WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL REGIONAL COMMITTEE Fifty-sixth session Noumea, New Caledonia 19-23 September 2005 Provisional agenda item 8.2 WPRlRC56/4 COIT.l
19 August 2005 ORIGINAL: ENGLISH
REPORT ON THE REGIONAL EVALUATION OF NONCOMMUNICABLE DISEASES PREVENTION AND CONTROL PROGRAMME
Corrigendum
Page 2, third para, line 1 should read: "In the 2002-2003 biennium, the Regional Director ... "
WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Fifty-sixth session Noumea, New Caledonia 19-23 September 2005 Provisional agenda item 8.2
WPR/RC56/4 26 July 2005 ORIGINAL: ENGLISH
REPORT ON THE REGIONAL EVALUATION OF NONCOMMUNICABLE DISEASES PREVENTION AND CONTROL PROGRAMME In 1999, the Executive Board asked the Director-General to prepare an “integrated plan for monitoring, evaluating and reporting results to the governing bodies”. In line with a greater emphasis on evaluation in the Organization, global and regional evaluations have been conducted. In recognition of the growing burden of noncommunicable diseases (NCD) in the Western Pacific Region, the Regional Director selected the NCD Prevention and Control Programme for review by an external evaluation team from Member States in the Region. The four-member team assessed the conceptual framework of the current strategy for NCD Prevention and Control. The team also examined the processes of technical collaboration with selected countries, their relevance to countries, and their outcome and future prospects. Five countries—China, the Philippines, Samoa, Tonga and Viet Nam—were visited, an extensive series of interviews was conducted and relevant documentation was reviewed. Overall, the team noted that the NCD programme appears on track to meet all of its expected results for the 2004-2005 biennium (Annex 1). Collaboration with the five countries resulted in significant progress in the areas of national planning, surveillance, lifestyles and environment, clinical preventive services, and networking. Countries reported that both WHO technical support and funding were critical at this stage of development of NCD control efforts and that initiatives would not have gone ahead without this support. The quality of WHO’s work is of a high technical standard and was well regarded by Member States, but it is too small in scope to meet the challenges posed by the magnitude of the NCD problem in the Region. Measures to strengthen WHO’s capacity in NCD are recommended. The report also made recommendations in the areas of advocacy, resource mobilization, integration and coordination, national planning and policy development, and surveillance. The report is being presented for the information of the Regional Committee and for discussion at its fifty-sixth session.
WPR/RC56/4 page 2
1. BACKGROUND
In 1999, the Executive Board of WHO asked the Director-General to prepare an "integrated plan for monitoring, evaluating and reporting results to the governing bodies". In line with a greater emphasis on evaluation in the Organization, global and regional evaluations have been conducted. Combined with the monitoring of Programme Budget performance every six months, these evaluations have provided more complete coverage of the Secretariat's performance. The lessons learnt have been taken into account in planning the future work and Programme Budgets of WHO. Within the evaluation framework of WHO, programmatic, thematic and country evaluations have unique terms of reference, and the evaluations require application of accepted quantitative and qualitative principles and procedures. Programmatic evaluations address achievements towards WHO Objectives and require an in-depth analysis of outcomes and the impact of WHO's work in a specific Area of Work. Thematic evaluations require an in-depth analysis of a topic, which may be of a different nature from an Area of Work and cut across Areas of Work. Country evaluations examine the collaborative programmes of WHO in a country as a whole. Each region and Headquarters conduct one programmatic or thematic evaluation each biennium. Programmatic, thematic and country evaluations will always include a review of relevant documents and an analysis of costs and expenses. The Programme, Budget and Administration Committee of the Executive Board, in the beginning of the subsequent biennium, considers the evaluations that have been conducted by the Organization. In the 2003-2004 biennium, the Regional Director selected the Stop TB Special Project for review by an external evaluation team because of the public health importance of tuberculosis in the Western Pacific Region. The evaluation commended the building of a secure foundation, the
increased collaboration with partners, and the establishment of a strong team for tuberculosis control at both regional and country levels. The report was presented at the fifty-fourth session of the Regional
WPR/RC56/4 page 3 Committee and the recommendations were used to strengthen the implementation of WHO's programme budget in the Region. A country evaluation of WHO's cooperation with Mongolia was completed in May 2004. The purpose of the evaluation was to assess the WHO's strategy for cooperation with Mongolia and to enable the different levels of the Organization to improve collaborative programmes with the country. The evaluation team made a number of recommendations that were related to implementation of the Country Cooperation Strategy, support to the country office, technical issues and improvement of the performance of the country team.
2. PROCESS
In recognition of the growing burden of noncommunicable diseases (NCD) in the Western Pacific Region, the Regional Director selected the NCD Prevention and Control Programme for review by an external evaluation team from Member States in the Region for the current biennium. A four-member team was identified in consultation with the governments of concerned Member States that included experts in NCD prevention and control from Australia, China, Fiji and Japan. The team assessed the conceptual framework of the current strategy for NCD Prevention and Control. The evaluators also examined the processes of technical collaboration with selected countries, their relevance to countries, and their outcome and future prospects. The evaluation was conducted in two stages. After an initial briefing and planning visit to the Western Pacific Regional Office beginning 18 April 2005, the team made field visits with counterparts in the Philippines. For subsequent field visits, the team divided into teams of two evaluators. Weeklong field visits were undertaken in Samoa, Tonga and Viet Nam. The second stage started on the 16 May when two team members visited China. The entire team reconvened in the Western Pacific Regional Office during the following week for debriefings, analysis and report writing.
3. POLICY FRAMEWORK
WPR/RC56/4 page 4 The policy framework and WHO's objectives for the NCD Prevention and Control Programme have been laid out in various documents listed below. They constitute the basic documents on which the programme evaluation was planned and organized. Global documents: World Health Assembly resolution WHA53.17 on prevention and control of noncommunicable diseases and a report to the Health Assembly 1 lay out the foundations of the global strategy on the prevention and control of NCD. The Western Pacific regional programme is built on three key documents: • •
Resolution WPR/RC51.R5 – Prevention and Control of Noncommunicable Disease (Annex 2). Western Pacific Declaration on Diabetes WHO, International Diabetes Federation (IDF), Secretariat of the Pacific Community (SPC), 2000.
•
Tonga Commitment to Promote Healthy Lifestyles and Supportive Environment (WHO/SPC, 2003).
4. FINDINGS AND RECOMMENDATIONS
Overall, the evaluation team noted that the NCD programme appears to be on track to meet all of its expected results for the 2004-2005 biennium (Annex 1). The team found that WHO
collaboration with the five countries where field visits were conducted had resulted in significant progress in the areas of national planning, surveillance, lifestyles and environment, clinical preventive services, and networking. Countries reported that both WHO technical support and funding were critical at this stage of development of NCD control efforts and that initiatives would not have gone ahead without this support. The quality of WHO's work is of a high technical standard and was well regarded by Member States, but it is too small in scope to meet the challenges posed by the magnitude of the NCD problem in the Region.
1
World Health Assembly document A53/14 Global strategy for the prevention and control of noncommunicable diseases (2000).
WPR/RC56/4 page 5 The team recommended that WHO expand its response to NCD in the Western Pacific Region, commensurate with the current and anticipated burden, and consistent with the new priority to be given to this area within the Organization globally, as a matter of urgency. Recommendations were also made to the Regional Director in the areas of advocacy, resource mobilization, integration and coordination, national planning and policy development, and surveillance. A need for a substantial and systematic increase in WHO's policy and advocacy role in the Region regarding NCD was highlighted, including the potential for closer liaison between the Regional Office and Headquarters to increase funding for NCD prevention and control. Several recommendations targeted improved coordination and the integration of input from different Areas of Work in the Regional Office. A focus on high burden, preventable conditions and their common risk factors for the next two bienniums was suggested and the importance of collaboration with countries was underscored, particularly in relation to NCD policy development and national planning. It was considered that WHO in the Region should support active networking and sharing of experiences across demonstration projects, both within and between countries. Continued support for STEPwise surveillance was considered necessary for all countries and areas in the Region to maintain comparative data on the NCD burden and trends and to support the tracking of progress. The team also recommended that development of the Regional NCD Country Network should be finalized as soon as possible, including a Regional NCD information system. In order for WHO to expand its response to NCD, the team noted that increased capacity is required in WHO offices at regional, intercountry and country levels. The report of the evaluation team is being presented for the information of the Regional Committee and for discussion at its fifty-sixth session.
WPR/RC56/4 page 6
WPR/RC56/4 page 7 ANNEX 1
PROGRAMMATIC EVALUATION OF THE WORK OF THE WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC IN NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL, 2004-2005 April-May 2005 Executive Summary INTRODUCTION In recognition of the growing burden of noncommunicable diseases (NCD) in the countries and areas of the Western Pacific Region, the Regional Committee in 2000 requested the Regional Director:1 • to give high priority to the prevention and control of NCD and to provide leadership and advocacy against NCD in partnership with key decision-makers and relevant agencies in the Region; • • to support Members States to build capacity for NCD prevention and control; to develop simple, standard tools and protocols for NCD surveillance, supported by regional and national networks; • to support the establishment and expansion of demonstration projects, and the development of national NCD programmes; • • to promote and support research in priority areas, including behavioural and economic studies; and to support countries and areas to develop and implement plan of action for 2000-2005 for the Western Pacific Declaration on Diabetes. The commitment to take action on NCD control was later reinforced by the Tonga Commitment to Promote Healthy Lifestyles and Supportive Environment.2 A further commitment was made at the Meeting of Ministers of Health for the Pacific Island Countries in Samoa in March 2005. A global endorsement was made by the Fifty-seventh World Health Assembly with the Global Strategy on Diet, Physical Activity and Health .3 These resolutions and documents, together with the Programme Budget for each biennium, provide the policy framework for the NCD programme in the Western Pacific Region. There is no single document setting out the entire NCD strategy for the Region.
1 2 3
Resolution WPR/RC51.R5. WHO/SPC, 2003. Resolution WHA57.17.
WPR/RC56/4 page 8 Annex 1 This Programme Evaluation 2004-2005 was established to test the quality and quantity of the Western Pacific Regional Office response to NCD prevention and control in the Region, through the NCD programme, within the policy framework set by the above documents.
Terms of Reference The terms of reference for the evaluation were: (1) to assess, in the light of available evidence, the conceptual framework of the current strategy for NCD Prevention and Control in WHO in the Western Pacific Region; (2) to assess the collaboration w ith selected countries on two levels: a. their suitability as models for other countries at similar stages of the health transition; and b. to assess the processes of technical collaboration, their relevance to countries, their principal results and their prospects for the future; and (3) to submit a report at the end of the assignment. In particular the evaluators were asked to document lessons learnt to date from the NCD programme, and to recommend ways in which the programme may be improved in quality, alignment w ith strategic direction, resourcing, and scale as an effective response to the regional NCD epidemic. The evaluation was conducted by an external, independent four-person review team. Five countries were selected by the WHO Regional Office for the Western Pacific for detailed assessment and field visits. These were: China, the Philippines, Samoa, Tonga and Viet Nam. Over a four-week period, the Evaluation Team conducted an extensive series of structured interviews with respondents in the Regional Office, the WHO Representative (WR) office for each of the selected countries, ministry officials, senior clinicians, and managers and staff of WHO-supported demonstration projects. Relevant documentation was reviewed and analysed, including mission reports, country cooperation strategies, country NCD strategies and plans, demonstration project evaluation reports and regional-level documents. Burden of disease in the Western Pacific Noncommunicable diseases account for seven out of every 10 deaths in the Western Pacific Region. Conditions which are at least in part preventable, particularly heart disease and many cancers, are major causes of premature mortality, and of preventable morbidity. The Asian part of the Region has a high burden of
WPR/RC56/4 page 9 Annex 1 preventable and untreated hypertension and a rapidly growing epidemic of diabetes. The Pacific part of the Region has world-leading rates of obesity and diabetes, with significant levels of cardiovascular disease and cancer. Rounded off to thousands of deaths daily, The World Health Report 2004 estimates that, out of a total of 33 000 deaths daily in the Western Pacific Region: §
5000 daily deaths are due to communicable diseases, nutrition deficiency, and maternal and perinatal causes combined;
§ §
3000 daily deaths are due to injury; 25 000 daily deaths are due to NCD and mental health causes; many of these are “premature” deaths. Mental health causes account for less than 500 of these deaths daily.
There is evidence that all of these conditions are growing. For example, the 2002 Nutrition and Health Survey in China found that there had been a “rapid increase in the prevalence of chronic noncommunicable diseases” (Table 1). Table 1 Condition Hypertension (>18 yrs) Diabetes Year 2002 (%) 18.8% Increase in prevalence of NCD in China No. of people 160 million (about 6% under control) More than 20 million (plus nearly 20 million with impaired glucose metabolism) Increase 31% since 1991
2.6%
Between 1996 and 2002 prevalence in larger cities increased from 4.6% to 6.4% (40% increase over 6 years) 39% since 1992 97% since 1992
Overweight Obesity
22.8% 7.1% (child obesity = 8.1%)
200 million 60 million
Source : China National Nutrition and Health Survey, 2002.
It is to be expected that countries and areas in economic transition will experience a further rise in NCD, and there appears a real danger of under-resourced health services in many transitional economies being overwhelmed by the demand for chronic illness care. Many countries face health professional workforce shortages, uneven geographic distribution, inappropriate skills mix and various levels of out-migration. Chronic disease is also likely to have a significant impact on economic productivity. For example, of the expected 9
WPR/RC56/4 page 10 Annex 1 million cardiovascular disease deaths in China in 2030, over one half will occur in the prime working ages 35641 . Against this background, it appears that current responses at the country and global levels are fragmentary and insufficient to adequately address the dimensions of the problem. There are likely to be significant long-term costs from a failure to invest in prevention and control at this stage of the epidemiological transition. Yet scarce resources continue to be required to confront infectious diseases and to provide basic health services. It is argued by many commentators that the response of both countries and international agencies needs to be scaled up if they are to stem the tide of these epidemics4 . IMPLEMENTATION AND PERFORMANCE FINDINGS Objectives and expected results The goals, objectives and performance indicators for the NCD programme are set out in the Regional Programme Budget. The strategic approaches to be implemented by the NCD programme are stated as: §
work with countries and areas to strengthen national, integrated NCD programmes and plans, addressing lifestyle and environmental change and strengthening NCD health services;
§ §
support regional networking and exchange of experiences by demonstration projects; work with countries and areas to develop standardized surveillance activities, especially for CVD, diabetes, cancer and their risk factors and complications; and
§
collaborate with countries and areas to support the implementation of appropriate clinical management guidelines in hypertension and diabetes in all countries and areas of the Region.
The indicators for the expected results of these activities are: § § § §
number of new countries and areas implementing STEPS surveys; number of members of regional NCD network; number of community demonstration projects reporting on their impact on intermediate risk factors; number of demonstration projects reporting on the impact of implementation of clinical management guidelines on NCD; and
4
Leeder, S. et al. The Global Burden of Chronic Disease: Overcoming Impediments to Prevention and Control. JAMA , June 2, 2004
WPR/RC56/4 page 11 Annex 1 §
number of countries and areas supported to develop an integrated approach to the prevention and control of NCD. Conceptual framework
The strategic approaches listed above reflect the conceptual framework underpinning the work of the NCD programme. Over time, the programme has evolved to adopt a strategic focus on five main areas. These five areas are: National Planning: The promotion of a National NCD Plan in all countries. It is also possible that countries opt to have separate plans for specific diseases and risk factors, but it is important to have a document that steers and coordinates the initiatives in a unified direction. Surveillance : The promotion of an evidence-based system for the collection of standardized data on prevalence of key NCD and their risk factors. The WHO STEPwise approach is the recommended mechanism for this in the Western Pacific Region. Lifestyles and Environments : The promotion of effective health promotion for the primary prevention of NCD through action on the behavioural risk factors and their determinants. The work of the NCD unit is in this endeavour intimately linked with that of the Tobacco Free Initiative, Health Promotion and Nutrition. Where appropriate, community-based demonstration projects are used as the means to develop and test methodology that is then extended to national level. Clinical Preventive Services : The promotion of effective, affordable programmes for the early recognition and effective management of cases of diabetes, hypertension, obesity, and the screening and palliation of cancer. This secondary prevention effort works through a combination of development of clinical guidelines, training, equipping health centres and auditing their work. Networking : The reach of the NCD strategy is to be amplified through the use of explicit regional networking activities, through direct meetings, and through the web. In working with countries and areas to support action on these issues, the NCD programme has made use of the STEPwise approach as a framework for NCD prevention and control policy development, planning and intervention. This framework assists countries to identify key actions for implementation in short-, medium- and long-term time frames, at various levels of resource availability. Implementation of the programme Overall, the NCD programme appears on track to meet all of its objectives and expected results for the 20042005 biennium. This was apparent from our site visits, the mission reports reviewed, feedback from the WHO
WPR/RC56/4 page 12 Annex 1 country offices, as well as WHO’s formal reporting and accountability requirements. Below we address specific areas of the achievements and performance of the programme with regard to the Terms of Reference. Collaboration with selected countries WHO collaboration with the countries selected for site visits for the Programme Evaluation has achieved many impressive results to date. Significant progress is being made in all of the areas contained in the conceptual framework for NCD prevention and control noted above. Table 2 gives examples of a number of the major projects and activities that have been supported by the WHO NCD programme in the selected countries, either financially or through technical assistance. In some cases WHO’s role has been a partner working alongside other agencies. In a number of instances, country informants noted that the success of particular planning or program development processes resulted from the expert advice, problem solving abilities and encouragement of the Regional Adviser. Countries reported that both WHO’s technical support and funding were critical at this stage of development of NCD control efforts, and that most initiatives would not have gone ahead without this support. Consultancies, training programs, workshops and technical guidance on project development all played a key role in local capacity-building and ensuring project quality. The importance of WHO’s role in helping mobilize additional resources (for example, the joint submission with Viet Nam to the World Diabetes Federation; AusAID support for STEPS surveys) was widely acknowledged. At this stage, assessment of the impact of the various initiatives is primarily dependent on process indicators, due to the developmental stage of many projects and data limitations. In most instances however, high quality baseline data, including clinical measures, has now been collected, and surveillance systems put in place. In the near future therefore, projects will start to present evidence of impact on intermediate risk factors, and, later, on health outcomes. Based on the underlying programme logic of these initiatives, the effort that has gone into capacity building and technical assistance, and the achievements to date, it is anticipated that the projects supported by WHO will achieve their objectives. In general, all projects visited reported a very high degree of satisfaction with the technical support and materials provided by WHO, with consultants employed by WHO usually held in high regard. WHO input was considered relevant, appropriate to local needs and of high technical quality. Where concerns were expressed, these were usually related to a real or perceived need for additional resources, given local resource constraints. Projects led by clinicians often expressed interest in obtaining additional health promotion support to assist with the healthy lifestyle education components of the initiative. Visits by the Regional Adviser were particularly highly valued. Occasional concerns were expressed about delays in the arrival of equipment, but there were no instances where the progress or viability of projects was in jeopardy. A comment made frequently by those
WPR/RC56/4 page 13 Annex 1 working on demonstration projects was the desire for more opportunities to share experiences with, and learn from others who had conducted similar projects in similar circumstances. Overall, from the documentation provided to us, the progress and achieveme nts we observed in the countries visited also appears to be reflected in the NCD Programme’s collaboration with countries and areas throughout the Western Pacific Region5 .
5
For example, progress in 14 Pacific island countries and areas is documented in the report Progress in the Implementation of the Tonga Commitment presented to the Meeting of Ministers of Health for the Pacific Island Countries held in Samoa, March, 2005
WPR/RC56/4 page 14 ANNEX 1 Table 2 China National Planning Senior level WHO support for NCD prevention and control. NCD Task Force established & national plan drafted. Philippines National Key Performance Indicators (KPI) for NCD Control developed. Coalition for Prevention and Control of NCD formed. National plan in development. NCD coalition has commenced negotiations with other sectors e.g. food industry. Surveillance Provincial surveillance network set up for BRFS*. National nutrition survey, 2002. Collaboration with WHO on 2nd National Nutrition Survey (NNS); Baseline NCD survey conducted in Pateros and Guimaras. Samoa National NCD plan drafted, but not officially published - led by support from AusAID with some backup technical support from WHO. Tonga Tonga National Strategy to Prevent and Control Noncommunicable diseases (2004-2009). Viet Nam PM decision on NCD prevention and control. Draft operational plan developed by national task force with WHO support. Cancer control review completed. WHO supporting small NCD team in Ministry to support Task Force Modified STEPS survey in planning stage (with other partners). National diabetes survey conducted2004. National NCD Surveillance System workshop completed. Draft system in development under National NCD Task Force.System being tested in community demonstration sites. WHO support for development of cancer registries. Healthy lifestyle education are components of diabetes and hypertension community demonstration projects First annual national healthy lifestyle campaign launched in 2004 with hypert ension as the theme; 2nd in 2005 Healthy Village Culture supported by WHO Health promotion with NCD component
STEPS survey draft reports produced.
Lifestyles and Environments
Integrated NCD intervention pilot community projects in Jiangsu, Shandong, Hubei, and Guangxi Provinces: Health-Promoting Schools project – obesity prevention.
Community demons tration projects in Guimaras and Pateros. Primary care training manual on promoting healthy lifestyles now adopted nationally and being considered for use in other countries. National healthy lifestyle campaign. Health promotion included in health centre accreditation
Healthy home projects as subset of Healthy Islands under collaboration of Ministry of Women and MOH – cooking and vegetable gardening programmes. Training of nurses as diabetes prevention community educators. NCD workshop for church leaders
Healthy Island activities implemented in at least four districts. WHO workshop for NCD control. Community demonstration sites - impact on intermediate risk factors. NCD programmes combined with health promotion - school, community and worksite settings. Major focus on physical activity, nutrition, weight control and smoking.
WPR/RC56/4 page 15 Annex 1 China Clinical Preventive Services Clinical prevention integrated in community projects. WHO has supported guidelines and IT capacity. Philippines Clinical management guidelines on NCD implemented in demonstration sites. Preventive care for NCD included in health insurance benefit package. Diabetes clinical management guidelines developed. Networking (Internal and external) Network of pilot communities Major role in Scaling Up established. Prevention and Control in Western Pacific workshop Director, NCD Control, hosted site visits for MOH attended Japan-WHO participants. International Visitors Programme**. Provincial Participation in Japan -WHO NCD officials international International Visitors fellowships. Participation in Programme**. Scaling Up Prevention and Control in Western Pacific workshop. Samoa National prevention and management guidelines for diabetes and CVD developed with technical support of WHO. Hospital-based tobacco cessation programmes conducted. Cancer pain management protocol. Medical officer participation in WHO workshop on tobacco control. Participation in Scaling Up Prevention and Control in Western Pacific workshop. Tonga National diabetes treatment guidelines developed. National register of diabetes patients implemented. Diabetes centre supports community screening programmes, patient education, training of health professionals. Participation in Japan-WHO International Visitors Programme**. Participation in Scaling Up Prevention and Control in Western Pacific workshop. Viet Nam Diabetes demonstration projects in Thai Binh and Than Hoa. WHO & WDF support. Quasiexperimental design. Training for health workers. Hypertension project in Phu Tuong.
Establishment of National NCD network is one of the priorities arising from PM decision. NCD Task Force MOH staff attended Japan International Visitors Programme**. Participation in Scaling Up Prevention and Control in Western Pacific workshop.
* Behavioural Risk Factor Survey ** Japan-WHO International Visitors Programme: Planning and Executing National NCD Prevention and Control Plans
WPR/RC56/4 page 16 Annex 1 A number of common themes also emerged in interviews with ministry officials at the national level in the selected countries, and with WHO Representatives. These can be summarized as: §
Concern about capacity (financial and human resources) to address the NCD epidemic within the Ministry, within the country health system overall, and in WHO country offices. The number of NCD programme staff located in WHO country offices, ranged from zero to one full-time position, in the countries visited.
§
Concern that while NCD control was a priority for the governments of most countries, this did not always translate into resource allocation decisions as a result of other pressures; in the Asian countries in particular, ministry officials felt that WHO could play a stronger role in advocating for NCD control with governments.
§
Both ministry officials and WHO Representatives believed they had very good working relationships with the NCD Programme, and that the Regional Adviser was very responsive to their needs.
§
WHO Representatives argued strongly for WHO’s contribution at the country level to be highly strategic, focused on key areas of leverage and, wherever appropriate, tightly integrated. The need for a strong, focused, vertical approach in certain instances was recognized as necessary (for example, in regard to the Framework Convention on Tobacco Control). In other cases, however, a more “joined-up” approach was needed (for example, where NCD prevention, health promotion and nutrition and physical activity promotion activities intersected, such as in healthy settings initiatives).
§
The importance of advocacy, coordination and building relationships with donor agencies and other funding bodies was emphasised.
Regional and intercountry initiatives The NCD Programme has made good progress in networking and sharing skills and experience at a regional level in 2004-2005. Key examples include: §
The meeting Scaling Up NCD Prevention and Control in the Western Pacific: Beyond Demonstration, Achieving Results (Aug 2004, Manila) provided a basis for sharing country level NCD strategies, informing participants about developments in regional and global initiatives (for example, The Global Strategy on Diet, Physical Activity and Health ), and establishing the basis of a regional NCD network. Baseline data on national NCD programmes has been collected from all countries in the Region, with results presented to this meeting.
WPR/RC56/4 page 17 Annex 1 §
An informal NCD surveillance network has been evolving to share standardized survey design and implementation protocols, and application of the data to policy-making. To date this has largely involved collaboration among several Pacific island countries, but this is expected to evolve to more formal networking in the subregion and ultimately the Western Pacific, under the regional NCD network.
§
The Manila meeting also provided the impetus for establishment of the Western Pacific Physical Activity Network (WP-PAN) within the regional NCD network. This will be an important joint achievement of the Western Pacific Region NCD and Nutrition Programmes.
§
A short course on Planning and Executing National NCD Prevention and Control Plans was conducted through the Japan-WHO International Visitors Programme in April 2005. This brought together national NCD Programme Managers from eight countries of the Western Pacific as well as Japan, and three countries from the South-East Asia Region of WHO. Participants formed a “community of practice”, based around mutual learning and development and focused on a systematic approach to NCD programme design and evaluation. Countries involved produced project proposals for evaluation over the next year. These projects will be supported by Japan Government Voluntary Funds over 2005-2006.
§
Progress on NCD Prevention and Control was reviewed in the Samoa Meeting of Ministers and Directors of Health of the Pacific Island Countries in March 2005. The Samoa Commitment endorsed and extended the Tonga Commitment to Healthy Lifestyles and Supportive Environment of two years before. The Regional Office input to the Samoa meeting exemplified a team approach to NCD prevention and control, with contributions from areas responsible for tobacco control, nutrition, physical activity and health promotion, as well as the NCD Programme.
WHO collaborating centres As part of the Programme Evaluation, the WHO Collaborating Centres that are administered under the NCD Programme were surveyed, and annual reports and other documentation analysed. A successful model for networking of Collaborating Centres in Nursing was also reviewed for comparative purposes. A list of the Collaborating Centres is at Appendix A. The benefits and costs associated with the administration of the Centres, as understood by the Evaluation Team, are summarized below. §
Benefits: WHO Coordinators report numerous valuable interactions with Collaborating Centres. Certain Centres use their own human or financial resources to develop reviews or publications that are directly in line with the NCD framework in the Region. Others have, at no cost to WHO, directly supported work in the Western
WPR/RC56/4 page 18 Annex 1 Pacific Region countries or provided fellowships to augment WHO's work. Others have provided advice, reviewed WHO documents, and contributed to WHO meetings at their own expense. Some Centres felt that they could contribute more towards prevention and control of NCDs but were constrained by lack of resources mainly funding. §
Costs: The large number of Centres in the NCD area represents a significant administrative burden. Centres that collaborate with WHO only through formal contracts or consultancies are not perceived to be different than any other person or institution who may be assigned or appointed by WHO to a specific job.
Strategic alignment The Western Pacific NCD Programme is required to manage a series of both vertical and horizontal relationships. It is situated between the global imperatives initiated by WHO Headquarters and the needs of countries, and of WHO offices in countries. The Evaluation Team was not able to conduct interviews with WHO Headquarters staff. However, the overall impression gained from WHO Representatives and Regional Office informants was that the programme generally manages to bridge the three levels effectively and sensitively. Global meetings of Regional Advisers contribute to the flow of information and strategic thinking between the Regional Office and Headquarters. Nevertheless, as NCD efforts are scaled up globally and in the Region, this is an area that will require ongoing management. There are also interrelationships and some overlaps between the NCD Programme and other areas of work, including: § § § § §
Tobacco Nutrition and Physical Activity Health Promotion Nursing Health systems development and financing
Once again, we found that these relationships are generally well managed by the Regional Office, and a number of processes are working to ensure that collaboration occurs when needed. As the interconnections between strategies become more manifest as increasing attention is focused on NCD, how these relationships are most effectively managed will also require further consideration.
WPR/RC56/4 page 19 Annex 1 NCD Programme Budget The changes in the specified NCD budget (excluding the budget allocated to Mental Health) were reviewed for past and current biennia, and as proposed for the next biennium (Fig.1). The figures are shown by country and intercountry programme (ICP), including both regular and external budget. Fig. 1 5,000,000 4,500,000 4,000,000 $3,260,674 3,500,000 3,000,000 $1,869,900 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 '00-01 '02-03 '04-05 '06-07 $2,368,714 $1,551,955 $1,354,110 $1,781,000 $1,708,719 $2,077,361 $1,997,272 $3,431,471 $3,650,900
Changes in Proposed Programme Budget for NCD (US$) $4,365,986 Country ICP
ICP: Inter - country program
Except for the biennium (2000-2001), the total budget for NCD has been gradually increasing (including relative to other areas), suggesting that the NCD Programme is indeed being given some priority in the Region. The changes in country budget for NCD in the selected countries are shown in Figure 2. The NCD budget in Viet Nam has shown a considerable increase in the recent three biennia. The proportion of NCD budget in the total country budget has increased in Viet Nam and Samoa, but decreased in Tonga. These figures only include the allocation specified for the NCD programme, and do not include other allocations such as for health promotion.
WPR/RC56/4 page 20 Annex 1 Fig. 5 Changes in country budget for NCD in selected countries (US$) 800,000
Amount for biennium (left) and proportion in total country budget (right) 25 CHN CHN PHL SMA TON
700,000
PHL SMA TON
20
VTN
600,000
VTN
500,000
15 (%)
400,000
10 300,000
200,000
5 100,000
0
0 2000-2001 2002-2003 2004-2005
2000-2001
2002-2003
2004-2005
CONCLUSIONS Quality of WHO Support Achievements The conceptual framework used by the NCD programme generally reflects current best practices. Aspects of the framework such as the STEPwise approach to intervention planning have been highly influential, even beyond the Region. When presented, the components are well understood by countries and areas. Some countries are now progressing to take "mini-STEPS" for area specific planning. In general, solid progress has been made in the areas the Programme has concentrated on: national planning, surveillance, healthy lifestyles, clinical services and networking. Objectives and expected results have largely been met. The programme has successfully leveraged additional resources from a variety of sources. Informants in countries expressed a high degree of satisfaction with the quality, relevance and timeliness of the NCD programme’s technical advice and assistance. Considerable momentum for NCD prevention and control has been built in the Region. This needs to be sustained. The majority of less developed and developing countries have little experience to draw on and few of the skills or little of the infrastructure nee ded to address the complex, multi-causal, long-term nature of NCD. Few other agencies are providing countries with support in NCD. WHO’s expertise is thus a most valued asset, almost unique among development agencies.
WPR/RC56/4 page 21 Annex 1 With scarce resources, the NCD programme cannot afford to have its efforts diluted. The NCD programme has remained focused on high burden, highly preventable conditions, particularly cardiovascular diseases, type 2 diabetes, certain cancers and chronic respiratory diseases. This focus is strategic and should be sustained. The overarching impression is that WHO has been able to use its limited human and financial resources in a very strategic fashion. It has mobilized a regional movement for NCD using very small investments. Needs More Staff: The NCD programme risks becoming the victim of its own success. The scale of WHO’s support needs to be massively increased if it is to meet the needs and demands of Member States. The capacity of country offices in NCD is extremely limited, and in some cases there are no full-time positions. As countries become more attuned to the growing burden of NCD, the requests for technical assistance will increase. In technical assistance and human resource terms alone therefore, WHO’s presence needs to be urgently scaled-up, commensurate with the dimensions of the problem. This increased capacity will be needed at Regional, subregional and country levels. Greater Investment: WHO’s financial contribution is considered less important than the provision of expertise. However, a significant injection of resources to the NCD prevention and control effort in countries and areas is, and will be, needed, if any serious progress in stemming the advance of NCD is to be made. A range of projects has been observed with a state of the art design yet with insufficient scale to provide an adequate intervention dose to make a measurable difference. In many cases, resources might be found by national governments if there is a will to do so. In other cases, donor support will be necessary. To achieve either of these requires a heightened advocacy effort by WHO. As noted, this was emphasised by Ministry of Health and provincial officials, senior clinicians, and WHO country offices. More Integration: Given the resource constraints, WHO resources need to be used as efficiently as possible. All of WHO’s efforts in NCD and in NCD-related areas such as health promotion, nutrition and tobacco control are highly regarded, but many believe greater synergies are possible. There is evidence that stronger effects may be achieved through comprehensive approaches. There are also pragmatic arguments for greater integration of effort, such as reductions in transaction costs in dealing with common settings and reducing the burden of multiple reporting lines. While the strengths of concentrated efforts and specialised programmes should be maintained, this is an area that warrants attention by WHO in the future.
WPR/RC56/4 page 22 Annex 1 More Communication: The conceptual framework behind the NCD Programme is not widely known or disseminated. Wider dissemination would assist understanding of what WHO is aiming to achieve in NCD prevention and control in the Region, and how various components of the total effort fit together. There is a need to clarify, develop further and articulate the total NCD effort of the Regional Office, beyond the work of the NCD unit specifically. National Planning Achievements Considerable progress is being made. At least 11 countries have national plans completed or in draft form, in almost every case as a result of collaboration with WHO. Needs The main concern in the selected countries visited was the need for high-level political and budgetary commitment to the plan. The visit to China by a joint Regional Office and Headquarters delegation in 2004 to discuss the importance of action on NCD was particularly timely and influential. Such visible high-level support to encourage national investment needs to be sustained and extended. Assistance is needed in helping countries address multisectoral issues, how to m ove NCD onto the agenda of other ministries, and to engage with other sectors. Surveillance Achievements WHO has assisted at least a dozen countries in the conduct or planning of STEPS surveys. WHO has been successful in obtaining additional financial support for STEPS through AusAID. In most countries where a WHO-supported NCD survey has been carried out, a parallel effort to develop a national NCD plan was observed. There was an effective synergy between the process of the survey and the development of the plan. Such synergy represents an instance of best practice. Needs The major challenges are: (a) to ensure this effort is sustained, and where appropriate to ensure adequate data is collected at subnational level; and (b) to further promote the analysis and use of the data to inform policy and programme development.
WPR/RC56/4 page 23 Annex 1 Healthy Lifestyles and Supportive Environments Achievements Many countries have organised healthy lifestyle campaigns with the support of WHO. These have taken the form of awareness raising on NCD-related Theme Days (World Diabetes Day, World No Tobacco Day, and others). There have also been efforts to set up a mechanism for an annual campaign with a recurring NCD theme, such as in Viet Nam. There has been an effort to foster environmental cha nge and multisectoral action. The dialogue between the Philippine NCD Coalition and the fast food industry is a promising example; some Healthy City initiatives have also successfully included primary and secondary prevention of NCD. Needs WHO technical assistance and support in this area needs to be extended in two ways. 1)
Scale: None of the interventions supported have had enough resources (national or international) to make a demonstrable impact. While the direction of change is positive, there is a comple te mismatch between the burden and the resources available for an adequate intervention dose.
2)
Focus: Most of the interventions have centred on awareness. This is necessary but not sufficient to achieve and sustain behaviour change. WHO must increasingly shift focus on effective multisectoral action to develop supportive environments. Clinical Preventive Services
Achievements WHO has supported some strong, well-designed intervention trials and demonstration projects, such as the diabetes guidelines implementation project in Thai Binh province in Viet Nam. The Pateros Community-based NCD Prevention and Control Project is a very useful demonstration of the use of insurance premiums to provide a benefit package for preventive health services in a low-income community. The quality of technical advice and support provided by WHO, for example in guideline development, was rated highly. Needs National and WHO investment in this area needs to be scaled up. There are examples of preventive care not succeeding as a result of access and financial barriers. For example, women found to have an abnormal Pap test result in a free screening programme, have not returned for follow -up when this entailed an out-of-pocket cost.
WPR/RC56/4 page 24 Annex 1 Relatively few interventions appeared to be based on a systematic approach to chronic disease management (i.e. incorporating register and recall systems, clinical audit, multidisciplinary care, family involvement etc). There is a need for the NCD programme in the future to engage more systematically with the wider health financing and health sector development agenda. Logistical issues need to be ironed out. Some problems were identified in delays with arrival of clinical equipment. Networking Achievements WHO has built the basis of an effective NCD network in the Region. Plans were reviewed for direct and virtual networking. Training and capacity building efforts to date have been well received but this could benefit from a more systematic approach in the future. Needs Further efforts at linking demonstration projects and related initiatives with other similar projects to share experiences and promote opportunities for mutual learning are needed. The multiple collaborating centres in the Region need to be utilized more effectively. They have demonstrated a willingness to engage in networking and this willingness should be tested and utilized if found effective. Collaborating Centres however have potential costs and benefits, and these should be weighed and reviewed in the case of each Centre at designation and re-designation: Suitability as models Achievements The role of successful projects in one or more countries to influence the uptake of best practice in others is exemplified in the diffusion and adaptation of the STEPwise approach to surveillance. A wide range of community intervention projects across the Region have now been initiated with WHO support, which offer further opportunities to demonstrate the effectiveness of different approaches to NCD prevention and control. In many cases these interventions draw on best practice in countries with more developed clinical protocols and intervention experience. In general, because of their basis in best evidence, and their adaptation to the needs of countries and areas with limited experience and resources, the projects initiated with WHO support can be considered as suitable models
WPR/RC56/4 page 25 Annex 1 for other countries. However, because of the context specific nature of community programmes and primary health care systems, the specific approaches taken may not themselves be transferable. Needs For effective uptake of the principles and design of demonstration programmes, the programme models and results will need to be proactively disseminated in the Region. This will require a proportion of future workshops and meetings to be focused on particular issues and specific techniques, for example the early detection of diabetes or the development of software for managing patient information. Demonstration projects that have addressed similar problems in different contexts can be bought together, and the overall lessons and experience shared with those wishing to embark on similar projects. The need to focus on issues of specific concern and interest in regional or sub regional meetings was expressed by many of the demonstration sites. RECOMMENDATIONS TO WHO Overview Many countries in the Region are at a critical point in the epidemiological transition, and are already facing mounting pressures on their health care systems from the NCD burden. The pressures will be exacerbated by age ing populations. Health care costs associated with NCD treatment will also worsen poverty for affected families. Investment is needed now to help ameliorate these pressures in the future. The quality of WHO's work in the Region in NCD is of a high technical standard, and well regarded by Member States, but it is too small to meet the challenges posed by the dimensions of the NCD problem. Strengthening WHO’s capacity in NCD WHO should scale up its response to NCD in the Western Pacific Region, commensurate with the current and anticipated burden, and consistent with the new priority to be given to this area within the Organization globally, as a matter of urgency. In particular there is a requirement for more professional staff at regional, subregional and country level; Staffing at the country level should be proportionate to the scale of the disease burden, the existing level of NCD response capacity within the country, and the population size; and In order to strengthen its capacity to respond to NCD in A sia, WHO should give consideration to the establishment of an Asian subregional NCD “hub” or “hubs” (possibly in China/Mongolia and Indo-China), complementing the WHO NCD role in Fiji for Pacific island countries and areas.
WPR/RC56/4 page 26 Annex 1 Advocacy WHO should substantially and systematically increase its policy and advocacy role in the Region regarding NCD. Consideration should be given to: §
reviewing and renewing Regional Committee resolution WPR/RC51.5 on prevention and control of noncommunicable diseases in 2006;
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organizing a high level Regional Summit for political, business and NGO leaders on the projected social and economic impact of NCD;
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commissioning studies on disease burden and country impact, including economic studies, to inform the Summit and other advocacy efforts;
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existing tools such as Profiles and WHO -Choice which could be used to support this work; modelling the relative impact on life expectancy to measures to control cardiovascular diseases in the Region in comparison to measures to address the Millennium Development Goals 6 ; and
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increasing the level of bilateral discussions with national governments, including both health and finance ministries, through high-level delegations, including use of senior Headquarters officials. Funding and resource mobilization
The Regional Office should work with WHO Headquarters to seek to increase the quantum of funding devoted to NCD prevention and control7 both in the regular budget and through extrabudgetary sources that are unspecified by donor partners. Efforts could include: §
a systematic strategy of consultations and advocacy for NCD with donor agencies and other major funding sources;
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WHO working with countries and areas to ensure that a greater proportion of country budgets are allocated to NCD;
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WHO working with countries and areas and donors to ensure extrabudgetary funds are aligned with country NCD priorities and the contributions of different agencies are embedded in a strategic and planned approach; and
6
This has been done for other Regions. See World Bank, Millennium Development Goals for Health in Europe and Central Asia. Relevance and Policy Implications (World Bank, Washington, DC, 2004) 7 This refers not only to the budget of the NCD unit, but to all the areas of work which contribute to prevention and control of NCD, ie the total effort should be increased.
WPR/RC56/4 page 27 Annex 1 §
WHO funds continue to be used in ways that obtain maximum leverage in influencing policy and funding decisions to support NCD prevention and control. Integration/coordination
The Regional Office's approach to NCD requires the input of multiple areas of work spread across different divisions. Effective coordination of these inputs should allow for integration across areas, while preserving the ability to act independently within fields of specialization. It is also recognized that a large number of areas of work are involved and it would not be meaningful to create a large working party on NCD, as this would quickly lose focus or meaning. It is therefore recommended that: • a Healthy Lifestyles Technical Working Group be set up that brings together specific content areas in the Building Healthy Communications and Popula tions Division (Tobacco Free Initiative, Alcohol, Nutrition, Health Promotion) with NCD. Relevant country office staff should be included as part of an extended network participating in this Working Group; • a Health Systems Technical Working Group be set up comprising the relevant areas of work in the Health Sector Development Division, together with NCD; and • The two technical working groups would meet separately or jointly at least twice a year each, with the NCD unit serving as the Secretariat. The terms o f reference would be to: a) produce and keep updated an evidence-based conceptual framework that maps out the contribution of each area of work to the general field of NCD prevention and control; b) identify components of individual and joint work plans that contribute to this conceptual framework, including approaches to common settings, common providers and common methodologies; and c) monitor the execution of these components. The WHO NCD programme should also: §
provide countries and WHO country offices with documentation demonstrating linkages and alignment between different areas of NCD work in the Regional Office, and clearly describing the conceptual framework for NCD prevention and control in the Region;
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assist WHO Representatives to harmonize the Regional Office NCD inputs and actions as appropriate as part of an integrated "one country strategy, plan and budget" for NCD;
WPR/RC56/4 page 28 Annex 1 §
give consideration to the development of a regional NCD interagency forum, including donors, lending organizations and other United Nations agencies (e.g. the Food and Agriculture Organization of the United Nations), similar to the Regional Interagency Coordination Committee (ICC) for the EPI and Stop TB, as a means of improving the profile and coordination of the regional NCD effort; and
§
consider the establishment of an external technical reference group, drawing on experts from collaborating centres, and country NCD focal points. Programme focus and priorities
WHO's NCD prevention and control programme for the next two biennia should remain focused on high burden, preventable conditions and their common risk factors, in particular cardiovascular disease, type 2 diabetes, certain cancers (those amenable to early detection and intervention), chronic respiratory disease, obesity and injury. National Planning and Policy Development The WHO NCD programme should continue, and as necessary increase, collaboration with countries in relation to NCD policy development and national planning, including: § §
strengthening policy development with other sectors; assisting with alignment of NCD policies and plans with broader health system reforms and directions (otherwise there may be a risk that an NCD plan will be developed but it will have limited influence on higher-level decision-making);
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supporting building of stronger internal partnerships and networks, across vertical programme and disciplinary boundaries;
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encouraging ongoing pooling and sharing of experiences, resources and plans (see networking and demonstration project recommendations below) between regional and subregional levels, and between countries;
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supporting countries to prioritize the use of WHO resources to achieve the most strategic impacts consistent with the national NCD plan; and
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providing technical standards (e.g. for target setting) and model guidelines as needed. Technical assistance/training
WHO should continue to provide, high quality, professional, technical and scientific assistance to countries and areas to support NCD efforts through the work of the Regional Adviser and selected short-term consultants
WPR/RC56/4 page 29 Annex 1 (STC). Wherever possible and appropriate, pools of STC should be organized as a virtual “technical advisory group” to enable a concentrated effort to be focused on specific problems or areas. Additional emphasis also needs to be given to local capacity-building (including fostering skills in leadership, partnership building, and team working), to increase the ability of countries to address technical issues themselves: §
an NCD human resources capacity-building strategy should be developed for the Region which would provide for a more systematic articulation between collaboration with consultants, occasional workshops, fellowships, continuing education and professional development, and on-the-job responsibilities;
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this structured programme of professional development could be used to support country nationals taking positions of greater responsibility in WHO country offices; and
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where appropriate WHO should actively foster learning networks or "communities of practice" of people working on common problems, on a country or subregional basis, as has begun with the recent Japan-WHO International Visitors Programme. Demonstration projects
WHO should support active networking and sharing of experiences across demonstration projects, both within and between countries. Each demonstration project should cumulatively contribute to a repository of best practices for each country and within the Region. Wherever possible at the country level, there should be a planned and systematic approach to the development of demonstration projects to minimize unnecessary duplication, and to maximize the likelihood of scale up of successful projects. Greater connectivity between secondary prevention and health promotion initiatives should be encouraged. Each demonstration project should be based on a specified hypothesis and evaluation plan, and structured to meet an identified gap in intervention capacity or service delivery, or to field test promising approaches. Common evaluation protocols for similar projects in across subnational areas or in different countries should be emphasized wherever possible. Evaluations should make greater use of health services research methods. Surveillance WHO should continue to support STEPwise surveillance (or appropriate variations within countries and areas) to ensure all countries in the Region maintain comparative data on NCD burden and trends, and support tracking progress of NCD programmes. Mortality registries, cancer registries and service use data also require support
WPR/RC56/4 page 30 Annex 1 and development in many cases. Expansion to subnational levels where appropriate should be considered to provide local area data if national level cannot be usefully disaggregated (e.g. due to sample size). WHO should work with countries to promote more effective use of surveillance data in informing and evaluating policy. WHO should further develop its Regional NCD database and distribute the tools for country utilization. Consideration should also be given to developing capacity to support countries to geo -code surveillance data, and map patterns of NCD and risk factor prevalence across geographic areas. Wherever possible, STEPS and other related surveys should be aligned and/or made consistent (common data standards, etc.). For example, the Global Youth Tobacco Survey could be expanded to incorporate other risk factors based on a STEPwise approach, and provide the basis for a complementary STEPS survey appropriate to children and younger people. Clinical Preventive Services and Health Systems Development and Financing WHO should consider the organization of a regional workshop on systems of care for chronic disease (including a focus on self-management and patient-centred care) drawing on the work of the WHO Observatory on Health Care for Chronic Conditions, to share the emerging evidence base in this area with senior health ministry officials, senior health service managers and leading clinicians. Following the workshop, countries should be supported: §
to analyse the appropriateness and value of various models of chronic illness care in the context of their own situation, including at subnational levels, and develop strategies to incorporate relevant elements into health service design, including the development of appropriate performance indicators;
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to consider the adequacy of their current and anticipated workforce for chronic care (including preventive services) and to formulate options for enhancing skills and capacity of existing medical staff, and including consideration of the potential role of community nurses and other allied health providers;
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to review health system financing arrangements in the light of the emerging burden of chronic NCD with particular regard to the limitations of out-of-pocket payments in supporting cost-effective, long- term management of chronic conditions (and the prevention of more costly complications) and the benefits of prepaid and/or government funded primary health care services; and
§
to strengthen national capacity in priority setting for NCD prevention and control, for example in economic evaluation, and securing resources to meet priorities.
WPR/RC56/4 page 31 Annex 1 Networking and Regional Information System WHO should move to finalize development of the Regional NCD Country Network as soon as possible, including development of a Regional NCD Information System to share and disseminate project experience and evaluations, new evidence on NCD and comparative data based on STEPwise and other surveys. The NCD programme should consider the value it is deriving from the 26 Collaborating Centres, and consider options to improve the contribution made by the Centres to the programme. It may be useful to incorporate those Centres with common interests into the proposed Regional Network.
WPR/RC56/4 page 32 Annex 1
WPR/RC56/4 page 33 Annex 1 Appendix 1: WHO COLLABORATING CENTRES
Major Programme: Building Healthy Communities and Populations Programme Area: Noncommunicable Diseases and Mental Health No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Title of centre WHO Collaborating Centre for Research and Training in Cardiovascular Diseases WHO Collaborating Centre for Prevention of Blindness WHO Collaborating Centre for Epidemiology of Diabetes Mellitus and Health Promotion for NCD Control. WHO Collaborating Centre for Population-Based Cardiovascular Diseases Prevention Programme WHO Collaborating Centre for the Prevention of Blindness WHO Collaborating Centre for Research on Cancer WHO Collaborating Centre for Prevention, Control and Research of Cardiovascular Diseases in China WHO Collaborating Centre for Research and Training in Cardiovascular Diseases WHO Collaborating Centre for Research and Training in Preventive Dentistry WHO Collaborating Centre for Research on Cancer WHO Collaborating Centre for Research and Training in Cardiovascular Diseases WHO Collaborating Centre for Research on Cancer WHO Collaborating Centre for Oral Health WHO Collaborating Centre for Prevention of Blindness WHO Collaborating Centre for Diabetes Treatment and Education Name & location of Institution Alfred and Baker Unit, Melbourne, Victoria, Australia Centre for Eye Research Australia Ltd., Melbourne, Victoria, Australia International Diabetes Institute, Caulfield South, Victoria, Australia Menzies Research Institute, Tasmania, Australia Beijing Institute of Ophthalmology, Beijing, China Cancer Institute and Hospital, Beijing, China Cardiovascular Institute and Fu Wai Hospital, Beijing, China Guangdong Provincial Cardiovascular Institute, Guangzhou, China Research Institute of Stomatology, Beijing, China Shanghai Cancer Institute, Shanghai, China Shanghai Institute of Cardiovascular Diseases, Shanghai, China Sun-Yat-Sen University Cancer Centre, Guangzhou, China Yuncheng Stomatological Health School, Shanxi Province, China Department of Ophthalmology, Juntendo University School of Medicine, Tokyo, Japan Diabetes Centre, Institute of Endocrinology and Metabolic Disease, Kyoto, Japan
WHO Collaborating Centre for Primary Preven-tion, Diagnosis National Cancer Centre Hospital, Tokyo, Japan and Treatment of Gastric Cancer WHO Collaborating Centre for Research and Training in Cardiovascular Diseases WHO Collaborating Centre for Cancer Pain Relief and Quality of Life National Cardiovascular Centre, Osaka, Japan Saitama Cancer Centre, Neurosurgery clinic, Ina Saitama, Japan
WPR/RC56/4 page 34 Annex 1 No. 19 20 21 22 23 Title of centre WHO Collaborating Centre for Research and Training in Diagnostic Endoscopy WHO Collaborating Centre for Health Promotion through Research and Training in Sports Medicine WHO Collaborating Centre for Research on Thyroid and Autoimmune Diseases WHO Collaborating Centre for Prevention and Control of Chronic Respiratory Diseases (CRD) WHO Collaborating Centre for Research and Training in Cardiovascular Diseases WHO Collaborating Centre Dental Epidemiology and Public Health Name & location of Institution Tokyo Medical University, Tokyo, Japan Tokyo Medical University, Tokyo, Japan Nagasaki University, Japan Dokkyo University School of Medicine, Japan Philippine Heart Centre, Diliman, Quezon City, Philippines University of Otago New Zealand
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