Second joint mission of the United Nations Interagency Task Force on the Prevention and Control of Noncommunicable Diseases, Sri Lanka, 23-27 April 2018

Second Joint Mission of the United Nations Interagency Task Force on the Prevention and Control of Noncommunicable Diseases Sri Lanka 23-27 April 2018 WHO/NMH/NMA/18.91 © World Health Organization 2018 Some rights reserved. This work is available under the Creative Commons Attribution-Non Commercial-Share Alike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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This publication contains the collective views of the United Nations Interagency Task Force on the Prevention and Control of Noncommunicable Diseases and does not necessarily represent the decisions or the policies of WHO. iii Contents Page Summary 3 The Joint Mission 4 Review of progress since the first joint mission 4 Prioritising actions for 2018-2020 6 UN and wider development partner support 7 Annex 1. Terms of reference of the Joint Mission 9 Annex 2. Members of the Joint Mission 13 Annex 3. Joint Mission programme 14 Annex 4. Review of progress since October 2015 UNIATF Mission 15 Annex 5. Recommended priority actions, 2018-2020 under the 2016-2020 National Multisectoral Action Plan 20 iv Executive Summary A Joint Mission of the United Nations Interagency Task Force on the Prevention and Control of Noncommunicable Diseases to Sri Lanka was held between 23-27 April 2018 at the invitation of the Government of Sri Lanka. Six United Nations system agencies participated. Member of the Joint Mission worked with the Government of Sri Lanka to (i) review progress on recommendations in the report of the first joint mission (5-9 October 2015); (ii) refine prioritised actions for 2018-2020 in the National Multisectoral Action Plan for the Prevention and Control of NCDs (NMSA 2016-2020), including a suitable monitoring and evaluation framework; and (iii) review the way that the UN system is working, including providing inputs to the design phase of the planned primary health care (PHC) reorganization supported by the World Bank. The Joint Mission witnessed good to excellent progress in a number of areas since the first joint programming mission in 2015. In some areas however there has been less progress, including the opportunity to strengthen monitoring and evaluation. The prioritised actions for 2018-2020 recommended by the Joint Mission are based on the updated set of cost effective, evidence-based solutions set out in “Best buys” and other recommended interventions for the prevention control of NCDs, endorsed by the World Health Assembly in 2017 and areas where there is political will and sufficient capacity to act quickly. If these actions are taken forward in a systematic way over the next two years, Sri Lanka will continue to make significant strides in tackling NCDs. Development partners agreed during the mission’s recommendation to prioritise their support to government on NCDs and to use the development partners’ forum for enhancing collaboration and identifying opportunities for joint programming. It was agreed that development partners would seek opportunities to identify funding from the Global Fund for comorbidities (e.g. TB, smoking and harmful use of alcohol). The Joint Mission welcomed the plans of the GoSL for reorganising the primary health care system through the support of the World Bank Primary Health care System Strengthening Project (PHSSP), which has a major focus on NCD outcomes. The Joint Mission recommended that the UN country team work with the Health Development Partners Forum to identify key areas of work for maximising the impact of these funds towards improving the status of NCDs in Sri Lanka. 1 The Joint Mission 1. The Second Joint Mission of the United Nations Interagency Task Force (UNIATF) on the Prevention and Control of Noncommunicable Diseases to Sri Lanka was held between 23-27 April 2018 at the invitation of the Government of Sri Lanka (GoSL). In alphabetical order, the following agencies participated in the mission: the Food and Agriculture Organization (FAO), United Nations Development Programme (UNDP), United Nations Population Fund (UNFPA), United Nations Children's Fund (UNICEF), the World Bank and the World Health Organization (WHO), which led the mission. 2. Terms of Reference, list of participants and the programme of the Joint Mission are provided in Annexes 1-3. The Joint Mission is grateful to the Government of Sri Lanka and the large number of individuals and agencies that participated in meetings during the mission. 3. Members of the Joint Mission worked with the Government of Sri Lanka to (i) review progress on recommendations in the report of the first joint mission (5-9 October 2015); (ii) refine prioritised actions for 2018-2020 in the National Multisectoral Action Plan for the Prevention and Control of NCDs (NMSA 2016-2020), including a suitable monitoring and evaluation framework; and (iii) review the way that the UN system is working, including providing inputs to the design phase of the planned primary health care (PHC) reorganization supported by the World Bank. 4. The Joint Mission was held 5 months before the Third High-level Meeting on NCDs to be held on 27 September 2018. 1 In recent years, Sri Lanka has shown outstanding regional and global leadership in prevention and controlling NCDs, resulting in the President of Sri Lanka being appointed as a co-chair to the WHO Independent High-level Commission on NCDs. 2 Review of progress since the first joint mission 5. A summary on progress against the recommendations of the first joint mission (5-9 October 2015) is shown in Annex 4. There are examples of progress against the four key areas where recommendations were made in 2015: (i) governance, coordination and accountability; (ii) surveillance; (iii) costing, coordinating, implementing and monitoring a small set of priorities; (iv) training and capacity building; and (v) awareness raising among the public. 6. There has been excellent progress in a number of areas. In other areas there has been less progress. 7. Examples of progress since the first joint mission include: 1 http://www.who.int/ncds/governance/third-un-meeting/en/ 2 http://www.who.int/ncds/governance/high-level-commission/en/ 2 • Establishment of a National NCD Council, chaired by Minister of Health, Nutrition and Indigenous Medicine (MoHNIM) with officials across government. • Establishment of an NCD bureau with a new DDG appointment to ensure greater leadership for NCDs and more effective working across the MoHNIM, and collaboration with other parts of government and non-government stakeholders. • Establishment of a Sri Lankan NCD Alliance to enable Government to coordinate non- State actors. • The development of a fully costed national NCD multisectoral action plan for 2016- 2020, including a prioritised set of actions for 2016-2017 with the M&E framework, and more recently prioritizing the activities for 2018-2020. • Increased domestic financing for NCDs with majority of this through GoSL funds. To augment this, GoSL are currently in the process of finalising a World Bank project for USD200 million to strengthen primary health care service delivery, with NCD prevention and control as a major component. • The establishment of multisectoral working groups for chronic respiratory diseases, physical activity and the development of salt reduction strategies. • Greater multisectoral coordination at the district levels with multisectoral action plans in around 50% of districts. District level NCD multisectoral committees headed by District Secretariat (administrative head) have been formed and meet regular. • Accession to the Protocol to Eliminate Illicit Trade in Tobacco Products in 2016, an introduction of a ban on smokeless tobacco and electronic nicotine delivery systems (ENDS) in 2016 with fines for their use, an increase in taxes on cigarettes in 2017, the announcement of phasing out of tobacco cultivation with alternative livelihood support plans, a national tobacco quit line on tobacco launched in 2017, and legislation for plan packaging on tobacco products has been approved by the cabinet of Ministers. • Introduction of a sugar tax for SSBs, with front of package labelling (traffic lights) for sugar in beverages introduced in 2016. • Revision of guidelines on the management of cardiovascular disease in PHC. Progress in developing guidelines for management of CRD, obesity and diabetes at the PHC • The essential NCD drug list has been revised. • The undertaking of a number of district level initiatives to increase public awareness on NCDs, their modifiable risk factors and ways that individuals and communities can prevent premature NCD mortality. • Action over the last few years to mobilize youth for prevention of NCD in collaboration with the Ministry of National Policies and Economic Affairs, National Youth Services Council and National Youth Corps. 8. There were however a number of areas where there has been less progress, for example: 3 • The Development Partners Forum on Health and Nutrition has not to date included NCDs in its work • The NMAP monitoring framework has not been systematically used to chart progress and a mid-term evaluation has not yet been undertaken. • Tobacco products remain displayed in retail outlets. • Tax on beer has actually been reduced and indigenous alcohol products remain priced at low levels and little in the way of developing, implementing and enforcing more robust alcohol pricing policy interventions. • Working with industry and food producers to (i) reduce salt in processed and manufactured food and (ii) develop user-friendly front of package labelling for food and beverages focusing on energy, sugar, salt and fat composition although the Joint Mission was made aware of ongoing discussions between industry and producers and the Environment and Occupational Health Unit of the MoHNIM. • No progress in legislating to replace trans fats with unsaturated fats. • School based programmes have been conducted in all districts. Several TV commercials on diet and physical activity have been aired during past few years. However, mass media campaign on diet and PA has not been conducted. A mass media campaign on diet, physical activity and tobacco is planned for 2018. • Levels of malnutrition among pre-school children. 9. A table describing progress against all recommendations from the 2015 Joint Programming is included in Annex 4. This progress report can be used by GoSL as part of their preparation for the 3 rd High-level Meeting, including describing progress in meeting the four time-bound commitments that Member States agreed at the 2014 High-level review in New York 3 . Prioritising actions for 2018-2020 10. The first Joint Mission report highlighted that a key challenge was prioritising action to a small number of fiscal, legislative and programmatic actions, with a greater focus on accountability. The NMAP includes a monitoring and evaluation framework but the Joint Mission considers that accountability mechanisms could be strengthened (e.g. regular quarterly review meetings and using the NCD council chaired by the President). 11. The Joint Mission reviewed the draft prioritised action plan, 2018-2020. Working with GoSL officials, the Joint Mission proposed a subset of these as a set of highly prioritised actions. These are based (i) the updated set of cost effective, evidence-based solutions set 3 http://www.who.int/nmh/events/2014/a-res-68-300.pdf?ua=1. The four time-bound commitments were: (i) by 2015, develop national multisectoral policies and plans; (ii) by 2015, set national targets; (iii) by 2016, reduce risk factors for NCDs through the implementation of interventions building on the guidance set out in Appendix 3 of the WHO Global NCD Action Plan 2013-2020; and (iv) by 2016, strengthen health systems through people-centred primary health care and universal health coverage, building on the guidance set out in Appendix 3 of the WHO Global NCD Action Plan 2013-2020. 4 out in the “Best buys” and other recommended interventions for the prevention control of NCDs, endorsed by the World Health Assembly in 2017; and (ii) areas where there is political will and sufficient capacity to act quickly. 4 12. The highly prioritised actions are set out in Annex 5. They are framed under the four existing strategic areas: (i) advocacy, partnership and leadership (n=7); (ii) health promotion and risk reduction (n=12); (iii) health system strengthening for early detection and management of NCDs and their risk factors (n=8); and (iv) surveillance, monitoring, evaluation and research (n=5). 12. The highly prioritised actions are the Joint Mission’s recommendations for action on NCDs over the next two years. If systematically taken forward by the end of 2020, Sri Lanka will have made significant strides in tackling NCDs. However, the Joint Mission considers that even greater coordinated action across government, the UN system and other development partners, including relevant private sector entities, will be required – and these form the basis of the priority actions under advocacy, partnership and leadership. 13. The Joint Mission discussed an appropriate monitoring framework with the GoSL and recommends that as a next step the GoSL reviews the highly prioritised actions and for each: (i) ensure an accountable focal point is identified with quarterly tracking on progress; (ii) agree the current position; and (iii) identify a SMART indicator for monitoring progress with clarity on the method of verification. The Joint Mission strongly recommends that quarterly tracking is undertaken in collaboration with an independent agency. UN and wider development partner support 14. The UN Sustainable Development Framework (UNSDF) in Sri Lanka provides a high level articulation of policy. NCDs is not included but the Joint Mission was repeatedly reassured that NCDs fits well within the UNSDF and is the sort of area that the UN should be working on together in Sri Lanka under Driver Group 3 (Human Security and Socio-Economic Resilience). 15. WHO continues to provide significant support to the GoSL on NCDs. While a number of other UN agencies continue to work on issues relating to NCDs, there remains significant opportunity to join up efforts in a more systematic way under UNSDF Driver Group 3 – an issue that was highlighted in the first joint mission report. Development partners agreed during the mission’s recommendation to prioritise their support to government on NCDs and to use the development partners forum for enhancing collaboration and identifying opportunities for joint programming. It was agreed that development partners would seek opportunities to identify funding from the Global Fund for comorbidities (e.g. TB, smoking and harmful use of alcohol). 4 Best buys’’ and other recommended interventions for the prevention and control of NCDs. http://apps.who.int/gb/ebwha/pdf_files/WHA70/A70_R11-en.pdf. 5 16. The Joint Mission met with officials that are developing a World Bank Primary Health care System Strengthening Project (PHSSP), which has a focus on NCD outcomes. The majority of financing will be provided to the Ministry of Health as budget support through the Ministry of Finance. However, around USD 14 million has been identified as an innovation grant through project support to the MoHNIM. 17. The Joint Mission recommends that this project support should in part be used to catalyse action beyond the health sector in a way that promotes: (i) pro-health partnerships with the private sector, community and other stakeholders, combined with improved policy coherence across government and better risk management of conflicts of interest in relation to prevention and control of NCDs; (ii) stronger legislative and regulatory environments in support of NCD prevention and control across various sectors; (iii) stronger systems in place for more effective procurement of NCD medicines, equipment and commodities in order to scale up treatment access and reduce system inefficiencies, along with related capacity building of health systems, health services and personnel; and (iv) community-based and population-wide responses to NCDs, including risk communication strategies. The Joint Mission recommends that Health development partner forum work closely together with Ministry of Health to identify key areas for maximising the impact of the upcoming World Bank PHSSP. = = = 6 Annex 1. Terms of Reference: Mission of the UN Inter-Agency Task Force on the Prevention and Control of NCDs to Sri Lanka, 23-27 April 2018 NCDs and sustainable development Four types of Non-communicable diseases (NCDs), cardiovascular diseases, cancers, chronic respiratory diseases and diabetes, make the largest contribution to mortality across the world. Together these NCDs account for over 14 million premature deaths (defined as aged 30 to 70 years) each year, of which 85 per cent live in developing countries. Up to two-thirds of NCDs are linked to exposure to four main risk factors - namely, tobacco use, unhealthy diet and physical inactivity, and the harmful use of alcohol. Most of these premature deaths from NCDs can be prevented. NCDs are now exerting a drag on the socio- economic development of many countries. These include the increasing financial burden on the health system and the loss of productivity among the workforce. The 2011 UN Political Declaration, the 2014 UN Outcome Document on NCDs and the WHO Global NCD Action Plan 2013-2020 highlight the need for a whole-of-government and whole-of-society response to NCDs. Member States have committed to: (i) developing national targets and indicators for NCDs based on national situations; (ii) developing, allocating and implementing budgets for national multi-sectoral NCD policies and plans; (iii) prioritizing the implementation of cost-effective and affordable interventions for the prevention and control of NCDs; and (iv) strengthening national surveillance systems for NCDs and measuring results. In 2015, NCDs and their related conditions were included in the 2030 Agenda for Sustainable Development. Target 3.4 is by 2030 to reduce by one third premature mortality from NCDs and promote mental health. Examples of other NCD SDG targets are shown below and examples of NCD-related SDG targets are shown in the figure below. Despite some successes in tackling NCDs, overall progress at the country level has remained insufficient and uneven and are still not a development priority across government and the 7 development system in many countries. Despite the increase of national multisectoral plans and NCD units in many countries, a large number of developing countries still lack the capacity to move from commitment to action. Ministries of Health cannot tackle NCDs alone: they require political commitment right across government. The same is so for WHO, as the specialised agency for health: a whole- of-UN response is required to provide effective support to Member States. NCDs in Sri Lanka Sri Lanka is in the advanced stages of a demographic and epidemiological transition owing largely to the marked increase in life expectancy and decrease in fertility rates. Beyond the rapidly changing age distribution, economic development, urbanization, increased motorization and lifestyle changes (including low levels of physical activity, less healthy eating, and tobacco and alcohol use) are contributing to the growing incidence of NCDs and the associated risk factors. Therefore, it faces major health challenges with increasing proportion of people affected with NCDs like diabetes, heart diseases, strokes, asthma, cancers and mental health related diseases and injuries. NCDs are now accounting for 85 percent of the total burden of disease and 75 percent of the deaths. Furthermore, 18 percent of the common four NCD deaths occur prematurely (between the ages of 30 to 70 years) (WHO, 2014). The age standardized death rates for the common four NCDs (heart diseases, diabetes, cancers and chronic respiratory diseases) are higher for males than females with cardiovascular death rate for males at nearly 350 deaths compared to approximately 200 deaths per 100,000 age standardized population (WHO, 2014). Sri Lanka benefited from the UNIATF mission in 2015. Having realized the potential of the country to progress in its activities to prevent and Control NCDs, WHO selected Sri Lanka as a fast-track country eligible to receive ‘One-WHO’ integrated technical support. Sri Lanka launched its National Multisectoral Action Plan for the Prevention and Control of NCDs 2016-2020 (NMSAP) in 2016. The Directorate of NCD of the Ministry of Health, Nutrition and Indigenous Medicine as the focal unit initiated and implemented many activities specified in the NMSAP and also acted as the coordinator to guide and monitor the activities of the other stakeholders. This coordinated multisectoral effort resulted in many achievements as indicated by the Status of the country from NCD Progress Monitor September 2017 (Figure 2). Considering its commitment to NCD agenda, Sri Lanka is invited to take an active role in the Third UN High-level meeting on NCDs in September 2018. His Excellency the President of Sri Lanka has accepted the invitation to co-chair the WHO Independent High-Level Commission on NCDs and is willing to take an active role in the Third UN High-Level Meeting on NCDs. It is also indicated that Sri Lanka will be invited to attend the GCM Dialogue on financing national NCD responses (Copenhagen, 9-12 April 2018). 8 2017 NCD Progress Monitor At this point in time, two years since initiation of the NMSAP and monitoring the Directorate of NCD has identified several pertinent changes as well as challenges to overcome to achieve the ten targets the country voluntarily set for it to be reached by 2015. In this backdrop, Sri Lanka proposes a mission of the UNIATF visit the country with the aims of achieving the following outcomes: a. A critical assessment on the progress of the National Multi-sectoral Action Plan on the Prevention and Control of NCDs (NMSAP) and coordination mechanisms across government, the UN and wider development partners, including non-State actors for its implementation. b. A critical assessment on the way that NCDs is being taken forward as a development issue across government and the UN system, with a review on progress against the recommendations made during the first Task Force mission in 2015. c. Guidance on the NMSAP and broader development frameworks with special emphasis on i. How to enhance the engagement of non-health sectors across government and its partners in contributing to the prevention and control of NCDs in Sri Lanka ii. Advocating for a high level mechanism to coordinate government and non- governmental partners on NCD prevention and control activities in Sri Lanka iii. Recommending revisions to the NMSAP in the light of the assessment and updated appendix 3 of the global NCD action plan, 2013-2020 (Best Buys and other recommended interventions for the prevention and control of NCDs in order for Sri Lanka to attain NCD and SDG targets. iv. Recommendations to overcome the main challenges such as promoting heathy life styles among school children within the exam oriented education and promoting healthy life styles among the work force within the local d. Inputs to the NCD results framework and its M and E plan e. Inputs to the design phase of the planned primary health care reorganization supported by the World Bank. Appendix to the Terms of Reference. Scaling up UN support for action on the NCD-related SDGs 9 A UN Interagency Task Force on the Prevention and Control of NCDs was established by the UN Secretary-General in 2013 and reports to ECOSOC annually. The Task Force was established in recognition that Member States require concerted and coordinated action from UN agencies in tackling NCDs as part of the development agenda. The Secretariat for the Task Force is located in WHO. The Task Force undertakes Joint Programming Missions to support UN Country Teams in their efforts to provide technical assistance to governments as they seek to develop and implement national NCD responses which contribute to the NCD -related targets in the SDGs. Joint Missions provide the opportunity for the UN System to engage with a range of government ministries and support them in adopting approaches to NCD policy development which involve all government departments. This ensures that NCD issues receive an appropriate, whole-of-government, multisectoral response. Joint Missions engage with other development partners, including NGOs, private sector entities, philanthropic foundations and academic institutions, thereby helping governments to promote a whole-of-society response to NCDs. To date, over 20 Joint Programming Missions have been conducted in different countries, with follow up action in many of those visited. Joint Mission take as their starting point: • National development and health strategies, policies and plans • The 2011 UN Political Declaration and 2014 UN Outcome Document on NCDs, and the 2030 Agenda for Sustainable Development; • The 2015 WHO NCD Progress Monitor which tracks the extent to which WHO Member States are implementing the four timebound commitments for 2015 and 2016 included in the 2014 UN Outcome Document on NCDs; • The 2014 WHO NCD Country Profiles which provides an overview of the NCD situation in each country; • The WHO Global NCD Action Plan 2013-2020, in particular the set of cost-effective and affordable interventions for all countries, and policy options to promote a whole-of-government and whole-of-society response to reducing risk factors and enabling heath systems to respond; • Terms of Reference for the UN Interagency Task 10 Annex 2. Members of the Joint Mission (agencies and individuals in alphabetical order) FAO Tina JAYARATNAM Liaison Officer, Sri Lanka Country Office. UNDP Kazuyuki UJI Policy Specialist, HIV, Health and Inclusive Development, Bangkok Regional Hub. UNFPA Madusha DISSANAYAKE Assistant Representative, Sri Lanka Country Office. UNICEF Safina ABDULLOEVA Child Survival and Development Manager, Sri Lanka Country Office. WORLD BANK Deepika ATTYGALLE Senior Health Specialist, Colombo office. WHO Nick BANATVALA Head of Secretariat, UN NCD Interagency Task Force, WHO HQ, Geneva. Sophie GENAY-DILIAUTAS Technical Officer, WHO HQ, Geneva. Nalika GUNAWARDENA National Professional Officer, Country Office, Sri Lanka. Thaksaphon (Mek) THAMARANGSI Director, NCDs and Environmental Health, South East Asia Regional Office, New Delhi. 11 Annex 3. Joint Mission Programme 23 April 2018 08.30-09.00 Meeting with DGHS DGHS office 10.00-12.30 Discussion meeting between the NCD team and Mission WHO office 14.30-15.30 Discussion meeting among the members of the UNIATF Mission WHO office 16.00-17.00 Meeting with the Acting UN Resident Coordinator UN RC office 24 April 2018 09.30-12.30 Meeting with MoH officials, academia and professional colleges Taj Samudra Hotel 13.00-15.00 Meeting with the officials from non-health ministries, NCD Alliance Lanka, NGOs and other partners Taj Samudra Hotel 15.00-16.00 Wrap up meeting of the members of the UNIATF Mission Taj Samudra Hotel 25 April 2018 09.00-10.00 Meeting with the officials from the Ministry of Education Ministry of Education 10.00-10.30 Meeting with the Registrar General Registrar General’s Department 13.00-14.00 Meeting with the Secretary of Health Ministry of Health 14.00-16.00 Meeting with Registrar Generals Department, Medical Statistic unit and the Department of Census and statistics MoH 16.00-17.00 Wrap up meeting WHO office 26 April 2018 08.30-10.30 Presentation and a discussion on the activities coordinated by the public Administration of the Gampaha district WHO office 1030-12.30 Meeting with the beverage, dairy product and food manufacturers WHO office 14.00-15.00 Meeting with the Development Partners WHO office 16.00-17.00 Meeting with Director General, Health Services MoH, DGHS office 27 April 2018 08.30-09.30 Meeting with MoH and World Bank officials coordinating the World Bank funded project WHO office 10.30-11.30 Meeting with NATA and D/MH NATA office 12.00-13.00 Meeting with the officials of the Ministry of Agriculture Ministry of Agriculture 14.30-16.00 Meeting with MoH to review priorities MoH 14.30-17.30 Wrap up meeting of the members of the UNIATF Mission WHO office Annex 4. Review of progress since October 2015 UNIATF Mission 12 2015 recommendations for Action Progress Good progress Some progress Limited or no progress A. Governance, coordination and accountability High level coordination mechanism is established to ensure that the multisectoral action plan is delivered and that progress is regularly shared in a transparent way National NCD Council was established. Chaired by Minister of Health, Nutrition and Indigenous Medicine with officials across government. Recent plan is for ministers to attend the Council in future. The Joint Donor Group includes NCDs into the newly formed CKD group NCDs was not included in the Joint Donor Group (now called the Partners Forum on Health and Nutrition) although new initiatives/ programmes under health sector are shared with this group. The MoH coordinates finalization of the national plan (including costing), in full consultation with all partners, and puts in place a robust implementation and monitoring plan that can been overseen by the high level mechanism. The plan should specifically include implementation and monitoring of required changes in the policies by non- health ministries. National Multisectoral Action Plan 2016-2020 was finalized and costed with a highly ambitious set of priority actions for 2016-2017. Six monthly monitoring frameworks developed but not regularly used to chart progress. Mid- term evaluation not yet undertaken. Nearly half of districts have developed their own plans in line with NMAP. Ministry of National Policies and Economic Affairs supports the above process and the monitoring of the plan in order to ensure that all relevant sectors are accountable for progress Ministry of National Policies and Economic Affairs participated in the process but not explicitly led. The MoH sets up the proposed NCD bureau which incorporates all relevant directorates and units that address NCD Prevention and Control NCD bureau was established with a new DDG appointment. The bureau consists of the NCD Unit, National Cancer Control Programme and Mental Health Unit. The MoH integrates NCDs into its National Health Performance Framework and the next National Health Master Plan that is developing National Health Performance Framework and National Health Master plan include NCDs. The MoH establishes separate multisectoral working groups for areas where insufficient action is putting national target at risk Multisectoral working groups have been established for chronic respiratory diseases, physical activity and the development of salt reduction strategies. NCDs are integrated into the work of provincial and district development committees Much stronger integration of NCDs into the development committees at Divisional Secretariat levels. A Sri Lankan NCD Alliance is established to enable Government to coordinate non-State actors NCD Alliance established. Membership includes NGOs, academia, and selected private sector entities. However Alliance still requires strengthening. The UN establishes a forum for the key agencies that have a role to play in NCDs to provide collaborative technical assistance to the Government in the priority areas that the Government will need to report in the Third High-level Forum has not been established. 13 Meeting. In the first instance this group should support Government to finalize and cost the action plan, and ensure the UNDAF mid-term review considers the recommendations of the Joint Mission. B. Surveillance The 2014 STEPS report is fully analyzed and a full report is issued and widely disseminated before the end of 2015. The necessary support from the UN and academic partners as well as professional organizations is identified. STEPS 2014 report finalized and disseminated. Global School-based survey published in 2016. SARA completed in 2017. Next STEPS survey planned for 2018. C. Costing, coordinating, implementing and monitoring a small set of priorities The Government (including NATA), the UN system and other development partners focus on costing, implementing and monitoring progress in a small number of international accepted cost-effective and feasible interventions (best-buys) in order to maximize the impact of NCD investment case. The case for investing in NCDs is undertaken. Multisectoral action plan costed in 2016. Significant additional government investment into NCDs. An NCD investment case has not yet been undertaken but a tobacco investment case will be done in June 2018. GoSL requested WB to invest in primary health care with a special focus on NCD for the next country engagement in Sri Lanka. Tobacco control: implementing the recommendations of the 2014 Sri Lanka Framework Convention on Tobacco Control (FCTC) assessment mission but in particular focusing on: Expanding tobacco taxation coverage to all tobacco, including smokeless tobacco and nicotine delivery system. Tax on cigarettes increased in 2017 but over recent years the price of cigarettes has not kept pace with purchasing power. Smokeless tobacco and ENDS was banned in 2016 with substantial fines for use – focus now is on enforcement. Simplifying taxation system by addressing taxation anomalies across types of tobacco product, and regularly adjusting tax rate according to economic situation, and strengthening. Maintain effective taxation on tobacco products and continue to explore opportunities to simplify taxation on all tobacco products. Revising the tobacco control legislation to enable full enforcement of smoke-free environments in all indoor workplaces, public places and public transports. Amendments approved, enforcement stronger, including community participation, but far from at the level required. Revising the tobacco control legislation to ban point-of- sale advertising and increasing the size of pictorial health warnings and use of plain packaging. Legislation approved but misunderstanding means that tobacco products remain displayed. While the size of pictorial health warning has not increased, Sri Lanka is now planning to adopt plain packaging (following recent approval by Cabinet). Banning sales of single sticks will go for Cabinet approval in the future. Sri Lanka ratifies the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products as soon as possible. Sri Lanka acceded to the Protocol in Feb 2016. Other NATA continues to drive forward action in tobacco control. Legislation with Cabinet to ban single stick sales. National tobacco quit line launched in 2017. Reduction of use of alcohol 14 Strengthening regulation to reduce the public availability of alcohol. The main issue is inadequate capacity to enforce existing regulations. While excise officers have legal authority to enforce regulations they are small in number. The police do not have this authority. Legislating to restrict or ban alcohol advertising and promotion, including sponsorship and point-of-sale marketing. Alcohol advertising and promotion on mainstream media now banned. Needs updating to reflect modern marketing. Developing, implementing and enforcing more robust pricing policy interventions. Tax on beer has actually been reduced and indigenous products remain priced at low levels. Diet and physical activity Working with industry and food producers to (i) reduce salt in processed and manufactured food and (ii) develop user- friendly front of package labelling for food and beverages focusing on energy, sugar, salt and fat composition. Workshops have been held and salt strategies for Sri Lanka has been developed. Several discussions have been conducted with the food manufacturers on reducing the salt in processed food and introducing traffic light system for salt. Front of package labelling (traffic light) for sugar in beverages introduced in 2016. Legislating to replace trans fats with unsaturated fats. Funds have been provided for the Medical Research Institute to purchase equipment to test transfats in commonly consumed food items. Sri Lanka is now planning on moving towards eliminating transfats. Legislating procedures (including pricing policies and taxation) to discourage use of high sugar, high fat, high salt content food items and processed food products. An initial sugar tax is now in place for SSBs. Discussions are underway to further adjust the levels of sugar used in the traffic light system of labelling SSB. Independent of fiscal, legislative and regulatory approaches: (i) MoH is in the process of implementing a communication for behavioural impact (COMBI) plan to reduce the consumption of SSB among school children; (ii) MoE in collaboration with MoH is working with schools to make healthy choices available in through the implementation of the healthy canteen policy; and (iii) an awareness programme for the school children is being carried out by the Medical Officers at local level. Legislating to increase restrictions on marketing to children. Nutrition profiling, a pre requisite was undertaken in 2017 as a first step towards introducing legislation on the marketing of unhealthy food to children. 15 Promoting public awareness through mass media public campaign (including school-based education) to increase awareness of a healthy diet (e.g. the need to reduce added salt to food and reduce intake of sugar and fat, and the need for regular physical activity). School based programmes have been conducted in all districts. Several TV commercials on diet and physical activity have been aired during past few years. However, mass media campaign on diet and PA has not been conducted. A mass media campaign on diet, PA and tobacco is planned for 2018. A number of innovative agriculture/subside projects are being led by the Ministry of Agriculture. Management of cardiovascular diseases and diabetes Setting up a MoH led Steering Group that includes other relevant stakeholders (including patients representatives) that report to the High–level coordination mechanism on: (i) ensuring primary healthcare centers are delivering glycaemic and BP control (using a total of risk approach) to individuals who have had a heart attack or stroke and to those at high risk (≥30%) of a fatal and nonfatal cardiovascular event in the next 10 years; and (ii) ensuring every person in Sri Lanka receives aspirin for an acute heart myocardial infarction (heart attack)- again both are best buys. Guidelines for the management of CVD at PHC have been prepared. Other guidelines have been developed by the professional colleges based on USA and UK guidelines. These have now been endorsed by the MoH. D. Training and capacity building The MoH and Ministry of National Policies and Economic Affairs work with a small group of UN partners, health and other professional organizations , postgraduate and undergraduate institutions and other relevant stakeholders to develop, cost and resource the implementation of a 3- year training capacity building programme aimed at senior and junior health and non-health professionals that focuses on multisectoral action for the prevention and control of NCDs. Progress across MoH and professional organizations with inputs from JICA, WHO and WB. Government finalizing health systems strengthening WB project with focus on NCDs – includes HR capacity building as a main pillar. 16 E. Awareness raising among the public As part of the NCD action plan, relevant government ministries and agencies work with selected partners (e.g. UN agencies, professional bodies, the media) to develop and implement a 2-year costed plan to increase public awareness on NCDs, their modifiable risk factors and ways that individuals and communities can prevent premature NCD mortality and to increase the demand for government to have effective regulatory, legislative, fiscal and policy measures in place. National initiatives are being scaled up by the MOO(NCD) at the district levels by providing funds to the districts. In addition, mass awareness campaigns were conducted specially on days identified to commemorate special days. In addition, awareness campaigns were conducted at the district level by mobilizing youth by working in collaboration with the Ministry of National Policies and economic development, National Youth Services council and the National youth Corp. NATA has undertaken a number of tobacco control campaigns. The partners agree amongst themselves and with other donors a package of funding to deliver this programme. In order to mobilize resources, the Government establishes a fund for this purpose with revenue obtained, for example, from the tobacco and alcohol taxes. No action and no plans to earmark tax revenues. World Bank is in the process of conducting a public expenditure review at national level (Ministry of Finance), where health and education sectors are also included. This may generate evidence for policy dialog in this area. 17 Annex 5. Highly prioritized actions, 2018-2020 under the 2016-2020 National Multisectoral Action Plan developed during the Task Force Mission Strategic area 1: Advocacy, partnership and leadership Category Prioritized actions Rationale 1.1. Advocacy 1.1.1 Greater understanding by parliamentarians on the need to prevent and control NCDs as a national development issue with NCDs considered annually in parliamentary health committee 5 and an annual advocacy event. Policy option 1.2. Awareness raising 1.2.1 Comprehensive annual mass media campaigns to educate the public on physical activity, healthy diet, tobacco and alcohol. Best-buy 1.3. Partnership 1.3.1 Develop institutional mechanisms to prevent industry interference in policy making and its enforcement. FCTC 5.3 Policy option 1.3.2 Strengthen government of Sri Lanka – UN collaboration on NCDs through the primary care reorganization. Policy option 1.4. Leadership 1.4.1 NCD Inter-Ministerial Group housed in the Presidential Secretariat to fast track Sri Lanka’s progress on NCDs. National NCD Council continues as an operational arm of the IMG attended by senior officials. Policy option 1.4.2 Strengthen the capacity of MoH through a capacity assessment, filling of vacancies and strengthening coordination between NCD Bureau and other NCD-related area to ensure that the prioritized plan can be delivered, including a review on institutional capacity of MOH to deliver its commitment on MSAP. Policy option 1.4.3 Clearly defined and resourced workplan from non- health ministries that describes aligned to the prioritized action plan, shared benefits and what is in it for them, including a review on NCD fiscal space. Policy option 5 Health human welfare and social empowerment 18 Strategic area 2: Health promotion and risk reduction Risk factors Prioritized actions 2.1. Tobacco use (NCD target 5) 2.1.1 Maintain taxation on tobacco products and continue to explore opportunities to simplify taxation on tobacco products. Best-buy 2.1.2 Enforce ban (and strengthen legislation) on tobacco smoking indoor workplaces (public places & transports). Best-buy 2.1.3 Establish tobacco cessation support programmes, including a quit line. Effective intervention 2.1.4 Enforce legislation passed in 2016 banning all forms of smokeless tobacco. 2.2. Harmful use of alcohol (NCD target 2) 2.2.1 Increasing excise taxes on alcoholic beverages. Best-buy 2.2.2 Identify ways to increase capacity of enforcing restrictions on the sale of alcohol. Best-buy 2.3. Unhealthy diet (NCD target 4) 2.3.1 Strengthen restrictions on marketing of unhealthy food and non-alcoholic beverages to children. Overarching/enabling action 2.3.2 Strengthen the monitoring of inappropriate promotion of food and beverages to infants and young children. Enabling action 2.3.3 Initiate front-of-pack labelling for salt, sugar and fat – currently only SSBs are covered. Best-buy 2.3.4 Reduce salt intake in public institutions such as hospitals and schools. Best-buy 2.3.5 Develop a national strategy and costed plan for eliminating trans-fat products. Effective intervention 2.4. Physical Inactivity (NCD target 3) 2.4.1 Strengthen physical education school program, ensuring quality physical education is available. Recommended intervention 19 Strategic area 3: Health system strengthening for early detection and management of NCDs and their risk factors Category Prioritized actions Rationale 3.1. Cardiovascular diseases and diabetes 3.1.1 Better coverage of treatment and counselling for those at high risk of cardiovascular diseases and diabetes. Best-buy 3.1.2 Development of national guidelines for management of cardiovascular diseases (heart attacks and hypertension) and diabetes, along with a program for their rollout. Policy option 3.1.3 Rollout of national guidelines for management of diabetes. Policy option 3.2. Cancer 3.2.1 Increased coverage of HPV vaccination program among teenage girls Best-buy 3.2.2 Increased uptake of pap smears for women aged 35 years and 45 years with treatment of precancerous lesions. Best-buy 3.2.3. strengthened oral cancer screening in high-risk groups (for example, tobacco users, betel-nut chewers) with timely treatment. Recommended 3.3. Chronic respiratory disease 3.3.1 Better care for patients with asthma, chronic obstructive pulmonary disease. Effective intervention 3.3.2 Improved access to improve stoves and cleaner fuels. Recommended Strategic area 4: Surveillance, monitoring, evaluation and research Category Prioritized actions 4.1. Surveillance 4.1.1 Continued collection of ongoing data to enhance NCD policy making and programming with a STEPS survey undertaken in 2018 and GATS survey done in 2018-2019. Policy option 4.1.2 Strengthen mortality data with development of a standardized tool, training of registrars and recruitment of coders. Policy option 4.2. monitoring and evaluation 4.2.1 Midterm review based on NMSAP monetary framework as part of finalizing prioritized action plan 2018-2020. This should include an understanding on institutional capacity. Policy option 4.2.2 End of term review. Policy option 4.3. Research 4.3.1 Generate evidence to inform policy making (tobacco investment case, fiscal space study and socioeconomic analysis on the impact of NCDs). Policy option