk factors, made up of experts in epidemiology, in order to support the work of the Secretariat and advise countries on data collecƟon and analysis. [AcƟon to be led by WHO Headquarters.] 3 Strengthen technical support to Member States in improving their collecƟon of data and staƟsƟcs on risk factors, determinants and mortality. • ConƟnue to support STEPS training within the Region. 4 Convene a representaƟve group of stakeholders, including Member States and internaƟonal partners, in order to evaluate progress on implementaƟon of this acƟon plan. The group will set realisƟc and evidence-based targets and indicators for use in both the mid-term and final evaluaƟons. • Promote exisƟng evaluaƟon frameworks for Member States to uƟlize, such as the Diet and Physical AcƟvity Strategy (DPAS) Framework to Monitor and Evaluate ImplementaƟon. • Develop relevant indicators and milestones for the Region, where none currently exist, and encourage countries to develop and monitor indicators and milestones at the naƟonal level.

5 Prepare progress reports in 2010 and 2013 on the global status of prevenƟon and control of noncommunicable diseases. [AcƟon to be led by WHO Headquarters.] • Within exisƟng frameworks and mechanisms, contribute to global NCD progress reports by collaƟng data on perƟnent indicators at a regional level.

Recommended acƟons for internaƟonal partners and WHO collaboraƟng centres 1 Work collaboraƟvely and provide support for the acƟons set out for Member States and the Secretariat in monitoring and evaluaƟng, at the regional and global levels, progress in prevenƟon and control of noncommunicable diseases. 2 Mobilize resources to support the system for regional and global monitoring and evaluaƟon of progress in the prevenƟon and control of noncommunicable diseases. 36

4

FINAL WORD

This Regional AcƟon Plan presents a way to operaƟonalize the reducƟon of the burden of chronic disease in the Western Pacific Region. It integrates various frameworks, strategies and acƟon plans addressing specific risk factors and parƟcular diseases into a holisƟc and definiƟve approach to NCD prevenƟon and control (see Annex D). The NCD burden within the Western Pacific is largely an avoidable burden. Current evidence indicates that a significant proporƟon of NCD morbidity, disability and premature deaths within the Region can be averted through prevenƟon, lifestyle modificaƟon and the judicious control of a few common risk factors that underlie the major categories of chronic disease (see Annex E). Member States are requested to seriously consider the strategic acƟons put forward in the Regional AcƟon Plan in light of their parƟcular situaƟon and naƟonal context. Member States are also urged to use this guide in creaƟng and implemenƟng locally relevant policy and regulatory intervenƟons, populaƟonbased lifestyle intervenƟons, targeted clinical intervenƟons and supporƟng strategic acƟons to build healthy populaƟons and communiƟes living in environments that support healthy choices. The Regional AcƟon Plan is a work in progress. Its success will depend on the applicaƟons in this document, and on the collecƟve ability of the countries and partners in the Region to learn from each other and share experƟse, knowledge and resources, and demonstrate poliƟcal commitment and leadership in effecƟng change for beƩer health.

37

38

ANNEXES

Annex A A Conceptual Framework for NCD PrevenƟon and Control in the Western Pacific: Basis for the Regional AcƟon Plan to OperaƟonalize the Global AcƟon Plan for NCD PrevenƟon and Control Annex B Official WHO documents that guided the development of this Regional AcƟon Plan Annex C Process for OperaƟonalizing the Regional AcƟon Plan for NCD PrevenƟon and Control Annex D Current WHO and other selected tools for NCD PrevenƟon and Control Annex E Affordability of Selected IntervenƟons Annex F WPR/RC59.R5 Noncommunicable Disease PrevenƟon and Control

39

Annex A A conceptual framework for noncommunicable disease prevenƟon and control: basis for the Western Pacific Regional AcƟon Plan The causaƟon pathway for chronic diseases provides the framework for elucidaƟng key components of a Regional AcƟon Plan to operaƟonalizing the Global AcƟon Plan. This framework, as depicted in Figure 2, delineates seven acƟon areas that address various points along the NCD causaƟon pathway:

1 2 3 4 5 6 7

environmental intervenƟons; lifestyle intervenƟons; clinical intervenƟons; advocacy; research, surveillance and evaluaƟon; leadership, mulƟsectoral partnerships and community mobilizaƟon; and health systems strengthening.

Environmental intervenƟons (macroeconomic, structural and policy) address the broad determinants of NCD risk. Lifestyle intervenƟons impact on the common modifiable risk factors, and, to a certain extent, the intermediate risk factors for chronic disease. Clinical intervenƟons bring about change at the level of intermediate risk factors and overt disease. Environmental and lifestyle intervenƟons target the enƟre populaƟon, while clinical intervenƟons target mostly high-risk individuals. Surveillance, research and advocacy are needed throughout the risk conƟnuum, as they fulfil an essenƟal supporƟng funcƟon to the other acƟon areas. AcƟon on the broad determinants largely fall outside of the direct reach of the health sector, but the health sector plays a role in advocacy and partnering with other sectors to effect change. Thus, the set of intervenƟons on the leŌ side of the intervenƟon pathway requires a predominantly “whole-of-government” and “whole-of-society”

40

approach. On the other end of the intervenƟon pathway, clinical intervenƟons rely heavily on the health system for service delivery. PopulaƟon-based lifestyle intervenƟons represent an area of overlap, requiring both a whole-ofgovernment and whole-of-society approach and health system involvement. In reality, governmental and societal acƟon at the macro level has impacts on clinical pracƟces, and, correspondingly, the health sector plays a role in determining policies at the macro level; the diagram aƩempts to portray the relaƟonal dynamics of these two approaches. Hence, to address the enƟre spectrum of chronic disease causaƟon, poliƟcal/community leadership, intersectoral partnerships, community mobilizaƟon and health systems strengthening are criƟcal. This framework emphasizes the requirement for comprehensive approaches that encompass and address the various levels of determinants and risks for noncommunicable diseases. It highlights the importance of a balance between “healthy choices” and “healthy environments” because it recognizes that supporƟve environments are needed to empower healthy choices. It also re-distributes responsibility across the whole of society, with government, health sector, the private sector, nongovernmental organizaƟons, communiƟes, families and individuals all sharing accountability for puƫng in place the necessary elements that promote healthy lifestyles and quality care for noncommunicable diseases. The framework is sufficiently flexible in that intervenƟons for a country can be tailored or concentrated along the specific area of work that is most relevant for the local situaƟon at a given point in Ɵme. For instance, in a country where the risk factors are rising, but overt disease is not yet prevalent, acƟons should be directed primarily towards environmental and lifestyle change. On the other hand, in a country where health expenditures are heavily skewed towards off-island referrals for terƟary-level care, immediate intervenƟons need to focus on improving clinical services. Over the long term, however, it will be necessary to allocate resources for all areas of work to achieve measurable and sustained reducƟons in prevalence of both risks and disease, and the aƩendant consequences of disability and death.

41

Annex B Official WHO documents that guided the development of this Regional AcƟon Plan GLOBAL GUIDANCE General framework, strategy and/or plan of acƟon

REGIONAL GUIDANCE 1 PrevenƟon and control of noncommunicable diseases (Regional CommiƩee for the Western Pacific Region ResoluƟon WPR/RC51.R5, 2000) Noncommunicable disease prevenƟon and control (Regional CommiƩee for the Western Pacific ResoluƟon WPR/RC57. R4, 2006) A Proposal for a Pacific Regional Framework for the PrevenƟon and Control of Noncommunicable Diseases (2007)

1

PrevenƟon and control of noncommunicable diseases (World Health Assembly ResoluƟon WHA53.17, 2000) PrevenƟon and control of noncommunicable diseases: implementaƟon of the global strategy (World Health Assembly ResoluƟons WHA60.23, 2007 and WHA61.14, 2008) AcƟon Plan for the Global Strategy for the PrevenƟon and Control of Noncommunicable Diseases (2008) PrevenƟng Chronic Disease: A Vital Investment (2005) Stop the Global Epidemic of Chronic Disease: Advocacy Toolkit (2007)

2

2

3

3

4 5

Specific to social determinants of noncommunicable diseases

1

Noncommunicable Disease and Poverty: The Need for Pro-poor Strategies in the Western Pacific Region: A Review (2007) IntegraƟng Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals (Module on Noncommunicable Diseases) (2007)

2

42

GLOBAL GUIDANCE Specific to NCD risk factors

REGIONAL GUIDANCE 1 2 Tobacco Free IniƟaƟve Regional AcƟon Plan 2005–2009 Regional Strategy to Reduce Alcohol-related Harm (2006)

1 2 3

WHO Framework ConvenƟon on Tobacco Control Global Strategy on Diet, Physical AcƟvity and Health Strategies to Reduce the Harmful Use of Alcohol (World Health Assembly ResoluƟon WHA61.4) PrevenƟon of Cardiovascular Disease: Pocket Guidelines for Assessment And Management of Cardiovascular Risk (2007) PrevenƟon of Cardiovascular Disease: Guidelines for Assessment and Management of Cardiovascular Risk (2007) Cancer Control: Knowledge into AcƟon, WHO Guide for EffecƟve Programmes (2006) Strengthening Health Systems to Improve Health Outcomes: WHO’s Framework for AcƟon (2007)

Specific to parƟcular noncommunicable diseases

1

1

2

Regional Plan for the Integrated PrevenƟon and Control of Cardiovascular Diseases and Diabetes for the Western Pacific Region 1998–2003 Plan of AcƟon (2006–2010) for the Western Pacific DeclaraƟon on Diabetes: from Evidence to AcƟon

2

3

Specific to health systems and noncommunicable diseases

1

1 2 3

Making Health Systems Work for Chronic Disease (2006) People-Centred Health Care: A Policy Framework (2007) Strategic Plan for Strengthening Health Systems in the WHO Western Pacific Region (2008)

Specific to NCD surveillance

1

WHO STEPwise approach to Surveillance of NCD Risk Factors (STEPS)

43

Annex C Process for operaƟonalizing the global acƟon plan for NCD prevenƟon and control The process for operaƟonalizing the Global AcƟon Plan in the Western Pacific Region, and for systemaƟcally achieving progress in NCD prevenƟon and control, incorporates four major steps: (1) profiling, (2) planning and priority seƫng, (3) puƫng into pracƟce (implementaƟon), and (4) evaluaƟon (Figure 3.1). Acknowledging that countries are in different steps of the process, and on different levels, the aim is to move countries from their baseline situaƟon to the next highest level in an iteraƟve process of learning and applying lessons learnt so that successive phases move countries closer to effecƟvely prevenƟng and controlling noncommunicable diseases (Figure 3.2). Countries can enter the process at different steps, corresponding to their exisƟng situaƟon and level of progress in stemming the burden of chronic diseases. However, regardless of the country’s point of entry, the process consistently incorporates eight key principles for acƟon: (1) a people-centred perspecƟve; (2) cultural relevance; (3) focused on reducing inequiƟes; (4) encompassing the enƟre care conƟnuum; (5) involving the whole of society; (6) integral to health systems strengthening; (7) consistent with the global acƟon plan, and supporƟve of exisƟng regional strategies; and (8) flexible, using a phased approach.

Figure 3.1 Process for systemaƟcally achieving progress in NCD prevenƟon and control in the Western Pacific Region

Profiling

EvaluaƟon

Planning Pl and priority seƫng

Source: Adapted from A Proposal for a Pacific Regional Framework for the PrevenƟon and Control of Noncommunicable Diseases. Manila, World Health OrganizaƟon, 2007.

Puƫng into pracƟce

44

Figure 3.2 Overall scheme for the process model for NCD prevenƟon and control in the Western Pacific Region

AssumpƟons 1 2 Countries are at differing levels of capacity for NCD prevenƟon and control. Regardless of level, all countries will undergo the iteraƟve process periodically, using lessons learnt to move along the various levels of capacity. IntervenƟons should match the countries’ current capacity and NCD situaƟon.

3

BEGINNING CAPACITY Policy and populaƟon-based intervenƟons in response to the specific needs emerging from iniƟal profiling ESTABLISH NCD INFRASTRUCTURE AND BASELINE

GROWING CAPACITY AddiƟonal policy, populaƟonbased and targeted intervenƟons to address an expanded list of risk factors and noncommunicable diseases relevant to a country, based on trends in risk factors and NCD prevalence from ongoing monitoring

WELLͳDEVELOPED CAPACITY OpƟmal mix of policy, populaƟon-based and targeted intervenƟons that address the whole range of risk factors and noncommunicable diseases in a country; monitored through an established surveillance system

45

Annex D Current WHO and other selected tools and resources for NCD prevenƟon and control

STEP 1: PROFILING ACTION AREA: Surveillance Determine profile of risk factors and disease Current tools and guides • • • • • Determine strengths, needs and capaciƟes • STEPS (WHO) Stroke STEPS (WHO) Surveillance of Risk Factors Report Series (SuRF 2) and WHO Global InfoBase: Newly available data on major risk factors, obesity, tobacco use (WHO) Cancer Epidemiology Database (InternaƟonal Agency for Research on Cancer [IARC]) Cardiovascular Survey Methods (WHO) Capacity mapping guide (WHO, Manila)

STEP 2: PLANNING AND PRIORITY SETTING Current tools and guides Translate data and informaƟon from Step 1 into decisions on prioriƟes, strategies and resource allocaƟon Establish prioriƟes and create a plan of work • • • • • • • PrevenƟng Chronic Disease: A Vital Investment (WHO) Cancer Control: Knowledge into AcƟon, WHO Guide for EffecƟve Programmes (WHO) STEPwise Framework to NCD IntervenƟon (WHO) AcƟon Plan for the Global Strategy for the PrevenƟon and Control of Noncommunicable Diseases (WHO) WHO Framework ConvenƟon on Tobacco Control Global Strategy on Diet, Physical AcƟvity and Health (WHO) Strategies to Reduce the Harmful Use of Alcohol (WHO)

46

• • • • • Select intervenƟons based on cost-effecƟveness data • •

WHO Strategy for the PrevenƟon and Control of Chronic Respiratory Diseases (WHO) Western Pacific DeclaraƟon on Diabetes (WHO, Manila) Plan of AcƟon 2006–2010 for the Western Pacific DeclaraƟon on Diabetes (WHO, Manila) Regional Strategy to Reduce Alcohol-related Harm (WHO, Manila) Tobacco Free IniƟaƟve Regional AcƟon Plan 2005–2009 (WHO, Manila) Choosing IntervenƟons that are Cost EffecƟve (WHO-CHOICE IntervenƟons) (WHO) Asaria P et al. Chronic disease prevenƟon: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet, 370:2044–2053.

STEP 3: PUTTING INTO PRACTICE (IMPLEMENTATION) ACTION AREA: Environmental and/or macro intervenƟons Create sustainable funding for NCD prevenƟon and control Current tools and guides • • • Develop policies to create healthy • environments and to support healthy lifestyles • • • • • The Establishment and Use of Dedicated Taxes for Health (WHO, Manila) Health PromoƟon Financing OpportuniƟes in the Western Pacific Region (WHO, Manila) Strategy on Health Care Financing (WHO, Manila and New Delhi) Enhancing Health Policy Development: A PracƟcal Guide To Understanding The LegislaƟve Process (WHO, Manila) Health Policy Development: A Handbook for Pacific Islands PracƟƟoners (WHO, Manila) Tobacco Control LegislaƟon: An Introductory Guide (2nd EdiƟon) (WHO) ProtecƟon from Exposure to Second-hand Smoke (WHO) A study on regulatory requirements for food forƟficaƟon in the Pacific (WHO, Manila) Using DomesƟc Law in the Fight against Obesity: An Introductory Guide for the Pacific (WHO, Manila)

47

ACTION AREA: Lifestyle change Increasing physical acƟvity

Current tools and guides • • • • • • Global Strategy on Diet, Physical AcƟvity and Health (WHO) A Guide for PopulaƟon-based Approaches for Increasing Levels of Physical AcƟvity (WHO) PromoƟng Physical AcƟvity and AcƟve Living in Urban Environments (WHO) Regional Guideline on Physical AcƟvity (WHO and Secretariat for the Pacific Community [SPC] NCD Exercise: Pacific Fitness videocasseƩe (SPC) PromoƟng Physical AcƟvity: A Guide for Community AcƟon (United States Department of Health and Human Services) Reducing Salt Intake in PopulaƟons (WHO) Diet, NutriƟon and PrevenƟon of Chronic Diseases (WHO) Guidelines in Food ForƟficaƟon and Micronutrients (WHO) Development of Food Based Dietary Guidelines for the Western Pacific Region (WHO, Manila) Towards Healthier Mothers, Children and Families: A NutriƟon Guide for Community Health Workers (WHO, Manila) Diet, Food Supply and Obesity in the Pacific (WHO, Manila) Obesity in the Pacific: Too Big to Ignore (WHO, Manila) NCD: Keep Healthy the Pacific Way flipchart (SPC) Healthy EaƟng videocasseƩe series (SPC) Teaching and Learning about Food and NutriƟon (SPC) Obesity: PrevenƟng and Managing the Global Epidemic (WHO) Obesity in the Pacific: Too Big to Ignore (WHO, Manila) Redefining Obesity and Its Treatment (WHO, Manila) PrevenƟon of PsychoacƟve Substance Use: A Selected Review of What Works in the Area of PrevenƟon (WHO) Primary PrevenƟon of Substance Abuse: A Workbook for Project Operators (WHO) Primary PrevenƟon of Substance Abuse: A Facilitator’s Guide (WHO) Regional Strategy to Reduce Alcohol-related Harm (WHO, Manila) Alcohol or Life: The Choice is Yours videocasseƩe (SPC)

Improving nutriƟon choices

• • • • • • • • • •

CombaƟng obesity

• • •

Reducing alcohol use

• • • • •

48

Reducing tobacco use

• • • •

Building Blocks for Tobacco Control: A Handbook (WHO) Policy RecommendaƟons for Smoking CessaƟon and Treatment of Tobacco Dependence (WHO) WHO Report on the Global Tobacco Epidemic 2008 – the MPOWER Package (WHO) Regional AcƟon Plan 2005–2009 for the Tobacco Free IniƟaƟve InnovaƟve Care for Chronic CondiƟons: Building Blocks for AcƟon (WHO) Secondary PrevenƟon of Noncommunicable Diseases in Low- and Middle-Income Countries through Community-based and Health Service IntervenƟons (WHO) Guidelines for the PrevenƟon, Management and Care of Diabetes Mellitus (WHO) PrevenƟon of Diabetes and its ComplicaƟons (WHO, forthcoming) Screening for Type 2 Diabetes (WHO) PrevenƟon of Blindness from Diabetes Mellitus (WHO) Health Care Decision-Making in the Western Pacific Region: Diabetes and the Care ConƟnuum in the Pacific Island Countries (WHO, Manila) Type 2 Diabetes PracƟcal Targets and Treatments (InternaƟonal Diabetes FederaƟon [IDF] Western Pacific) Consensus on Type 2 Diabetes PrevenƟon (IDF) Global Guidelines for Type 2 Diabetes (IDF) Ten Steps to BeƩer Glucose Control: A PracƟcal Guide (IDF) Guidelines for Management of Post-meal Glucose (IDF) InternaƟonal Consensus on the DiabeƟc Foot (IDF) Diabetes flipchart (SPC) Cancer Control: Knowledge into AcƟon, WHO Guide For EffecƟve Programmes (WHO) Cancer Pain Relief (WHO) Cancer Pain Relief and PalliaƟve Care (WHO) Comprehensive Cervical Cancer Control: A Guide to EssenƟal PracƟce (WHO) NaƟonal Cancer Control Programmes Policies and Managerial Guidelines, 2nd ediƟon (WHO)

ACTION AREA: Clinical services Use of clinical guidelines for screening, acute and chronic care and rehabilitaƟon a. Diabetes

Current tools and guides • • • • • • • • • • • • • •

b. Cancer

• • • • •

49

• • • • • c. Cardiovascular diseases • • • • d. Chronic respiratory diseases • • • • IncorporaƟng evidence-based intervenƟons into various seƫngs – the WHO Healthy Seƫngs approach •

Guidelines for the Early DetecƟon and Screening of Breast Cancer (WHO) Guidelines for the Management of Breast Cancer (WHO) Manual on the prevenƟon and control of common cancers (WHO, Manila) Cancer Monographs (IARC) Handbooks on Cancer PrevenƟon (IARC) PrevenƟon of Cardiovascular Disease Guidelines for Assessment and Management of Cardiovascular Risk (WHO) PrevenƟon of Cardiovascular Disease Pocket Guidelines for Assessment and Management of Cardiovascular Risk (WHO) PrevenƟon of recurrent heart aƩacks and strokes in low and middle income populaƟons (WHO) WHO CVD-risk management package for low- and medium-resource seƫngs (WHO) WHO Strategy for the PrevenƟon and Control of Chronic Respiratory Diseases (WHO) Global Surveillance, PrevenƟon and Control of Chronic Respiratory Disease (WHO) ImplementaƟon of the WHO Strategy for the PrevenƟon and Control of Chronic Respiratory Diseases (WHO) PrevenƟon and Control of Chronic Respiratory Diseases at Country Level (WHO) Health PromoƟng Schools: Guidelines for Health PromoƟng Schools (WHO, Manila) NutriƟon-friendly School IniƟaƟve (NFSI) (WHO, Manila) Food in Schools (SPC) Urbani School Health Kit (WHO)

• • •

Regional Guidelines for Developing a Healthy CiƟes Project (WHO, Manila) Regional Guidelines for the Development of Healthy Workplaces (WHO, Manila) Health PromoƟng CommuniƟes: Healthy Marketplaces in the Western Pacific Region: Guiding Future AcƟon. Applying a Seƫngs Approach to the PromoƟon of Health in Marketplaces (WHO, Manila)

50

STEP 4: EVALUATION Assess programme implementaƟon process, outcomes and impact • • • ACTION AREA : Advocacy • • • ACTION AREA: Leadership, partnerships and community mobilizaƟon ACTION AREA: Health Systems Strengthening • • • • • Global Strategy on Diet and Physical AcƟvity for Health Framework to Monitor and Evaluate ImplementaƟon (WHO) Manual on Monitoring Cardiovascular Diseases (WHO, Manila) Teaching and Learning about Food and NutriƟon (SPC) – contains a secƟon on evaluaƟng nutriƟon programmes Stop the Global Epidemic of Chronic Disease: Advocacy Toolkit (WHO) AcƟng on Noncommunicable Diseases: An Advocacy Guide for the Western Pacific (draŌ) (WHO, Manila) Diabetes EducaƟon Modules (IDF) Training Manual for Community-based IniƟaƟves (WHO) Social MobilizaƟon for Health PromoƟon (WHO, Manila) Managing Systems for BeƩer Health (WHO) People-Centred Health Care: A Policy Framework (WHO, Manila) Making Health Systems Work for Chronic Disease (draŌ discussion paper) (WHO, Manila)

51

Annex E Affordability of selected intervenƟons A series of articles published in December 2007 in the journal Lancet examined the cost–benefit profiles of three selected interventions to prevent and control noncommunicable diseases: (1) tobacco control, (2) salt reducƟon, and (3) mulƟdrug treatment of individuals at high risk of cardiovascular disease.18,19,20 The authors esƟmated that the three intervenƟons would result in about 31.7 million lives saved (Table 5.1) at a combined cost of about US$ 1.44 per capita per year over the period 2005–2015 (Table 5.2). The health benefits in terms of lives saved would account for about 88% of the global goal of saving 36 million lives from noncommunicable diseases. Table 5.3 compares the total cost per capita of these three intervenƟons to the average per capita health expenditure for a selected group of countries in the Western Pacific Region. Among the least developed countries, this package of intervenƟons would account for, at most, 8% of the per capita health expenditure per year, highlighƟng their affordability.

Table 5.1 Lives saved from noncommunicable diseases resulƟng from a package of intervenƟons over a 10-year period INTERVENTION Salt reducƟon Tobacco reducƟon MulƟdrug treatment TOTAL DEATHS AVERTED OVER A 10-YEAR PERIOD 8.3 million 5.5 million 17.9 million 31.7 million

Sources: Gaziano TA et al. Lancet, 2007, 370:1939–1946; Asaria P et al. Lancet, 2007, 370:2044–2053; Lim S et al. Lancet, 2007, 370:2054–2061.

52

Table 5.2. EsƟmated cost per capita per year for selected intervenƟons INTERVENTION Salt reducƟon plus tobacco control MulƟdrug treatment TOTAL COST PER HEAD (US$) 0.36 (0.14 - 0.38 in low- to middle-income countries) (0.52 - 1.04 in middle- to high-income countries) 1.08 (0.75 - 1.40) 1.44 (0.89 - 1.78 in low-to middle-income countries) (1.27 - 2.88 in middle- to high-income countries)

Sources: Gaziano TA et al. Lancet, 2007, 370:1939–1946; Asaria P et al. Lancet, 2007, 370:2044–2053; Lim S et al. Lancet, 2007, 370:2054–2061.

Table 5.3 Comparison of cost per capita of selected intervenƟons with annual per capita health expenditure in selected Western Pacific Region countries COUNTRY Cambodia China Fiji Lao People’s DemocraƟc Republic Malaysia Mongolia Papua New Guinea Philippines Viet Nam ANNUAL PER CAPITA HEALTH EXPENDITURE (US$, 2005) 27.90 80.87 158.40 17.46 179.37 35.00 35.72 38.75 31.78 COST OF INTERVENTION PACKAGE PER CAPITA PER YEAR (US$) 1.44 1.44 1.44 1.44 1.44 1.44 1.44 1.44 1.44 COST OF INTERVENTIONS AS A PERCENTAGE OF PER CAPITA HEALTH EXPENDITURE (%) 5.20 1.80 0.91 8.30 0.80 4.10 4.00 3.70 4.50

Sources: Gaziano TA et al. Lancet, 2007, 370:1939–1946; Asaria P et al. Lancet, 2007, 370:2044–2053; Lim S et al. Lancet, 2007, 370:2054–2061.Per capita health expenditure taken from Country Health InformaƟon Profiles (CHIPS) at www.wpro.who.int.

53

Annex F WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE

WPR/RC59.R5 Noncommunicable Disease PrevenƟon and Control

R E S O L U T I O N REGIONAL COMMITTEE FOR THE WESTERN PACIFIC COMITE REGIONAL DU PACIFIQUE OCCIDENTAL

WPR/RC59.R5 25 September 2008 NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL The Regional CommiƩee, Acknowledging the significant and growing burden of noncommunicable diseases (NCD), especially cardiovascular diseases, cancer, diabetes, chronic pulmonary diseases and mental health condiƟons, on public health and socioeconomic development in the Western Pacific; Recognizing that noncommunicable diseases share common risk factors and social determinants, and that a comprehensive, evidence-based and mulƟsectoral approach is essenƟal to reduce the Region’s NCD burden; Further recognizing that government leadership and poliƟcal commitment are essenƟal to coordinate the necessary mulƟsectoral response to the regional NCD burden; Further acknowledging that diet, physical acƟvity and healthy behaviours involve complex personal choices and that healthy choices lessen the impact of noncommunicable diseases; NoƟng that cost-effecƟve intervenƟons exist and need to be prioriƟzed in countries; Affirming that the strengthening of health systems is fundamental to address noncommunicable diseases in parƟcular, through the integraƟon of NCD prevenƟon and control into primary health care and community-based intervenƟons using the chronic care model; Deeply concerned that investments in NCD prevenƟon and control remain inadequate within the Region, despite the growing burden; Recognizing that the Western Pacific Regional AcƟon Plan for Noncommunicable Diseases provides a framework for implemenƟng the global and regional mandates that support NCD prevenƟon and control, including the PrevenƟon and Control of Noncommunicable Diseases: ImplementaƟon of the Global Strategy endorsed by Member States at the recently concluded Sixty-first World Health Assembly; the Global Strategy on Diet, Physical AcƟvity and Health; the WHO Framework ConvenƟon on Tobacco Control;

54

the Western Pacific DeclaraƟon on Diabetes; the Western Pacific Regional Strategy to Reduce Alcohol-related Harm; and the Pacific Framework for the PrevenƟon and Control of Noncommunicable Diseases, 1. ENDORSES the Western Pacific Regional AcƟon Plan for Noncommunicable Diseases;1 2. URGES Member States: (1) to support and implement the recommended acƟons contained in the Regional AcƟon Plan in a manner appropriate to each country’s burden and consistent with naƟonal circumstances; (2) to situate noncommunicable diseases high on the naƟonal health agenda and to mobilize support at regional, naƟonal and community levels; (3) to invest in strengthening health systems to more effecƟvely respond to the challenge of NCD prevenƟon and control;

(4) to develop naƟonal and cross-country mulƟsectoral mechanisms for networking, collaboraƟon and informaƟon disseminaƟon in the area of noncommunicable diseases; (5) to encourage and support ciƟzens to take responsibility for their own health, including adopƟng healthy behaviours; 3. REQUESTS the Regional Director: (1) to consistently situate noncommunicable diseases as a priority for the regional public health agenda and to mobilize support for prevenƟon and control of noncommunicable diseases among relevant regional partners and stakeholders, including the private sector; (2) to expand technical support to Member States in selecƟng and implemenƟng strategic acƟons to reduce the NCD burden, based on the Regional AcƟon Plan, and in adapƟng and strengthening naƟonal health systems to more effecƟvely respond to noncommunicable diseases; (3) to establish a regional mulƟsectoral mechanism for networking, collaboraƟon and informaƟon disseminaƟon in the area of noncommunicable diseases.

Seventh meeƟng, 25 September 2008 WPR/RC59/SR/7

1

Annex 1 of document WPR/RC59/6.

55

References 1

Document WPR/RC57/6. Noncommunicable disease prevenƟon and control. FiŌy-seventh session of the WHO Regional CommiƩee for the Western Pacific, Auckland, 19–22 September 2006. Manila, World Health OrganizaƟon, 2006. Strong K et al. PrevenƟng chronic disease: how many lives can we save? Lancet, 2005, 366:1578–1582. Global forum on integrated NCD prevenƟon and control. Geneva, World Health OrganizaƟon, 2001. World Health StaƟsƟcs 2008. Geneva, World Health OrganizaƟon, 2008 (hƩp://www.who.int/whosis/whostat/2008/en/index. html, accessed 20 May 2008). World Health Report 2002. Geneva, World Health OrganizaƟon, 2002. Evans T et al. World Health Report 2003. Geneva, World Health OrganizaƟon, 2003. Document WPR/RC51/8. PrevenƟon and control of noncommunicable diseases. FiŌy-first session of the WHO Regional CommiƩee for the Western Pacific, Manila, 18–22 September 2000. Manila, World Health OrganizaƟon, 2000. Noncommunicable disease and poverty: the need for pro-poor strategies in the Western Pacific Region: a review. Manila, World Health OrganizaƟon, 2006. PrevenƟng chronic diseases: a vital investment. Geneva, World Health OrganizaƟon, 2005. Ibid, page 5. Document WPR/RC51/8. PrevenƟon and control of noncommunicable diseases. FiŌy-first session of the WHO Regional CommiƩee for the Western Pacific, Manila, 18–22 September 2000. Manila, World Health OrganizaƟon, 2000. Document WHA53.17. PrevenƟon and control of noncommunicable diseases. FiŌy-third World Health Assembly, Geneva, 20 May 2000. WHO, Geneva, 2000. Document WHA61.8. PrevenƟon and control of noncommunicable diseases: implementaƟon of the global strategy. Sixty-first World Health Assembly, Geneva, May 2008. Geneva, World Health OrganizaƟon, 2008. People-Centred Health Care: A Policy Framework. Manila, World Health OrganizaƟon, 2007. InnovaƟve Care for Chronic CondiƟons: Building Blocks for AcƟon. Geneva, World Health OrganizaƟon, 2002. Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes: WHO’s Framework for AcƟon. Geneva, World Health OrganizaƟon, 2007. People at the Centre of Health Care Harmonizing Body and Mind, People and Systems. Manila, World Health OrganizaƟon, 2007. Gaziano TA, Galea G, Reddy KS. Scaling up intervenƟons for chronic disease prevenƟon: the evidence. Lancet, 2007, 370:1939–1946. Asaria P et al. Chronic disease prevenƟon: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet, 2007, 370:2044–2053. Lim S et al. PrevenƟon of cardiovascular disease in high-risk individuals in low-income and middle-income countries: health effects and costs. Lancet, 2007, 370:2054–2061.

2 3 4

5 6 7

8

9 10 11

12

13

14 15 16

17

18

19

20

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Avoidable NCD Deaths and Disability To raise the priority accorded to noncommunicable disease in development work at global and national levels

A Region Free of

To promote research for the prevention and control of noncommunicable diseases

To establish and strengthen national policies and plans for the prevention and control of noncommunicable diseases

To promote partnerships for the prevention and control of noncommunicable diseases To promote interventions to reduce the main shared modifiable risk factors for noncommunicable diseases: tobacco use, unhealthy diets, physical inactivity and harmful use of alcohol

To monitor noncommunicable diseases and their determinants, and evaluate progress at the national, regional and global levels

Western Pacific Regional Action Plan FOR NONCOMMUNICABLE DISEASES A Region free of avoidable NCD deaths and disability

Process Model

beginning capacity Policy and population-based interventions in response to the specific needs emerging from initial profiling establish ncd infrastructure and baseline

growing capacity Additional policy, populationbased and targeted interventions to address an expanded list of risk factors and noncommunicable diseases relevant to a country, based on trends in risk factors and NCD prevalence from ongoing monitoring

well-developed capacity Optimal mix of policy, population-based and targeted interventions that address the whole range of risk factors and noncommunicable diseases in a country; monitored through an established surveillance system

Strategic Approach and Action Areas lifestyle interventions clinical interventions • Clinical preventive services • Risk factor detection (screening) and control • Acute care • Chronic care and rehabilitation • Palliative care

• Behavioural interventions • Health promotion • Information and education • Improving the ‘built’ environment

(macroeconomic and policy change) • Governance • Policy and legislation • Creating supportive environments

environmental interventions

ADVOCACY RESEARCH, SURVEILLANCE AND EVALUATION Health sector response “Whole -of-government” and whole-of-society response • Leadership • Multisectoral partnership • Community mobilization

• Primary health care • Chronic care management • Health systems strengthening

The Causation Pathway for Chronic Disease Underlying Determinants Globalization Urbanization Population ageing Social determinants

Unhealthy diet Physical inactivity Tobacco and alcohol use Air pollution Age (non-modifiable) Heredity (non-modifiable)

common risk factor

Raised blood sugar Raised blood pressure Abnormal blood lipids Overweight/obesity Abnormal lung function

intermediate risk factor

diseases Cardiovascular disease (Heart disease and stroke) Cancer Diabetes Chronic respiratory disease