Evaluation of impact of WHO publications related to NCDs and health systems in Sri Lanka (2013–2019)

Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 1

3Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka 2013–2019 Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 4 Evaluation of Impact of WHO Publications Related to NCDs and Health Systems in Sri Lanka (2013–2019) ISBN: 978-92-9022-778-6 © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 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. 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Printed in Sri Lanka Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 5 Technical Advisory Group: Dr Palitha Abeykoon, Ex. WHO Senior Consultant Prof Rohini Fernandopulle, Professor in Pharmacology Dr Sujatha Samarakoon, Public Health Specialist Prof Shamini Prathapan, Professor in Community Medicine Prof Wasantha Gunatunge, Professor in Community Medicine Mrs Shirani Ranasinghe, Deputy Librarian Prof. Amala de Silva, Professor in Department of Economics Staff of WHO Dr Razia Pendse, WHO Representative to Sri Lanka Dr Sophie Genay-Diliautas, Technical Officer Dr Lluis Vinals, Advisor on Health Policy & Systems Dr Olivia Nieveras, Public Health Administrator Dr Padmal De Silva, National Professional Officer Dr Nalinda Wellapuli, Medical Officer Dr Nalika Gunawardena, National Professional Officer Mrs Shyamalie Thebuwana, Executive Assistant Contractual partner - PricewaterhouseCoopers (Pvt.) Ltd. Sri Lanka: Dr Ranjith Batuwanthudawe, Specialist in Community Medicine Dr Budhdhika Sudasinghe, Specialist in Community Medicine Ms Chithra Abeygunasekera, Library and Information Scientist Mr Bertram Somaweera, Digital Media Consultant Dr Dimuth Pieris, Specialist in Community Medicine Dr Enoka Wickramasinghe, Specialist in Community Medicine Dr Chinthana Perera, Specialist in Community Medicine Acknowledgement of the contribution: Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 6 LIST OF TABLES 8 LIST OF ANNEXURES 10 EXECUTIVE SUMMARY 11 Phase 1 Phase 2 12 12 CHAPTER 1: INTRODUCTION 21 1.1. General Objectives 1.2. Specific Objectives 21 22 CHAPTER 2: METHODOLOGY 23 Phase 1 Phase 2 23 26 CHAPTER 3: RESULTS AND DISCUSSION 50 3.1. How does WHO define its target audiences for different types of publications and different modes of dissemination and the extent towhich the intended reach is achieved. 50 3.1.1. How does WHO define its target audiences for different types of publications and different modes of dissemination. 3.1.2. Extent of the reach of different types of WHO publications. 3.1.3. Bibliometric analysis 3.1.4. Downloads from WHO website in Sri Lanka 3.1.5. Social media engagement 50 59 78 78 79 3.2. Does the mode of dissemination affect the reach and does WHO uses the correct mode of dissemination to effectively convey WHO information to different audiences. 81 3.3. How does WHO publications respond to global strategies that are applicable to countries and priorities that are based on needs assessment. 84 3.3.1. Desk review 3.3.2. Findings on qualitative survey among key WHO publication staff involved in the production of WHO publications, both from a strategic, process and content point of view 3.3.3. Case product study 84 91 92 3.4. The extend which WHO publications respond to and meet the priority information needs of their intended audiences and whether the format and language affect their perception of usefulness. 98 3.4.1. The extent the WHO publications responds and meet the priority information needs of their intended audiences. 3.4.2. The extent which the format and the language of WHO publications affect the intended target audience perception of usefulness of the WHO publications. 98 99 TABLE OF CONTENTS Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 7 3.5. The perceived influence and impact of WHO publications on the formulation of national policies and strategies and healthcare practices as well as the perceived comparative advantage of WHO publications in relation to the ones by other stakeholders. 101 3.5.1. Perceived influence and impact of WHO publications on the formulation of national health policies and strategies and healthcare practices. 3.5.2. Findings on Perceived comparative advantage of WHO publications in relation to the ones by other stakeholders from key informant interviews. 101 113 3.6. The perceived level of quality (credibility, authoritativeness, trustworthiness and reputability) of WHO publications. 115 3.6.1. Findings of quantitative survey. 3.6.2. Important factors from key informant interviews 115 116 3.7. The extent to which WHO publications are used as an authoritative source of health information understanding the circumstances and criteria for it. 117 3.7.1. Desk review on use of WHO publications on country actions. 3.7.2. Quantitative survey 117 125 3.8. The type of and the publications that have demonstrated to contribute significantly to public health as well as those have not. 127 3.8.1. Publications that have demonstrated to contribute significantly to Sri Lanka public health 3.8.2. Publications that have not contributed significantly to Sri Lanka public health 127 129 3.9. Evidence of adoption of the content of WHO publications leading to changes in policy, clinical practice or individuals behaviours’. 132 3.9.1. Desk review 3.9.2. Quantitative survey 132 143 3.10. The extent to which the language, format and mode of dissemination of WHO publications influence their use as reference and authoritative source. 145 3.11. Recommendations on how WHO can foster better use of health information in Sri Lanka? 146 CHAPTER 4: CONCLUSIONS AND RECOMMENDATIONS 149 ABBREVIATIONS 153 DISCLAIMER 154 Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 8 TABLE 01 SELECTED PUBLICATIONS FOR EVALUATION BY IDENTIFIED TARGET AUDIENCES 29 TABLE 02 NCDS AND HEALTH SYSTEMS WHO PUBLICATION EVALUATION MATRIX 31 TABLE 03 DOCUMENT REVIEWS/ DESK REVIEWS / CASE PRODUCT STUDIES CARRIED OUT IN THE NCDS AND HEALTH SYSTEMS WHO PUBLICATION EVALUATION 46 TABLE 04 NUMBER OF RESPONDENTS IN EACH IDENTIFIED TARGET AUDIENCES 50 TABLE 05 SUMMARY OF FINDINGS FROM OPINIONS GIVEN BY WHO HQ AND SEARO PUBLICATION STAFF 52 TABLE 06 IDENTIFICATION OF TARGET AUDIENCES AND MODE OF DISSEMINATION OF TWENTY SELECTED NCD AND HEALTH SYSTEMS WHO PUBLICATIONS 54 TABLE 07 SIX SELECTED DOCUMENTS FOR EVALUATION OF EVIDENCE OF REACH OF WHO PUBLICATIONS 59 TABLE 08 SUMMARY OF FINDINGS OF THE DESK REVIEW OF SRI LANKA MINISTRY OF HEALTH TECHNICAL DOCUMENTS FOR EVIDENCE OF REACH OF RELEVANT WHO PUBLICATIONS 66 TABLE 09 REACH OF SELECTED TWENTY WHO PUBLICATIONS (TEN EACH ON NCDS AND HEALTH SYSTEMS) TO SRI LANKA HEALTH MINISTRY OFFICIALS (QUESTION IN THE SURVEY QUESTIONNAIRE “HAVE YOU SEEN THIS PUBLICATION?”) 67 TABLE 10 REACH OF SELECTED TWENTY WHO PUBLICATIONS (TEN EACH ON NCDS AND HEALTH SYSTEMS) TO SRI LANKA HEALTH MINISTRY OFFICIALS (QUESTION IN THE SURVEY QUESTIONNAIRE “HAVE YOU ACCESSED/ GOT HOLD OF THIS PUBLICATION?”) 69 TABLE 11 REACH OF SELECTED TWENTY WHO PUBLICATIONS (TEN EACH ON NCDS AND HEALTH SYSTEMS) TO SRI LANKA HEALTH MINISTRY NATIONAL TECHNICAL CONSULTANTS. (QUESTION IN THE SURVEY QUESTIONNAIRE “HAVE YOU SEEN THIS PUBLICATION?”) 70 TABLE 12 REACH OF SELECTED TWENTY WHO PUBLICATIONS (TEN EACH ON NCDS AND HEALTH SYSTEMS) TO SRI LANKA HEALTH MINISTRY NATIONAL TECHNICAL CONSULTANTS. (QUESTION IN THE SURVEY QUESTIONNAIRE “HAVE YOU ACCESSED THIS PUBLICATION?”) 71 TABLE 13 REACH OF SELECTED FOUR WHO PUBLICATIONS TO THE OTHER TARGET AUDIENCES (PERCENTAGES ARE CALCULATED AS AN AVERAGE FOR ALL TWENTY PUBLICATIONS) 73 TABLE 14 REACH OF SELECTED FOUR WHO SRI LANKA COUNTRY OFFICE’S FACEBOOK UPLOADS TO THE GENERAL PUBLIC 74 TABLE 15 DESCRIPTION OF MODE OF REACH OF THE SELECTED WHO PUBLICATIONS TO THE TARGET AUDIENCES (PERCENTAGES ARE CALCULATED AS AN AVERAGE FOR ALL TWENTY PUBLICATIONS) 74 TABLE 16 DESCRIPTION OF THE MODE OF REACH OF THE SELECTED FOUR WHO SRI LANKA COUNTRY OFFICE’S FACEBOOK UPLOADS TO THE GENERAL PUBLIC 75 TABLE 17 DESCRIPTION OF THE MODE OF REACH OF THE SELECTED FOUR WHO SRI LANKA COUNTRY OFFICE’S FACEBOOK UPLOADS TO THE GENERAL PUBLIC 75 TABLE 18 DESCRIPTION OF THE USE OF THE SELECTED WHO PUBLICATIONS BY THE TARGET AUDIENCES (PERCENTAGES ARE CALCULATED AS AN AVERAGE FOR ALL TWENTY PUBLICATIONS) 76 TABLE 19 DESCRIPTION OF DOWNLOADS FROM WHO WEBSITE IN SRI LANKA IN 2017 – 2019 78 TABLE 20 ENGAGEMENT OF SOCIAL MEDIA UPLOADS AND WHO WEBSITE UPLOADS BY THE GENERAL PUBLIC 79 TABLE 21 RESPONSE TO “WILL THE ‘ONLINE ONLY’ IMPROVE OR HINDER THE REACH OF WHO PUBLICATIONS?” 81 TABLE 22 ARE THERE ANY PARTICULAR TYPE OF PUBLICATION SUITED FOR ONLINE ONLY PUBLICATIONS? 81 TABLE 23 ARE THERE ANY SPECIFIC TARGET AUDIENCES WHO ARE MORE SUITABLE FOR ONLINE ONLY PUBLICATIONS? 82 LIST OF TABLES Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 9 TABLE 24 NUMBER OF WHO PUBLICATION STAFF WHO RESPONDED TO THE QUESTIONS RELATED TO GLOBAL STRATEGIES AND PRIORITIES 91 TABLE 25 RESPONSES BY WHO PUBLICATION STAFF AT WHO/ HQ AND SEARO ON ABOVE TWO VARIABLES 91 TABLE 26 DESCRIPTION OF RESPONSES IF WHO PUBLICATIONS RESPONDS AND MEET THE INTENDED AUDIENCES’ PRIORITY INFORMATION NEEDS 96 TABLE 27 TARGET AUDIENCES PERCEPTION OF USER FRIENDLINESS OF WHO PUBLICATIONS 99 TABLE 28 RESPONSES TO THE QUESTION “DOES WHO PUBLICATIONS BEING IN ENGLISH ONLY AFFECTS THE USEFULNESS IN SRI LANKA?” 100 TABLE 29 RESPONSES TO THE QUESTION “IS THE LANGUAGE USED IN WHO PUBLICATIONS IS TOO TECHNICAL? 100 TABLE 30 SELECTED SRI LANKAN DOCUMENTS AND THE SECTIONS WITH THE DESCRIPTIONS 102 TABLE 31 COMPARISON OF CONTENT AREAS IN RELEVANT WHO PUBLICATIONS AND THE SRI LANKAN POLICY DOCUMENT 105 TABLE 32 OTHER WHO PUBLICATIONS BENEFICIAL FOR STRATEGIC FRAMEWORK OF SELECTED PUBLIC HEALTH PROGRAMMES IN SRI LANKA 107 TABLE 33 COMPARISON BETWEEN THE STRATEGIES IN THE MULTI-SECTORAL ACTION PLAN TO PREVENT AND CONTROL NCD IN SRI LANKA AND THE OBJECTIVES OF THE WHO PUBLICATION GLOBAL ACTION PLAN TO PREVENT AND CONTROL NCD 109 TABLE 34 EVIDENCE OF ADOPTION OF WHO KEY PRINCIPLE ON SCREENING BY THE GUIDELINE FOR SCREENING CKDU IN SRI LANKA 112 TABLE 35 DESCRIPTION OF FINDINGS ON THE FOUR DIMENSIONS OF QUALITY OF WHO PUBLICATIONS (UNDER EACH DIMENSION, THE NUMBER OF RESPONDENTS GIVEN. AN AVERAGE FIGURE IS CALCULATED AS A PERCENTAGE) 115 TABLE 36 SELECTED SRI LANKAN DOCUMENTS AND THE DESCRIPTIONS ON EXTENT OF AUTHORITATIVE USE OF WHO PUBLICATIONS 117 TABLE 37 COMPARISON OF CONTENT AREAS IN RELEVANT WHO PUBLICATIONS AND THE SRI LANKAN POLICY DOCUMENT 120 TABLE 38 POSSIBLE SOURCE OF INFORMATION FOR THE CONTENT IN THE SRI LANKAN DOCUMENT NATIONAL MULTI-SECTORAL ACTION PLAN FOR THE PREVENTION AND CONTROL OF NCD 2016 – 2020 122 TABLE 39 EVIDENCE OF ADOPTION OF WHO KEY PRINCIPLE ON SCREENING BY THE GUIDELINE FOR SCREENING CKDU IN SRI LANKA 124 TABLE 40 RESPONSE TO THE QUESTION “HAVE WHO PUBLICATIONS BEEN USED AS AN AUTHORITATIVE SOURCE OF INFORMATION IN SRI LANKA?” 126 TABLE 41 SRI LANKAN DOCUMENTS REVIEWED TO DEMONSTRATE EVIDENCE OF THE CONTENT OF WHO PUBLICATIONS LEADING TO CHANGES 132 TABLE 42 COMPARISON BETWEEN THE STRATEGIES IN THE MULTI-SECTORAL ACTION PLAN TO PREVENT AND CONTROL NCD IN SRI LANKA AND THE OBJECTIVES OF THE WHO PUBLICATION GLOBAL ACTION PLAN TO PREVENT AND CONTROL NCD 139 TABLE 43 EVIDENCE OF ADOPTION OF WHO KEY PRINCIPLE ON SCREENING BY THE GUIDELINE FOR SCREENING CKDU IN SRI LANKA 142 TABLE 44 RESPONSE TO THE QUESTION “HAS THE CONTENT OF WHO PUBLICATIONS LED TO CHANGES IN POLICY, CLINICAL PRACTICES OR INDIVIDUAL BEHAVIOURS IN SRI LANKA?” 144 TABLE 45 RESPONSE TO THE QUESTION “HAVE WHO PUBLICATION BEEN USED AS REFERENCE AND AUTHORITATIVE SOURCE IN SRI LANKA?” 145 TABLE 46 OPINIONS EXPRESSED BY THE RESPONDENTS ON WAYS WHO CAN FOSTER BETTER USE OF HEALTH INFORMATION IN SRI LANKA 146 Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 10 ANNEX 1 NCD PUBLICATIONS FOR EVALUATION ANNEX 2 HEALTH SYSTEMS PUBLICATIONS FOR EVALUATION ANNEX 3 DESCRIPTION OF TARGET AUDIENCES ANNEX 4 LIST OF SOCIAL MEDIA UPLOADS SELECTED FOR GENERAL PUBLIC ANNEX 5 LIST OF TWENTY SELECTED NCD AND HEALTH SYSTEMS PUBLICATIONS ANNEX 6 PUBLICATIONS SELECTED FOR OTHER CATEGORIES OF TARGET AUDIENCE OTHER THAN HEALTH MINISTRY OFFICIALS AND NATIONAL TECHNICAL CONSULTANTS. ANNEX 7 SURVEY TOOL - HEALTH MINISTRY OFFICIALS ANNEX 8 SURVEY TOOL - HEALTH MINISTRY NATIONAL TECHNICAL CONSULTANTS ANNEX 9.1 SURVEY TOOL - MEMBERS OF COLLEGE OF COMMUNITY PHYSICIANS ANNEX 9.2 SURVEY TOOL - MEMBERS OF COLLEGE OF MEDICAL ADMINISTRATORS OF SRI LANKA ANNEX 9.3 SURVEY TOOL - MEMBERS OF CEYLON COLLEGE OF PHYSICIANS ANNEX 9.4 SURVEY TOOL - MEMBERS OF COLLEGE OF PATHOLOGISTS OF SRI LANKA AND COLLEGE OF SURGEONS ANNEX 9.5 ASURVEY TOOL - MEMBERS OF SRI LANKA COLLEGE OF ENDOCRINOLOGISTS ANNEX 9.6 SURVEY TOOL - MEMBERS OF SRI LANKA MEDICAL NUTRITIONISTS ASSOCIATION ANNEX 10 SURVEY TOOL - NON MEDICAL PROFESSIONAL COLLEGES ANNEX 11 SURVEY TOOL - OFFICERS OF FINANCE MINISTRY ANNEX 12 ASURVEY TOOL - OFFICERS OF EDUCATION MINISTRY ANNEX 13 SURVEY TOOL - MEMBERS OF CIVIL SOCIETY ORGANISATIONS IN NCD WORK ANNEX 14 SURVEY TOOL - MEDICAL RESEARCH COMMUNITY ANNEX 15 SURVEY TOOL - GENERAL PUBLIC ANNEX 16 POOL OF QUESTIONS FOR THE QUALITATIVE KII DISCUSSION GUIDE ANNEX 17 RESPONSES OF ADDITIONAL WHO PUBLICATIONS SEEN BY THE RESPONDENTS ANNEX 18 WHO PUBLICATIONS CITED BY SRI LANKAN AUTHORS ANNEX 19 WHO - TOP 160 WHO PUBLICATION DOWNLOADS IN SRI LANKA – 2017 ANNEX 20 WHO - TOP 160 WHO PUBLICATION DOWNLOADS IN SRI LANKA – 2018 ANNEX 21 WHO - TOP 160 WHO PUBLICATION DOWNLOADS IN SRI LANKA – 2019 ANNEX 22 RECOMMENDATIONS BY RESPONDENTS TO IMPROVE THE REACH OF WHO PUBLICATIONS LIST OF ANNEXURES Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 11 EXECUTIVE SUMMARY Introduction: Evaluations are one of the most powerful tools available for programme managers and implementers to achieve their targets and to direct their programmes to achieve the intended outcomes. Over the years, World Health Organization (WHO) has developed a series of mechanisms to enhance the quality of its publications in terms of technical content, relevance and presentation, cost-effectiveness and accessibility. With this backdrop, it is of immense value that WHO Sri Lanka Country Office took the initiative to evaluate the reach, usefulness and use of WHO publications in Sri Lanka. General and Specific Objectives: 1. To quantify the extent of reach of the WHO publications on Noncommunicable diseases (NCDs) and health systems to its intended audiences in Sri Lanka and to describe major gaps in coverage and the reasons for such gaps. • To describe the way WHO defines its target audiences for different types of publications and different modes and the extent to which the intended reach is achieved. • To describe if the mode (web-only, print) affects reach and if so whether WHO uses the right media to effectively convey WHO information for different audiences. 2. To describe the level of perceived usefulness of various WHO publications on NCDs and health systems in Sri Lanka. • To explore the extent to which WHO publications respond to global strategies and priorities and are based on needs assessment. • To describe the extent to which WHO publications respond to and meet the priority information needs of their intended audiences, and whether the format, language and dissemination mode of those affect their perception of usefulness. • To discuss the perceived level of quality (e.g. credibility, authoritativeness, trustworthiness, and reputability) of WHO publications as well as their related shortcomings. 3. To describe the extent of use of WHO publications on NCDs and health systems in Sri Lanka as reference and authoritative source of information for decision-making in clinical, public health and policy contexts. • To describe the perceived influence and impact of WHO publications on the formulation of national health policies and strategies and healthcare practices, as well as the perceived comparative advantage of WHO publications in relation to the ones by other stakeholders. • To describe the extent to which WHO’s publications are used as an authoritative source of health information, understanding the circumstances and criteria for it. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 12 • To determine the type of, and the publications that have demonstrated to contribute significantly to public health, as well as those that have not. • To describe evidence of the adoption of the content of WHO publications, leading to changes in policy, clinical practice, or individuals’ behaviours. • To explore the extent to which the language, format and mode of WHO publications influence their use as authoritative sources. • To recommend how WHO can foster better use of health information, either in the form of WHO publications, or through different mechanisms. Methodology: The evaluation was carried out in two phases: Phase 1 The first phase was to compile a list of relevant publications on NCDs and health systems published by WHO from 2013 to 2019 at global, regional and national levels. This compilation was based on a set of eligibility criteria to include print or electronic publications in English, issued between January 2013 and March 2019 with specific subject areas within the NCDs and health systems. WHO publications in the categories of advocacy, general health, scientific or technical reports, specific/thematic and country based technical products, training materials/ manuals and guidelines were selected and included in the list. The excluded publications were communication materials, such as notes for the media, press releases, official WHO statements, general text included in the body of the WHO website, governing body documents, WHO headquarters and Region-based journals and WHO external publications. Based on above criteria, the selected NCDs and health systems publications for the evaluation in the phase two were 366 and 202 respectively. Phase 2 Phase two of the study comprised a triangulation of methodological approaches to achieve the objectives. Assessment of the extent of reach of WHO publications on NCDs and health systems to its intended audiences in Sri Lanka and describing major gaps in coverage and the reasons for such gaps was carried out through desk reviews, key informant interviews, a quantitative survey using a web based and a paper based self-administered survey questionnaire and bibliographical evaluations. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 13 The key informants and the audiences to be targeted for quantitative survey were identified as ministry of health officials, national technical leads in the subject areas of NCDs and health systems in the Ministry of Health, representatives of professional colleges of different disciplines of medicine, officials from other government institutions relevant to NCDs and health systems, representatives of medical and non-medical research community, representatives of civil society organizations and representatives of the general public. Desk reviews, key informant interviews, the quantitative survey using a web based and a paper based self-administered questionnaire and case product studies were the methods used to describe the level of perceived usefulness of various WHO publications on NCDs and Health systems in Sri Lanka. Information on the extent of use of WHO publications on NCDs and health systems in Sri Lanka as reference and authoritative source of information for decision-making in clinical, public health and policy contexts was through desk reviews, key informant interviews, the quantitative survey using a web-based format and a paper format and case product studies. Twenty publications, ten each in the areas of NCDs and health systems were selected and used as examples when obtaining information related to reach, use and usefulness from the ministry of health officials, national technical leads in the subject areas of NCDs and health systems in the ministry of health. The publications used for this study was from the lists complied in Phase 1, which were selected in consultation with the technical advisory group using a systematic approach to cover all years under study, to include publications from WHO headquarters and WHO Regional Offices South- East Asia and to represent main subject/ content areas under NCDs and health systems. Members of medical professional colleges, medical research community, officials of non-health ministries and representatives of civil society organizations were offered four publications which were selected based on the relevance to the subject areas. Four digital media publications were used for survey of responses of the general public. Results Reach of WHO publications to Sri Lankan target audiences: How WHO defines its target audiences for different types of publications, different modes and the extent to which the intended reach is achieved. The methods used for identification of target audiences by the WHO seems well structured and organized. The fact that five domains being used for target audience identification in publication production is commendable. However, if a brief description of the intended target group is provided in the preface or introduction to the publication, it would be very helpful for the publications to be directed at the right audiences and also in providing appropriate weightage in future impact evaluations. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 14 Over 50% Health Ministry officials and Health Ministry national technical consultants who had reached a WHO publication had done so by actively searching for it online. Over 80% of the respondents who accessed the WHO publications had intended to use them as reference in their professional/ academic work or to improve on their knowledge. The extent of reach of WHO publications to Sri Lankan authorities in general appears to be moderate to low by the evidence in documents in policy, strategic plan and guidelines spheres. However, WHO’s NCD publications in contrast showed a higher level of reach to relevant Sri Lankan authorities. Several selected NCDs and health systems publications selected to be evaluated, appeared in the top 160 WHO publications downloaded in Sri Lanka from the WHO website. In the two target groups from the Health Ministry (Health Ministry officials and Health Ministry national technical consultants) the reach of the WHO publications showed a low reach of publications of just over 20%. However, when a publication is reached them around sixty percent (60%) of them accessed the publication. The highest reach for a particular publication had been recorded by the WHO publication “WHO Framework Convention for Tobacco Control” with over 40% of the respondents having seen this document. It was further revealed that each respondent had seen at least one document under reference and also each document had been seen by at least one respondent. Does the mode of dissemination (web-only, print) affects reach and if so whether WHO uses the right media to effectively convey WHO information for different audiences? Over 80% of the respondents in target audiences with a medical background said they had read the publications to enhance their knowledge or to be used in their work. However, majority of the respondents were of the opinion that making WHO publications “Online only” wound hinder their reach to a wider population of Sri Lankan readers. Overwhelming 95% of the respondents were of the opinion that WHO publications are user friendly. Over 50% Health Ministry officials and Health Ministry national technical consultants who had reached a WHO publication had done so by actively searching for it online. It is of interest to note that over 36% in both these target audiences had accidentally come across the publication online. Medical research community had reached the WHO publications by actively searching online (37%), accidentally online (32%) and on being introduced to it at a workshop (24%). The three most common answers given as suggestions for WHO to improve the dissemination of publications were: (1) targeted notification by emails on new releases, (2) web-based updating through google scholar or google play and (3) provision of hard copies to key people and program managers in ministry of health. Facebook uploads by WHO country office resulted around 20% reach among the general public. The penetration of WHO Facebook uploads to the Sri Lankan general public appeared to be low, while social media engagement also appeared to be poor. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 15 Usefulness of WHO publications to Sri Lankan target audiences: How does WHO publications respond to global strategies and are based on needs assessment? On reviewing the WHO publication “Regional Health Strategy for Universal Health Coverage, WHO 2015” it was evident that it had given a common definition for Universal Health Coverage. In general, the whole publication had provided a general overview of strategic directions, instead of providing recommendations, based on specific needs of each WHO member country. In the publication “Working towards achieving the SDGs: A WHO toolkit” information/ guidelines had been provided in general for all countries rather than addressing issues in the context of specific country. However, in the development of the publication “Global action plan on Physical Activity 2018 – 2030” a worldwide consultation process had been followed thoroughly six regional consultation processes with the guidance of multisectoral and multidisciplinary global expert advisory committee, indicating that the document had addresses and responded to the global as well as regional needs and strategies. The publication “Global strategy on human resources for health: workforce 2030” had managed to stick to a global theme because of the alignment with SDG. The whole publication can be considered as responding to global strategies and priorities at a very high level of intensity. Overall “A practice guide to effective population-based food policy actions to promote healthy diets” had not succeeded in addressing the global priorities and strategies other than its relevance to NCD prevention and control. It also had fallen short of demonstrating a need assessment at country or stakeholder level. Do WHO publications respond to target audience priority information needs? Overwhelming majority of over 90% of medical related target audiences responded that WHO publications respond to and meet their priority information needs. Over 95% of the medical target audiences responded that WHO publications are reader friendly. Over 80% respondents of Health Ministry officials, Health Ministry national technical consultants and members of medical professional colleges did not agree that English used in WHO publications were too technical. Perceived level of quality of WHO publications as well as their related shortcomings Over 97% of the respondents in target audiences with a medical background agreed that WHO publications under reference had maintained a very high or high levels of quality in terms of credibility, authoritativeness, trustworthiness and reputability. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 16 Use of WHO publications by Sri Lankan target audiences: Perceived influence of WHO publications in formulation of national polices The perceived influence and impact of WHO publications on the formulation of national health policies, strategies and healthcare practices as well as the perceived comparative advantages of WHO publications in relation to those published by other stakeholders was evaluated by examining six Sri Lankan documents. i. “National policy and strategic framework for cancer prevention and control” was clearly influenced by the most applicable WHO publications. ii. Perceived influence and impact of WHO publications on the Sri Lankan document ‘National policy on health care quality and safety’ tend to be satisfactory. However, lack of a list of references was a serious limitation in assessing the extent of the influence. iii. Perceived influence and impact of WHO publications on Sri Lankan strategic frameworks of the public health programs are poor as per evidence elicited by reviewing the Sri Lankan strategic plan “National health strategic plan for preventive sector 2016 – 2025”. iv. The WHO publication, “Global Action Plan for the Prevention and Control of on-communicable Diseases 2013 – 2020” had a greater influence and impact on the formulation of the National Multi-sectoral Action Plan for Prevention and Control of Non-communicable Diseases in Sri Lanka, published by the Ministry of Health, Nutrition and Indigenous Medicine in Sri Lanka. v. Perceived influence and impact of WHO publications on the formulation of national guidelines was moderate as evidenced by reviewing the Sri Lankan document ‘Screening Guidelines Chronic Kidney Disease Sri Lanka 2017’. vi. Perceived influence and impact of WHO publications on the formulation of ‘Pain Management Guideline for Adults with Cancer 2017’ in Sri Lanka appears to be moderate. Use of WHO publications as an authoritative source. The extent to which WHO publications are used as an authoritative source of health information giving due recognition to them, depending on the relevance and specific circumstances was evaluated by reviewing six Sri Lankan documents. i. National policy and strategic framework for cancer prevention and control: It can be perceived that most applicable WHO publications at policy level have been referred extensively as an authoritative source of health information in drafting this National policy document on cancer prevention and control in Sri Lanka. ii. National policy on health care quality and safety: The extent to which WHO publications have been used as an authoritative source of information could not be established even after comparing the contents of the Sri Lankan document with the relevant WHO publications. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 17 iii. National health strategic plan for preventive sector 2016 – 2025: Overall, WHO publications have been used to a lesser extent as an authoritative source of health information in drafting the ‘National health strategic plan for preventive sector 2016-2025’. iv. National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020: Publications by the WHO have been used as an authoritative source of health information to a greater extent in the National Multi-sectoral Action Plan for the Prevention and Control of Non-communicable Diseases 2016 – 2020. v. Screening Guidelines Chronic Kidney Disease Sri Lanka 2017: The use of available and relevant WHO’s publications was not as a very authoritative source of health information in drafting the guidelines for screening CKDu in Sri Lanka. vi. Pain Management Guideline for Adults with Cancer 2017: The use of WHO publications as authoritative source of health information in the Sri Lankan document ‘Pain Management Guideline for Adults with Cancer 2017’ is moderate. Almost 90% of the respondents from medical fraternity agreed that WHO publications have been used as authoritative source of health information in Sri Lanka. The publications that have demonstrated to contribute significantly to public health as well as those have not. WHO publications on tobacco control has demonstrated very significant contributions to Sri Lankan public health. Action plan publications on NCD control and prevention from WHO has demonstrated significant contribution to Sri Lanka public health. However, review reports and evaluation reports on NCD and NCD interventions did not demonstrate required level of contribution to Sri Lanka public health significantly. Health Promotion related WHO publications do not demonstrate significant contribution to Sri Lanka public health. However, analysing of reasons for this outcome is beyond the scope of this review. Health economic related WHO publications also do not demonstrate to have significantly contributed to Sri Lanka public health, except for publications on national health accounts. Evidence of adoption of the content of WHO publications leading to changes in policy, clinical practice or individual’s behaviour In the Sri Lankan policy document ‘National policy and strategic framework for cancer prevention and control’ there were ample evidence of adoption of content from WHO publications and references had been made to a greater extent in preparing the National policy on cancer control and prevention. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 18 Adoption of the content of WHO publications leading to changes in the Sri Lankan policy could not be well established in the Sri Lankan document ‘National policy on health care quality and safety’ (2015). Evidence indicated that the adoption of the contents of WHO publications in the Sri Lankan strategic plan “National health strategic plan for preventive sector 2016–2025” was at a very low level. Adoption of the content of relevant WHO publications in compiling the ‘National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020’ was very high. Evidence of adoption indicates that the two documents are almost mirror images. Evidence for the adoption of the content of WHO publications in the reviewed guideline document ‘Screening Guidelines Chronic Kidney Disease Sri Lanka 2017’ was not sufficient. Adoption of WHO publication contents in the Sri Lankan document ‘Pain Management Guideline for Adults with Cancer 2017’ was clearly evident. Over 80% of respondents in the quantitative survey from all medical related target audiences agreed that WHO publications have significantly contributed to changes in policy, clinical practices or individual behaviours in Sri Lanka. The extent to which the language, format and mode of dissemination of WHO publications influence their use as reference and authoritative source. A very high majority of the medical related target audiences (Health Ministry officials, Health Ministry national technical consultants, members of medical professional colleges, and medical research community) admitted that WHO publications have consistently been used as an authoritative source of health information in Sri Lanka. Conclusions and recommendations Reach of WHO publications to the Sri Lankan reader 1. WHO publication process has a well-organized method of identification of target audiences. However, the review revealed that indicating the target audience in the publication is not a regular practice in the WHO publications which adversely affect WHO publications reaching the intended target audiences. 1.1. It is recommended that for each publication, the intended target audiences to be identified at the initial stage of publication development and displayed/ indicated in the publication to improve the reach of WHO publication to the intended target audiences. Any future revision of WHO publication policy to include this as a directive. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 19 2. The extent of reach of WHO publications to Sri Lankan authorities appears to be in the moderate to low range based on the evaluation of the publications of Sri Lanka Ministry of Health policies, strategic plan and guideline documents though this evaluation was affected by shortcomings/ non-availability of referencing in the Sri Lankan publications. 2.1. A main suggestion to improve the situation was found to be promoting referencing by providing citation/ how to cite the source document at the beginning of the WHO publication. This recommendation will also contribute to more objective evaluation of evidence of reach, usefulness and use of WHO publications, in the future. 3. Online mode was the popular mode of distribution of the WHO publications reaching Health Ministry officials and Health Ministry national technical consultants. Majority of medical research community either actively searched online for WHO publications or noticed them accidently online. 3.1. Adopting innovative ways of boosting the dissemination of online versions of WHO publications are recommended as oppose to printed publications. 4. Reach of WHO Sri Lanka country office Facebook uploads to the Sri Lankan general public appears to be low. Social media engagement by Sri Lankans also appears to be poor. 4.1. Proactive use of social media platform is recommended to reach the Sri Lankan general public. Creating Facebook pages with regular and frequent uploads and actively increasing the friends and followers will promote the reach of Sri Lankan general public through social media via Facebook. Usefulness of WHO publications to the Sri Lankan reader 1. Overwhelming majority of the members of four target groups with a medical background responded that WHO publications respond to and meet their priority information needs. This indicates that WHO publications which are based on health information needs of the reader will achieve higher usefulness to the reader. 1.1. It is recommended that future WHO publications should focus to address readers priority information needs which will improve the usefulness of WHO publications to the reader. 2. Publications with lesser technical contents and use of more reader friendly formats, including infographics appears to be more appealing to the Sri Lankan reader. 2.1. Making WHO publications concise and use of modern communication methods and techniques are recommended which will improve the usefulness of WHO publications to the Sri Lankan reader. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 20 3. Near 100% agreement was expressed by Health Ministry officials and Health Ministry national technical consultants that WHO publications are of high quality. They responded by very strongly agreeing that WHO publications are very high/ high in perceived credibility, authoritativeness, trustworthiness and reputability, the four dimensions of quality. Use of WHO publications by the Sri Lankan reader 1. Review of Sri Lankan Ministry of Health published policy, strategic plan and guideline documents for their references to WHO publications revealed that the extent to which the relevant WHO publications have been used as authoritative sources of health information is very high in NCD and cancer prevention related publications. 2. Greater majority of the target audiences with a medical background agreed that WHO publications are used as authoritative sources of health information in Sri Lanka. 3. WHO publications on Health Promotion and related to Health Economics does not show a significant contribution to public health in Sri Lanka. 3.1. It is recommended that Health Promotion and Health Economics related information needs to be identified as priority areas in Sri Lanka to promote the use of relevant WHO publications in Sri Lanka. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 21 CHAPTER 1: INTRODUCTION Non-Communicable Diseases (NCDs) have become a major issue of national health agenda in Sri Lanka. Control and prevention of NCDs are highlighted and recognized as a priority area of work in national development and Health Policy and plans. The National Policy on Chronic NCD prevention addresses Diabetes, Cardiovascular Diseases, Hypertension and Chronic Respiratory Diseases. Strategies for reduction of major risk factors: smoking, alcohol, obesity, unhealthy diet and sedentary lifestyles are implemented through the existing health network with the support of both government and non-governmental organizations in the country. Sri Lanka is currently facing a triple transition when public health is considered. Epidemiological transition, demographic transition and socio-economic transition all three transitions are making an impact on health and health indices of Sri Lanka. In addition to these three transitions two more transitions namely, cultural transition and dietary/ nutritional transitions which have direct implications on NCD prevention and control in Sri Lanka. Some of the effects of these transitions may be mutually inclusive or even overlapping. Routine health systems in the country were geared more to curative services and it is therefore imperative that the health authorities do a situation review and adjust and re-adjust systems to meet the demands of the country’s new health profile and health services demand landscape in Sri Lanka. World Health Organization (WHO) being the leading health related development partner of Sri Lanka over the years has made a tremendous contribution to the country’s achievements in health. It is of paramount importance to assess the impact WHO has made to Sri Lanka taking into consideration the numerous inputs and insights provided by it. WHO publications, while spanning the total health related subject spectrum, publications related to NCD and health systems comes to the centre of importance in deciding the Sri Lanka’s road map to meet the challenges of the main triple transitions the country is facing. Evaluation of the impact of WHO publications related to Non-Communicable Diseases and the health systems in Sri Lanka can therefore be considered as a timely activity to deliver directions for both WHO and Sri Lanka how best to use WHO communications to navigate the complexities of the NCDs and health systems related issues in the country. Information on reach, usefulness and use of WHO publications will provide invaluable directions for future. With the intention of making recommendations to both WHO and the Ministry of Health of Sri Lanka on dissemination and use of WHO publications, this evaluation was carried out with the undermentioned objectives. 1.1. General Objectives 1. To quantify the extent of reach of the WHO publications on NCDs and health systems to its intended audiences in Sri Lanka and to describe major gaps in coverage and the reasons for such gaps. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 22 2. To describe the level of perceived usefulness of various WHO publications on NCDs and health systems in Sri Lanka. 3. To describe the extent of use of WHO publications on NCDs and health systems in Sri Lanka as reference and authoritative source of information for decision-making in clinical, public health and policy contexts. 1.2. Specific Objectives 1. To describe the way WHO defines its target audiences for different types of publications and different modes and the extent to which the intended reach is achieved. 2. To describe if the mode (web-only, print) affects reach and if so whether WHO uses the right media to effectively convey WHO information for different audiences. 3. To explore the extent to which WHO publications respond to global strategies and priorities and are based on needs assessment. 4. To describe the extent to which WHO publications respond to, and meet, the priority information needs of their intended audiences, and whether the format, language and dissemination mode of those affect their perception of usefulness. 5. To describe the perceived influence and impact of WHO publications on the formulation of national health policies and strategies and healthcare practices, as well as the perceived comparative advantage of WHO publications in relation to the ones by other stakeholders. 6. To discuss the perceived level of quality (e.g. credibility, authoritativeness, trustworthiness, and reputability) of WHO publications as well as their related shortcomings. 7. To describe the extent to which WHO’s publications are used as an authoritative source of health information, understanding the circumstances and criteria for it. 8. To determine the type of, and the publications that have demonstrated to contribute significantly to public health, as well as those that have not. 9. To describe evidence of the adoption of the content of WHO publications, leading to changes in policy, clinical practice, or individuals’ behaviours. 10. To explore the extent to which the language, format and mode of WHO publications influence their use as authoritative sources. 11. To recommend how WHO can foster better use of health information, either in the form of WHO publications, or through different mechanisms. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 23 CHAPTER 2: METHODOLOGY The study was conducted in two phases. 1. Phase 1: Compiling, consolidation, cleaning and identification of WHO publications in NCDs and health systems published during the period 2013 – 2019. 2. Phase 2: 2.1. Quantitative component - Survey 2.2. Qualitative component - Desk reviews/ Document reviews - Key informant interviews - Case product study - Bibliography - Web and Social media evaluation Phase 1 The Phase 1 was conducted to identify WHO publications to be evaluated. Several searches conducted through different approaches were triangulated to complete the lists. Electronic searches in the WHO IRIS (Institutional Repository for Information Sharing, https://apps.who.int/iris/), WHO Country office web site, other WHO publication links as well as manual search for any Sri Lankan Country office publications was carried out to ensure that all eligible publications are identified. Paper based publications available at Sri Lanka country office were cross-checked with online databases to identify any publications which may have missed the online lists. All the publications that fulfilled the following inclusion and exclusion criteria were used to identify publications for the evaluation. Compilation of publication lists for evaluation Inclusion criteria: A. Publications in English B. Print or electronic C. Published and issued between January 2013 and March 2019. D. Published by WHO Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 24 E. Subject areas to be related to 1. Non-communicable Diseases/ five (5) main NCDs a. Cardiovascular diseases b. Diabetes mellitus c. Chronic respiratory diseases d. Cancers e. Chronic kidney diseases 2. Five (5) main risk factors a. Diet b. Physical inactivity c. Alcohol d. Tobacco e. Air pollution 3. Health systems a. Health service delivery b. Universal health coverage c. Health workforce d. Health information systems e. Access to essential medicines f. Health systems financing g. Leadership and governance- e.g. Sustainable Development Goals. F. WHO publications in the following categories: 1. Advocacy materials/ general health information - factsheets, information kits, campaign material, newsletters) 2. Scientific or Technical material 3. World Health Reports/ Global Reports 4. Technical Publications (programme/ thematic based and country based) 5. Training Materials/ Manuals 6. Guidelines Exclusion criteria: 1. Communication materials, such as notes for the media, press releases 2. Official WHO statements Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 25 3. General text included in the body of the WHO website 4. Governing Bodies documents 5. WHO-Head Quarters and Region-based journals (including Weekly Epidemiological Record and WHO Bulletin) 6. WHO external publications 7. Articles in peer reviewed journals 8. Articles in non- peer reviewed journals 9. Book chapters and books, including textbooks The results of the Phase 1 were prepared in the forms of: 1. An algorithm/s depicting the different search strategies used and the number of WHO publications identified 2. Lists of WHO publications were identified with the details of a. Main subject area (NCD/ HS) b. Title of the publication c. Year of publication d. Form of publication- print and or electronic e. Source of publication (HQ, SEAR, Country office) f. Category of publication Compiled NCDs and health systems publication data lists were rigorously cleaned checked for duplications and then following screening process was conducted. 1. Sri Lanka country office publications were removed from the lists. 2. Regional office publications other than SEAR were omitted. 3. Lists were submitted to Sri Lanka country officer, SEAR office and Head Quarters to be compared with the data bases available with them and necessary additions and deletions were done accordingly. Completed Publication lists are available as the Annexures. 1. NCD publications for evaluation (Annex 1) 2. Health Systems publications for evaluation (Annex 2). Having the Phase 1 successfully completed and the two products finalized, the second phase of the study was undertaken. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 26 Phase 2 Phase two of the study comprised of several methodological approaches. 1. Conducting a quantitative survey using a web-based format. 2. Conduction desk reviews/ document reviews. 3. Conducting case product studies. 4. Conducting bibliographical evaluations. 5. Evaluating web-based utilization and social media engagement. 6. Key informant interviews with key Health Ministry office bearers. 7. Key informant interviews with content specialists. Identification of target audiences for Phase 2 of the study The following target audiences were identified for evaluation of NCDs and health systems related WHO publications. 1. Health Ministry officials 2. Health Ministry national technical consultants 3. Medical professional colleges 4. Medical research community 5. Non-medical professional colleges 6. Officials from other government institutions relevant to NCDs and Health Systems. 7. Civil Society organizations 8. General public Annex 3 indicates the categories which were identified in each of the above target audience and estimated number to be invited to participate in the evaluation. For the members of professional colleges, the invitation to participate with the link to the online survey was emailed to the respective president of the college and followed up with the secretary of the college. Selection of publications for evaluation by each identified target audience Selection of publications for evaluation were done with consultation and concurrence of the technical advisory group constituted by the WHO Sri Lanka country office to guide the evaluation. The following three steps were carried out to select the final publications for evaluation. 1. From the finalized NCDs and health systems lists 50 titles from each were selected randomly. 2. It was further filtered 50% retaining publications from years to cover all years under study, from HQ and from SEARO, to cover main subject / content areas under NCDs and Health Systems. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 27 3. In the third step at a consultation with the technical advisory group the following ten publications in each NCDs and health systems were selected after deliberation to minimize overlap of subject areas and to have best possible spread of topics relevant to Sri Lanka. List of ten NCD publications selected for evaluation by the two target audiences Health Ministry officials and Health Ministry national technical consultants. 1. Global Action Plan on Physical Activity 2018-2030: More Active People for a Healthier World. World Health Organization; 2018 2. WHO Framework convention on tobacco control: Guidelines for Implementation. World Health Organization. Regional Office for South-East Asia; 2014 3. Integrating palliative care and symptom relief into primary health care: a WHO guide for planners, implementers and managers. World Health Organization; 2018 4. The SHAKE technical package for salt reduction. World Health Organization; 2016 5. Global report on diabetes. World Health Organization; 2016 6. Tackling NCDs: ‘best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. World Health Organization; 2017 7. National capacity for prevention and control of noncommunicable diseases in WHO South-East Asia Region. Results from NCD country capacity survey 2017. World Health Organization. Regional Office for South-East Asia; 2018 8. Noncommunicable diseases country profiles. World Health Organization; 2018 9. HEARTS: Technical package for cardiovascular disease management in primary health care: access to essential medicines and technology. World Health Organization; 2018 10. ACTIVE: a technical package for increasing physical activity. World Health Organization; 2018 List of ten health systems publications selected for evaluation by the two target audiences Health Ministry officials and Health Ministry national technical consultants. 1. World health statistics 2018: monitoring health for the SDGs, sustainable development goals. World Health Organization; 2018 2. Regional strategy for patient safety in the WHO South-East Asia Region (2016-2025). WHO Regional Office for South-East Asia; 2015 3. Global strategy on human resources for health: workforce 2030. World Health Organization; 2016 4. Equitable access to medicines for Universal Health Coverage by 2030. World Health Organization. Regional Office for South-East Asia; 2017 5. Understanding national health workforce accounts. World Health Organization; 2017 Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 28 6. Global reference list of 100 core health indicators. World Health Organization; 2015 7. Global strategic directions for strengthening nursing and midwifery 2016-2020. World Health Organization; 2016 8. Monitoring progress towards universal health coverage at country and global levels: framework, measures and targets. World Health Organization; 2014 9. WHO global strategy on people-centred and integrated health services: interim report. World Health Organization; 2015 10. Health financing country diagnostic: a foundation for national strategy development. World Health Organization; 2016 The above mentioned twenty publications were used for the following activities and the specific target audiences. 1. Health ministry officials – for qualitative survey and key informant interviews. 2. Health ministry national technical consultants - for qualitative survey and key informant interviews. 3. Content experts – for key informant interviews. For the following target audiences it was decided to use only four publications for evaluations. Two publications which are common to all target audiences and two publications specific to each particular target group was selected. 1. Members of medical professional colleges 2. Medical research community 3. Members of non-medical professional colleges 4. Education ministry and finance ministry officials. 5. Members of civil society organizations. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 29 Following list of publications presented in the TABLE 1 was used for each target audience as indicated. The first two publications were used for all target audiences. TABLE 1: SELECTED PUBLICATIONS FOR EVALUATION BY IDENTIFIED TARGET AUDIENCES Target Audience Publications selected for evaluation Two common publications to all audiences 1. World health statistics 2018: monitoring health for the SDGs, sustainable development goals 2. Tackling NCDs: ‘best buys’ and other recommended interventions for the prevention and control of Non-Communicable Diseases Medical professional colleges College of Community Physicians of Sri Lanka 1. Ten years in public health, 2007 – 2017: report by Dr Margaret Chan, Director-General, World Health Organization 2. A practice guide to effective population-based food policy actions to promote healthy diets College of Medical Administrators of Sri Lanka 1. Improving the quality of health services: tools and resources 2. Regional strategy for patient safety in the WHO South-East Asia Region (2016 – 2025) Ceylon College of Physicians 1. Global status report on alcohol and health – 2014. 2. Global action plan on physical activity 2018 – 2030: more active people for a healthier world College of Pathologists and College of Surgeons 1. International Agency for Research on Cancer (2017). WHO classification of tumours of haematopoietic and lymphoid tissues, fourth rev. ed., edited by Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA Stein H & Thiele J., Lyon: IARC 2. Strategic framework for the comprehensive control of cancer cervix in South-East Asia Region College of Endocrinologists 1. Effect of reduced sodium intake on blood pressure, renal function, blood lipids and other potential adverse effects 2. Effect of reduced sodium intake on cardiovascular disease, coronary heart disease and stroke Sri Lanka Medical Nutritionists Association 1. Ambition and action in nutrition: 2016 – 2025 2. The nutrition challenge: food system solutions Medical Research Community 1. Effect of reduced sodium intake on blood pressure, renal function, blood lipids and other potential adverse effects 2. Regional strategy for patient safety in the WHO South- East Asia Region (2016-2025) Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 30 Non-medical professional colleges 1. Improving the quality of health services - Tools and resources. 2. Shake the Salt Habit: The SHAKE technical package for salt reduction Finance ministry officials 1. Non-Communicable Diseases: what ministries of finance, tax and revenue need to know 2. Towards universal health coverage: thinking public: overview of trends in public expenditure on health (2000 – 2014) Education ministry officials 1. Non-Communicable Diseases: what ministries of education need to know 2. A framework for implementing the set of recommendations on the marketing of foods and non-alcoholic beverages to children Civil society organizations in NCD work 1. Improving the quality of health services - Tools and resources. 2. Shake the Salt Habit: The SHAKE technical package for salt reduction. Identification of publication for evaluation by general public It was decided to use four digital media publications for the evaluation of target audience of general public. Three Facebook uploads by Sri Lanka country office and one infographics related to SDG in the WHO website were selected for evaluation (Annex 4). Following the identification of the specific WHO publications for evaluation and the target groups an evaluation matrix was developed to map out the activities for each specific objective. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 31 TABLE 2: NCDS AND HEALTH SYSTEMS WHO PUBLICATION EVALUATION MATRIX Specific objective Area of research Proposed methods Target audience Publications that will be subjected to evaluation Data collection method 1. To describe the way WHO defines its target audiences for different types of publications and different modes of dissemination and the extent to which the intended reach is achieved. 1. Analysis of the way WHO defines its target audiences for different types of publications and different media a. Review WHO publication policy - - Document review b. Qualitative study / inquiry among key WHO staff involved in the production of WHO publications WHO publication staff HQ SEARO Colombo In general, with no reference to any specific info products Survey c. Review of sample of publications to identify how they have specified target audiences and the mode of dissemination - Annex 5 1. Selected 10 NCD publications 2. Selected 10 health systems publications Document review d. Qualitative KII among content experts based on selected info products expert opinion on whether WHO has defined target audience correctly or whether it is more suitable for another target group Content experts Annex 5 1. Selected 10 NCD publications 2. Selected 10 health systems publications Key informant interview e. Qualitative KII among content experts based on selected info products Whether WHO has used the correct mode of dissemination (that will be e/print) through appropriate channels for it to reach the target audience. Content experts Annex 5 1. Selected 10 NCD publications 2. Selected 10 health systems publications Key informant interview Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 32 Specific objective Area of research Proposed methods Target audience Publications that will be subjected to evaluation Data collection method 2. identify the extent of reach 1. Desk review of technical documents and research for evidence of ‘reach’ 1. Health ministry officials 2. Health ministry national technical consultants 3. Members of medical professional colleges 4. Medical research community 5. Members of non-medical professional colleges 6. Education and finance ministry officials 7. Members of civil society organizations 8. General public 1. Policy Documents 1.1. National policy and strategic framework for cancer prevention and control 1.2. National policy on health care quality and safety 2. Strategic Plans/ Action plans 2.1. National Health Strategic Master plan 2016 – 2025, Preventive Services. 2.2. NCD multi sector action plan 2016 – 2020. 3. Guidelines 3.1. Screening Guidelines – CKD Sri Lanka 2017. 3.2. Pain management guidelines for adults with cancer Document review 2. Quantitative Survey among ALL categories of target audience. 1. Health ministry officials 2. Health ministry national technical consultants 3. Members of medical professional colleges 4. Medical research community 5. Members of non-medical professional colleges 6. Education and finance ministry officials 7. Members of civil society organizations 8. General public Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 33 Specific objective Area of research Proposed methods Target audience Publications that will be subjected to evaluation Data collection method 3. Bibliometric analysis in terms of quantity indicators (to measure the productivity of a particular researcher) and performance indicators a. Bibliographic analysis of 1. Thesis and PhD Colombo, Kelaniya and SJP, 2015 – 2018 2. MD theses PGIM 3. Selected NCDs and HS related peer review articles that have been published in high impact journals b. Downloads of the selected publications in Sri Lanka c. Social media engagement of uploaded WHO materials. Bibliography 2. To describe if the mode of dissemination (web-only, print) affects reach and if so whether WHO uses the right mode to effectively convey WHO information for different audiences 1. identify whether the media (web-only, print) affects reach if so whether WHO uses the right media to effectively convey WHO information for different audiences a. Qualitative KII among content experts based on selected info products: Was the media a reason for non-reach a. Qualitative KII among content experts based on selected info products: Was the media a reason for non-reach Annex 5 1. Selected 10 NCD publications 2. Selected 10 health systems publications Key informant interview Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 34 Specific objective Area of research Proposed methods Target audience Publications that will be subjected to evaluation Data collection method b. Quantitative survey among ALL categories of target audience based on selected info products: Was the mode of dissemination a reason for non-reach, suggestions to improve the media used by WHO 1. Health ministry officials 2. Health ministry national technical consultants 3. Members of medical professional colleges 4. Medical research community 5. Members of non-medical professional colleges 6. Education and finance ministry officials 7. Members of civil society organizations 8. General public Annex 6 Publications selected for each category of target audience Survey Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 35 Specific objective Area of research Proposed methods Target audience Publications that will be subjected to evaluation Data collection method 3. To explore the extent to which WHO publications respond to global strategies that are applicable to countries and priorities and are based on needs assessment. 1. explore the extent to which WHO publications respond to global strategies and priorities a. Desk review to assess the response to selected global strategies and priorities 1. Regional strategy for Universal Health Coverage. 2. Working towards achieving Sustainable Development Goals: a WHO toolkit. 3. Global Action Plan for prevention and control of Non-Communicable Diseases 2013 – 2020. Document review / Desk review Content experts 1. Regional strategy for Universal Health Coverage. 2. Working towards achieving Sustainable Development Goals: a WHO toolkit 3. Global Action Plan for prevention and control of Non- Communicable Diseases 2013 – 2020. Key informant interview a. Qualitative study / inquiry among Key WHO staff involved in the production of WHO publications, both from a strategic, process and content point of view WHO regional advisor on information and publications. WHO HQ focal point on information and publications. In general, with no reference to any specific info products. Survey b. Case studies of specific publications 1. HRH work force strategy 2030 2. A practice guide to effective population-based food policy actions to promote healthy diets Case product study Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 36 Specific objective Area of research Proposed methods Target audience Publications that will be subjected to evaluation Data collection method 4. To describe the extent to which WHO publications respond to, and meet, the priority information needs of their intended audiences, and whether the format, language and mode of dissemination of those affect their perception of usefulness. 1. describe the extent to which WHO publications respond to, and meet, the priority information needs of their intended audiences a. Quantitative survey among ALL categories of target audience in general on all publications 1. Health ministry officials 2. Health ministry national technical consultants 3. Members of medical professional colleges 4. Medical research community 5. Members of non-medical professional colleges 6. Education and finance ministry officials 7. Members of civil society organizations 8. General public In general, with no reference to any specific info products. Also, in relation to the specific products identified for each category. Survey 2. whether the format, language affect their perception of usefulness a. Quantitative survey among ALL categories of target audience in general on all publications and specifically on selected publications 1. Health ministry officials 2. Health ministry national technical consultants 3. Members of medical professional colleges 4. Medical research community 5. Members of non-medical professional colleges 6. Education and finance ministry officials 7. Members of civil society organizations 8. General public In general, with no reference to any specific info products. Also, in relation to the specific products identified for each category. Survey Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 37 Specific objective Area of research Proposed methods Target audience Publications that will be subjected to evaluation Data collection method 5. To describe the perceived influence and impact of WHO publications on the formulation of national health policies and strategies and healthcare practices, as well as the perceived comparative advantage of WHO publications in relation to the ones by other stakeholders. 1. perceived influence and impact of WHO publications on the formulation of national health policies and strategies and healthcare practices a. Desk review national health policies and strategies and documents on healthcare practices to identify evidence of influence 1. Policy Documents 1.1. National policy and strategic framework for cancer prevention and control 1.2. National policy on health care quality and safety 2. Strategic Plans / Action plans 2.1. National Health Strategic Master plan 2016 – 2025, Preventive Services 2.2. NCD multi sector action plan 2016 – 2020. 3. Guidelines 3.1. Screening Guidelines – CKD Sri Lanka 2017 3.2. Pain management guidelines for adults with cancer Desk review b. Qualitative KII on perceptions of selected target audiences on selected publications 1. Health ministry officials 2. Health ministry national technical consultants 3. Members of medical professional colleges In general, with no reference to any specific info products. Also, in relation to the specific products identified for each category. Few specific publications to be referred to. Key informant interview Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 38 Specific objective Area of research Proposed methods Target audience Publications that will be subjected to evaluation Data collection method 2. Perceived comparative advantage of WHO publications in relation to the ones by other stakeholders a. Qualitative KII on perceptions of selected target audiences in general on all publications and specifically on selected publications 1. Health ministry officials 2. Health ministry national technical consultants 3. Members of medical professional colleges In general, with no reference to any specific info products. Also, in relation to the specific products identified for each category. Key informant interview 6. To discuss the perceived level of quality (e.g. credibility, authoritativeness, trustworthiness, and reputability) of WHO publications as well as their related shortcomings. 1. perceived level of quality (e.g. credibility, authoritativeness, trustworthiness, and reputability) of WHO publications as well as their related shortcomings a. Quantitative survey among ALL categories of target audience in general on all publications and specifically on selected publications 1. Health ministry officials 2. Health ministry national technical consultants 3. Members of medical professional colleges 4. Medical research community 5. Members of non-medical professional colleges In general, with no reference to any specific info products. Also, in relation to the specific products identified for each category. Survey b. Qualitative KII among selected categories of target audience in general on all publications and specifically on selected publications 1. Health ministry officials 2. Health ministry national technical consultants 3. Members of medical professional colleges In general, with no reference to any specific info products. Also, in relation to the specific products identified for each category. Key informant interview Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 39 Specific objective Area of research Proposed methods Target audience Publications that will be subjected to evaluation Data collection method 7. To describe the extent to which WHO’s publications are used as an authoritative source of health information, understanding the circumstances and criteria for it 1. extent to which WHO’s publications are used as an authoritative source of health information, understanding the circumstances and criteria for it a. Desk review on use of WHO publications on country actions 1. Policy Documents 1.1. National policy and strategic framework for cancer prevention and control 1.2. National policy on health care quality and safety 2. Strategic Plans/ Action plans 2.1. National Health Strategic Master plan 2016 – 2025, Preventive Services 2.2. NCD multi sector action plan 2016 – 2020. 3. Guidelines 3.1. Screening Guidelines – CKD Sri Lanka 2017 3.2. Pain management guidelines for adults with cancer b. Quantitative survey among selected categories of target audience on selected publications 1. Health ministry officials 2. Health ministry national technical consultants 3. Members of medical professional colleges 4. Medical research community 5. Members of non-medical professional colleges 6. Education and finance ministry officials 7. Members of civil society organizations In general, with no reference to any specific info products. Also, in relation to the specific products identified for each category. Survey Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 40 Specific objective Area of research Proposed methods Target audience Publications that will be subjected to evaluation Data collection method 8. To determine the type of, and the publications that have demonstrated to contribute significantly to public health, as well as those that have not. 1. What are the type of, and the publications that have demonstrated to contribute significantly to public health, as well as those that have not. a. Case studies of specific publications 1. Publications that have contributed significantly 1.1. Tackling NCDs: ‘best buys’ and other recommended interventions for the prevention and control of NCDs. 1.2. WHO Global Action Plan for prevention and control of Non- Communicable Diseases 2013 – 2020. 1.3. Tobacco control: progress and plans for implementing the framework convention on tobacco control (‎FCTC)‎ 2. Publications that have not contributed significantly. 2.1. Strengthening health systems to accelerate delivery of NCDs services at the primary health care level: one year progress review of the implementation of the 2016 Colombo declaration on NCDs. 2.2. TRIPS, intellectual property rights and access to medicines 2.3. Promoting health in the SDGs: report on the ninth Global conference for health promotion, Shanghai, China, 21–24 November 2016: all for health, health for all. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 41 Specific objective Area of research Proposed methods Target audience Publications that will be subjected to evaluation Data collection method 9. To describe evidence of the adoption of the content of WHO publications, leading to changes in policy, clinical practice, or individuals’ behaviours. 1. Evidence of the adoption of the content of WHO publications, leading to changes in policy, clinical practice, or individuals’ behaviours. a. Desk review 1. Policy Documents 1.1. National policy and strategic framework for cancer prevention and control 1.2. National policy on health care quality and safety 2. Strategic Plans / Action plans 2.1. National Health Strategic Master plan 2016 – 2025, Preventive Services 2.2. NCD multi sector action plan 2016 – 2020. 3. Guidelines 3.1. Screening Guidelines – CKD Sri Lanka 2017 3.2. Pain management guidelines for adults with cancer Desk review b. Quantitative survey among selected categories of target audience 1. Health ministry officials 2. Health ministry national technical consultants 3. Members of medical professional colleges 4. Medical research community 5. Members of non-medical professional colleges 6. Education and finance ministry officials 7. Members of civil society organizations In general, with no reference to any specific info products. Also, in relation to the specific products identified for each category. Survey Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 42 Specific objective Area of research Proposed methods Target audience Publications that will be subjected to evaluation Data collection method 10. to explore the extent to which the language and format of WHO publications influence their use as an authoritative sources 1. the extent to which the language, and format of WHO publications influence their use as authoritative sources a. Quantitative survey among selected categories of target audience 1. Health ministry officials 2. Health ministry national technical consultants 3. Members of medical professional colleges 4. Medical research community 5. Members of non-medical professional colleges 6. Education and finance ministry officials 7. Members of civil society organizations In general, with no reference to any specific info products. Also, in relation to the specific products identified for each category. Survey Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 43 Specific objective Area of research Proposed methods Target audience Publications that will be subjected to evaluation Data collection method 11. To recommend how WHO can foster better use of health information, either in the form of WHO publications, or through different mechanisms 1. how WHO can foster better use of health information, either in the form of WHO publications, or through different mechanisms a. Quantitative survey among selected categories of target audience 1. Health ministry officials 2. Health ministry national technical consultants 3. Members of medical professional colleges 4. Medical research community 5. Members of non-medical professional colleges 6. Education and finance ministry officials 7. Members of civil society organizations In general, with no reference to any specific info products. Also, in relation to the specific products identified for each category. Survey b. Qualitative study / inquiry among Key WHO staff involved in production of WHO publications, both from a strategic, process and content point of view WHO regional advisor on information and publications. WHO HQ focal point on information and publications. In general, with no reference to any specific info products. Also, in relation to the specific products identified for each category. Survey Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 44 Quantitative Survey data collection tools Survey tools were developed on the web based commercial “Survey Monkey” platform. Survey links were developed for each different target audience since different publications were used in each group. However, in all target groups, except for the general public and WHO publication staff, same questions in same format was used. Annex 7 – Survey tool for Health Ministry officials Annex 8 – Survey tool for Health Ministry national technical consultants Annex 9 – Survey tool for medical professional colleges Annex 10 – Survey tool for non-medical professional colleges Annex 11 – Survey tool for finance ministry officials Annex 12 – Survey tool for education ministry officials Annex 13 – Survey tool for civil society organizations Annex 14 – Survey tool for general public Annex 15 – Survey tool for medical research community In addition to the above web-based approach to reach the potential respondents, same web format was printed and was made available for the selected respondents as a self-administered questionnaire. Qualitative Survey data collection Survey Monkey survey link was emailed to the survey participants. Three rounds of emails were sent to identify target audiences through email groups available with respective organizations and professional colleges. Reminder emails were sent after each emailing activity. General public were identified through conveniently available email groups from two private sector organizations. However, even after three reminders the response was poor from the general public target group. Therefore to supplement the online data collection, a further 300 printed copies of the survey format was used to collect a sufficient number of responses from the general public. Key informant Interviews Guiding questions were developed to be used in the key informant interviews. The interviews were conducted by the principal investigator. (Annex 16). Following key informant interviews were conducted 1. Deputy Director General of Health Services (Planning) – 1 person 2. Health ministry directors involved in NCD work – 2 persons 3. Provincial Director of Health Services – 2 persons 4. Regional Director of Health Services – 2 persons. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 45 Following content experts were interviewed to achieve the objectives as indicated in the evaluation matrix. 1. Professor emeritus, Colombo University, Professor in Community Medicine. 2. Professor, Colombo University, Professor in Medicine 3. Deputy Director General of Health Services (Public Health Services) Desk reviews/ Document reviews/ Case product studies The following desk reviews were conducted as indicated in TABLE 3. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 46 TABLE 3: DOCUMENT REVIEWS/ DESK REVIEWS / CASE PRODUCT STUDIES CARRIED OUT IN THE NCDS AND HEALTH SYSTEMS WHO PUBLICATION EVALUATION Specific objective Proposed methods Publications that will be subjected to evaluation Data collection method 1. To describe the way WHO defines its target audiences for different types of publications and different modes of dissemination and the extent to which the intended reach is achieved. a. Review WHO publication policy Document review b. Review of sample of publications to identify how they have specified target audiences and the mode of dissemination Annex 5 1. Selected 10 NCD publications 2. Selected 10 health systems publications Document review c. Desk review of technical documents and research for evidence of ‘reach’ 1. Policy Documents 1.1. National policy and strategic framework for cancer prevention and control 1.2. National policy on health care quality and safety 2. Strategic Plans / Action plans 2.1. National Health Strategic Master plan 2016 – 2025, Preventive Services 2.2. NCD multi sector action plan 2016 – 2020. 3. Guidelines 3.1. Screening Guidelines – CKD Sri Lanka 2017 3.2. Pain management guidelines for adults with cancer Document review d. Bibliometric analysis in terms of quantity indicators (to measure the productivity of a particular researcher) and performance indicators a. Bibliographic analysis of 1. Thesis and PhD Colombo, Kelaniya and SJP, 2015 – 2018. 2. MD theses PGIM 3. selected NCD and HS related peer review articles that have been published in high impact journals b. Downloads of the selected publications in Sri Lanka c. Social media engagement of uploaded WHO materials. Bibliography Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 47 Specific objective Proposed methods Publications that will be subjected to evaluation Data collection method 2. To explore the extent to which WHO publications respond to global strategies that are applicable to countries and priorities and are based on needs assessment. a. Desk review to assess the response to selected global strategies and priorities 1. Regional strategy for Universal Health Coverage 2. Working towards achieving Sustainable Development Goals: a WHO toolkit 3. Global Action Plan for prevention and control of Non-Communicable Diseases 2013 – 2020. Document review / Desk review 1. Case studies of specific publications 1. HRH work force strategy 2030 2. A practice guide to effective population-based food policy actions to promote healthy diets Case product study 3. To describe the perceived influence and impact of WHO publications on the formulation of national health policies and strategies and healthcare practices, as well as the perceived comparative advantage of WHO publications in relation to the ones by other stakeholders. a. Desk review national health policies and strategies and documents on healthcare practices to identify evidence of influence 1. Policy Documents 1.1. National policy and strategic framework for cancer prevention and control 1.2. National policy on health care quality and safety 2. Strategic Plans / Action plans 2.1. National Health Strategic Master plan 2016 – 2025, Preventive Services 2.2. NCD multi sector action plan 2016 – 2020 3. Guidelines 3.1. Screening Guidelines – CKD Sri Lanka 2017 3.2. Pain management guidelines for adults with cancer Desk review 4. To describe the extent to which WHO’s publications are used as an authoritative source of health information, understanding the circumstances and criteria for it a. Desk review on use of WHO publications on country actions 1. Policy Documents 1.1. National policy and strategic framework for cancer prevention and control 1.2. National policy on health care quality and safety 2. Strategic Plans / Action plans 2.1. National Health Strategic Master plan 2016 – 2025, Preventive Services 2.2. NCD multi sector action plan 2016 – 2020, 3. Guidelines 3.1. Screening Guidelines – CKD Sri Lanka 2017 3.2. Pain management guidelines for adults with cancer Desk review Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 48 Specific objective Proposed methods Publications that will be subjected to evaluation Data collection method 5. To determine the type of, and the publications that have demonstrated to contribute significantly to public health, as well as those that have not. a. Case studies of specific publications 1. Publications that have contributed significantly 1.1. Tackling NCDs: ‘best buys’ and other recommended interventions for the prevention and control of NCDs. 1.2. WHO Global Action Plan for prevention and control of Non-Communicable Diseases 2013 – 2020. 1.3. Tobacco control: progress and plans for implementing the framework convention on tobacco control (‎FCTC)‎. 2. Publications that have not contributed significantly. 2.1. Strengthening health systems to accelerate delivery of NCDs services at the primary health care level: one year progress review of the implementation of the 2016 Colombo declaration on NCDs. 2.2. TRIPS, intellectual property rights and access to medicines 2.3. Promoting health in the SDGs: report on the 9th Global conference for health promotion, Shanghai, China, 21–24 November 2016: all for health, health for all. Case product study 6. To describe evidence of the adoption of the content of WHO publications, leading to changes in policy, clinical practice, or individuals’ behaviours. a. Desk review 1. Policy Documents 1.1. National policy and strategic framework for cancer prevention and control 1.2. National policy on health care quality and safety 2. Strategic Plans / Action plans 2.1. National Health Strategic Master plan 2016 – 2025, Preventive Services 2.2. NCD multi sector action plan 2016 – 2020. 3. Guidelines 3.1. Screening Guidelines – CKD Sri Lanka 2017 3.2. Pain management guidelines for adults with cancer Desk review Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 49 All available Health Ministry policy documents, strategic plans, action plans and guidelines were listed. The document repository of the Sri Lanka Ministry of Health and other documents available were scrutinized to prepare the list of documents. Out of the documents available the following six documents were selected with the consultation of the technical advisory group to be reviewed to achieve the stated objectives. 1. Policy Documents 1.1. National policy and strategic framework for cancer prevention and control 1.2. National policy on health care quality and safety 2. Strategic Plans / Action plans 2.1. National Health Strategic Master plan 2016 – 2025, Preventive Services 2.2. NCD multi sector action plan 2016 – 2020 3. Guidelines 3.1. Screening Guidelines – CKD Sri Lanka 2017 3.2. Pain management guidelines for adults with cancer Bibliographic analysis 1. Citation analysis of NCD and Health system related journal articles written by authors with Sri Lankan affiliation in peer reviewed local and international journals were carried out to find out the impact of WHO Publications on NCDs and health systems publications. 2. Citations, bibliography/ list of references in postgraduate theses submitted to Sri Lankan universities and Post Graduate Institute of Medicine by MD, MSc, MPhil and PhD students on NCDs and health systems related disciplines during 2013 – 2019 were also examined. 3. All the articles related to NCD and NCD risk factors published in Local and international peer reviewed journals were searched in PUBMED/ MEDLINE database and Google Scholar. Non-Communicable Disease, Diabetes mellitus, Chronic Respiratory Diseases, Neoplasm or Cancer, Cardiovascular Diseases, Chronic Kidney Diseases Unknown Etiology (CKDu), Risk Factors, Physical Activity, Obesity, Diet Alcohol, Tobacco and Pollution were the terms used as main keywords for the search. To limit the search results, the author affiliation “Sri Lanka” and year of publication was used. Health Systems, Delivery of Health Care, Universal Health Coverage SDGs, Access to medicine were used as key words for health systems related disciplines. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 50 CHAPTER 3: RESULTS AND DISCUSSION Eight target audiences comprised the total study sample and following TABLE 4 provides the number of respondents in each group. TABLE 4: NUMBER OF RESPONDENTS IN EACH IDENTIFIED TARGET AUDIENCES Target audience Number Health Ministry officials 87 Health Ministry national technical consultants 25 Members of medical professional colleges 93 Medical research community 74 Members of non-medical professional colleges 8 Education and finance ministry officials 8 Members of civil society organizations 6 General Population 395 3.1. How does WHO define its target audiences for different types of publications and different modes of dissemination and the extent to which the intended reach is achieved. 3.1.1. How does WHO define its target audiences for different types of publications and different modes of dissemination. 3.1.1.1. WHO publication policy Following documents were reviewed to identify target audience defining process and mode of dissemination defining process in WHO publications. 1. Information Circular, IC-2017-02 of 10 February 2017: Regional Office for South East Asia – Publication policy, procedures and role of Regional Publishing Policy Group 2. Report of the twenty first meeting, 11-12 November 2013: Publishing Policy Coordination Group. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 51 3. Report by the Secretariat. EBI123/7 of 14 April 2008: WHO Publication Policy: Guidance on implementation and evaluation. 4. Report by the secretariat. EB122/20 of 06 December 2007: WHO publications 5. Web access – 14 February 2020: https://www.who.int/about/who-we-are/publishing-policies/ open-access 6. Web access – 14 February 2020: https://www.who.int/about/who-we-are/publishing-policies/ data-policy 7. Web access – 14 February 2020: https://www.who.int/about/who-we-are/publishing-policies/ copyright 8. Web access – 14 February 2020: https://www.who.int/about/who-we-are/publishing-policies/ logo WHO reference materials on publications and publications policy deals mostly on administrative procedures related to content development, production, logistics, staff responsibilities and authorization process. References are also available for dissemination, archiving, evaluation, collaborations and external publications. Copyright, sale of publications and mechanisms for approvals also clearly stated. Steps in content development of a particular publication are the responsibility of the technical unit concerned. Responsibility of the technical quality is rested with the director of the department concerned. Report by the secretariat spells out that policy is designed to ensure that all WHO publications: (1) Comply with agreed standards of quality in terms of technical content, relevance and presentation. (2) Comply with cost effectiveness in terms of production, distribution and accessibility. (3) Comply with in terms of appropriate formats and languages. The closest statement referring to target audiences was identified as “Implementing the policy will ensure that WHO products are made available in formats and languages that are relevant to the needs of target audiences.” Under approval process, the three stages of publishing process (planning/ content development/ lay out, type setting and production) and approvals for such process is clearly stated. It also stated that all technical officers who initiate information product development should ensure that a needs assessment has been conducted and that the product meets the objectives and that measures are in place to ensure the quality of the final content. It appears that stated process and contents related to content development does not directly addresses the identification of target audiences or mode of dissemination. However, it is understood that when the ensuring of quality of the publication is vested with the technical officers and the director of the particular department, the identification of target audiences is carried out by them, as and when deemed necessary. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 52 It is also stated that the publication policy will be regularly evaluated at the highest level. It will be a timely and necessary activity to highlight and state in the next revision of the publication policy that the target audience/s and mode/s of dissemination of the prospective information product has to be identified. This activity of identification of the target groups along with stating a written down communication objective must precede the content development. 3.1.1.2. Qualitative study through Survey Monkey form of WHO headquarters and Regional Office for South-East Asia publication staff Three technical officers involved in WHO publication process participated in the online survey and expressed their opinion on defining target audiences, mode of dissemination, needs assessments and means of improving better use of WHO publications. None of them had a role to play in defining target audiences for WHO publications and one of them was involved in deciding modes of dissemination of the WHO publications. There were five open ended questions to seek their opinions. Survey Questions Yes No Do you play a role in defining target audiences for different WHO publications? 0 3 Do you play a role in deciding modes of dissemination of different types of WHO publications? 1 2 Survey questions (Qualitative) Answered Not answered Briefly describe your views on how WHO defines target audiences for different types of publications 3 0 Briefly describe your views on how WHO decides the mode of dissemination for different types of publications 3 0 Briefly describe your views on how WHO can foster better use of health information, either in the form of WHO publications, or through different mechanisms. 3 0 TABLE 5: SUMMARY OF FINDINGS FROM OPINIONS GIVEN BY WHO HQ AND SEARO PUBLICATION STAFF Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 53 Summary findings How WHO defines target audiences for different types of publications 1. It is hard to define the audience. o Usually WHO caters to everyone o Currently a wide range from health minister to health consumer. o It should be kept to very specific audiences. o Audience defining should be based on needs assessment. 2. WHO defines for publications through five domains. (a) Need analysis (b) Systematic reviews (c) Identification of target audience groups (d) Prioritization of target audience groups. (e) Evaluation of established criteria. o This process is very thorough and evidence based. o Publications of collaborative efforts and those with country health ministries may be based on local felt needs. How WHO decides the mode of dissemination for different types of publications • Print format has undying relevance. o However, most publications go online for dissemination alone. o Always printing a minimum number of hard copies for every document is preferred. • Perception that when digital files are posted on WHO website whole world will come to it does not hold ground. o It is more likely people go to other social sources (Wikipedia, Google) and public research platforms (PMC, NCBI Bookshelf, Google scholar) or national public health sites/ consumer health sites / general or specialist health products. o Digital should be the primary medium, printed products can be provided on demand. • WHO has shifted to online mode. o In reality this has shifted to printing cost from WHO to the end user. o WHO readers still do print the publications. • Low internet access • High cost of internet access. o While there is logistical savings by not printing, “print on demand” should be adopted rather than massive runs of print copies. o E-copies should be adapted and made available to mobile devices platforms. The fact that there were five domains used for target audience identification in publication production is commendable. It is recommended that a description of the intended target audience be given in preface or introduction to the publication. This would be helpful in future impact evaluations as well. It is therefore advisable to have the identified target audience/s documented in the publication itself which could be adopted as a practice in future WHO publications. Target group identification will also help in future need identification and publication evaluation processes. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 54 3.1.1.3. Review of selected 20 NCD and health systems publications to explore for identification and documentation of the target audiences. 3.1.1.4. Review of selected 20 NCD and health systems publications to explore for identification and documentation of the mode of dissemination. Findings from the above two reviews are presented in the TABLE 6 below. TABLE 6: IDENTIFICATION OF TARGET AUDIENCES AND MODE OF DISSEMINATION OF TWENTY SELECTED NCD AND HEALTH SYSTEMS WHO PUBLICATIONS WHO publication Target Audience Mode of Dissemination More active people for a healthier world Not identified. Not documented. Not indicated. WHO Framework convention on tobacco control: Guidelines for Implementation Not identified. Not documented. Not indicated. Integrating palliative care and symptom relief into primary healthcare Identified. Documented. Not indicated. Shake the salt habit: The SHAKE Technical package for salt reduction Identified. Documented. Not indicated. Global report on diabetes Not identified. Not documented Not indicated. Tackling NCDs: 'Best Buys' and other recommended interventions for the prevention and control of Non-Communicable Diseases Identified. Documented. Not indicated. National capacity for prevention and control of Non- Communicable Diseases in WHO South-East Asia Region. Not identified. Not documented Not indicated. Non-Communicable Diseases, Country profiles 2018 Not identified. Not documented Not indicated. HEARTS: Technical package for cardiovascular disease management in primary health care: access to essential medicines and technology Identified. Documented. Not indicated. ACTIVE: A technical package for increasing physical activity Not identified. Not documented Not indicated. World health statistics 2018: monitoring health for the SDGs, sustainable development goals Not identified. Not documented Not indicated. Regional strategy on patient safety in the WHO South-East Asia Region (2016 – 2025) Not identified. Not documented Not indicated. Global strategy for human resources for health: Workforce 2030 Identified. Documented. Not indicated. Equitable access to medicines for Universal Health Coverage by 2030 Identified. Documented. Not indicated. Understanding national health workforce accounts Not identified. Not documented Not indicated. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 55 Global reference list of 100 core health indicators Not identified. Not documented Not indicated. The global strategic directions for strengthening nursing and midwifery 2016 – 2020. Not identified. Not documented Not indicated. Monitoring progress towards universal health coverage at country and global levels: framework, measures and targets Not identified. Not documented Not indicated. WHO global strategy on people-centred and integrated health services: Interim report Not identified. Not documented Not indicated. Health financing guide No. 1 – Health financing country diagnostic: a foundation for national strategy development Not identified. Not documented Not indicated. 3.1.1.5. Qualitative KII with content experts if the target audience is correctly defined. The following descriptions 3.1.1.5.1 to 3.1.2.5.20 are on the selected ten NCD and ten health systems publications. 3.1.1.5.1. MORE ACTIVE PEOPLE FOR A HEALTHIER WORLD This publication is a generic technical document addressed at increasing physical activity and decreasing physical inactivity among general population. The content speaks about all age groups all audiences. However, the main emphasis is on policy actions. The target audience is not identified. Herein a great opportunity has been foregone due to not identifying the target audiences for advocacy and advocacy communication strategy. However, the reader would understand from the content the publication as what target audience has been focussed on, where all four chapters are on an individual objective which has 4 to 6 policy actions identified in each chapter/objective. Had each target audience for each policy action was defined this publication would have served as an excellent advocacy document for policy makers. Even though it is indicated, that 4 to 6 policy actions are discussed in each objective, the focus had been more on what is to be implemented rather than how it should be implemented to achieve the desired outcome. While target audiences are appropriate, it seemed quite difficult to have such a wide range of target audiences covered in a single publication, especially when the intended target group consists of policy makers. 3.1.1.5.2. WHO FRAMEWORK CONVENTION ON TOBACCO CONTROL: GUIDELINES FOR IMPLEMENTATION This is a generic publication with a much focused subject matter and actions. Form the start the stakeholders are identified as integral to the discussion. Therefore, even without written down target audiences, the target audiences are recognizable and well addressed individually. Under the subsection of Purpose, scope and applicability relevant target audiences have been identified. Target audience identification is appropriate and appears to be successful considering that this Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 56 document has been one of the most important and definable WHO publications. Similarly, the publication on tobacco control guidelines was identified as a key document published WHO. 3.1.1.5.3. INTEGRATING PALLIATIVE CARE AND SYMPTOM RELIEF INTO PRIMARY HEALTHCARE Target audiences are identified and indicated right on the cover page. Giving an indication at whom the document is targeted can be considered a progressive move in light of the time constrains of present day reader. In addition to specifying the target audiences it has also indicated that the publication was a “guide”. This tendency to disclose target audience is appreciable. However, the three different identified target audiences spanned through a wide range when considering health information needs. 3.1.1.5.4. SHAKE THE SALT HABIT: THE SHAKE TECHNICAL PACKAGE FOR SALT REDUCTION This publication is targeted for member states outlining policies and interventions for the reduction of salt intake. When policy level is addressed by a document is it important to minimize inclusion of technical matter, keeping the relevance to the intended target audience. It is indicated in the introduction that this tool kit was to assist member states. “Member states” as a target audience of a publication seemed incomprehensible, hence using “member states” as a target audience in organisational sense, needs to be considered. Inclusion of a pictorial message on a cover page relating to the topic can have a very strong conveyance of concepts which can also help attract the right audience which really need/seek the information. 3.1.1.5.5. GLOBAL REPORT ON DIABETES This publication is a global report. Even though target audiences are not defined or identified, it conveyed that the report was an update on the state of affairs on diabetes in the year of publication. In this case any reader who is interested in diabetes would self-identify him/ herself as a target audience for the particular publication. Readers/ users of reports may sometimes expect data and figures at the global level in relation to their own country. On the other hand having numerous data/ details for regions may distract from or dilute the importance of content to the individual reader/ user from a particular country. In view of presentation of data, it would therefore be appropriate if the content of reports provide information/ data pertaining to global and regional contexts, in relation to the perceived importance to that particular country. 3.1.1.5.6. TACKLING NCDS: ‘BEST BUYS’ AND OTHER RECOMMENDED INTERVENTIONS FOR THE PREVENTION AND CONTROL OF NON-COMMUNICABLE DISEASES Form the cover page if the reader is dealing with NCD or SDG he/she can identify himself/ herself as a member of the intended target audience. Section on “What is in this document” on page 2 is a progressive element. The write up starts with Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 57 “This document provides policymakers….” thus identifying the policymaker as the sole/main target group. However, the document is on “what to do” (which is more suited for the implementer) rather than “how to do” (which is more intended for policy maker). The general trend of technical matter making a bigger chunk of available information makes the document more suited for implementing technical person rather than for the top level policymaker. 3.1.1.5.7. NATIONAL CAPACITY FOR PREVENTION AND CONTROL OF NON-COMMUNICABLE DISEASES IN WHO SOUTH-EAST ASIA REGION. The cover page itself indicates that this is a survey report from South East Asian region. Therefore major target audience may identify themselves from these two variables: the region and the survey. Executive summary also gives a clear picture for intended readers to select the publication. In comparison to global report where regional level data are presented in this regional report where country wise data are presented is better facilitates with identification of potential target audiences. 3.1.1.5.8. NON-COMMUNICABLE DISEASES, COUNTRY PROFILES 2018 The name of the publication itself asserts the target audiences. NCD country profiles of 2018 had the appeal to every reader from all member states. The reader is able to concentrate on their particular countries of interest. 3.1.1.5.9. HEARTS: TECHNICAL PACKAGE FOR CARDIOVASCULAR DISEASE MANAGEMENT IN PRIMARY HEALTH CARE: ACCESS TO ESSENTIAL MEDICINES AND TECHNOLOGY Cover page itself gave an indication to whom this publication was targeted for. In the introduction itself the various target groups have been explicitly identified. In addition to the identification of the specific target groups, the formats and the presentation styles are impressive and stand out among others. Minimal technical content and point form presentation have shortened the length of the publication. All these progressive factors are target group specific and adopting this method should be encouraged. 3.1.1.5.10. ACTIVE: A TECHNICAL PACKAGE FOR INCREASING PHYSICAL ACTIVITY This publication being a technical package speaks about four policy action areas. This document even though it is for action areas emphasises more on “how to do” more than “what to do”. This is approach of providing more of “how to do” is quite welcome and should be promoted. 3.1.1.5.11. WORLD HEALTH STATISTICS 2018: MONITORING HEALTH FOR THE SDGS, SUSTAINABLE DEVELOPMENT GOALS The document name indicates the intended target groups in a broad manner. Any reader who is working on SDG or health statistics and information is a target audience for this publication. Essentially the fact that this publication is on statistics and SDG defines its target audiences in an indirect manner. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 58 3.1.1.5.12. REGIONAL STRATEGY ON PATIENT SAFETY IN THE WHO SOUTH-EAST ASIA REGION (2016 – 2025) This document, as it is from South East Asian Region, suggests that its main target audience was from that region. Since it is a regional strategy it will attract more regional audiences and prospective chronology indicates that health planners are also an intended target audience. However technical details are overwhelming and minimal “how to do” makes this publication more academic and technical reader oriented. 3.1.1.5.13. GLOBAL STRATEGY FOR HUMAN RESOURCES FOR HEALTH: WORKFORCE 2030 The intended primary target audience and other target audiences are well identified under point number four of Introduction. While it is well identified and documented, the name also implies the intended target audiences. 3.1.1.5.14. EQUITABLE ACCESS TO MEDICINES FOR UNIVERSAL HEALTH COVERAGE BY 2030 This technical brief on universal health coverage is a very good example of advocacy materials and target audience is well identified and documented. National level policy makers are the primary and main target identified and publication has kept its promise to be a technical brief for policy makers, being only two paged document. 3.1.1.5.15. UNDERSTANDING NATIONAL HEALTH WORKFORCE ACCOUNTS At 16 pages total, this publication presents itself as a higher level policy advocacy document. Name of the document may be new to readers thus misleading as well as misunderstood by potential target audience readers. It’s intended target audiences are planners at national regional and global level, which may not be clear to inadvertent reader. 3.1.1.5.16. GLOBAL REFERENCE LIST OF 100 CORE HEALTH INDICATORS More relevant target audiences are at national to global level monitoring and evaluating stakeholders. However, it should target implementer and planner as well at an equal prominence and intensity. 3.1.1.5.17. THE GLOBAL STRATEGIC DIRECTIONS FOR STRENGTHENING NURSING AND MIDWIFERY 2016 – 2020 As the name implies this document’s intended target audiences are global to national level. This publication is mostly intended for planners and policy and advocacy groups. However, since this topic is rare implementers and evaluators also must be equally included as intended target audiences. 3.1.1.5.18. MONITORING PROGRESS TOWARDS UNIVERSAL HEALTH COVERAGE AT COUNTRY AND GLOBAL LEVELS: FRAMEWORK, MEASURES AND TARGETS The cover page itself indicates that the intended target audiences are at national and global level. This publication appears to be more an advocacy intended publication but fails to present itself as a policy document. Therefore intended target audiences while not clear nor focussed would have been more clearly defined at outset. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 59 3.1.1.5.19. WHO GLOBAL STRATEGY ON PEOPLE-CENTRED AND INTEGRATED HEALTH SERVICES: INTERIM REPORT While being vague and fluid the document fails to identity its intended target audiences because the document itself is not focussed. It is not clear if the document is a repackaging of all facts and not to leave anything behind. Also, the fact that it presents an abstract conceptual framework without and direction of “what to do” or “how to do” does not help in identification of intended target audiences. 3.1.1.5.20. HEALTH FINANCING GUIDE NO. 1 - HEALTH FINANCING COUNTRY DIAGNOSTIC: A FOUNDATION FOR NATIONAL STRATEGY DEVELOPMENT The regular rule of thumb that the name of the document should shed light on the intended target audience does not appear to hold ground for this publication. Either a more refined publication name or identification of intended target audiences would have done more justice to this publication which presents health financing fundamentals to the reader. 3.1.1.6. Qualitative KII with content experts’ if mode of dissemination is correctly defined Evaluation of the twenty selected WHO publications on NCD and health systems revealed that the mode of dissemination is not a standard variable included in the format of the documents or within the administrative of academic write up of the publication. 3.1.2. Extent of the reach of different types of WHO publications. 3.1.2.1 Desk review of Sri Lanka ministry of health technical documents for evidence of reach of relevant WHO publications. Six Sri Lankan documents were selected, two from each policy documents, two from strategic/ action plans and two from guidelines. The TABLE 7 below shows the descriptions of evaluated documents. Type of document Selected document Description Policy document National policy and strategic framework for cancer prevention and control 3.1.2.1.1 National policy on health care quality and safety 3.1.2.1.2 Strategic plan / Action plan National health strategic plan for preventive sector 2016 -2025 3.1.2.1.3 National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020. 3.1.2.1.4 Guidelines Screening Guidelines Chronic Kidney Disease Sri Lanka 2017 3.1.2.1.5 Pain Management Guideline for Adults with Cancer 2017 3.1.2.1.6 TABLE 7: SIX SELECTED DOCUMENTS FOR EVALUATION OF EVIDENCE OF REACH OF WHO PUBLICATIONS Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 60 3.1.2.1.1. FIRST OF THE TWO SRI LANKAN POLICY DOCUMENTS REVIEWED FOR EVIDENCE OF REACH OF WHO PUBLICATIONS: “NATIONAL POLICY AND STRATEGIC FRAMEWORK FOR CANCER PREVENTION AND CONTROL” The document originated from Sri Lanka ‘National policy and strategic framework for cancer prevention and control’ was reviewed to identify the extent of the reach of WHO publications. Due to the unavailability of a list of references in the Sri Lankan document (‘National policy and strategic framework for cancer prevention and control’), relevant WHO publications were studied to achieve the objective. Thus examined WHO publications include ‘National Cancer Control Programmes – Policies and managerial guidelines’ and the six modules on the WHO publication series ‘Cancer Control – Knowledge into Action’. Publications by IARC (International Agency for Research in Cancer) also were considered in the analysis. In the absence of a reference list in the Sri Lankan document under review, ‘National policy and strategic framework for cancer prevention and control’, it was compared with the above-mentioned WHO publications for the similarities in the technical content to identify the extent of the reach. Findings: The IARC is the specialized cancer agency of the WHO, with the main objective of promoting collaboration for cancer research. Hence IARC has many publications on cancer including incidence and prevalence data, estimates/ projections as well as in the fields of cancer preventive, control and palliative care. These publications by the IARC has reached effectively the national policy and strategic framework for cancer prevention and control published in 2014 by the Ministry of Health, Nutrition and Indigenous Medicine of Sri Lanka (MoH) as described below. The IARC Global cancer observatory and IARC World cancer report have been used in describing magnitude of the problem at the global level (page 1-2), which reflect the successful reach of these documents at Sri Lankan level. But it is unclear to what extent other WHO publications on cancer control and prevention strategies have reached this Sri Lankan policy document, even though the publication states that evidence-based strategies will be integrated in cancer control activities in Sri Lanka (page 6-7), as the document does not indicate the references to the said strategies. However, the document states the WHO country office as a development partner of the publication under consideration, which might indicate the reach of other WHO publications related to cancer control and prevention. Conclusion: The extent of the reach of relevant WHO publications relevant to this policy document, “National policy and strategic framework for cancer prevention and control” was satisfactory. However, lack of references or bibliography in the document was a serious limitation in identifying the extent of reach of WHO publications to Sri Lankan policy makers when developing the national policy and strategies. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 61 3.1.2.1.2 SECOND OF THE TWO SRI LANKAN POLICY DOCUMENTS REVIEWED FOR EVIDENCE OF REACH OF WHO PUBLICATIONS: “NATIONAL POLICY ON HEALTH CARE QUALITY AND SAFETY” The Sri Lankan document ‘National policy on health care quality and safety’ (2015) was reviewed to assess the reach of relevant WHO publications. Since the Sri Lankan document did not have a list of references, most relevant WHO publications were searched to assess their reach. As a result, ‘A background for national quality policies in health systems’, ‘World alliance for patient safety, forward programme 2008 – 2009’ and ‘Regional strategy for patient safety in the WHO South-East Asia Region (2016-2025)’ were selected. The selected WHO publications were compared with the Sri Lankan document under review, ‘National policy on health care quality and safety’ (2015) to assess whether the core contents and/or key messages in WHO publications were reflected in the Sri Lankan document. ‘A background for national quality policies in health systems’ and ‘World alliance for patient safety, forward programme 2008 – 2009’ were reviewed in this regard. The most applicable publication, ‘Regional strategy for patient safety in the WHO South-East Asia Region (2016-2025)’ was disregarded as its year of publication was the same as the Sri Lankan document under review. Findings: In the WHO publication ‘World alliance for patient safety, forward programme 2008 – 2009’, five themes had been recommended to ensure the patient safety, namely assessing and understanding the problems of unsafe care, developing norms and establishing standards to reduce harm, improving knowledge access/ use and evaluating impact, promoting innovation and sustaining commitment and strengthening capacity for patient safety worldwide (page 4). The other WHO publication under concern, ‘A background for national quality policies in health systems’ discusses the background required for an effective quality policy (page 9). In the discussion, the mainly stressed areas include, national values and priorities for quality including legislations, national organization and institutionalization of quality, Methods/ techniques and tools for development of quality, resources for quality improvement, identify structure/ roles and accountability, define and disseminate practical guidance, research and pilot quality projects, develop knowledge, attitudes and skills, national minimum data set, and dissemination of data. On the other hand, the ‘National policy on health care quality and safety’ in Sri Lanka discusses its contents in seven broad key result areas. These are customer/ patient satisfaction, managerial systems and process improvement, clinical effectiveness, risk management, safety and enabling a culture for quality improvement, staff development and welfare and research for quality improvement and patient safety. Under each key result area, strategies to achieve the result are outlined. Although the Sri Lankan national policy lacks a smooth flow, it basically covers all the areas identified by the WHO publications except for legislations, having a minimum data set and a system to monitor and evaluate the activities. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 62 Conclusion: The reach of relevant WHO publications seems to be satisfactory in this Sri Lankan policy document ‘National policy on health care quality and safety’. However, it should be noted that absence of a reference list or in-text citation in the Sri Lankan document was a serious limitation in assessing the reach of relevant WHO publications. 3.1.2.1.3. FIRST OF THE TWO SRI LANKAN STRATEGIC PLAN / ACTION PLAN DOCUMENTS REVIEWED FOR EVIDENCE OF REACH OF WHO PUBLICATIONS: “NATIONAL HEALTH STRATEGIC PLAN FOR PREVENTIVE SECTOR 2016 – 2025” The ‘National health strategic plan for preventive sector 2016 – 2025’ extensively discusses vision, mission, goals, objectives and major activities or strategic framework to achieve the programme objectives of 32 Public Health institutions/ programmes in the state sector of the country. In addition, the document produces a gap analysis to achieve universal health coverage in the respective field of service for each Public Health institution. Using a common format to gather information from all considered parties could be considered as a step taken to improve the consistency of the document. However, disparities could still be seen in the write ups of institutions such as omitting of references, which had a negative impact in achieving the objective of assessing the extent of reach of relevant WHO publications. In addition, even when the source of information is mentioned, reference to the text was not made but the bibliography was presented as a list, hence making it difficult to assess the extent of reach. Findings: Of the 32 Public Health institutions discussed in the document, 11 (34.4%) had not mentioned the sources of information. Out of the rest (n=21), only 9 (42.9%) had mentioned a WHO publication as a source of reference, while the majority (57.1%, n=12) had not mentioned WHO publications as a source of reference. Among those who had not provided sources of reference for their strategies, were some very important Public Health institutions/ programmes/ profiles such as Family Health Bureau (FHB) which is the national programme for maternal and child health in the country, Sri Lanka College of Obstetricians and Gynaecologists, Epidemiology unit (selected units), migration health unit and the National Cancer Control Programme. Despite availability of numerous WHO guidelines and publications on effective preventive strategies, the reach could not be evaluated due to this limitation of unavailability of a list of references among these important programmes. Many other important institutions had listed their references, but had not referred to any WHO publications as a source of information. Among these institutions, Non-Communicable Diseases bureau and the quarantine unit can be emphasized, as the considerable number of WHO publications the respective units/ programmes could have utilized in preparing the strategic frameworks. For example, the WHO publication ‘Global action plan for the prevention and control of NCDs 2013 – 2020 https://www.who.int/nmh/publications/ncd-action-plan/en/ is a very useful document which directly has a bearing on the Sri Lankan document under consideration. ‘Tackling NCDs’ is another such useful WHO document https://www.who.int/ncds/management/best-buys/en/ that discusses Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 63 best buys and other recommended interventions to prevent and control NCDs. International Health Regulations (IHR) https://www.who.int/ihr/IHR_2005_en.pdf is a core document applicable to quarantine health. However, it is not mentioned as a source of reference under the quarantine unit profile in the Sri Lankan document. In contrast, the Health Promotion Bureau (HPB), Anti-Leprosy campaign, CKDu unit, Leishmaniasis programme under the Epidemiology unit, College of Community Physicians of Sri Lanka, Environmental and Occupational Health unit, National Programme for Tuberculosis Control and Chest Diseases (NPTCCD) and the Food Safety unit had provided WHO references as source of information, indicating good reach. However, it is noteworthy that of the eight public health units which had referred WHO publications, three had used them only to include estimates on the disease burden (CKDu unit, NPTCCD and Food Safety unit) while the rest have used the WHO publications to refer to either guidelines or action plans. Non-inclusion of very significant Public Health programmes such as the directorate of mental health and the directorate of quality of healthcare and patient safety in the National Strategic Plan for Health Sector, the document under review was noted and is considered as unacceptable error at the national level due to the significance of their roles in prevention and control of NCD and improving the health of the public in Sri Lanka. Conclusion: Overall, evaluation of the ‘National health strategic plan for preventive sector 2016 – 2025’ for evidence of reach of WHO publications depicts poor reach of WHO publications to the target audience at the level of strategies/ major activities of public health institutions/ programmes in Sri Lanka. Even among the reached, the extent of reach seemed unsatisfactory, as only 5 programmes/ units had referred the WHO technical documents in guidelines and action plans except for estimates of the disease burden. 3.1.2.1.4. SECOND OF THE TWO SRI LANKAN STRATEGIC PLAN / ACTION PLAN DOCUMENTS REVIEWED FOR EVIDENCE OF REACH OF WHO PUBLICATIONS: “NATIONAL MULTI-SECTORAL ACTION PLAN FOR THE PREVENTION AND CONTROL OF NON-COMMUNICABLE DISEASES 2016 – 2020” The National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020 was a comprehensive plan that has been developed in order to achieve the ten voluntary targets adopted by Sri Lanka based on the nine global targets and the specific regional targets identified for the South East Asia Region. The plan discusses outcomes to be achieved, specific activities to be implemented, required multi-sector partnerships and the time frame by which the targets are to be achieved. A desk review of WHO publications that were relevant to the Sri Lankan document was done to compare the extent of their reach in the Sri Lankan document. The WHO publication that has a direct implication on this Sri Lankan document is the ‘WHO Global Action Plan for prevention and control of Non-Communicable Diseases 2013 – 2020’, which has been prepared by compiling all the previous work and evidence on NCD. Therefore, the contents in the said WHO publication was compared with the Sri Lankan document to assess the reach and its extent. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 64 Findings: The WHO publication ‘Global Action Plan for prevention and control of Non-Communicable Diseases 2013 – 2020’ discusses vision, goal, overarching principles, objectives, voluntary global targets and a global monitoring framework. In overall comparison, the Sri Lankan action plan also describes vision, goal, overarching principles, objectives, Sri Lankan targets, and strategic priority action areas. Most of the Sri Lankan targets and strategies harmonize with the global targets and strategies. The nine overarching principles in the WHO publication (page 3), which can be seen in the exact order and wordings in the Sri Lankan document as well (page 17). The six objectives documented in the WHO publication (page 5) also can be seen in exact same words in the Sri Lankan document (page 17-18). Sri Lanka has also taken up the nine voluntary global targets stated in the WHO publication (page 5) without any alterations (page 19). The Sri Lankan action plan is focused on four strategic areas, namely ‘advocacy’, ‘partnership and leadership’, ‘health promotion and risk reduction’, ‘strengthen health system for early detection and management of NCD and their risk factors’ and ‘surveillance, monitoring, evaluation and research’ to improve the NCD burden of the country. The WHO publication also discusses their main objectives focusing on similar principles. Even at the level of activities, proposed actions in the Sri Lankan document (page 22-79) well aligned with suggested policy options for member states and other suggested activities in the WHO publication. Conclusion: The extent of the reach of WHO publications in compiling the ‘National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020’ was observed to be very satisfactory. 3.1.2.1.5. FIRST OF THE TWO SRI LANKAN GUIDELINE DOCUMENTS REVIEWED FOR EVIDENCE OF REACH OF WHO PUBLICATIONS: ‘SCREENING GUIDELINES CHRONIC KIDNEY DISEASE SRI LANKA 2017’ ‘Screening Guidelines Chronic Kidney Disease Sri Lanka 2017’ is an update and revision of the first guideline on screening for Chronic Kidney Disease (CKD) in Sri Lanka published in 2014. It is expected that this document will serve as a comprehensive guide for the health care providers engaged in screening programme. The publication clearly describes the high-risk geographic areas, target populations and exclusion criteria, screening settings, screening methods, screening tools, administration of screening tools, sample collection and dispatch, required calculations, quality assurance of laboratory tests, cut-off values for laboratory and other investigations, interpretation of results, referral procedures and indications, field screening clinics, implementation plan, monitoring and evaluation, district level indicators and targets as well as data analysis and dissemination of information. ‘Screening Guidelines Chronic Kidney Disease Sri Lanka 2017’, was evaluated to assess the reach of relevant WHO publications. Understandably, most WHO publications have focused on kidney diseases with a known aetiology such as Diabetes, Cardio-vascular diseases, Chronic pulmonary Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 65 diseases and Cancer in their publications on chronic diseases, and there was no specific publication on screening for CKDu. The WHO publication titled ‘International expert consultation on CKDu’ was published in 2017, three years after the publication of the Sri Lankan document. Hence it was not considered. In the absence of any other document, comparison was done with the ‘Principles and practice of screening for diseases’ (1968) by the WHO. Findings: The mentioned WHO publication discusses the essential, core components for the implementation of effective screening programme as “The disease or disorder considered for screening must be well defined, of public health importance, and of known prevalence in the population. An effective, affordable and acceptable treatment must be available to those who require it. In the Sri Lankan document under review, the disease CKDu, is well defined by the means of required investigations (page 5-7), cut-off values for the investigations (page 9) and interpretation of results (page 9). The care pathway for the patients who become screen positives for required treatment and management of the disease is clearly described in the referral procedure for persons with abnormal test results (page 10). In addition, mentioning of the implementation plan, monitoring and evaluation as well as dissemination of information has made the Sri Lankan document a comprehensive guideline. However, the magnitude of the problem was not clearly presented with prevalence data, nor the effectiveness of screening for CKDu was not justified with evidence. Conclusion: The extent of reach of relevant WHO publications is moderate in the evaluated Sri Lankan guideline document ‘Screening Guidelines Chronic Kidney Disease Sri Lanka 2017’. 3.1.2.1.6. SECOND OF THE TWO SRI LANKAN GUIDELINE DOCUMENTS REVIEWED FOR EVIDENCE OF REACH OF WHO PUBLICATIONS: ‘PAIN MANAGEMENT GUIDELINE FOR ADULTS WITH CANCER 2017’ ‘Pain Management Guideline for Adults with Cancer 2017’ is the Sri Lankan document under consideration. The publication by the National Cancer Control Programme (NCCP) of Sri Lanka had a list of references and also in-text citations, making it feasible to accurately evaluate the reach of WHO publications on the Sri Lankan document. In addition, to assess the reach, other relevant WHO publications published before 2017 but are not mentioned in the reference list of the Sri Lankan document were also analysed. ‘Cancer pain relief’ (1996) by the WHO was the other most relevant publication thus selected to compare with the Sri Lankan document for its reach. The Sri Lankan document under review, ‘Pain Management Guideline for Adults with Cancer 2017’, was studied with regard to the in-text citation and the list of references for the inputs from WHO publications. Additionally, other WHO publications relevant to the Sri Lankan guidelines were searched to assess the reach. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 66 Findings: The Sri Lankan document lists ten references as source of information, and only the WHO’s ‘Cancer pain ladder for adults’ (2017) is listed as a WHO publication. The pain management principle described by the WHO has been used to explain principles of pharmacological treatment of pain. There was no indication of the use of the ‘Cancer Pain Relief’, the other relevant WHO publication in the Sri Lankan document. Conclusion: The extent of the reach of the WHO publications is low in the Sri Lankan document ‘Pain Management Guideline for Adults with Cancer 2017’. Evaluated Sri Lankan document Evidence of reach of WHO publications National policy and strategic framework for cancer prevention and control The extent of the reach of relevant WHO publications is satisfactory. National policy on health care quality and safety The extent of the reach of relevant WHO publications is satisfactory. National health strategic plan for preventive sector 2016 – 2025 The extent of the reach of relevant WHO publications is poor. National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020 The extent of the reach of relevant WHO publications is very satisfactory. Screening Guidelines Chronic Kidney Disease Sri Lanka 2017 The extent of the reach of relevant WHO publications is moderate. Pain Management Guideline for Adults with Cancer 2017 The extent of the reach of relevant WHO publications is low. TABLE 8: SUMMARY OF FINDINGS OF THE DESK REVIEW OF SRI LANKA MINISTRY OF HEALTH TECHNICAL DOCUMENTS FOR EVIDENCE OF REACH OF RELEVANT WHO PUBLICATIONS Box 1: Evidence of reach of relevant WHO publications in Sri Lanka government documents. The extent of reach of WHO publications to Sri Lankan authorities appeared to be moderate to low by the evidence in documents in policy, strategic plan and guidelines spheres. Only Non-Communicable Diseases subject area as demonstrated in “National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020” demonstrated a high level of reach of relevant WHO publications. Comparing the level of development of the six subject areas in Sri Lanka covered by the six documents evaluated for the reach of WHO publications, surprisingly more developed subject areas (Preventive programmes and Cancer control) as well as currently developing subject areas (Healthcare safety and Quality and pain management), equally showed low reach. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 67 3.1.2.2. Quantitative survey among target audiences for the reach of WHO publications Health Ministry officials and Health Ministry national technical consultants were shown ten (10) NCD and ten (10) health systems publications and were asked to indicate if they (a) have seen the publication and (b) have accessed/ got hold of the publication, as a measure of reach. Publication Title Yes No No: % No: % WHO Framework convention on tobacco control: Guidelines for Implementation 33 40% 49 60% TACKLING NCDs: ‘Best Buys’ and other recommended interventions for the prevention and control of NCDs. 23 31% 52 69% Non-Communicable Diseases, Country profiles 2018 22 29% 53 71% National capacity for prevention and control of NCD WHO South-East Asia Region. 21 28% 54 72% Global report on diabetes. 16 21% 60 79% Integrating palliative care and symptom relief into primary healthcare. 15 19% 64 81% Shake the salt habit: The SHAKE Technical Package for Salt Reduction. 13 17% 65 83% More active people for a healthier world. 11 13% 76 87% ACTIVE: A technical package for increasing physical activity. 7 9% 68 91% HEARTS: Technical package for cardiovascular disease management in primary health care: access to essential medicines and technology. 7 9% 68 91% Average for the ten NCD publications 22% 78% World health statistics 2018: monitoring health for the SDGs, sustainable development goals. 16 23% 55 77% Global Strategy for Human Resources for Health Workforce 2030: Workforce 2030. 13 19% 55 81% Global Reference List of 100 Core Health Indicators. 11 17% 54 83% Understanding National Health Workforce Accounts 10 15% 57 85% Monitoring progress towards universal health coverage at country and global levels: framework, measures and targets 10 15% 55 85% Regional Strategy on Patient Safety in the WHO South-East Asia Region (2016 – 2025) 10 14% 59 86% Equitable access to Medicines for Universal Health Coverage by 2030 9 13% 59 87% Health financing guide No. 1 - Health financing country diagnostic: a foundation for national strategy development 7 11% 58 89% WHO global strategy on people-centred and integrated health services: Interim Report 1 2% 64 98% TABLE 9: REACH OF SELECTED TWENTY WHO PUBLICATIONS (TEN EACH ON NCDS AND HEALTH SYSTEMS) TO SRI LANKA HEALTH MINISTRY OFFICIALS (QUESTION IN THE SURVEY QUESTIONNAIRE “HAVE YOU SEEN THIS PUBLICATION?”) Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 68 Out of the ten NCD related publications which were shown to the respondents, WHO framework convention on Tobacco Control was the most seen document; by 33 (40%) respondents. On average 22% of the respondents have seen at least one publication out of the ten NCD related publications which were shown to them. Reach of health systems related documents were less than NCD related publication reach to the Health Ministry officials, only 13% of the respondents had seen at least one health systems publication out of the ten documents shown to them. World health statistics: monitoring health for the SDG’s was the most seen HS related publication. The two least seen (by only one person) publications were the global strategic directions for strengthening nursing and midwifery and WHO global strategy on people centred and integrated health services. The Global Strategic Directions for Strengthening Nursing and Midwifery 2016 – 2020 1 2% 64 98% Average for the ten health systems publications 13% 87% * Total number of Yes + No for each publication differs because some respondents have skipped some publications. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 69 TABLE 10: REACH OF SELECTED TWENTY WHO PUBLICATIONS (TEN EACH ON NCDS AND HEALTH SYSTEMS) TO SRI LANKA HEALTH MINISTRY OFFICIALS (QUESTION IN THE SURVEY QUESTIONNAIRE “HAVE YOU ACCESSED/ GOT HOLD OF THIS PUBLICATION?”) Publication Title Yes No No: % No: % Shake the salt habit: The SHAKE Technical Package for Salt Reduction 7 88% 1 13% Non-Communicable Diseases country profiles 2018 9 82% 2 18% More active people for a healthier world. 8 80% 2 20% Tackling: 'Best Buys' and other recommended interventions for the prevention and control of NCDs. 8 67% 4 33% ACTIVE: A technical package for increasing physical activity 4 67% 2 33% Global report on diabetes. 5 56% 4 44% WHO Framework convention on tobacco control: Guidelines for Implementation 7 54% 6 46% National capacity for prevention and control of NCDs in WHO South- East Asia Region. 4 40% 6 60% Integrating palliative care and symptom relief into primary healthcare 2 33% 4 67% HEARTS: Technical package for cardiovascular disease management in primary health care: access to essential medicines and technology 1 25% 3 75% Average for the ten NCD publications 59% 41% Health financing guide No. 1 – Health financing country diagnostic: a foundation for national strategy development 5 100% 0 0% WHO global strategy on people-centred and integrated health services: Interim Report 1 100% 0 0% Global Strategy for Human Resources for Health Workforce 2030: Workforce 2030 6 86% 1 14% Global Reference List of 100 Core Health Indicators 5 83% 1 17% World health statistics 2018: monitoring health for the SDGs, sustainable development goals 11 69% 5 31% Understanding National Health Workforce Accounts 4 67% 2 33% Monitoring progress towards universal health coverage at country and global levels: framework, measures and targets 3 43% 4 57% Equitable access to Medicines for Universal Health Coverage by 2030 2 40% 3 60% Regional Strategy on Patient Safety in the WHO South-East Asia Region (2016 – 2025) 1 20% 4 80% The Global Strategic Directions for Strengthening Nursing and Midwifery 2016 – 2020 0 0% 1 100% HEALTH SYSTEMS AVERAGE 58% 42% * Total number of Yes + No for each publication differs because some respondents have skipped some publications. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 70 TABLE 11: REACH OF SELECTED TWENTY WHO PUBLICATIONS (TEN EACH ON NCDS AND HEALTH SYSTEMS) TO SRI LANKA HEALTH MINISTRY NATIONAL TECHNICAL CONSULTANTS. (QUESTION IN THE SURVEY QUESTIONNAIRE “HAVE YOU SEEN THIS PUBLICATION?”) Publication Title Yes No No: % No: % WHO Framework convention on tobacco control: Guidelines for Implementation 13 52% 12 48% TACKLING NCDs: 'Best Buys' and other recommended interventions for the prevention and control of NCDs. 12 48% 13 52% Non-Communicable Diseases; Country profiles 2018 11 44% 14 56% National capacity for prevention and control of NCDs in WHO South-East Asia Region. 10 40% 15 60% More active people for a healthier world. 10 40% 15 60% Global report on diabetes. 9 36% 16 64% Shake the salt habit: The SHAKE Technical Package for Salt Reduction 8 32% 17 68% ACTIVE: A technical package for increasing physical activity 6 24% 19 76% Integrating palliative care and symptom relief into primary healthcare 6 24% 19 76% HEARTS: Technical package for cardiovascular disease management in primary health care: access to essential medicines and technology 4 16% 21 84% Average for the ten NCD publications 36% 64% World health statistics 2018: monitoring health for the SDGs, sustainable development goals 11 44% 14 56% Monitoring progress towards universal health coverage at country and global levels: framework, measures and targets 7 30% 16 69% Global Strategy for Human Resources for Health Workforce 2030: Workforce 2030 7 28% 18 72% Global Reference List of 100 Core Health Indicators 6 26% 17 73% Understanding National Health Workforce Accounts 6 25% 18 75% Equitable access to Medicines for Universal Health Coverage by 2030 6 24% 19 76% Health financing guide No. 1 – Health financing country diagnostic: a foundation for national strategy development 5 21% 18 78% Regional Strategy on Patient Safety in the WHO South-East Asia Region (2016 – 2025) 5 20% 20 80% The Global Strategic Directions for Strengthening Nursing and Midwifery 2016 – 2020 1 4% 22 95% WHO global strategy on people-centred and integrated health services: Interim Report 1 4% 22 95% Average for the ten health systems publications 23% 77% * Total number of Yes + No for each publication differs because some respondents have skipped some publications. Out of the respondents who have seen the particular publication, majority close to 60% have accessed the publication. Similar trend was seen in both NCD publications and health systems publications. Even though a particular trend or a pattern cannot be visible, it is of interest to note that the highest number of respondents (11 respondents) accessed the “World health statistics 2018: monitoring health for the SDGs, sustainable development goals”. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 71 Respondents in the target group Health Ministry national technical consultants showed higher reach than that of the Health Ministry officials. Average of the respondents who has seen one of the ten NCD publications increased to 36% from 22% and for the ten health systems publications average increased from 13% to 23%. TABLE 12: REACH OF SELECTED TWENTY WHO PUBLICATIONS (TEN EACH ON NCDS AND HEALTH SYSTEMS) TO SRI LANKA HEALTH MINISTRY NATIONAL TECHNICAL CONSULTANTS. (QUESTION IN THE SURVEY QUESTIONNAIRE “HAVE YOU ACCESSED THIS PUBLICATION?”) Publication Title Yes No No: % No: % Shake the salt habit: The SHAKE Technical Package for Salt Reduction 7 88% 1 13% Non-Communicable Diseases Country profiles 2018 9 82% 2 18% More active people for a healthier world. 8 80% 2 20% TACKLING NCDs: 'Best Buys' and other recommended interventions for the prevention and control of NCDs. 8 67% 4 33% ACTIVE: A technical package for increasing physical activity 4 67% 2 33% Global report on diabetes. 5 56% 4 44% WHO Framework convention on tobacco control: Guidelines for Implementation 7 54% 6 46% National capacity for prevention and control of NCDs in WHO South-East Asia Region. 4 40% 6 60% Integrating palliative care and symptom relief into primary healthcare 2 33% 4 67% HEARTS: Technical package for cardiovascular disease management in primary health care: access to essential medicines and technology 1 25% 3 75% NCD AVERAGE 59% 41% Health financing guide No. 1 – Health financing country diagnostic: a foundation for national strategy development 5 100% 0 0% WHO global strategy on people-centred and integrated health services: Interim Report 1 100% 0 0% Global Strategy for Human Resources for Health Workforce 2030: Workforce 2030 6 86% 1 14% Global Reference List of 100 Core Health Indicators 5 83% 1 17% Understanding National Health Workforce Accounts 4 67% 2 33% World health statistics 2018: monitoring health for the SDGs, sustainable development goals 11 44% 4 56% Monitoring progress towards universal health coverage at country and global levels: framework, measures and targets 3 43% 4 57% Equitable access to Medicines for Universal Health Coverage by 2030 2 40% 3 60% Regional Strategy on Patient Safety in the WHO South-East Asia Region (2016– 2025) 1 20% 4 80% The Global Strategic Directions for Strengthening Nursing and Midwifery 2016– 2020 0 0% 1 100% Average for the ten health systems publications 58% 42% * Total number of Yes + No for each publication differs because some respondents have skipped some publications. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 72 Reach of NCD WHO publications to the Health Ministry national technical consultants appears to be average. Only 36% of them have seen at least one of the ten NCD publications selected for evaluation. Close to 60% of those who have seen the publication have proceeded to access the publication either online or as a hard copy. This may be an indication of the proportion those who are in a real need of the information. Even among the Health Ministry officials, where average NCD publication reach was only 23%, among those who have seen the publication, accessing the publication was around 60%. Reach of health systems publications fared poorer than the NCD publications. This difference may be due to the fact that NCD has a much wider appeal to the readers than health systems. Only 23 % of the national technical consultants and 13% Health Ministry officials have seen at least one of the ten health system publications which were evaluated. However, similar to NCD publication access, even in health systems publications, close to 60% of the respondents who have seen a publication, proceeded to access the publication. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 73 Description of the responses from the other categories of respondents, who were shown four WHO publications and the average of the responses to the questions “Have you seen this publication?” and Have you accessed/ got hold of the publication?” is given in the TABLE 13 below. TABLE 13: REACH OF SELECTED FOUR WHO PUBLICATIONS TO THE OTHER TARGET AUDIENCES (PERCENTAGES ARE CALCULATED AS AN AVERAGE FOR ALL TWENTY PUBLICATIONS) Have seen Have not seen Have accessed* Have not accessed Members of medical professional colleges (n=93) 33 (35%) 60 (65%) 22 (67%) 11 (33%) Medical research community (n=74) 13 (18%) 61 (82%) 11 2 Members of non-medical professional colleges (n=8) 4 (50%) 4 (50%) 2 0 Education and finance ministry officials (n=8) 4 (50%) 4 (50%) 2 0 Members of civil society organizations (n=6) 3 (50%) 3 (50%) 3 0 * Some respondents who have seen the publication did not answer if they have accessed or not. Reach of the WHO publication to the members of medical professional colleges (35%) was similar to the reach of Health Ministry national technical consultants (36%). Majority of them (67%) proceeded to access respective publications. This result was observed to be a significant one considering the fact that the subject matter may or may not have directly related to their research interests or not. However, reach among medical research community was at a low level (18%) in comparison. This is a matter of concern, where PGIM trainees, who constituted a major proportion of medical research community target audience, are expected to read far and wide. There may be a possibility that the WHO publications which were presented to this target audience did not directly corresponded to their current research interests and therefore the reach of these particular WHO publications to them remained low. The general public was presented with four Facebook publications which were published in WHO Sri Lanka Country Office web page. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 74 TABLE 14: REACH OF SELECTED FOUR WHO SRI LANKA COUNTRY OFFICE’S FACEBOOK UPLOADS TO THE GENERAL PUBLIC TABLE 15: DESCRIPTION OF MODE OF REACH OF THE SELECTED WHO PUBLICATIONS TO THE TARGET AUDIENCES (PERCENTAGES ARE CALCULATED AS AN AVERAGE FOR ALL TWENTY PUBLICATIONS) Type of document Yes No Total No: (%) No: (%) FB Publication 1: Salt: WHO recommends less than 5 grams per day. 64 (16%) 331 (84%) 395 FB Publication 2: WHO guideline on healthy diet 44 (11%) 340 (89%) 384 FB Publication 3: Antibiotics do not treat viral infections, like colds and flu 75 (20%) 307 (80%) 382 FB Publication 4: Banner with UN’s 17 Sustainable Development Goals 75 (20%) 306 (80%) 381 A cc id en ta lly c am e ac ro ss it o nl in e A ct iv el y se ar ch a nd f o un d a so ft c o p y A cc id en ta lly f o un d a h ar d co p y 7% A ct iv el y se ar ch ed a nd g o t a ha rd c o p y A c o p y w as p re se nt ed t o m e W as in tr o d uc ed a t a w o rk sh o p N o ne o f ab o ve Health ministry officials 18% 50% 7% 4% 09% 12% 0% Health ministry national technical consultants 17% 53% 6% 1% 9% 14% 0% Members of medical professional colleges 18% 36% 3% 3% 12% 22% 6% Medical research community 32% 37% 0 0 0 25% 6% Members of non-medical professional colleges 0 100% 0 0 0 0 0 Education and finance ministry officials 0 100% 0 0 0 0 0 Members of civil society organizations 100% 0 0 0 0 0 0 The three Facebook uploads from the Sri Lanka country office had been seen by at least 10% of the respondents of the general public. Facebook uploads on antibiotic use (20%) and the web publication on the sustainable development goals (20%) had a better reach than the Facebook uploads on health diet (11%) and salt reduction (16%). This could have been due to recent interests on antibiotics and the publicity given to the SDG. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 75 TABLE 16: DESCRIPTION OF THE MODE OF REACH OF THE SELECTED FOUR WHO SRI LANKA COUNTRY OFFICE’S FACEBOOK UPLOADS TO THE GENERAL PUBLIC TABLE 17: DESCRIPTION OF THE MODE OF REACH OF THE SELECTED FOUR WHO SRI LANKA COUNTRY OFFICE’S FACEBOOK UPLOADS TO THE GENERAL PUBLIC Total Facebook Internet webpages WhatsApp/ Viber/ Imo Printed materials Other FB Publication 1: Salt: WHO recommends less than 5 grams per day. 62 36 (58%) 13 (21%) 1 (1%) 12 (20%) - FB Publication 2: WHO guideline on healthy diet 43 14 (33%) 8 (18%) 2 (5%) 17 (39%) 2 (5%) FB Publication 3: Antibiotics do not treat viral infections like colds and flu 74 39 (53%) 19 (26%) 1 (1%) 10 (13%) 5 (7%) FB Publication 4: Banner with UN’s 17 Sustainable Development Goals 75 28 (37%) 26 (35%) 3 (4%) 16 (21%) 2 (3%) Total It appeared on my Facebook wall I actively searched for related information on social media I actively searched for related information on internet None of above FB Publication 1: Salt: WHO recommends less than 5 grams per day. 62 50 15 22 13 FB Publication 2: WHO guideline on healthy diet 43 22 38 27 14 FB Publication 3: Antibiotics do not treat viral infections like colds and flu 74 34 6 42 18 FB Publication 4: Banner with UN’s 17 Sustainable Development Goals 75 31 8 32 28 Average 34 17 31 18 Over 50% Health Ministry officials and Health Ministry national technical consultants who had reached a WHO publication did so by actively searching for it online. It is of interest to note that most of the respondents revealed they accidentally came across the publication online. The rates of access on this publication have been recorded as; Health ministry officials – 18%, Health ministry national consultants – 17%, members of professional colleges – 18% and medical research community – 32%. Facebook was the most popular social media platform general public used to reach WHO social media uploads. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 76 Of the general public 20% had seen the WHO country office Facebook upload on antibiotic misuse (Table 14). Most of them have seen it because this upload was displayed on their Facebook wall This happens when a friend of the person likes or shares a face book entry. In the four medical related target audiences, over 90% of the respondents had read the WHO publications to increase their knowledge or to be used as a reference in their work. This indicates very good reach as well as the wide use of WHO publications. When the respondents were asked if they have seen any WHO publications other than the ones which were shown to them, members of professional colleges and Health Ministry national technical consultants offered a higher affirmative response of over 50%. TABLE 18: DESCRIPTION OF THE USE OF THE SELECTED WHO PUBLICATIONS BY THE TARGET AUDIENCES (PERCENTAGES ARE CALCULATED AS AN AVERAGE FOR ALL TWENTY PUBLICATIONS) I did not use this publication I read this to improve my knowledge I used this as a reference in my work Other Health ministry officials 7% 47% 45% 1% Health ministry national technical consultants 9% 41% 49% 1% Members of medical professional colleges 7% 48% 42% 3% Medical research community 6% 48% 46% 0 Members of non-medical professional colleges 0 40% 60% 0 Education and finance ministry officials 0 40% 60% 0 Members of civil society organizations 0 100% 0 0 Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 77 FIGURE 1. RESPONSE FROM MEDICAL RELATED TARGET AUDIENCES TO THE QUESTION “HAVE YOU SEEN OTHER WHO PUBLICATIONS THAN THE ONES SHOWN TO YOU?” An open ended follow up question asked was to name up to three titles or the areas of additional publications they have seen. There were up to 20 different answers provided by the respondents. Following were the three most common responses. (Refer Annex 17 for a complete list of responses.) 1. Step Survey 2. Non-Communicable Diseases 3. Cannot recall offhand Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 78 3.1.3. Bibliometric analysis Final output of the search on NCDs and health systems related disciplines were searched again in ‘Scopus’ database to look for citations under each item. References list of full text articles were manually checked for those not cited in Scopus World Health Organizational publications. Fact sheets, journal articles, web sites which were counted and cited items that had been published between 2013 to 2019 were selected for further review. Seventy eight citations were finally screened out from 83 citations provided in 177 journal articles related to NCD. (Complete list – Annex 18). Seventeen Citations appeared in 11 MD and MSc Theses. Some citations given in articles could not be traced, possibly due to faulty links. Some citations were incomplete and the original document could not be traced. (e.g.: WHO-Government of Sri Lanka study 2012). Less number of recent NCDs related WHO publications (2013–2019) cited in journal articles and postgraduate theses although there were many before 2012. Fact sheets, news item from WHO websites predominately cited and some are currently not accessible. Among the Publications, Global Status Report on NCD 2014, Global action plan for the prevention and control of NCDs 2013-2020, Non-Communicable Diseases country profiles 2014, and Non-Communicable Disease Risk Factor Survey Sri Lanka (STEPS REPORT), Ministry of Health Sri Lanka, WHO, 2015 were the highly cited NCD Reports. 3.1.4. Downloads from WHO website in Sri Lanka From the 160 top downloads in 2017 (Annex 19), the most downloaded publication was “Communicable disease epidemiological profile Sri Lanka” at 924 downloads. One of the NCD publications, “Global report on Diabetes” in the selected list of ten NCD publications of the present study came at third with 691 downloads. In 2018, while the “Global report on Diabetes” ranked second place with 872 downloads, “World health statistics 2018: monitoring health for the SDGs, sustainable development goals” came as sixth most downloaded with 463 downloads (Annex 20). In 2019, “World health statistics 2018: monitoring health for SDGs” climbed up to the second most downloaded WHO document form Sri Lanka with 696 downloads (Annex 21). Downloads from WHO website from Sri Lanka Total Number of publications from selected 10 NCD list Number of publications from selected 10 health systems list Top Downloads in 2017 160 3 0 Top Downloads in 2018 160 3 1 Top Downloads in 2019 160 5 1 TABLE 19: DESCRIPTION OF DOWNLOADS FROM WHO WEBSITE IN SRI LANKA IN 2017 – 2019 It appears that downloads in Sri Lanka from WHO website moving up every year. Prominence received by health systems related publications were also seen gaining upward trend. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 79 3.1.5. Social media engagement Out of the four social uploads the one on harmful effects of antibiotic use had the highest reach and also it showed the highest number of sharing in the Facebook. Section end summary box 1: How does WHO define its target audiences for different types of publications and different media of dissemination and the extent to which the intended reach is achieved. Likes Shares Comments FB Publication 1: Salt: WHO recommends less than 5 grams per day. Uploaded on 07 March 2019 5 2 0 FB Publication 2: WHO guideline on healthy diet Uploaded on 02 September 2019 4 3 0 FB Publication 3: Antibiotics do not treat viral infections, like colds and flu Uploaded on 12 November 2018 14 12 0 FB Publication 4: Banner with UN’s 17 Sustainable Development Goals - - - TABLE 20: ENGAGEMENT OF SOCIAL MEDIA UPLOADS AND WHO WEBSITE UPLOADS BY THE GENERAL PUBLIC In the WHO publication policy, the closest statement referring to target audiences is “Implementing the policy will ensure that WHO products are made available in formats and languages that are relevant to the needs of target audiences.” Ensuring of quality of the publication is vested with the technical officers and the director of the particular department. WHO reference materials on publications and publications policy deals mostly on administrative procedures related to content development, production, logistics, staff responsibilities and authorization process. References are also available for dissemination, archiving, evaluation, collaborations and external publications. Copyright, sale of publications and mechanisms for approvals also clearly stated. While most of the WHO publication staff are not involved in target group identification, they may play a role in the mode of dissemination. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 80 It appears that WHO has a well-organized method of identification of target audiences. The fact that there are five domains used for target audience identification in publication production is commendable. However, if a description of the target group is given in preface or introduction to the publication, it would be helpful in future impact evaluations. The extent of reach of WHO publications to Sri Lankan authorities appears to be moderate to low by the evidence in documents in policy, strategic plan and guidelines spheres. However, NCD publications showed a higher level reach of relevant WHO publications to Sri Lankan authorities. Reach of NCD WHO publications to the Health Ministry national level technical consultants appears to be average and the reach of health systems publications appears to be low. However when a publication is reached to them close to sixty prevent of them accessed the publication. Within the target audiences with a medical background, Health Ministry national technical consultants showed a higher reach of WHO publications, while medical research community showed a lower reach of WHO publications. However, the reach of WHO publications to non- medical fields appears to be very low. Over 50% Health Ministry officials and Health Ministry national technical consultants who had reached a WHO publication did so by actively searching for it online. Over 80% of the respondents accessed the WHO publications to be used in their reports / to improve their knowledge. Several selected NCDs and health systems publications evaluated appeared in the top 160 WHO publications downloaded from the WHO website in Sri Lanka. Over the years an increasing trend of WHO publications downloading is evident. Reach of WHO face book uploads to the Sri Lankan general public appears to be low. Social media engagement also appears to be poor. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 81 3.2. Does the mode of dissemination affect the reach and does WHO uses the correct mode of dissemination to effectively convey WHO information to different audiences. In the quantitative survey respondents were asked if the WHO publications were tagged “online only” would it improve or hinder the reach of the product to the intended users. The respondents were asked if there are specific type of publications which are more suitable for online only publication. The TABLE 22 below gives the analysis of the answers to that question. Improve Hinder Total No: % No: % Health ministry officials 33 (54%) 28 (46%) 61 Health ministry national technical consultants 11 (43%) 12 (57%) 23 Members of medical professional colleges 30 (39%) 46 (61%) 76 Medical research community 24 (35%) 45 (65%) 69 Members of non-medical professional colleges 5 (63%) 3 (37%) 8 Education and finance ministry officials 1 (25%) 3 (75%) 4 Members of civil society organizations 0 6 (100%) 6 Improve Hinder Total No: % No: % Health ministry officials 16 26% 45 74% 61 Health ministry national technical consultants 5 22% 18 78% 23 Members of medical professional colleges 37 49% 39 51% 76 Medical research community 19 28% 50 72% 69 Education and finance ministry officials 2 50% 2 50% 4 Members of non-medical professional colleges 4 50% 4 50% 8 Members of civil society organizations 0 0 6 100% 6 TABLE 21: RESPONSE TO “WILL THE ‘ONLINE ONLY’ IMPROVE OR HINDER THE REACH OF WHO PUBLICATIONS?” TABLE 22: ARE THERE ANY PARTICULAR TYPE OF PUBLICATION SUITED FOR ONLINE ONLY PUBLICATIONS? Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 82 Improve Hinder Total No: % No: % Health ministry officials 34 56% 27 44% 61 Health ministry national technical consultants 11 48% 12 52% 23 Members of medical professional colleges 51 67% 25 33% 76 Medical research community 32 46% 37 54% 69 Education and finance ministry officials 2 50% 2 50% 4 Members of non-medical professional colleges 4 50% 4 50% 8 Members of civil society organizations 0 0 6 100% 6 TABLE 23: ARE THERE ANY SPECIFIC TARGET AUDIENCES WHO ARE MORE SUITABLE FOR ONLINE ONLY PUBLICATIONS? In an open ended question which followed the above question they were asked to give examples. Following are the ten mostly given answers by the respondents. 1. Reports on evaluation (progress/ comparisons of countries), Reports that are targeted to the top level officials (national level). 2. Publications for professionals since they will actively search in the web for references and to update themselves 3. Short video vlog 4. If the Publication only benefit for top level administrators yes, otherwise if its concerns everyone web only publication is not suitable 5. Reports - weekly, monthly or annually. Other publications such as 5 year plans etc. should be provided both online and hard copies. Also the message of availability of such documents should be spread among relevant health staff. 6. Global observatories 7. Publications related to capacity building 8. Fact sheets 9. Bulky publications 10. Country profiles and monitoring reports Subsequent to the above question on “online only” availability of publications, the respondents were asked if there were any particular target groups that can be reached better with online only publications. In the next open ended question they were asked to name such target groups which they think who can be reached better through online only publications. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 83 While 56% of the Health Ministry officials and 67% members of medical professional colleges agreed that there are specific target audiences more amenable for online only publications, 52% Health Ministry national consultants and 54% medical research community disagreed. The respondents were asked to write down any suggestion they have to improve the mode of dissemination used by WHO to disseminate the publications giving space to provide three answers. Following were the most common responses received. A common response requested free access to the publications and WHO website. This indicates that the respondents were not aware that the publications are already freely available free of charge. (Full list of suggestions appears in Annex 22.) 1. Use email notifications to interested groups (PGIM, Ministry, Professional Colleges) 2. Provide regular notifications through Google play when new publications are released. 3. Provide hard copies to key personnel in the ministry of health and to relevant program managers. 4. Making a short summary available through email/ SMS / popups. Section end summary box 2: Does the mode of dissemination affect the reach and does WHO uses the correct mode of dissemination to effectively convey WHO information to different audiences. Over 50% Health Ministry officials and Health Ministry national technical consultants who had reached a WHO publication did so by actively searching for it online. It is of interest to note that over 36% of both these target audiences accidentally came across the publication online. Medical research community had reached the WHO publications by actively searching online (37%), accidentally online (32%) and being introduced to it at a workshop (24%). Health ministry officials (54%) responded that online only policy will improve the reach of WHO publications. The other health categories: health ministry national consultants (57%), members of medical professional colleges (61%)and medical research community (65%) responded otherwise, agreeing that online only will hinder the reach of WHO publications in Sri Lanka. When asked if there is a particular type of publication suited for online on publication, majority of the target groups with medical background responded negatively. Those who responded positively mentioned evaluation reports, reports which are targeted for higher level Health Ministry officials and periodicals suitable for online publication. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 84 When asked if there is any particular target group suitable for online only publications: Health ministry officials (56%), members of professional colleges (67%) agreed and Health Ministry national technical consultants (48%) and medical research community (46%) disagreed. Those who agreed that there are particular target groups, administrators, researchers and students were the three commonest answers. The three commonest answers given as suggestion for WHO to improve the dissemination of publications were: (1) targeted notification by emails on new releases, (2) web based updating through google scholar or google play and (3) provision of hard copies to key people and program managers in ministry of health. 3.3. How does WHO publications respond to global strategies that are applicable to countries and priorities that are based on needs assessment. 3.3.1. Desk review Three publications were selected and the following table shows the relevant sections of the findings related to two variables studied in each publication. Extend to which WHO publication responds to global strategies that are applicable to countries and priorities. Extent to which the WHO publications show evidence that the publications has been based on needs assessment. Regional Health Strategy for Universal Health Coverage, WHO 2015 3.3.1.1.1 3.3.1.1.2 Working towards achieving the sustainable development goals: a WHO toolkit 3.3.1.2.1 3.3.1.2.2 Global action plan on Physical Activity 2018–2030. 3.3.1.3.1 3.3.1.3.2 Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 85 3.3.1.1. First of the three case products studied exploring the extent to which WHO publications respond to global strategies and priorities and based on need assessment: Regional Health Strategy for Universal Health Coverage, WHO 2015 3.3.1.1.1. EXTENT TO WHICH THE WHO PUBLICATION “REGIONAL HEALTH STRATEGY FOR UNIVERSAL HEALTH COVERAGE, WHO 2015” RESPONDS TO GLOBAL STRATEGIES THAT ARE APPLICABLE TO COUNTRIES AND PRIORITIES Giving a broad overview of the justification for Primary Health Care strengthening in the member states, focusing on Universal Health Coverage (UHC), at the beginning of this publication makes the reader start with an overall idea of the objective of the document and its four strategies for UHC in the SEAR. Giving a common definition for Universal Health Coverage along with a practical framework for development of a UHC strategy are beneficial for all member states, in developing their own context specific strategies. The four strategies were clearly stated and explained, but unnecessary repetitions were seen over the same sections. All four strategies are globally accepted and regionally applicable. Although at the beginning the document it was stated that relevant country specific examples are given in the respective sections, it had not been consistently provided throughout the document. Under strategic direction 1, the document gives Nepal and Thailand as examples. Absence of how Thailand has achieved a more comprehensive service package had not been described, nor had any reference been given (page 10). This restricts the usefulness of the description due to its inconclusive nature. Explanation of how Thailand achieved this status, the strengths, barriers and best practices would have been more useful for the reader. Similarly, achievement of significant progress in UHC in five member states of SEAR have been mentioned, without any description of the achievements made or references. Moreover, the next paragraph (page 10) mentions UHC is an ‘aspiration’, and not achieved in entirety other than in Nordic region, while mentioning Thailand and Costa Rica on making significant coverage with economic constraints. Then it is important to know how Nordic region achieved that aspiration, as well as how Thailand and Costa Rica have achieved this within low cost and economic constraints. Figure 2 illustrates a conceptual framework for strengthening of PHC services. However, it is a complex framework, which needs explanation. Only the WHO, services covered and the cost of services covered are explained. The diagram of Primary Health Care reforms needs simplification, for it to be useful. The recommendation of pragmatic way forward being phased approach or ‘phasing-in’ to be incorporated by the low-income settings is mentioned in one sentence. It is important to mention Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 86 what is meant by phasing in, it’s processes and how it can be incorporated into the different member states, in the context of respective countries. Examples of what phased approach is or what specific countries can use this have not been mentioned, which are necessary consider the publication as useful. Strategic direction 2 – achieving financial equity Out of pocket expenditure has been identified as one of the key drivers related to health inequities and recommends the member countries to maintain it at less than 5% or 1/3 of total health expenditure, without stating root causes for OOP in the mentioned countries. However, it is useful that the social protection mechanisms such as shifting to mandatory pre-payment, consolidated pooling and examples (Revenue collection, pooling, purchasing) for healthcare financing options have been stated. Figure 8 illustrates the stages of social protection in UHC. Sri Lanka has been stated as an example for significant progress of social protection. However, in the reference provided Withanachchi and Uchida, (2006) states that this is ineffectively done. One reference document will not be adequate to give such a conclusion of a country, which reflects the superficial nature of this analysis. Hence, highlighting three countries Ghana, Sri Lanka and Costa Rica as examples for significant progress on social protection based on just three references would not provide valid information. However, in the text, the examples of Bangladesh and India allow reader to get a description of the concept. Box 2 also provides useful examples of domestic financing options from international experiences even though not many regional examples are stated. However, their applicability to the Member States of WHO Regional Office for South-East Asia have not been analysed based on the needs of the SEAR countries. Mentioning pooling for a common health fund is a beneficial recommendation. It would have been better if this was supported with examples. The linking of strategy 2 and 3 have been very well done. Strategic Direction 3 The purpose of more money for health was dealt in strategy 2, while strategy 3 covers more health for money. In the key messages box, four broad areas of system inefficiencies: expenditure on medicines, decentralized service delivery organization strengthening of regulation and overall systems governance alternative provider payment methods. There are two controversial points in this. Firstly, the alternative provider payment method description gives the meaning that it has been effectively used in to correct the health systems incentive structure. Though this has been effectively used, why it is considered a system inefficiency has not been addressed. Secondly, the organization of decentralized service delivery particularly procurement of medicines has been discouraged. However, to address the issue of moving away from reducing out of pocket expenditure on medicines based on area specific needs; this needs to operate at the decentralized area, rather than depending on the central drug supplies. However, the descriptions under the strategic direction 3 are more detailed than the sections. Particularly the Box 3: the top 10 causes of systems inefficiencies from international perspective provides a summary of various issues faced by different countries. However, if the font size was larger Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 87 and elaboration of summated facts were provided it would have been more useful for the member states to understand more clearly the root causes of the issues. Under the section on ‘market entry’ of providers, institutions and insurers, a general statement of several countries of the region lacking appropriate licensing procedures for both providers and institutions had been made. However, it would have been more useful if country specific information is given following a situational analysis or scoping evidence from the specific countries. Overall the descriptions are more generalized global strategies rather than addressing country specific needs. Strategic Direction 4 In the introduction of this section, three best practice elements have been mentioned, without any global or SEAR evidence. Similarly, this same issue is seen also in the section on findings from SEAR on NHPSP best practice elements: sound process, realistic and comprehensive, balanced and coherent content. Rather than providing general theoretical concepts it’s useful to describe the examples with evidence. Though protecting patient safety is not one of the most priority issues amongst others in SEAR countries, patient safety is a global UHC strategy. This has not been addressed in this publication, though there are unpublished information on violence towards patients exist in the SEAR countries. 3.3.1.1.2. EXTENT TO WHICH THE WHO PUBLICATION “REGIONAL HEALTH STRATEGY FOR UNIVERSAL HEALTH COVERAGE, WHO 2015”, SHOWS EVIDENCE THAT THE PUBLICATION HAS BEEN BASED ON NEEDS ASSESSMENT In general, the whole publication gives an overall general overview of strategic directions, instead of providing recommendations based on the SEAR member states specific needs. Strategy 2 Box 2 also provide useful examples of domestic financing options from international experiences even though not many regional examples are stated. However, their applicability to the SEAR member states have not been analysed based on the needs of the SEAR countries. It would have been beneficial, if the document contained information on applicability of the theoretical concepts given, for the different member states of the SEAR region, based on the situation in different countries of the region. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 88 3.3.1.2. Second of the three case products studied exploring the extent to which WHO publications respond to global strategies and priorities and based on need assessment: Working towards achieving the sustainable development goals: a WHO toolkit 3.3.1.2.1. EXTENT TO WHICH THE WHO PUBLICATION “WORKING TOWARDS ACHIEVING THE SUSTAINABLE DEVELOPMENT GOALS: A WHO TOOLKIT” RESPONDS TO GLOBAL STRATEGIES THAT ARE APPLICABLE TO COUNTRIES AND PRIORITIES This WHO publication aims at helping countries to achieve the sustainable development goals by 2030. It has identified six main action lines of activities, with identified different tools and resources for the countries to use in achievement of these. For each action line different resources have been listed in six Annexures, with specific sectors and relevant URL’s to refer specific information. It is a tedious process to go through the lists of Annexures for the six different action lines. Whether those address the different country needs is questionable. Whether these have been developed for and addressed the country needs were also not clear. Action line 1: Intersectoral action by multiple stakeholders for synergy between interconnected systems. A major challenge faced by healthcare managers in this to implement health programs through other relevant sectors has long been, leveraging connections between sectors for improving health outcomes. Hence, it is a global need for healthcare planners and managers to develop necessary skills and tools to advocate the other sectors for intersectoral collaborative work. Therefore, the stated two tools for intersectoral action are useful resources for all countries in achieving Sustainable Development Goals. a. Health in all policies: The training manual on health in all policies, addresses the negotiation strategies, and other advocacy skills b. Progressing the Sustainable Development Goals through health in all policies: case studies from around the world document provide examples for the countries to use. However, it would have been beneficial if at least an outline of the salient points of each were described even in a text box in this book. These provide information in general for all countries rather than addressing country specific contexts or issues. Action line 2: Strengthening health systems for universal health coverage The meaning of strengthening health systems include, coordinated effort to improve access to high- quality health services, medicines, technologies, sustainable financing and health system governance. In this section a brief description of the main two publications: Health Systems for Universal health coverage- a joint vision for healthy lives and strategizing national health in the twenty first century: a Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 89 handbook was given. It provides an overview for the reader to decide on using the publication. There was no evidence to suggest it has been developed based on the global and regional contexts but addressing the theme SDGs. Action line 3: Respect for Equity and Human Rights With the learned experience of millions being left out, following implementation of Millennium Development Goals, maintaining equity in obtaining health outcomes has been identified as an important area. ‘Innov8’: technical handbook is the example given in the text. The text mentions that the ‘Innov8’ is an eight-step process to identify health inequities in subpopulations. Also, the text identifies Health Equity Assessment Toolkit as another tool which can be used along with ‘Innov8’. The text mentions the key areas dealt in these two documents, which motivates the countries to use and helps the reader to decide on what parts are important for the use. Action Line 4: Sustainable Financing In moving towards sustainable development goals, the ability of a country to deliver universal health coverage depends on the domestic public funding. Even though the text mentions that WHO provides a robust set of health financing tools, only the e-learning course on health financing policy for Universal Health coverage has been mentioned in the text of the document. Action Line 5: Scientific Research and Innovation Action Line 6: Monitoring and Evaluation In both these areas also, only a brief introduction to one resource material has been given in addition to the lengthy Annexures 5 and 6. 3.3.1.2.2. EXTENT TO WHICH THE WHO PUBLICATION “WORKING TOWARDS ACHIEVING THE SUSTAINABLE DEVELOPMENT GOALS: A WHO TOOLKIT”, SHOWS EVIDENCE THAT THE PUBLICATION HAS BEEN BASED ON NEEDS ASSESSMENT There is no country specific information provided, hence no indication of any country specific needs assessment in the development of this publication has been carried out or not. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 90 3.3.1.3. Third of the three case products studied exploring the extent to which WHO publications respond to global strategies and priorities and based on need assessment: Global action plan on Physical Activity 2018 – 2030 3.3.1.3.1. EXTENT TO WHICH THE WHO PUBLICATION “GLOBAL ACTION PLAN ON PHYSICAL ACTIVITY 2018 – 2030”, RESPONDS TO GLOBAL STRATEGIES THAT ARE APPLICABLE TO COUNTRIES AND PRIORITIES In the development of this Global action plan, a worldwide consultation process followed by six regional consultation processes and guidance from a multisectoral and multidisciplinary global expert advisory committee, indicating that the document responds to the global strategies. Further, author states the four strategic objectives and the 20 policy actions were based on the global evidence base on the physical inactivity. Also, the global target on physical activity increment has been set according to relevant data from the “WHO country comparable estimates on physical inactivity, 2016”, publication. Cost effectiveness of the interventions had been made but the reference not given to assess the sources of evidence. The actions suggested have been developed using evidence from all the regions, hence decision on having the four selected objectives of creating active societies, active environments, active people and active systems have been based on the evidence generated. However, specific needs assessment information is not found in the document. The 20 policy actions are stated in general, for the different countries to tailor-made according to the country specific needs assessment. This indicates that the publication does not specifically address the needs of countries according to its principal of the proportional universality, but rather describing general strategies for increase of physical activity in the countries. 3.3.1.3.2. EXTENT TO WHICH THE WHO PUBLICATION “GLOBAL ACTION PLAN ON PHYSICAL ACTIVITY 2018 – 2030”, SHOWS EVIDENCE THAT THE PUBLICATION HAS BEEN BASED ON NEEDS ASSESSMENT In the page 7, it is stated that in some countries levels of inactivity can be as high as 70%. However, there is no reference or evidence of what those countries are. In implementation of the systems approach to policy actions the publication advices the countries assess their own current situation to identify existing policy which can be strengthened, as well as policy opportunities and gaps. Hence emphasizes the need for country specific implementation, based on proportional universality pondering greatest focus towards least active populations. Author describes an extensive sequence of how the publication was developed incorporating wide assessment of every region of the world including a 7 week open public consultation in the preparation of this document. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 91 In addition, all the relevant sectors such as health, education, sports, transport and planning of the 83 members states have been consulted during the regional and member state consultations, indicating extensive needs and situational assessments have been done prior to the development of the publication. 3.3.2. Findings on qualitative survey among key WHO publication staff involved in the production of WHO publications, both from a strategic, process and content point of view WHO staff were asked several questions in the survey on their opinion about WHO publications responding to global strategies and priorities. Survey Questions Survey questions (Qualitative) Answered Not answered Briefly describe your views on the extent to which WHO publications respond to global strategies and priorities. 3 0 Briefly describe your views on whether WHO publications are based on the needs of the countries. 3 0 Summary findings The extent to which WHO publications respond to global strategies and priorities.  WHO publications are guided by o timely and topical • Normative guidelines and norms • Global and regional strategies o Respond to imminent and emergent health situations o Respond to recommendations made at regional committees.  Most of WHO publications are written for academics. o Long reports are good for those who (Masters/PhD level) want to understand all aspects. o Health policy makers need concise briefing papers. o Concise instructions how to implement basic health services. o Average implementer needs the “how to version” of the publication TABLE 24: NUMBER OF WHO PUBLICATION STAFF WHO RESPONDED TO THE QUESTIONS RELATED TO GLOBAL STRATEGIES AND PRIORITIES TABLE 25: RESPONSES BY WHO PUBLICATION STAFF AT WHO/ HQ AND SEARO ON ABOVE TWO VARIABLES A summary of findings is presented in the TABLE 25 below. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 92 3.3.3. Case product study Two WHO publications were selected for this case product study. • Global strategy on human resources for health: workforce 2030 • A practice guide to effective population-based food policy actions to promote healthy diets. 3.3.3.1. First of the two case products studied exploring the extent to which WHO publications respond to global strategies and priorities: Global strategy on human resources for health: workforce 2030 This publication is presented in four main sections based on four main objectives. Objective 1: To optimize performance, quality and impact of the health workforce through evidence informed policies on human resources for health, contributing to healthy lives and well-being, effective universal health coverage, resilience and strengthened health systems at all levels. Findings: This objective addresses best possible use of available resources. While taking the best use of available resources, an effort has been made to address population needs for SDGs. The document highlighted effective and efficient use of resources to ensure availability and coverage. Implementation of HRH plan is a part of long-term national health and broader development strategies. This ensures the sustainability of HRH developments. Universal access to health care and people-centred integrated service delivery is supported by effective referral to secondary and specialized care. Public and private sector investments in health personnel education will be linked with population needs and health system demands. Education strategies are focused for investment in trainers for a high social rate of return. Along with this cost effectiveness motivation, satisfaction of health workers will be optimised for a better performance. Information and Communication Technology (ICT) will be used as a cost-effective measure. Training schools will be accredited, and Governments will collaborate with professional councils and other regulatory authorities to regulate the process of human resource development. Attention will be made to promote gender sensitive working environment. Are WHO publications based on the needs of the countries?  Yes, most of the time. o Sometimes regional and global strategies, action plans, response mechanisms may overlap. o Greater oversight at all 3 levels (Global/ regional/country) is required.  There is a demand from health professionals’ underserved areas for basic primary health texts. o WHO produces little in this area. o There is no suitable alternative product in the market. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 93 Conclusion: This section of the document explains activities to be done when there are good health systems in a country. But when health systems are collapsed or no proper health systems, it will be a difficult task to develop health resources. This document has explained extensively on how to achieve the above objective covering global priorities such as universal health coverage and sustainable development goals. In view of SDG era it can be stated that this chapter is in line with global strategies and priorities. Objective 2: To align investment in human resources for health with the current and future needs of the population and of health systems, taking account of labour market dynamics and education policies; to address shortages and improve distribution of health workers, so as to enable maximum improvements in health outcomes, social welfare, employment creation and economic growth. Findings: Future global health workforce requirement has been forecasted for next decades considering the demographic and epidemiologic transitions. Shortage and inequitable distribution are identified as major issues. Involvement of public sector for HRH and building planning capacity to develop or improve HRH policy and strategies were among important suggestions. Collaboration with non-health sectors for HRH development facilitated by health sector maintaining rights of male and female workers with provision of working environments were also highlighted. Some suggestions have been made for some countries only. Invest in the education and training, recruitment, deployment and retention of health workers, re-skilling workers from declining sectors and industries, increase investments to boost market-based demand and supply of the health workforce mobilize resources for HRH from both traditional and innovative sources including general budget, progressive taxation, social health insurance, dedicated earmarked funds were recommended for some countries. Telemedicine was recommended for small countries. As the final suggestion for this objective request had been made for international partners to invest on HRH. Conclusion: This section has focused well on some SDGs such as gender equality and partnerships for goals. Some recommendations were given for all countries and others for some countries depending on the context. But this ambiguity might affect negatively when it comes to choose activities for a country. Selection may solely depend on feasibility rather than other important factors. However, this objective and given activities have focused well on global priorities. Objective 3: To build the capacity of institutions at sub-national, national, regional and global levels for effective public policy stewardship, leadership and governance of actions on human resources for health. Findings: Importance of technical and management capacities to advocate political will and decisions for implementation have been discussed. This is supported by global governance mechanisms to implement national HRH agendas. Recommendations have given for all countries to have HRH units Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 94 within the Ministry of Health and strengthen technical and management capacity. The document has mentioned importance of national mechanism for HRH governance and investment in HRH for SDGs, UHC and universal access to healthcare. Align incentives for health workforce education and health-care provision and strengthen the institutional environment for health workforce education, deployment, retention and performance management were recommended for some countries. WHO will provide technical support and training for member countries. Conclusions: Some activities and areas for improvement have been mentioned under objective three. There are many repetitions found under objectives such as descriptions on gender and intersectoral coordination. Some of the areas described are complicated and may find difficult for some countries to initiate. It is noteworthy that the objective sheds importance on subnational level in addition to national HRH plans. Sri Lanka, despite health achievements have maldistribution of HRH resources within the country and regionally. This objective therefore should be considered as an important global strategy and a global priority. This objective sets the agenda for a very much needed strategy which should be a priority for all countries: establishing HRH units in the ministries of health. Even for a country like Sri Lanka which has achieved a lot it is only during last five years the importance of this strategy being formalized. Sri Lanka will soon establish a HRH unit in the ministry of health. Objective 4: To strengthen data on human resources for health, for monitoring and ensuring accountability for the implementation of national and regional strategies, and the Global Strategy. Findings: HRH data is critical enabler to enhance advocacy, planning, policy-making, governance and accountability at national, regional and global levels. This reliable workforce information is a must to project future workforce requirements. It is recommended to include workforce characteristics; remuneration, worker competency, performance, absence, labour dynamics, attacks against health workers and performance of HRH management system itself. Proactive use of workforce data for international public policies and programmes linked to health targets of SDGs have mentioned in the document. This strategy includes an accountability framework to assess progress on its recommendations. Global monitoring of this strategy will be linked with accountability framework of the SDGs. Invest in analytical capacity of countries for HRH and health system data using technological advances such as internet. Establish national health workforce registries of the competent and practising workforce and using collected data for local decision making and emergencies and disasters have recommended. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 95 Conclusion: Collection of workforce data is used for policy development and these policies are targeted to achieve SDGs. Proactive use of collected data will benefit to forecast workforce gaps and requirements for the future. Management information services should definitely adopt HRH data as a priority. It is a good move to set HRH data as a global strategy and a global priority. Overall conclusion: Although this publication, ‘Global strategy on human resources for health: workforce 2030’, is a strategic plan, it has managed to stick to a global theme because of the alignment with SDG. The whole publication can be considered as responding to global strategies and priorities at a very high level of intensity. The publication provides a blueprint example for being based on needs assessment. All stakeholder and member countries have contributed over three years of publication development phase. Rigorous planning and extracting contribution of all stakeholders and member states also has taken place. Extensive forward motion discussions and retrospective consultations with all stakeholders have contributed to the universal applicability of the publication. 3.3.3.2. Second of the two case products studied exploring the extent to which WHO publications respond to global strategies and priorities: A practice guide to effective population-based food policy actions to promote healthy diets Findings: This document gives an overview of healthy diets, need of diet related data, classifying food as healthy or unhealthy, policy process and five main regulatory policy options to effect population-based food policy actions. It is advised to have combination of approaches tailored to the local context rather than a single approach. The document highlighted the importance of having local data to plan activities for a country to promote healthy diet. It has been suggested to update food composition tables and expand to include nutrient composition of ultra-processed foods and beverages. This document further describes changing dietary habits due to globalization of food systems and resulting Non-Communicable Diseases and rise in overweight and obesity. Prevention of obesity is supported by having an environment conducive for a healthy diet. Therefore, this document has proposed population-based actions including regulatory measures, to improve the food environment. Herein, five main regulatory policy options have been proposed. 1. Nutrition labelling of pre-packaged foods: Nutrient declaration and providing supplementary nutrition information is intended to support consumers to make a healthy food choice. This is further supported by front-of-pack labelling and inserting nutrient content and health claims in the label. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 96 2. Implementing the set of recommendations on marketing of food and non-alcoholic beverages to children: This document has quoted12 recommendations made by the Sixty-third World Health Assembly in year 2010. 3. Product reformulation: This is described as change of the composition of processed foods to obtain a healthier product. 4. Fiscal policies to promote healthy food consumption: Taxes are to be raised for less healthy foods to reinforce healthy food choices. 5. Food provision and access; improving quality of food served in institutions: Creating a healthy dietary environment in schools and workplaces will direct consumers for healthy food choices. Monitoring and evaluation of above policy options must be an integral part of the process. Conclusion: This document has mainly focused on five regulatory policy options. All these five options have targeted to make the environment more supportive to make healthy food choices and enactment of laws to control availability of less healthy foods. They are global strategies use to reduce obesity and NCDs. The document promotes consumption of natural foods rather than processed foods. Reformulation is enforced to change some healthy food to more appealing for consumption. When increasing trends of NCDs are considered, it can be accepted this publication is addressing a global priority focused on NCDs. The publication also addresses the health promotion principle of providing conducive environment. However, the world as it is now, increasingly facing challenges in food security and food safety. While the publication is discussing food based policy, mostly when the food security and food safely is achieved, it has failed to address the global priority of food safety and food security. The value of population approaches on nutrition related interventions are not global strategies or global priorities. These interventions while have failed to demonstrate effective outcomes and return on investment are popular due to individual success stories from prescribed demarcated geographical interventions which addressed a specific local nutritional deficiency. Outcomes of fiscal policies on nutrition or outcomes of labelling interventions have not demonstrated success addressing global priorities in nutrition nor made the base of strategies of improving nutritional status at global level. Overall this publication has failed to address global priorities and strategies other than its relevance to NCD prevention and control. The publication does not show evidence of being based on stakeholder contributions. The publication also has failed to demonstrate need assessments at country level or stakeholder level which formed the base of the publication. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 97 Section end summary box 3: How do WHO publications respond to global strategies that are applicable to countries and priorities that are based on a needs assessment? Desk review: Publication 1: Regional Health Strategy for Universal Health Coverage, WHO 2015 Giving a common definition for Universal Health Coverage along with a practical framework for development of a UHC strategy is beneficial for all member states, in developing their own context specific strategies. It is important to mention how the strategies can be incorporated in the different member states, based on the contexts of the respective countries. All four strategies given are globally accepted and regionally applicable. However, though at the beginning the document states that relevant country specific examples are given in the respective sections, this was not present throughout. In general, the whole publication gives an overall general overview of strategic directions, instead of providing recommendations based on the SEAR member states specific needs. Publication 2: Working towards achieving the SDGs: A WHO toolkit. Information provided is general for all countries rather than addressing country specific contexts or issues. Six different action lines are given in Annexures. Whether those address the different country needs is questionable. If these have been developed and addressed the country needs is not clear. In the absence of country specific information, there is no indication of carrying out any country specific needs assessment in the development of this publication. Publication 3: Global action plan on Physical Activity 2018 – 2030 In the development of this Global action plan, a worldwide consultation process followed by six regional consultation processes and guidance from a multisectoral and multidisciplinary global expert advisory committee, indicating that the document responds to the global strategies. An extensive sequence of publication development incorporating wide assessment of every region of the world including a 7 week open public consultation in the preparation of this document is available. Case product study 1: Global strategy on human resources for health: workforce 2030 This publication has managed to stick to a global theme because of the alignment with SDG. The whole publication can be considered as responding to global strategies and priorities at a very high intensity. This publication provides a blueprint example for being based on needs assessment. All stakeholder and member countries have contributed over three years of publication development phase. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 98 Case product study 2: A practice guide to effective population-based food policy actions to promote healthy diets Overall this publication has failed to address global priorities and strategies other than its relevance to NCD prevention and control. The publication does not show evidence of being based on stakeholder contributions. It also has failed to demonstrate need assessments at country level or stakeholder level which formed the base of the publication. 3.4. The extend which WHO publications respond to and meet the priority information needs of their intended audiences and whether the format and language affect their perception of usefulness. 3.4.1. The extent the WHO publications responds and meet the priority information needs of their intended audiences. In the quantitative survey the respondents were asked of their opinion, the extent to which the WHO publications respond to and meet the priority information needs of their intended target audiences. Three options were available for them to indicate their response: (1) Very well met (2) somewhat met (3) not met. While only a few respondents selected “not met” overwhelming majority agreed with “somewhat met” and “very well met”. Very well met Somewhat met Not met Total Number No: % No: % No: % Health ministry officials 20 33% 38 62% 3 5% 61 Health ministry national technical consultants 6 26% 17 74% 0 0% 23 Members of medical professional colleges 23 30% 48 63% 5 7% 76 Medical research community 11 16% 51 74% 7 10% 69 Education and finance ministry officials 2 50% 2 50% 0 0 4 Members of non-medical professional colleges 4 50% 4 50% 0 0 8 Members of civil society organizations 6 100% 0 0 0 0 6 TABLE 26: DESCRIPTION OF RESPONSES IF WHO PUBLICATIONS RESPONDS AND MEET THE INTENDED AUDIENCES’ PRIORITY INFORMATION NEEDS Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 99 3.4.2. The extent which the format and the language of WHO publications affect the intended target audience perception of usefulness of the WHO publications. The format of WHO publications (style of presentation, images, attractiveness readability etc.) was subjected to evaluation by the respondents of the quantitative survey. Their opinion in general about the WHO publications format was inquired and the following three answer options were given: “very reader friendly”, “somewhat reader friendly” and “not reader friendly”. Very reader friendly Somewhat reader friendly Not reader friendly Total No: % No: % No: % Number Health ministry officials 29 48% 30 49% 2 3% 61 Health ministry national technical consultants 10 43% 12 52% 1 4% 23 Members of medical professional colleges 34 45% 41 54% 0 0% 75 Medical research community 18 26% 45 65% 4 6% 67 Education and finance ministry officials 2 25% 6 75% 0 0% 8 Members of non-medical professional colleges 1 25% 3 75% 0 0 4 Members of civil society organizations 6 100% 0 0 0 0 6 TABLE 27: TARGET AUDIENCES PERCEPTION OF USER FRIENDLINESS OF WHO PUBLICATIONS Over 95% of the medical target audiences responded that WHO publications are reader friendly. On the language used in WHO publications, two more enquiries were made in the quantitative survey. To the question “Do you think the language of WHO publications being only in English affected the usefulness of the product in Sri Lanka?” majority answered in disagreement. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 100 Only less than 40% of the respondents of Health Ministry officials and Health Ministry national technical consultants agreed that WHO publications being in English only affects the usefulness of them in Sri Lanka. They were also asked if the language used in WHO publications were too technical. For this question the majority expressed disagreement. Over 80% respondents in Health Ministry officials, Health Ministry national technical consultants and members of medical professional colleges did not agree that English used in WHO publications are too technical. Out of the responded from non-medical target groups, 50% thought that WHO publications are too technical for their users. Yes No Do not know Total Number No: % No: % No: % Health ministry officials 23 39% 26 44% 10 17% 59 Health ministry national technical consultants 9 39% 8 35% 6 26% 23 Members of medical professional colleges 41 55% 26 35% 7 9% 74 Medical research community 26 38% 31 45% 12 17% 69 Education and finance ministry officials 4 100% 0 0 0 0 4 Members of non-medical professional colleges 7 88% 0 0 1 12% 8 Members of civil society organizations 3 50% 0 0 3 50% 6 Yes No Do not know Total Number No: % No: % No: % Health ministry officials 5 8% 48 81% 6 10% 59 Health ministry national technical consultants 2 9% 19 83% 2 9% 23 Members of medical professional colleges 11 15% 59 80% 4 5% 74 Medical research community 18 26% 32 46% 19 28% 69 Education and finance ministry officials 1 50% 1 50% 0 0 2 Members of non-medical professional colleges 2 25% 2 25% 4 50% 8 Members of civil society organizations 3 50% 3 50% 0 0 6 TABLE 28: RESPONSES TO THE QUESTION “DOES WHO PUBLICATIONS BEING IN ENGLISH ONLY AFFECTS THE USEFULNESS IN SRI LANKA?” TABLE 29: RESPONSES TO THE QUESTION “IS THE LANGUAGE USED IN WHO PUBLICATIONS IS TOO TECHNICAL?” Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 101 Section end summary box 4: The extend which WHO publications respond to and meet the priority information needs of their intended audiences and whether the format and language affect their perception of usefulness Overwhelming majority of over 90% of medical related target groups responded that WHO publications respond to and meet the priority information needs. Over 95% of the medical target audiences responded that WHO publications are reader friendly. Only less than 40% of the respondents of Health Ministry officials and Health Ministry national technical consultants agreed that WHO publications being in English only affects the usefulness of them in Sri Lanka. Over 80% respondents in Health Ministry officials, Health Ministry national technical consultants and members of medical professional colleges did not agree that English used in WHO publications are too technical. 3.5. The perceived influence and impact of WHO publications on the formulation of national policies and strategies and healthcare practices as well as the perceived comparative advantage of WHO publications in relation to the ones by other stakeholders. 3.5.1. Perceived influence and impact of WHO publications on the formulation of national health policies and strategies and healthcare practices. Six Sri Lankan Health Ministry documents from policy, strategic/ action plans and guidelines were evaluated for perceived influence and impact of WHO publications. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 102 Type of document Very reader friendly Total Policy document National policy and strategic framework for cancer prevention and control 3.5.1.1 National policy on health care quality and safety 3.5.1.2 Strategic plan / Action plan National health strategic plan for preventive sector 2016 – 2025. 3.5.1.3 National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020. 3.5.1.4 Health ministry officials Health ministry national technical consultants Screening Guidelines Chronic Kidney Disease Sri Lanka 2017 3.5.1.5 Pain Management Guideline for Adults with Cancer 2017 3.5.1.6 TABLE 30: SELECTED SRI LANKAN DOCUMENTS AND THE SECTIONS WITH THE DESCRIPTIONS 3.5.1.1. First of the two Sri Lankan policy documents reviewed for evidence of perceived influence and impact of WHO publications on the formulation of national health policies and strategies and health practices: “National policy and strategic framework for cancer prevention and control” The Sri Lankan policy document ‘National policy and strategic framework for cancer prevention and control was reviewed to describe the perceived influence and impact of WHO publications on the formulation of national health policies and strategies and healthcare practices. Due to the unavailability of a list of references in the Sri Lankan document, relevant WHO publications were studied to achieve the objective. Thus, examined WHO publications include ‘National Cancer Control Programmes. Policies and managerial guidelines’ and the six modules on the WHO publication series ‘Cancer Control. Knowledge into Action’. Publications by IARC (International Agency for Research in Cancer) also were considered in the analysis. In the absence of a reference list in the Sri Lankan document under review, ‘National policy and strategic framework for cancer prevention and control’, it was compared with the above- mentioned WHO publications for the similarities in the technical content to identify the perceived influence and impact of WHO publications. Findings: The National policy and strategic framework for cancer prevention and control in Sri Lanka – 2014, clearly stipulates policy objectives and strategies to achieve said policy objectives to control and prevent cancer in Sri Lanka. Among many publications by the WHO, ‘Cancer control: knowledge into action series’ could be viewed as the most applicable WHO publication for this policy document. There are six modules in this series, namely Planning, Prevention, Control, Diagnosis and Treatment, Palliative care and Policy and Advocacy. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 103 Even though evidence of clear influence by the WHO publications on these objectives and strategies could not be established as references for any of the strategies mentioned in the policy document is not been stated, it is highly possible that the ‘Knowledge into action’ series was influential. Interpretations of the eight basic principles of cancer control mentioned in the WHO series could be seen throughout in this Sri Lankan policy document. For example, under the key principle one ‘Leadership’, continuous learning has been interpreted in the policy document as ‘To promote professional education of doctors, nurses, technicians and health workers to augment trained human resources (policy objective 6) and promote research and utilization of its findings for prevention and control of cancers (policy objective 7). In addition, strategy 4 for the policy objective 1, collaborating with other health-related sectors with regard to primary prevention of other environmental and occupational risk factors, strategy 4 for the policy objective 2, building public/ private partnership with private health sector for screening and early diagnosis of cancer and strategy 8 for the policy objective 3, building partnership with private health sector for provision of quality care for cancer patients and strategy 2 for policy objective 5, facilitating inter-sectoral coordination in surveillance of cancers could be shown as examples for integrating key principle 2, involvement of all stakeholders, and key principle 3, creation of partnerships, mentioned in the WHO knowledge into action series. Basic principle 4 in the WHO series of responding to the needs of people is reflected in the policy objective 3 spelled out as ‘ensure equitable and continuous accessibility to diagnosis and treatment facilities for cancers’. Core features discussed in the basic principle 5 in the WHO series of decision making has been incorporated in the policy objective 2, strategy 1 as strengthening evidence-based feasible and cost- effective screening service provision. Influence of the sixth basic principle of application of a systemic approach to share the goals with other related programmes and the health systems could be seen in the policy objective 1 strategy 1, where it is mentioned ‘strengthen health promotion in the community in tune with the National Health Promotion policy and National Non-Communicable Diseases prevention policy’. The seventh basic principle in the WHO series of seeking continuous improvement has been taken up at policy objective 3, strategy 1 as provision of resources for diagnosis of cancer in secondary and tertiary levels of care, strategy 5 as to expand radiotherapy facilities and strategy 6 as to improve paediatric oncology services. The policy objective 4 is on expanding rehabilitation, survivorship care and palliative care facilities for cancer patients, which also has the influence of the basic principle 7 of the WHO series. Strategy 3 of policy objective 5, to improve and strengthen medical records services and also to develop the population-based cancer registry in Colombo district, and introducing hospital- based cancer registries and routine coding of cancers internationally accepted coding systems under the policy objective 5 are examples for the influence of the WHO basic principle 7 on this policy document. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 104 The final basic principle, adoption of a step-wise approach to plan and implement interventions could be seen in policy objectives 2, 3 and 4, where establishing and expansion of screening, treatment and palliative services are discussed. Conclusion: It could be concluded that the Sri Lankan policy document under review, ‘National policy and strategic framework for cancer prevention and control was clearly influenced by the most applicable WHO publications and the impact of the WHO publication of knowledge into action series on this policy document was significant. However, lack of references or bibliography in the document caused a serious limitation in carrying out the desk review. 3.5.1.2. Second of the two Sri Lankan policy documents reviewed for evidence of perceived influence and impact of WHO publications on the formulation of national health policies and strategies and health practices: “National policy on health care quality and safety” The Sri Lankan policy document ‘National policy on health care quality and safety’ (2015) was reviewed to describe the perceived influence and impact of WHO publications on the formulation of national health policies and strategies and healthcare practices of relevant WHO publications. Since the Sri Lankan document did not have a list of references, most relevant WHO publications were searched to assess their reach. As a result, ‘A background for national quality policies in health systems’, ‘World alliance for patient safety, forward programme 2008 – 2009’ and ‘Regional strategy for patient safety in the WHO South-East Asia Region (2016 – 2025)’ were selected. The selected WHO publications were compared with the Sri Lankan document under review, ‘National policy on health care quality and safety’ (2015) to assess whether the core contents and/or key messages in WHO publications were reflected to assess the influence and impact on the Sri Lankan document. ‘A background for national quality policies in health systems’ and ‘World alliance for patient safety, forward programme 2008 – 2009’ were reviewed. The most applicable publication, ‘Regional strategy for patient safety in the WHO South-East Asia Region (2016-2025)’ was disregarded as its year of publication was the same as the Sri Lankan document under review. Findings: Most of the technical content discussed in the WHO publications were mentioned in the Sri Lankan document as well (TABLE 31 below). Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 105 WHO publications Sri Lankan document A background for national quality policies in health systems World alliance for patient safety, forward programme 2008 – 2009 National policy on health care quality and safety’ National values and priorities for quality including legislations Assessing and understanding the problems of unsafe care Customer/ patient satisfaction National organization and institutionalization of quality Developing norms and establishing standards to reduce harm Managerial systems and process improvement Methods/ techniques and tools for development of quality Improving knowledge access and use Clinical effectiveness Resources for quality improvement Evaluating impact Risk management Identify structure/ roles and accountability Promoting innovation Safety and enabling a culture for quality improvement Define and disseminate practical guidance Sustaining commitment and strengthening capacity for patient safety worldwide Staff development and welfare Research and pilot quality projects Research for quality improvement and patient safety Develop knowledge, attitudes and skills National minimum data set and dissemination of data TABLE 31: COMPARISON OF CONTENT AREAS IN RELEVANT WHO PUBLICATIONS AND THE SRI LANKAN POLICY DOCUMENT As depicted in the above table, many technical areas in the Sri Lankan document reflect the content in WHO publications, except for a data set and a system to monitor and evaluate the quality programme. Conclusion: Perceived influence and impact of WHO publications on the Sri Lankan document ‘National policy on health care quality and safety’ tend to be significant. However, lack of a list of references was a serious limitation. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 106 3.5.1.3. First of the two Sri Lankan strategic plan / action plan documents reviewed for evidence of perceived influence and impact of WHO publications on the formulation of national health policies and strategies and health practices: “National health strategic plan for preventive sector 2016 – 2025” The ‘National health strategic plan for preventive sector 2016 – 2025’ was reviewed to describe the perceived influence and impact of WHO publications on the formulation of national health policies and strategies and healthcare practices. This document extensively discusses vision, mission, goals, objectives and major activities or strategic framework to achieve the programme objectives of 32 Public Health institutions/ programmes in the state sector of the country. Findings: Of the 32 programmes discussed in the Sri Lankan document under review, only 21 (65.6%) had listed their sources of information for the content. Out of this number, only 9 (42.9%) had listed a WHO publication as a source of information. Many important public health institutions had listed their references, but had not referred to any WHO publications as a source of information. Among these institutions, Non-Communicable Diseases bureau and the quarantine unit can be emphasized, as the considerable number of WHO publications the respective units/ programmes could have utilized in preparing the strategic frameworks. For example, the WHO publication ‘Global action plan for the prevention and control of NCDs 2013 – 2020 https:// www.who.int/nmh/publications/ncd-action-plan/en/ is a very useful document which directly has a bearing on the Sri Lankan document under consideration. ‘Tackling NCDs’ is another such useful WHO document https://www.who.int/ncds/management/best-buys/en/ that discusses best buys and other recommended interventions to prevent and control NCDs. International Health Regulations (IHR) https://www.who.int/ihr/IHR_2005_en.pdf is a core document applicable to quarantine health. However, it is not mentioned as a source of reference under the quarantine unit profile in the Sri Lankan document. Even among those who had used WHO publications, three national programmes (National Programme for Tuberculosis Control and Chest Diseases, the Food Safety unit and CKDu unit) had used the document to obtain information/ estimates on the disease burden but not on technical recommendations on preventive and control strategies. There are WHO publications that could have been used in drafting the document by Sri Lankan public health programmes/ units. For instance, there are WHO resolutions on tuberculosis (TB) that are easily accessible and highly relevant (https:// www.who.int/tb/publications/resolutions/en/) for the Sri Lankan document. In addition, Engage TB approach: Operational guidance series (https://www.who.int/tb/publications/2012/engage_tb_ policy/en/), Recommendation for investigating contacts of persons with TB in lower middle income countries (https://www.who.int/tb/publications/2012/contact_investigation2012/en/), Guidance for national programmes on the treatment of TB in children https://www.who.int/tb/publications/childtb_ guidelines/en/) and systematic screening for active TB (https://www.who.int/tb/tbscreening/en/) are few other WHO publications that would have improved the evidence-based nature of the strategic frameworks discussed in the Sri Lankan document. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 107 The national public health programmes/ units that had used evidence in WHO publications and the respective publication they have referred to are as follows: As the examples depicted in the TABLE 32 below, there are many other beneficial operational guidelines and publications by the WHO that could have a potential impact on the Sri Lankan strategic frameworks. • Occupational and Environmental health unit • STD/AIDS campaign • Leishmaniasis surveillance unit • Anti-leprosy campaign • Health promotion bureau • WHO global plan of action for workers’ health (2008-2017): Baseline for implementation • Indoor air quality guidelines • WHO guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV • WHO 2010 Technical report series. Control of the Leishmaniasis. • WHO 2009 Enhanced Global Strategy for further reducing the disease burden due to Leprosy – operational guidelines • Ottawa charter for Health Promotion 1986 Public health programme WHO document Occupational and Environmental health unit 1. Protecting Worker’s Health series 2. Global strategy on occupational health for all: The way to health at work 3. Connecting Health and Labour: What Role for Occupational Health in Primary Health Care 4. Guideline for human resources planning in environmental and occupational health 5. Regional strategy for protecting health from climate change TABLE 32: OTHER WHO PUBLICATIONS BENEFICIAL FOR STRATEGIC FRAMEWORK OF SELECTED PUBLIC HEALTH PROGRAMMES IN SRI LANKA Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 108 STD/AIDS campaign 1. HIV/ AIDS prevention, treatment and care in the health sector (2010) 2. Accelerating progress on HIV, tuberculosis, malaria, hepatitis and neglected tropical diseases (2015) 3. HIV Programmes: Achieving our goals (2016) 4. Planning guide for the health sector response to HIV (2011- 2012) Leishmaniasis surveillance unit 1. Framework for action on cutaneous leishmaniasis 2. The Post Kala-Azar Dermal Leishmaniasis (PKDL) atlas: A manual for health workers Anti-leprosy campaign 1. Monitoring enhanced global leprosy strategy (2012) 2. Guidelines for strengthening participation of persons affected by leprosy in leprosy services (2014) Health promotion bureau 1. Health in all policies: report on perspectives and intersectoral actions in the South-East Asia Region 2. Regional Framework on Health in All Policies for South-East Asia 3. Recommendation on Healthy Public Policy: second Global Conference on Health Promotion Conclusion: Perceived influence and impact of WHO publications on Sri Lankan strategic frameworks of the public health programmes/ units as per evidence elicited by reviewing the Sri Lankan strategic plan “National health strategic plan for preventive sector 2016 – 2025’ , was observed to be insignificant. 3.5.1.4. Second of the two Sri Lankan strategic plan / action plan documents reviewed for evidence of perceived influence and impact of WHO publications on the formulation of national health policies and strategies and health practices: “National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020” The National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020 is a comprehensive plan that has been developed in order to achieve the ten voluntary targets adopted by Sri Lanka based on the nine global targets and the specific regional targets identified for the South East Asia region. The plan discusses outcomes to be achieved, specific activities to be implemented, required multi-sector partnerships and the time frame by which the targets are to be achieved. The National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020 was reviewed to describe the perceived influence and impact of WHO publications on the Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 109 formulation of national health policies and strategies and healthcare practices on this national action plan. Relevant WHO publications were compared with the contents in the Sri Lankan document to evaluate the perceived influence and impact of WHO publications on the national action plan. Findings: The WHO publication that has a direct implication on this Sri Lankan document is the ‘WHO Global Action Plan for prevention and control of Non-Communicable Diseases 2013 – 2020’, which has been prepared by compiling all the previous work and evidence on NCD. Therefore, the comparison was done between this WHO publication and the Sri Lankan action plan. ‘Global Action Plan for prevention and control of Non-Communicable Diseases 2013 – 2020’ by the WHO discusses vision, goal, overarching principles, objectives, voluntary global targets and a global monitoring framework. In overall comparison, the Sri Lankan action plan also describes vision, goal, overarching principles, objectives, Sri Lankan targets, and strategic priority action areas to prevent and control NCD in Sri Lanka. A basic comparison of the content in the two documents are shown in the TABLE 33 below. Content area WHO publication 1 Sri Lankan document 2 Vision A world free of the avoidable burden of Non-Communicable Diseases. A country free of the avoidable burden of Non-Communicable Diseases Goal To reduce the preventable and avoidable burden of morbidity, mortality and disability due to Non- Communicable Diseases by means of multisectoral collaboration and cooperation at national, regional and global levels, so that populations reach the highest attainable standards of health, quality of life, and productivity at every age and those diseases are no longer a barrier to well-being or socioeconomic development. To reduce the preventable and avoidable burden of morbidity, mortality and disability due to Non- Communicable Diseases by means of multisectoral collaboration and cooperation at national level, so that populations reach the highest attainable standards of health and productivity at every age and those diseases are no longer a barrier to well- being or socioeconomic development. Overarching principles 1. Life course approach 2. Empowerment of people and communities 3. Evidence-based strategies 4. Universal health coverage 5. Management of real, perceived or potential conflicts of interest 6. Human rights approach 7. Equity-based approach 8. National action and international cooperation ad solidarity 9. Multisectoral action 1. Life course approach 2. Empowerment of people and communities 3. Evidence-based strategies 4. Universal health coverage 5. Management of real, perceived or potential conflicts of interest 6. Human rights approach 7. Equity-based approach 8. National action and international cooperation ad solidarity 9. Multisectoral action TABLE 33: COMPARISON BETWEEN THE STRATEGIES IN THE MULTI-SECTORAL ACTION PLAN TO PREVENT AND CONTROL NCD IN SRI LANKA AND THE OBJECTIVES OF THE WHO PUBLICATION GLOBAL ACTION PLAN TO PREVENT AND CONTROL NCD Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 110 Objectives 1. To raise the priority accorded to the prevention and control of Non- Communicable Diseases in global, regional and national agendas and internationally agreed development goals, through strengthened international cooperation and advocacy 1. To raise the priority accorded to the prevention and control of Non- Communicable Diseases in global, regional and national agendas and internationally agreed development goals, through strengthened international cooperation and advocacy 2. To strengthen national capacity, leadership, governance, multisectoral action and partnerships to accelerate country response for the prevention and control of Non-Communicable Diseases 2. To strengthen national capacity, leadership, governance, multisectoral action and partnerships to accelerate country response for the prevention and control of Non-Communicable Diseases 3. To reduce modifiable risk factors for Non-Communicable Diseases and underlying social determinants through creation of health- promoting environments 3. To reduce modifiable risk factors for Non-Communicable Diseases and underlying social determinants through creation of health- promoting environment 4. To strengthen and orient health systems to address the prevention and control of Non-Communicable Diseases and the underlying social determinants through people- centred primary health care and universal health coverage 4. To strengthen and orient health systems to address the prevention and control of Non-Communicable Diseases and the underlying social determinants through people- centred primary health care and universal health coverage 5. To promote and support national capacity for high-quality research and development for the prevention and control of Non- Communicable Diseases 5. To promote and support national capacity for high-quality research and development for the prevention and control of Non-Communicable Diseases 6. To monitor the trends and determinants of Non- Communicable Diseases and evaluate progress in their prevention and control 6. To monitor the trends and determinants of Non- Communicable Diseases and evaluate progress in their prevention and control Interventions and policy options for member states Appendix 3 (page 65-71) Strategic priority action areas (page 22-66). At the activity level, most of the interventions suggested in the WHO document had been listed in the Sri Lankan action plan, except for the interventions recommended by the WHO to combat individual diseases, namely Cardiovascular disease, Diabetes, Cancer, Chronic respiratory diseases (page 69). In the Sri Lankan document, attention has not been paid to interventions that helps to improve prevention and control of individual diseases. Other than this disparity, the two documents were almost identical. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 111 Conclusion: The WHO publication, Global Action Plan for the Prevention and Control of Non-Communicable Diseases 2013 – 2020’ has a greater influence and impact on the formulation of the National Multi- sectoral Action Plan for Prevention and Control of Non-communicable Diseases in Sri Lanka, published by the Ministry of Health, Nutrition and Indigenous Medicine in Sri Lanka. 3.5.1.5. First of the two Sri Lankan guideline documents reviewed for evidence of perceived influence and impact of WHO publications on the formulation of national health policies and strategies and health practices: “Screening Guidelines Chronic Kidney Disease Sri Lanka 2017” ‘Screening Guidelines Chronic Kidney Disease Sri Lanka 2017’ was an update and revision of the first guideline on screening for chronic kidney disease (CKD) in Sri Lanka published in 2014. It is expected that this document will serve as a comprehensive guide for the health care providers engaged in screening programme. The publication clearly describes the high-risk geographic areas, target populations and exclusion criteria, screening settings, screening methods, screening tools, administration of screening tools, sample collection and dispatch, required calculations, quality assurance of laboratory tests, cut-off values for laboratory and other investigations, interpretation of results, referral procedures and indications, field screening clinics, implementation plan, monitoring and evaluation, district level indicators and targets as well as data analysis and dissemination of information. The Sri Lankan document under review, ‘Screening Guidelines Chronic Kidney Disease Sri Lanka 2017’, was reviewed to describe the perceived influence and impact of WHO publications on the formulation of national health policies and strategies and healthcare practices. Understandably, most WHO publications have focused on Diabetes, Cardio-vascular diseases, Chronic pulmonary diseases and Cancer in their publications on chronic diseases, and there was no specific publication on screening for CKDu. The WHO publication titled ‘International expert consultation on CKDu’ was published in 2017, after the publication of the Sri Lankan document. Since the Sri Lankan document preceded the WHO document, the WHO document was not considered for comparison for evidence of influence. In the absence of any other document, comparison was done with the ‘Principles and practice of screening for diseases’ (1968) by the WHO. Findings: The Sri Lankan document discusses the methodology for the screening for CKDu within Sri Lanka in a comprehensive manner. The ten principles described in the WHO publication on effective screening programmes (page 26-27) are well reflected in the Sri Lankan document, as shown in the TABLE 34 below. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 112 No. Key principle Evidence for adoption in the Sri Lankan document 1 Condition sought should be an important health problem Magnitude of the problem is not mentioned nor screening is not justified with evidence 2 Availability of an accepted treatment for patients with recognized disease Not discussed 3 Facilities for diagnosis and treatment should be available Available and referral pathways are described in the chapter ‘Referral procedures for persons with abnormal test results’ (page 10) 4 Availability of a recognizable latent or early symptomatic stage Not discussed 5 Availability of a suitable test or examination Screening tool and its administration discussed in page 5. 6 The test should be acceptable to the population Not discussed 7 The natural history of the condition should be known Not discussed 8 Agreed policy to say whom to treat as patients Described in the Chapters ‘cut-off values for blood pressure and laboratory investigations’ and ‘Interpretation of results’ (page 9) 9 Cost effectiveness Not discussed 10 Should be a continuous process Discussed under the chapter ‘Monitoring and evaluation’ (page 13) TABLE 34: EVIDENCE OF ADOPTION OF WHO KEY PRINCIPLE ON SCREENING BY THE GUIDELINE FOR SCREENING CKDU IN SRI LANKA Overall, four out of ten key principles on screening by the WHO are reflected on the contents of the Sri Lankan document. However, it should be noted that the Sri Lankan document has been prepared to describe the methodology of the screening process, rather than to justify the establishment of a screening programme for CKDu in the country. Nevertheless, having such a technical justification would have improved the quality of the Sri Lankan publication. Conclusion: Perceived influence and impact of WHO publications on the formulation of national guidelines is moderate as evidenced by reviewing the Sri Lankan document ‘Screening Guidelines Chronic Kidney Disease Sri Lanka 2017’. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 113 3.5.1.6. Second of the two Sri Lankan guideline documents reviewed for evidence of perceived influence and impact of WHO publications on the formulation of national health policies and strategies and health practices: “Screening Guidelines Chronic Kidney Disease Sri Lanka 2017” ‘Pain Management Guideline for Adults with Cancer 2017’ is the Sri Lankan document which was reviewed to describe the perceived influence and impact of WHO publications on the formulation of national health policies and strategies and healthcare practices. The publication by the National Cancer Control Programme of Sri Lanka had a list of references and also in-text citations, making it feasible to accurately evaluate the influence and impact of WHO publications on the Sri Lankan document. The content, in-text citation and the list of references in the Sri Lankan document under review, ‘Pain Management Guideline for Adults with Cancer 2017’, was studied to assess the influence from WHO publications. In addition, other relevant WHO publications published before 2017 but are not mentioned in the reference list of the Sri Lankan document were also analysed to assess the influence of such WHO publications on the Sri Lankan document. ‘Cancer pain relief’ (1996) by the WHO was the other most relevant publication thus selected to compare with the Sri Lankan document. Findings: The Sri Lankan document lists 10 references for the content, and only one WHO publication is listed amongst them. The ‘WHO three-step analgesic ladder’ is the only reference from the WHO and it has been used to describe the principles of pharmacological treatment of pain (page 20). There was no evidence of influence from the other relevant WHO publication, ‘Cancer pain relief’ on the Sri Lankan document. Conclusion: Perceived influence and impact of WHO publications on the formulation of ‘Pain Management Guideline for Adults with Cancer 2017’ in Sri Lanka were observed to be moderate. 3.5.2. Findings on Perceived comparative advantage of WHO publications in relation to the ones by other stakeholders from key informant interviews. WHO publications not only on NCDs and health systems, but on all subjects provide opportunities for sharing experiences of success stories. However, when it comes to learning from all experiences is hindered because WHO seldom uses failure stories to learn from. Possibly because WHO is bound by diplomacy and its boundaries, using experiences where expected outcomes were far from intended is not taken as case studies. WHO is well known and respected for its work in communicable diseases and not to be outdone, all agree that its work on both NCDs and health systems are also carried on with the same reputation, reliability and authoritativeness. Despite SDG goals comes under UN umbrella shared by all UN organizations, it is only natural that WHO publications had a very high reputability as referral publications for SDGs compared to publications by other agencies. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 114 Provincial level and regional level experts in Sri Lanka have higher perception than the central/ national level experts on authoritativeness of WHO publications. In public health management WHO publications are considered as having an indisputable superiority over the rest. However, in clinical management sphere, experts in their particular speciality tend to give preference to publications by European and American professional colleges. Reliable and ready to access publications (posted to WHO website) also was a perceived comparative advantage for WHO publications. Section end summary box 5: The perceived influence and impact of WHO publications on the formulation of national policies and strategies and healthcare practices as well as the perceived comparative advantage of WHO publications in relation to the ones by other stakeholders. Sri Lankan policy document “National policy and strategic framework for cancer prevention and control” was clearly influenced by the most applicable WHO publications and the impact of the WHO publication of knowledge into action series on this policy document was great. However, lack of references or bibliography in the document was a serious limitation in assessing the extent of the influence. Perceived influence and impact of WHO publications on the Sri Lankan document ‘National policy on health care quality and safety’ tend to be satisfactory. However, lack of a list of references was a serious limitation in assessing the extent of the influence. Perceived influence and impact of WHO publications on Sri Lankan strategic frameworks of the public health programmes/ units are poor as per evidence elicited by reviewing the Sri Lankan strategic plan “National health strategic plan for preventive sector 2016 – 2025’. The WHO publication, Global Action Plan for the Prevention and Control of on-communicable Diseases 2013 – 2020’ has a greater influence and impact on the formulation of the National Multi-sectoral Action Plan for Prevention and Control of Non-communicable Diseases in Sri Lanka, published by the Ministry of Health, Nutrition and Indigenous Medicine in Sri Lanka. Perceived influence and impact of WHO publications on the formulation of national guidelines is moderate as evidenced by reviewing the Sri Lankan document ‘Screening Guidelines Chronic Kidney Disease Sri Lanka 2017’. Perceived influence and impact of WHO publications on the formulation of ‘Pain Management Guideline for Adults with Cancer 2017’ in Sri Lanka is moderate. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 115 3.6. The perceived level of quality (credibility, authoritativeness, trustworthiness and reputability) of WHO publications. 3.6.1. Findings of quantitative survey. Perception of the level of quality of the WHO publications by the reader is a very important parameter. The quality of a publication is comprised of four dimensions: credibility, authoritativeness, trustworthiness and reputability. • Credibility of a WHO publication was defined as “WHO publications can be believed as accurate”. • Authoritativeness: “WHO publications are recognized as being an authority”. • Trustworthiness:” WHO publications are honest and can be trusted”. • Reputability: “WHO publications have a good reputation among professionals”. TABLE 35: DESCRIPTION OF FINDINGS ON THE FOUR DIMENSIONS OF QUALITY OF WHO PUBLICATIONS (UNDER EACH DIMENSION, THE NUMBER OF RESPONDENTS GIVEN. AN AVERAGE FIGURE IS CALCULATED AS A PERCENTAGE) C re d ib ili ty A ut ho ri ta ti ve ne ss Tr us tw o rt hi ne ss R ep ut ab ili ty A ve ra g e Health ministry officials Very High 22 15 22 26 36% High 37 44 36 33 64% Low 0 0 1 0 0% Health ministry national technical consultants Very High 10 7 11 13 45% High 13 16 11 10 54% Low 0 0 1 0 1% Members of medical professional colleges Very High 35 25 30 34 42% High 39 48 44 39 57% Low 0 1 0 1 1% Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 116 Medical research community Very High 20 19 20 24 30% High 47 49 47 43 67% Low 2 1 2 2 3% Members of non-medical professional colleges Very High 4 5 4 5 50% High 4 3 4 3 39% Low 4 0 0 0 11% Education and finance ministry officials Very High 2 3 2 3 63% High 2 1 2 1 37% Low 0 0 0 0 0 Members of civil society organizations Very High 6 6 6 6 100% High 0 0 0 0 0 Low 0 0 0 0 0 Almost all the respondents were in the opinion that WHO publications are of high quality. The top most “Very high” response of 45% was received from the target group, Health Ministry national technical consultants. 3.6.2. Important factors from key informant interviews WHO publications are held with very high esteem and credibility and being considered as associated with highest level of authority. These are unmatched and unquestionable attributes of WHO publications, especially with regards communicable diseases, Non-Communicable Diseases, public health, vaccine preventable diseases and health systems. Primary health care is another exclusive authoritative domain of WHO. Universal health coverage (UHC) is also another trademark authoritative domain of WHO. WHO publications receive high recognition for authoritativeness because they are on general meant to be relevant for all the countries across the globe. All member states and regions are generally covered or addressed in WHO publications. However this practice can adversely affect the credibility of their publications because countries may show tendency to be reluctant to accept and adopt a publication which do not display specific relevance to that particular country. It is an accepted fact that WHO publications are broad-based to increase the applicability to all the countries and each country is free and welcome to adopt the guidelines given in WHO publications to the best advantage of that particular country. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 117 Section end summary box 6: The perceived level of quality (credibility, authoritativeness, trustworthiness and reputability) of WHO publications. Over 97% of the respondents in target audiences with a medical background agreed that WHO publications have very high and high levels of quality in terms of credibility, authoritativeness, trustworthiness and reputability. The fact that WHO publications are broad based to be able to apply to all member countries, while increases the authoritativeness could adversely affect the credibility. 3.7. The extent to which WHO publications are used as an authoritative source of health information understanding the circumstances and criteria for it. 3.7.1. Desk review on use of WHO publications on country actions. Six Sri Lankan Health Ministry documents were studied to understand the extent to which WHO publications are used as an authoritative source of health information understanding the circumstances and criteria for it. Type of document Selected document Description Policy document National policy and strategic framework for cancer prevention and control 3.7.1.1 National policy on health care quality and safety 3.7.1.2 Strategic plan / Action plan National health strategic plan for preventive sector 2016 – 2025 3.7.1.3 National Multi-sectoral Action Plan for the Prevention and Control of Non- Communicable Diseases 2016 - 2020 3.7.1.4 Guidelines Screening Guidelines Chronic Kidney Disease Sri Lanka 2017 3.7.1.5 Pain Management Guideline for Adults with Cancer 2017 3.7.1.6 TABLE 36: SELECTED SRI LANKAN DOCUMENTS AND THE DESCRIPTIONS ON EXTENT OF AUTHORITATIVE USE OF WHO PUBLICATIONS Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 118 3.7.1.1. First of the two Sri Lankan policy documents reviewed for evidence of use of WHO publications as authoritative source of information: “National policy and strategic framework for cancer prevention and control” The Sri Lankan document ‘National policy and strategic framework for cancer prevention and control’ was reviewed to identify the extent of the reach of WHO publications. Due to the unavailability of a list of references in the Sri Lankan document, relevant WHO publications were studied to achieve the objective. Thus examined WHO publications include ‘National Cancer Control Programmes. Policies and managerial guidelines’ and the six modules on the WHO publication series ‘Cancer Control. Knowledge into Action’. Publications by IARC (International Agency for Research in Cancer) also were considered in the analysis. In the absence of a reference list in the Sri Lankan document under review, ‘National policy and strategic framework for cancer prevention and control’, it was compared with the above-mentioned WHO publications for the similarities in the technical content to identify the extent to which WHO publications have been used as an authoritative source of information. Findings: The National policy and strategic framework for cancer prevention and control in Sri Lanka – 2014 guides the direction of activities related to control and prevention of cancer in the country. The document spells out seven policy objectives, expanding in a wide array of fields ranging from primordial to tertiary prevention, with explicit strategies. Lack of references/ bibliography in the document is a serious limitation in achieving the specific objective of assessing the extent to which WHO publications are used as an authoritative source of health information. Nevertheless, an attempt was made to compare the key ideas mentioned in the Sri Lankan policy document under review and relevant WHO publications to achieve the objective. Out of all WHO publications on cancer control and prevention (https://www.who.int/cancer/ publications/en/), the most relevant and applicable WHO publications for the national policy under review are the six modules in the series ‘Cancer control: knowledge into action’, which was developed as a response to the World Health Assembly resolution on cancer prevention and control (WHA58.22) and the ‘National Cancer Control Programmes. Policies and managerial guidelines (Second Edition)’. Use of both these WHO publications in the Sri Lankan policy document could be perceived by comparing the contents of the documents. As also described under the specific objective two, basic principles described in the ‘Cancer control: knowledge into action’ series have been incorporated into all the policy objectives. For example, under the key principle one ‘Leadership’, continuous learning has been interpreted in the policy document as ‘To promote professional education of doctors, nurses, technicians and health workers to augment trained human resources (policy objective 6) and promote research and utilization of its findings for prevention and control of cancers (policy objective 7). Likewise, all effect of basic principles described in the WHO series could be seen in the objectives. The other WHO publication applicable to the Sri Lankan policy document under review is the ‘National Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 119 Cancer Control Programmes. Policies and managerial guidelines (Second Edition)’, which discusses challenges facing cancer control programmes, approaches to cancer control and managing national cancer control programmes. The content discussed under the topic ‘Approaches to cancer control’ could be found throughout the policy objectives in the document under review. For instance, the topics discussed in the WHO document Prevention, Early detection of cancer, Diagnosis and treatment of cancer, Pain relief and palliative care, Cancer control research and Surveillance in cancer control coincide with the policy objectives 1, 2, 3, 4, 7 and 5 respectively. Hence it could be perceived that the WHO document has been referred to a greater extent in preparing the National policy on cancer control and prevention. Conclusion: It could be perceived that most applicable WHO publications at policy level have been referred extensively as an authoritative source of health information in drafting the National policy document on cancer prevention and control in Sri Lanka. 3.7.1.2. Second of the two Sri Lankan policy documents reviewed for evidence of use of WHO publications as authoritative source of information: “National policy on health care quality and safety” The Sri Lankan document ‘National policy on health care quality and safety’ (2015) was reviewed to assess the extent to which WHO publications are used as an authoritative source of health information. Since the Sri Lankan document did not have a list of references, most relevant WHO publications were searched. As a result, ‘A background for national quality policies in health systems’, ‘World alliance for patient safety, forward programme 2008 – 2009’ and ‘Regional strategy for patient safety in the WHO South-East Asia Region (2016 – 2025)’ were selected. The selected WHO publications were compared with the Sri Lankan document under review, ‘National policy on health care quality and safety’ (2015) to assess whether the core contents and/or key messages in WHO publications were reflected. ‘A background for national quality policies in health systems’ and ‘World alliance for patient safety, forward programme 2008 – 2009’ were reviewed. The most applicable publication, ‘Regional strategy for patient safety in the WHO South-East Asia Region (2016-2025)’ was disregarded as its year of publication was the same as the Sri Lankan document under review. Findings: Most of the technical content discussed in the WHO publications were mentioned in the Sri Lankan document as well (TABLE 37). Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 120 WHO publications Sri Lankan document A background for national quality policies in health systems World alliance for patient safety, forward programme 2008 – 2009 National policy on health care quality and safety’ National values and priorities for quality including legislations Assessing and understanding the problems of unsafe care Customer/ patient satisfaction National organization and institutionalization of quality Developing norms and establishing standards to reduce harm Managerial systems and process improvement Methods/ techniques and tools for development of quality Improving knowledge access and use Clinical effectiveness Resources for quality improvement Evaluating impact Risk management Identify structure/ roles and accountability Promoting innovation Safety and enabling a culture for quality improvement Define and disseminate practical guidance Sustaining commitment and strengthening capacity for patient safety worldwide Staff development and welfare Research and pilot quality projects Research for quality improvement and patient safety Develop knowledge, attitudes and skills National minimum data set and dissemination of data TABLE 37: COMPARISON OF CONTENT AREAS IN RELEVANT WHO PUBLICATIONS AND THE SRI LANKAN POLICY DOCUMENT As depicted in the TABLE 37, many technical areas in the Sri Lankan document reflect the content in WHO publications, except for a data set and a system to monitor and evaluate the quality programme. However, establishing the source of information for the content in the Sri Lankan document was not possible due to lack of references. Conclusion: The extent to which WHO publications have been used as an authoritative source of information could not be established even after comparing the contents of the Sri Lankan document with the relevant WHO publications. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 121 3.7.1.3. First of the two Sri Lankan strategic plan / action plan documents reviewed for evidence of use of WHO publications as authoritative source of information: “National health strategic plan for preventive sector 2016 – 2025” The ‘National health strategic plan for preventive sector 2016 – 2025’ extensively discusses vision, mission, goals, objectives and major activities or strategic framework to achieve the programme objectives of 32 Public Health institutions/ programmes in the state sector of the country. Findings: Of the 32 programmes discussed in the Sri Lankan document under review, only 21 (65.6%) had listed their sources of information for the content. Among this 21, only 9 (42.9%) had listed a WHO publication as a source of information in preparing the document, hence limiting the objective of assessing the extent to which WHO publications have been an authoritative source of information to few public health programmes. When the impact of the used WHO publication is considered, the National Programme for Tuberculosis Control and Chest Diseases (NPTCCD), the Food Safety unit and the Chronic Kidney Disease Unit have only used the WHO publication to obtain disease burden and/ or the estimates. The NPTCCD mentions ‘WHO regional office for South-East Asia (2015), TB control in the South East Asia region’ as the only WHO publication out of the list of six references on page 159. The Food Safety unit lists two references on page 191: one of them is ‘WHO estimates of the global burden of foodborne diseases’. ‘Investigation and evaluation of the CKDu in Sri Lanka’ is the only WHO publication listed under the references of the publications of the CKDu unit (page 83). On the other hand, few other units/ programmes had referred WHO publication for more technical input. Overall, it is only a minority of 18.7% (6/32) of all programmes/ units that have discussed their strategic plans to achieve the objectives of the respective programme. The Occupational Health unit listed ‘WHO Global Plan of Action on Workers’ Health (2008-2017): Baseline for implementation 2013’ (page 175), while the Environmental Health unit has referred ‘WHO Indoor Air Quality guideline’ as one of their two references (page 178). National STI/ AIDS campaign referred ‘WHO guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV’ as one of 16 sources they have listed (page 127). In addition, the anti-leprosy campaign has stated ‘WHO 2009 Enhanced Global Strategy for further reducing the disease burden due to Leprosy – operational guidelines’ (page 98) and the same for the leishmaniasis surveillance unit is one out of five, ‘WHO 2010 Technical report series. Control of the Leishmaniasis’ being the only WHO publication (page 63). The Health Promotion Bureau also lists only the “Ottawa Charter 1986’ as the only WHO reference out of four references (page 105). Conclusion: Overall, WHO publications have been used to a lesser extent as an authoritative source of health information in drafting the ‘National health strategic plan for preventive sector 2016 – 2025’. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 122 3.7.1.4. Second of the two Sri Lankan strategic plan / action plan documents reviewed for evidence of use of WHO publications as authoritative source of information: “National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020” The National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020 is a comprehensive plan that has been developed in order to achieve the ten voluntary targets adopted by Sri Lanka based on the nine global targets and the specific regional targets identified for the South East Asia region. The plan discusses outcomes to be achieved, specific activities to be implemented, required multi-sector partnerships and the time frame by which the targets are to be achieved. The National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016–2020 was evaluated to describe the extent to which WHO’s publications are used as an authoritative source of health information. Relevant WHO publications were compared with the contents in the Sri Lankan document to evaluate the perceived influence and impact of WHO publications on the national action plan. Findings: The WHO publication that has a direct implication on this Sri Lankan document is the ‘WHO Global Action Plan for prevention and control of Non-Communicable Diseases 2013–2020’, which has been prepared by compiling all the previous work and evidence on NCD. Findings of the comparison between this WHO publication and the Sri Lankan action plan are depicted in the TABLE 38. Content area in the Sri Lankan document WHO publication Vision Same vision Goal Same goal Overarching principles Same nine principles Objectives Same six objectives Strategic action areas with proposed actions Similar interventions suggested Monitoring framework Similar TABLE 38: POSSIBLE SOURCE OF INFORMATION FOR THE CONTENT IN THE SRI LANKAN DOCUMENT NATIONAL MULTI-SECTORAL ACTION PLAN FOR THE PREVENTION AND CONTROL OF NCD 2016 – 2020 Conclusion: Publications by the WHO have been used as an authoritative source of health information to a greater extent in the National Multi-sectoral Action Plan for the Prevention and Control of Non-communicable Diseases 2016–2020. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 123 3.7.1.5. First of the two Sri Lankan guideline documents reviewed for evidence of use of WHO publications as authoritative source of information: “Screening Guidelines Chronic Kidney Disease Sri Lanka 2017” ‘Screening Guidelines Chronic Kidney Disease Sri Lanka 2017’ is an update and revision of the first guideline on screening for Chronic Kidney Disease (CKD) in Sri Lanka published in 2014. It is expected that this document will serve as a comprehensive guide for the health care providers engaged in screening programme. The publication clearly describes the high-risk geographic areas, target populations and exclusion criteria, screening settings, screening methods, screening tools, administration of screening tools, sample collection and dispatch, required calculations, quality assurance of laboratory tests, cut-off values for laboratory and other investigations, interpretation of results, referral procedures and indications, field screening clinics, implementation plan, monitoring and evaluation, district level indicators and targets as well as data analysis and dissemination of information. A desk review of the Sri Lankan document under review, ‘Screening Guidelines Chronic Kidney Disease Sri Lanka 2017’, was carried out to assess the extent to which WHO publications are used as an authoritative source of health information. The WHO publication titled ‘International expert consultation on CKDu’ was published in 2017, three years after the publication of the Sri Lankan document. Hence it was not considered. In the absence of any other document, comparison was done with the ‘Principles and practice of screening for diseases’ (1968) by the WHO. Findings: Comparison of the contents revealed that less than half basic principles mentioned in the WHO document had been discussed in the Sri Lankan document as mentioned in the TABLE 39 below. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 124 No. Key principle Evidence for adoption in the Sri Lankan document 1 Condition sought should be an important health problem Magnitude of the problem is not mentioned nor screening is not justified 2 Availability of an accepted treatment for patients with recognized disease Not discussed 3 Facilities for diagnosis and treatment should be available Available and referral pathways are described in the chapter ‘Referral procedures for persons with abnormal test results’ (page 10) 4 Availability of a recognizable latent or early symptomatic stage Not discussed 5 Availability of a suitable test or examination Screening tool and its administration discussed in page 5 6 The test should be acceptable to the population Not discussed 7 The natural history of the condition should be known Not discussed 8 Agreed policy to say whom to treat as patients Described in the Chapters ‘cut-off values for blood pressure and laboratory investigations’ and ‘Interpretation of results’ (page 9) 9 Cost effectiveness Not discussed 10 Should be a continuous process Discussed under the chapter ‘Monitoring and evaluation’ (page 13) TABLE 39: EVIDENCE OF ADOPTION OF WHO KEY PRINCIPLE ON SCREENING BY THE GUIDELINE FOR SCREENING CKDU IN SRI LANKA The fact that many components in the WHO document being not discussed in the Sri Lankan document could be due to that the main focus of the Sri Lankan document being to describe the methodology for the screening process, rather than justifying the establishment of a screening programme for CKDu in the country. Conclusion: The use of available and relevant WHO’s publications was not as a very authoritative source of health information in drafting the guidelines for screening CKDu in Sri Lanka, most probably due to the fact that the main focus of the Sri Lankan document was to describe the methodology in screening for CKDu in Sri Lanka, which was the main focus at that period of time in the Sri Lankan context. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 125 3.7.1.6. Second of the two Sri Lankan guideline documents reviewed for evidence of use of WHO publications as authoritative source of information: “Pain Management Guideline for Adults with Cancer 2017” ‘Pain Management Guideline for Adults with Cancer 2017’ is the Sri Lankan document under consideration. The publication by the National Cancer Control Programme of Sri Lanka had a list of references and also in-text citations, making it feasible to accurately evaluate the extent to which WHO’s publications are used as an authoritative source of health information. In addition, other relevant WHO publications published before 2017 but are not mentioned in the reference list of the Sri Lankan document were also analysed to assess the influence of the WHO publications on the Sri Lankan document. ‘Cancer pain relief’ (1996) - WHO was the other most relevant publication thus selected to compare with the Sri Lankan document. The content, in-text citation and the list of references in the Sri Lankan document under review, ‘Pain Management Guideline for Adults with Cancer 2017’, was studied to assess the influence from WHO publications. In addition, other relevant WHO publications published before 2017 but are not mentioned in the reference list of the Sri Lankan document were also analysed to assess the influence of the WHO publications on the Sri Lankan document. ‘Cancer pain relief’ (1996) by the WHO was the other most relevant publication thus selected to compare with the Sri Lankan document. Findings: The WHO reference was used as the sole source of information to describe the principles of pharmacological treatment of pain which is described as the backbone for treatment of pain (page 10). However, there was no evidence on any references from other relevant WHO publications. Conclusion: The use of WHO publications as authoritative source of health information in the Sri Lankan document ‘Pain Management Guideline for Adults with Cancer 2017’ is moderate. 3.7.2. Quantitative survey In the quantitative survey from the target groups in the health sector, their opinion was inquired if the WHO publications have been used as an authoritative source of health information in Sri Lanka. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 126 Yes No Total No: % No: % Health ministry officials 51 (88%) 7 (12%) 58 Health ministry national technical consultants 21 (91%) 2 (07%) 23 Members of medical professional colleges 64 (88%) 8 (12%) 72 Medical research community 60 (87%) 9 (13%) 69 TABLE 40: RESPONSE TO THE QUESTION “HAVE WHO PUBLICATIONS BEEN USED AS AN AUTHORITATIVE SOURCE OF INFORMATION IN SRI LANKA?” Almost 90% of the respondents from medical fraternity agreed that WHO publications have been used as authoritative source of health information in Sri Lanka. It is significant to note that even among the medical research community where the reach of WHO publications were comparatively low, the agreement with that WHO publications have been used as authoritative sources of information is high and similar to other medical target groups is a significant finding. It appears that medical community as a whole has trust in WHO publications as an authoritative source of information. Section end summary box 7: The extent to which WHO publications are used as an authoritative source of health information understanding the circumstances and criteria for it. Desk review document 1: National policy and strategic framework for cancer prevention and control. It can be perceived that most applicable WHO publications at policy level have been referred extensively as an authoritative source of health information in drafting this National policy document on cancer prevention and control in Sri Lanka. Desk review document 2: National policy on health care quality and safety. The extent to which WHO publications have been used as an authoritative source of information could not be established even after comparing the contents of the Sri Lankan document with the relevant WHO publications. Desk review document 3: National health strategic plan for preventive sector 2016 – 2025. Overall, WHO publications have been used to a lesser extent as an authoritative source of health information in drafting the ‘National health strategic plan for preventive sector 2016- 2025’. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 127 3.8. The type of and the publications that have demonstrated to contribute significantly to public health as well as those have not. Desk review document 4: National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020. Publications by the WHO have been used as an authoritative source of health information to a greater extent in the National Multi-sectoral Action Plan for the Prevention and Control of Non-communicable Diseases 2016 – 2020. Desk review document 5: Screening Guidelines Chronic Kidney Disease Sri Lanka 2017. The use of available and relevant WHO’s publications was not as a very authoritative source of health information in drafting the guidelines for screening CKDu in Sri Lanka, most probably due to the fact that the main focus of the Sri Lankan document was to describe the methodology in screening for CKDu in Sri Lanka, which was the main focus at that period of time in the Sri Lankan context. Desk review document 6: Pain Management Guideline for Adults with Cancer 2017. The use of WHO publications as authoritative source of health information in the Sri Lankan document ‘Pain Management Guideline for Adults with Cancer 2017’ is moderate. Almost 90% of the respondents from medical fraternity agreed that WHO publications have been used as authoritative source of health information in Sri Lanka. 3.8.1. Publications that have demonstrated to contribute significantly to Sri Lanka public health Three WHO publications were identified as having demonstrated significant contribution to Sri Lanka public health. 1. Tackling NCDs: ‘best buys’ and other recommended interventions for the prevention and control of NCDs. 2. WHO Global Action Plan for prevention and control of Non-Communicable Diseases 2013 – 2020’. 3. Tobacco control: progress and plans for implementing the framework convention on tobacco control (FCTC). Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 128 1. Tackling NCDs: ‘best buys’ and other recommended interventions for the prevention and control of Non-Communicable Diseases. Sri Lankan NCD documents including NCD policy document “The National Policy and Strategic Framework for Prevention and Control of Chronic Non-Communicable Diseases” which was published by the Ministry of Health in 2010 and National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020 has been significantly influenced by the WHO publication “Tackling NCDs: ‘best buys’ and other recommended interventions for the prevention and control of Non-Communicable Diseases”. This publication is based on an update of Appendix 3 of the Global Action Plan for the Prevention and Control of NCDs 2013 – 2020. Concept of four diseases, four risk factors and four interventions approach for NCD prevention and control made the initial strategic foundation of Sri Lanka attempts of control and prevention of NCDs. 2. ‘WHO Global Action Plan for prevention and control of Non-Communicable Diseases 2013–2020’. Among the studied WHO publications, some had contributed significantly to the development of national publications at policy level as well as at programmatic level, while some had not. The ‘WHO Global Action Plan for prevention and control of Non-Communicable Diseases 2013 – 2020’ is such a publication that had contributed significantly to the development of the ‘National Multi-sectoral Action Plan for the Prevention and Control of Non-communicable Diseases 2016 – 2020’ of Sri Lanka. ‘Global Action Plan for prevention and control of Non-Communicable Diseases 2013–2020’ by the WHO discusses vision, goal, overarching nine principles, six objectives, voluntary global targets and a global monitoring framework. In overall comparison, the local action plan also mentions the same vision, same goal, same overarching nine principles, same six objectives, local targets similar to global targets, and a similar monitoring framework to prevent and control NCD in Sri Lanka. The basic comparison of contents discussed under each key area are also the same in the two documents. At the activity level, most of the interventions suggested in the WHO document has been listed in the local action plan, except for the interventions recommended by the WHO to combat individual diseases, namely Cardiovascular disease, Diabetes, Cancer, Chronic respiratory diseases (page 69). In the local document, attention has not been paid to interventions that help to improve prevention and control of individual diseases. Other than this disparity, the two documents are almost identical. Therefore, it can be concluded that the WHO publication, Global Action Plan for the Prevention and Control of on-communicable Diseases 2013–2020’ had contributed significantly to Sri Lanka Public Health. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 129 3. Tobacco control: progress and plans for implementing the Framework Convention on Tobacco Control (FCTC). Sri Lanka ratified the Framework Convention on Tobacco Control in 2003 and implemented some comprehensive tobacco control policies. From 01 June 2015, health warnings on cigarette packages in Sri Lanka. Sri Lanka law requires health warnings in the form of pictures and text on every packet, package or carton containing cigarettes or other tobacco products. The warnings must be placed on the top surface area of both front and back sides and must cover 80% of the top surface area of the front and back. The regulations establish four categories of warnings with some categories containing more than one warning. The front warning must differ from the back warning. Manufacturers with more than one brand must ensure that two different brands do not share the same warning simultaneously. Manufacturers also must ensure that the warnings are changed every six months. Importers of tobacco products from outside Sri Lanka must use a sticker health warning. These provisions align with FCTC Article 11 and the FCTC Article 11 Guidelines. WHO publication “Tobacco control: progress and plans for implementing the framework convention on tobacco control (FCTC)” can be stated as one with the most prominent influence on Sri Lank public health. 3.8.2. Publications that have not contributed significantly to Sri Lanka public health Three documents were identified as having not contributed significantly to Sri Lanka public health. 1. Strengthening health systems to accelerate delivery of NCDs services at the primary health care level: one year progress review of the implementation of the 2016 Colombo declaration on NCDs. 2. TRIPS, intellectual property rights and access to medicines 3. Promoting health in the SDGs: report on the 9th Global conference for health promotion, Shanghai, China, 21–24 November 2016: all for health, health for all. 1. Strengthening health systems to accelerate delivery of Non-Communicable Diseases services at the primary health care level: one year progress review of the implementation of the 2016 Colombo declaration on NCDs Non-Communicable Diseases have become a major issue of national health agenda in Sri Lanka. Sri Lanka is currently facing a triple transition when public health is considered. Epidemiological transition, demographic transition and socio-economic transition all three transitions are making an impact on health and health indices of Sri Lanka. Control and prevention of NCDs are highlighted and recognized as a priority area of work in national development and health policy and plans. Traditional health systems in the country was geared more to curative services and it is imperative the health systems do a situation review and adjust and re-adjust to meet the demands of the new health profile and demand landscape of the country. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 130 The Colombo Declaration highlights renewed commitment by Member States to accelerate NCD service delivery through a people-centred primary health care approach to realize the global and regional voluntary targets for NCD prevention and control. The publication “Strengthening health systems to accelerate delivery of Non-Communicable Diseases services at the primary health care level: one year progress review of the implementation of the 2016 Colombo declaration on NCDs” provides a very good insight to lessons learnt during one year of implementation of the Colombo Declaration 2016. During review of documents related to Sri Lanka attempt at prevention and control of NCDs reference to this publication and reference to Colombo declaration was not present. Reviews and progress reports play a major role in monitoring and reprograming of existing NCD preventive and control measures. It appears to be a major drawback in Sri Lankan efforts that reports of above nature are not extensively used to direct its strategies. 2. TRIPS, intellectual property rights and access to medicines In Sri Lanka health economics and health accounts are a developing sub-specialty with a very few experts in pursuing this specialty. National health accounts were started only in 2015 and since it is a well-established component. Since 2015 ministry of health publishes annual health accounts. Sri Lanka is not a major pharmaceutical producing country. However, successive governments attempted to increase medicinal product manufacture in the country through the Health Ministry arm, State Pharmaceutical Manufacturing Cooperation (SPMC). TRIPS, Trade Related Aspects of Intellectual Property Rights agreement which is one of World Trade Organizations (WTO) agreements where Sri Lanka is a member and has to abide by. Of Sri Lanka’s health expenditure 32% on average is spent on pharmaceuticals. Bio medical Equipment also costs another 4% of the health expenditure. Opportunities for innovation and new developments are not encouraged because of uncertain future and competition from international players. TRIPS provide a framework to address such issues and provide find opportunities to be self-sufficient with medical technology driven products and new pharmaceuticals with intellectual rights. Sri Lanka needs to pay more attention to self-sufficiency with the newly acquired middle income country status. 3. Promoting health in the SDGs: report on the 9th Global conference for health promotion, Shanghai, China, 21–24 November 2016 When reviewing the health promotion landscape in Sri Lanka it is quite evident that health promotion has not got off the ground in Sri Lanka in comparison to many other global initiatives. The current health promotion policy of Sri Lanka was formulated in 2008-9 and approved by the cabinet of ministers in March 2010. Since then the policy has not been updated. There has been no strategic plan or action plans based on 2010 national health promotion policy. One of the strategies identified in the policy; upgrading the Health Education Bureau as a Health Promotion Bureau had been effected only in 2019. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 131 Ninth global conference on health promotion was held in Shanghai, China in November 2016 and its report “Promoting health in the SDGs: report on the 9th Global conference for health promotion, Shanghai, China, 21–24 November 2016: all for health, health for all” was one of the latest global document by WHO on health promotion. This document discusses challenges and opportunities for health promotion in realizing sustainable development agenda in 2030. The fact that health promotion is not in the forefront of Sri Lanka health agenda is a matter of concern. Not only the above Shanghai health promotion report, other key health promotion initiatives like “health in all policies” have failed to take root in Sri Lanka. Section end summary box 8: The type of and the publications that have demonstrated to contribute significantly to public health as well as those have not. WHO publications on tobacco control has demonstrated very significant contributions to Sri Lanka public health. WHO action plan publications on NCD control and prevention has demonstrated significant contribution to Sri Lanka public health. However, review reports and evaluation reports on NCD and NCD interventions do not demonstrate their contribution to Sri Lanka public health significantly. Health Promotion related WHO publications do not demonstrate significant contribution to Sri Lanka public health. However, it is beyond the scope of the present review to analyse the reasons for this outcome. Health economic related WHO publications also does not demonstrate to have significantly contributed to Sri Lanka public health, except for publications on national health accounts. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 132 3.9 Evidence of adoption of the content of WHO publications leading to changes in policy, clinical practice or individual’s behaviour. 3.9.1. Desk review Six Sri Lankan ministry of health documents were reviewed to identify if they demonstrate evidence of the content from WHO publications leading to changes in policy, clinical practice or individual behaviours. 1. Tackling NCDs: ‘best buys’ and other recommended interventions for the prevention and control of NCDs. 2. WHO Global Action Plan for prevention and control of Non-Communicable Diseases 2013 – 2020’. 3. Tobacco control: progress and plans for implementing the framework convention on tobacco control (FCTC). Type of document Selected document Description Policy document National policy and strategic framework for cancer prevention and control 3.9.1.1 National policy on health care quality and safety 3.9.1.2 Strategic plan / Action plan National health strategic plan for preventive sector 2016 – 2025. 3.9.1.3 National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020. 3.9.1.4 Guidelines Screening Guidelines Chronic Kidney Disease Sri Lanka 2017 3.9.1.5 Pain Management Guideline for Adults with Cancer 2017 3.9.1.6 TABLE 41: SRI LANKAN DOCUMENTS REVIEWED TO DEMONSTRATE EVIDENCE OF THE CONTENT OF WHO PUBLICATIONS LEADING TO CHANGES 3.9.1.1. First of the two Sri Lankan policy documents reviewed for evidence of adoption of content of WHO publications: “National policy and strategic framework for cancer prevention and control” The Sri Lankan policy document ‘National policy and strategic framework for cancer prevention and control’ was reviewed to identify the evidence of adoption of content of WHO publications. Due to the unavailability of a list of references in the Sri Lankan document, relevant WHO publications were studied to achieve the objective. Thus, examined WHO publications include ‘National Cancer Control Programmes. Policies and managerial guidelines’ and the six modules on the WHO publication series Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 133 ‘Cancer Control. Knowledge into Action’. Publications by IARC (International Agency for Research in Cancer) also were considered in the analysis. In the absence of a reference list in the Sri Lankan document under review, ‘National policy and strategic framework for cancer prevention and control’, it was compared with the above-mentioned WHO publications for the similarities in the technical content to identify evidence of the adoption of content in WHO publications. Findings: The National policy and strategic framework for cancer prevention and control – 2014 is the first ever policy document on cancer control and prevention in Sri Lanka at national level. It could be perceived that applicable WHO publications have been referred and adopted in drafting this Sri Lankan policy document. However, lack of references or bibliography in the Sri Lankan policy document under review posed a serious limitation in achieving the specific objective of assessing the extent to which the WHO publications have been used. Comparison of the contents in the Sri Lankan policy document with the applicable WHO publications was done to achieve the objective. The most relevant and applicable WHO publications for the national policy under review are the six modules in the series ‘Cancer control: knowledge into action’, which was developed as a response to the World Health Assembly resolution on cancer prevention and control (WHA58.22) and the ‘National Cancer Control Programmes: Policies and managerial guidelines (Second Edition)’. The WHO series on ‘Cancer control: knowledge into action’ discusses eight basic principles in cancer control, 1. Leadership, 2. Involvement of stake holders, 3. Creation of partnership, 4. Responding to the need of people, 5. Decision-making, 6. Application of a systemic approach, 7. Seeking continuous improvement and 8. Adoption of a stepwise approach. The eight basic principles of cancer control discussed above in the WHO series could be reflected among the policy objectives mentioned in the Sri Lankan policy document, as described below. Under the key principle one ‘Leadership’, continuous learning has been interpreted in the policy document as ‘To promote professional education of doctors, nurses, technicians and health workers to augment trained human resources (policy objective 6) and promote research and utilization of its findings for prevention and control of cancers (policy objective 7). Key principle 2 in the WHO series is involvement of stakeholders has been incorporated in the policy document in many policy objectives. For instance, strategy 6 for the policy objective 4 is to establish a network among governmental and non-governmental organizations including community-based organizations to deliver coordinated care for cancer patients and their family members. In addition, strategy 4 for the policy objective 1, collaborating with other health-related sectors with regard to primary prevention of other environmental and occupational risk factors, strategy 4 for the policy objective 2, building public/ private partnership with private health sector for screening and early diagnosis of cancer and building partnership with private health sector for provision of quality Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 134 care for cancer patients and strategy 2 for policy objective 5, facilitating inter-sectoral coordination in surveillance of cancers could be shown as examples for integrating WHO key principle 2, involvement of all stakeholders, and key principle 3, creation of partnerships, mentioned in the WHO knowledge into action series. Basic principle 4 in the WHO series of responding to the needs of people is reflected in the policy objective 3 spelled out as ‘ensure equitable and continuous accessibility to diagnosis and treatment facilities for cancers’. Core features discussed in the basic principle 5 in the WHO series of decision making has been incorporated in the policy objective 2, strategy 1 as strengthening evidence-based feasible and cost-effective screening service provision. Influence of the sixth basic principle of application of a systemic approach to share the goals with other related programmes and the health systems could be seen in the policy objective 1 strategy 1, where it is mentioned ‘strengthen health promotion in the community in tune with the National Health Promotion policy and National Non-Communicable Diseases prevention policy’. The seventh basic principle in the WHO series of seeking continuous improvement has been taken up at policy objective 3, strategy 1 as provision of resources for diagnosis of cancer in secondary and tertiary levels of care, strategy 5 as to expand radiotherapy facilities and strategy 6 as to improve paediatric oncology services. The policy objective 4 is on expanding rehabilitation, survivorship care and palliative care facilities for cancer patients, which also has the influence of the basic principle 7 of the WHO series. Strategy 3 of policy objective 5, to improve and strengthen medical records services and also to develop the population-based cancer registry in Colombo district, and introducing hospital- based cancer registries and routine coding of cancers internationally accepted coding systems under the policy objective 5 are examples for the influence of the WHO basic principle 7 on this policy document. The final basic principle, adoption of a step-wise approach to plan and implement interventions could be seen in policy objectives 2,3 and 4, where establishing and expansion of screening, treatment and palliative services are discussed. The other WHO publication applicable to this Sri Lankan policy document is the National Cancer Control Programmes. Policies and managerial guidelines (Second Edition)’. The content discussed in this WHO publication under the topics Prevention, Early detection of cancer, Diagnosis and treatment of cancer, Pain relief and palliative care and Cancer control research could be found throughout the policy objectives in the document under review. For instance, the topics discussed in the WHO document Prevention, Early detection of cancer, Diagnosis and treatment of cancer, Pain relief and palliative care, Cancer control research and Surveillance in cancer control coincide with the policy objectives 1, 2, 3, 4, 7 and 5 respectively. Conclusion: In the Sri Lankan policy document ‘National policy and strategic framework for cancer prevention and control’ there are ample evidence of adoption of content from WHO publications and they had been referred to a greater extent in preparing the National policy on cancer control and prevention. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 135 3.9.1.2. Second of the two Sri Lankan policy documents reviewed for evidence of adoption of content of WHO publications: “National policy on health care quality and safety” The Sri Lankan document ‘National policy on health care quality and safety’ (2015) was reviewed to assess the evidence of adoption of WHO publications. Since the Sri Lankan document did not have a list of references, most relevant WHO publications were searched. WHO publications of ‘A background for national quality policies in health systems’, ‘World alliance for patient safety, forward programme 2008–2009’ and ‘Regional strategy for patient safety in the WHO South-East Asia Region (2016–2025)’ were selected for the analysis. The selected WHO publications were compared with the Sri Lankan document under review, ‘National policy on health care quality and safety’ (2015) to assess whether the core contents and/or key messages in WHO publications were reflected. ‘A background for national quality policies in health systems’ and ‘World alliance for patient safety, forward programme 2008 – 2009’ were reviewed. The most applicable publication, ‘Regional strategy for patient safety in the WHO South-East Asia Region (2016-2025)’ was disregarded as its year of publication was the same as the Sri Lankan document under review. Findings: The Sri Lankan policy document had covered many technical areas discussed in the WHO publications under consideration. In the WHO publication ‘World alliance for patient safety, forward programme 2008 – 2009’, five themes are been recommended to ensure the patient safety, namely assessing and understanding the problems of unsafe care, developing norms and establishing standards to reduce harm, improving knowledge access/ use and evaluating impact, promoting innovation and sustaining commitment and strengthening capacity for patient safety worldwide (page 4). The other WHO publication under concern, ‘A background for national quality policies in health systems’ discusses the background required for an effective quality policy (page 9). In the discussion, the mainly stressed areas include, national values and priorities for quality including legislations, national organization and institutionalization of quality, Methods/ techniques and tools for development of quality, resources for quality improvement, identify structure/ roles and accountability, define and disseminate practical guidance, research and pilot quality projects, develop knowledge, attitudes and skills, national minimum data set and dissemination of data. On the other hand, the ‘National policy on health care quality and safety’ in Sri Lanka discusses its contents in seven broad key result areas. These are customer / patient satisfaction, managerial systems and process improvement, clinical effectiveness, risk management, safety and enabling a culture for quality improvement, staff development and welfare and research for quality improvement and patient safety. Under each key result area, strategies to achieve the result are outlined. Although the Sri Lankan national policy lacks a smooth flow, it basically covers all the areas identified by the WHO publications except for legislations, having a minimum data set and a system to monitor and evaluate the activities. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 136 Despite having overlapping content areas in the compared publications, adoption of WHO content could not be commented on due to differences in the order of presentation and categorization. Conclusion: Adoption of the content of WHO publications leading to changes in the Sri Lankan policy could not be well established in the Sri Lankan document ‘National policy on health care quality and safety’ (2015). 3.9.1.3. First of the two Sri Lankan strategic plan / action plan documents reviewed for evidence of adoption of content of WHO publications: “National health strategic plan for preventive sector 2016 – 2025” The ‘National health strategic plan for preventive sector 2016 – 2025’ extensively discusses vision, mission, goals, objectives and major activities or strategic framework to achieve the programme objectives of 32 Public Health institutions/ programmes in the state sector of the country. Findings: In achieving the objective of demonstrating evidence for adoption of contents in WHO publications was assessed only among the public health programmes/ units that have listed a WHO publication in the reference list, as it was not feasible for other units/ programmes. Even among the programmes/ units that have listed sources of information, in-text citation has not been indicated, making it difficult to assess which component in the write up was taken up from which publication. Therefore, the content of the write up was read and compared with the WHO publication to look for evidence of the adoption. Of the 32 programmes/ units that have discussed their strategic plans in the Sri Lankan document under review, only 21 had provided a list of sources of information. Out of those 21, only eight have listed a WHO publication as a source of information for the content. The respective programme and the WHO publication referred is as shown below. • National Programme for Tuberculosis Control and Chest Diseases (NPTCCD) • Food Safety unit • Chronic Kidney Disease unit • Occupational and Environmental health unit • WHO regional office for South-East Asia (2015). TB control in the South East Asia region • WHO estimates of the global burden of foodborne diseases’ • Investigation and evaluation of the CKDu in Sri Lanka • WHO global plan of action for workers’ health (2008-2017): Baseline for implementation • Indoor air quality guidelines Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 137 • STD/AIDS campaign • Leishmaniasis surveillance unit • Anti-leprosy campaign • Health Promotion Bureau • WHO guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV • WHO 2010 Technical report series. Control of the Leishmaniasis. • WHO 2009 Enhanced Global Strategy for further reducing the disease burden due to Leprosy – operational guidelines • WHO 2009 Enhanced Global Strategy for further reducing the disease burden due to Leprosy – plan period: 2011-2015 • Ottawa charter for health promotion 1986 Of the eight programmes/ units that listed a WHO publication for reference, three technical units (the NPTCCD, chronic kidney disease unit and the Food Safety unit) have referred the mentioned WHO publication as a source of information on the estimates of the disease burden rather than for technical inputs on strategies for control and/ or prevention of a disease. The occupational unit mentions the ‘WHO global plan of action for workers’ health (2008-2017): Baseline for implementation’ in drafting their strategic framework. A variety of activities are recommended for implementation by this publication, which are devising a workers’ health policy, protecting and promoting health at work place, improving access to occupational health services, providing evidence for action and incorporating workers’ health into other policies. But the strategies in the Sri Lankan document discusses only about improving the surveillance, improving service provision at all levels and enhancing inter-sector collaboration (page 174). There is a mismatch between the contents in the two documents, indicating poor trickling of WHO information to the national level. The Environmental Health unit lists ‘Indoor air quality guidelines’ as a source of WHO references, but discusses strengthening the capacity of the Ministry of Health, strengthening the stakeholder participation and providing necessary services to the community as the programme objectives. This clearly depicts a mismatch between the references and the content in the strategies of the Environmental Health Unit. The STD/ AIDS account written by the College of Community Physicians listed ‘WHO guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV’, but mentions a wide range of outputs such as access for testing and treatment without legal barriers, improving quality of testing and other services, zero discrimination and zero stigma, access to quality school education for infected people etc. In addition to the WHO, the authors have referred publications by the UNAID publication, which is a pioneering global agency in the fight against HIV/AIDS. Therefore, the WHO publications were not used as an authoritative source of information by the national HIV/AIDS control programme write up by the College of Community physicians. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 138 The WHO publication ‘2010 Technical report series. Control of the Leishmaniasis’ was referred by the leishmaniasis surveillance unit in drafting the strategic framework. The technical report series make recommendations on new therapeutic regimens for visceral and cutaneous leishmaniasis, rapid diagnostic tests, management of leishmania-HIV coinfection, research priorities including epidemiological and therapeutic studies. The WHO report not only provides guidance on implementation but also elaborates the strategic approaches in controlling the disease. In contrast, the Sri Lankan document only discusses capacity building of the health care providers and public awareness improvement using IEC materials (page 63). This evidence of adoption comparison reveals poor penetration of WHO strategic recommendations to the Sri Lankan national strategic plan for leimaniasis prevention and control. Anti-leprosy campaign is the only programme which had listed more than one WHO publication in the list of references. However, the programme does not describe the strategies or major activities to achieve the goal of the programme. Instead, they have listed the output indicators and the means of verification for the indicators. The WHO publication on operational guidelines discusses strategies for case detection, diagnosis, treatment, Prevention of Disability (PoD) and self-care, rehabilitation, monitoring, recording and reporting as well as organizational issues for programme managers. However, the Sri Lanka anti-leprosy programme strategic plan discusses only case detection and treatment aspects in their objectives as well as in the output indicators (page 97). Therefore, it can be concluded that the technical content given in the WHO publication has not infiltrated the strategic framework of the anti-leprosy campaign in Sri Lanka. However, the anti-leprosy programme output indicators are in line with the preventive and control strategies for leprosy discussed in the WHO publications. In the write up by the Health Education Bureau, only the programme objectives (indicators and means of verification columns are empty) and output indicators have been discussed in relation to the activity plan, making it impossible to assess whether the technical knowledge in the Ottawa charter, the mentioned WHO publication as a source of information, has been put into action effectively. Conclusion: Evidence indicates that the adoption of the contents of WHO publications in the Sri Lankan strategic plan “National health strategic plan for preventive sector 2016–2025” is at a very low level. 3.9.1.4. Second of the two Sri Lankan strategic plan / action plan documents reviewed for evidence of adoption of contents of WHO publications: “National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020” The National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020 is a comprehensive plan that has been developed in order to achieve the ten voluntary targets adopted by Sri Lanka based on the nine global targets and the specific regional targets identified for the South East Asia region. The plan discusses outcomes to be achieved, specific Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 139 activities to be implemented, required multi-sector partnerships and the time frame by which the targets are to be achieved. A desk review of the National Multi-sectoral Action Plan for the Prevention and Control of Non- Communicable Diseases 2016 – 2020 was done to assess the perceived influence and impact of WHO publications on the national action plan. Relevant WHO publications were compared with the contents in the Sri Lankan document to describe evidence of adoption of the content in WHO publications in Sri Lankan strategic action plan. Findings: The WHO publication that has a direct implication on this Sri Lankan document is the ‘WHO Global Action Plan for prevention and control of Non-Communicable Diseases 2013–2020’, which has been prepared by compiling all the previous work and evidence on NCD. Findings of the comparison between this WHO publication and the Sri Lankan action plan are depicted in the TABLE 42. ‘Global Action Plan for prevention and control of Non-Communicable Diseases 2013–2020’ by the WHO discusses vision, goal, overarching principles, objectives, voluntary global targets and a global monitoring framework. In overall comparison, the Sri Lanka action plan also describes vision, goal, overarching principles, objectives, Sri Lankan targets, and strategic priority action areas to prevent and control NCD in Sri Lanka. A basic comparison of the content in the two documents are shown in the TABLE 42. Content area WHO publication 1 Sri Lankan document 2 Vision multisectoral collaboration and cooperation at national, regional and global levels, so that populations reach the highest attainable standards of health, quality of life, and productivity at every age and those diseases are no longer a barrier to well-being or socioeconomic development. multisectoral collaboration and cooperation at national level, so that populations reach the highest attainable standards of health and productivity at every age and those diseases are no longer a barrier to well- being or socioeconomic development. Goal 1. Life course approach 2. Empowerment of people and communities 3. Evidence-based strategies 4. Universal health coverage 5. Management of real, perceived or potential conflicts of interest 6. Human rights approach 7. Equity-based approach 8. National action and international cooperation ad solidarity 9. Multisectoral action 1. Life course approach 2. Empowerment of people and communities 3. Evidence-based strategies 4. Universal health coverage 5. Management of real, perceived or potential conflicts of interest 6. Human rights approach 7. Equity-based approach 8. National action and international cooperation ad solidarity 9. Multisectoral action TABLE 42: COMPARISON BETWEEN THE STRATEGIES IN THE MULTI-SECTORAL ACTION PLAN TO PREVENT AND CONTROL NCD IN SRI LANKA AND THE OBJECTIVES OF THE WHO PUBLICATION GLOBAL ACTION PLAN TO PREVENT AND CONTROL NCD Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 140 Overarching principles 1. Life course approach 2. Empowerment of people and communities 3. Evidence-based strategies 4. Universal health coverage 5. Management of real, perceived or potential conflicts of interest 6. Human rights approach 7. Equity-based approach 8. National action and international cooperation ad solidarity 9. Multisectoral action 1. Life course approach 2. Empowerment of people and communities 3. Evidence-based strategies 4. Universal health coverage 5. Management of real, perceived or potential conflicts of interest 6. Human rights approach 7. Equity-based approach 8. National action and international cooperation ad solidarity 9. Multisectoral action Objectives 1. To raise the priority accorded to the prevention and control of Non- Communicable Diseases in global, regional and national agendas and internationally agreed development goals, through strengthened international cooperation and advocacy 1. To raise the priority accorded to the prevention and control of Non-Communicable Diseases in global, regional and national agendas and internationally agreed development goals, through strengthened international cooperation and advocacy 2. To strengthen national capacity, leadership, governance, multisectoral action and partnerships to accelerate country response for the prevention and control of Non-Communicable Diseases 2. To strengthen national capacity, leadership, governance, multisectoral action and partnerships to accelerate country response for the prevention and control of Non-Communicable Diseases 3. To reduce modifiable risk factors for Non- Communicable Diseases and underlying social determinants through creation of health-promoting environments 3. To reduce modifiable risk factors for Non-Communicable Diseases and underlying social determinants through creation of health- promoting environments 4. To strengthen and orient health systems to address the prevention and control of Non-Communicable Diseases and the underlying social determinants through people-centred primary health care and universal health coverage 4. To strengthen and orient health systems to address the prevention and control of Non-Communicable Diseases and the underlying social determinants through people- cantered primary health care and universal health coverage 5. To promote and support national capacity for high-quality research and development for the prevention and control of Non- Communicable Diseases 5. To promote and support national capacity for high-quality research and development for the prevention and control of Non- Communicable Diseases 6. To monitor the trends and determinants of Non-Communicable Diseases and evaluate progress in their prevention and control 6. To monitor the trends and determinants of Non- Communicable Diseases and evaluate progress in their prevention and control Sources: 1. WHO Global Action Plan for prevention and control of Non-Communicable Diseases 2013 – 2020 2. National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 141 At the activity level, most of the interventions suggested in the WHO document had been listed in the Sri Lankan action plan, except for the interventions recommended by the WHO to combat individual diseases, namely Cardiovascular disease, Diabetes, Cancer, Chronic respiratory diseases (page 69). In the Sri Lankan document, attention has not been paid to interventions that helps to improve prevention and control of individual diseases. Other than this disparity, the two documents are almost identical. Conclusion: Adoption of the content of relevant WHO publications in compiling the ‘National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 -2020’ was very high. Evidence of adoption indicates that the two documents are almost identical. 3.9.1.5. First of the two Sri Lankan guideline documents reviewed for evidence of adoption of contents of WHO publications: ‘Screening Guidelines Chronic Kidney Disease Sri Lanka 2017’ ‘Screening Guidelines Chronic Kidney Disease Sri Lanka 2017’ is an update and revision of the first guideline on screening for Chronic Kidney Disease (CKD) in Sri Lanka published in 2014. It is expected that this document will serve as a comprehensive guide for the health care providers engaged in screening programme. The publication clearly describes the high-risk geographic areas, target populations and exclusion criteria, screening settings, screening methods, screening tools, administration of screening tools, sample collection and dispatch, required calculations, quality assurance of laboratory tests, cut-off values for laboratory and other investigations, interpretation of results, referral procedures and indications, field screening clinics, implementational plan, monitoring and evaluation, district level indicators and targets as well as data analysis and dissemination of information. A desk review of the Sri Lankan document under review, ‘Screening Guidelines Chronic Kidney Disease Sri Lanka 2017’, was done to assess the reach of relevant WHO publications. Understandably, most WHO publications have focused on Diabetes, Cardio-vascular diseases, Chronic pulmonary diseases and Cancer in their publications on chronic diseases, and there was no specific publication on screening for CKDu. The WHO publication titled ‘International expert consultation on CKDu’ was published in 2017, three years after the publication of the Sri Lankan document. Hence this publication was not considered for reviewing. In the absence of any other relevant WHO publication, comparison was done with the ‘Principles and practice of screening for diseases’ (1968) by the WHO. Findings: The Sri Lankan document discusses the methodology for the screening for CKDu within Sri Lanka in a comprehensive manner. The ten principles described in the WHO publication on effective screening programmes (page 26-27) are well reflected in the Sri Lankan document, as shown in the TABLE 43. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 142 Key principle Evidence for adoption in the Sri Lankan document Condition sought should be an important health problem Magnitude of the problem is not mentioned nor screening is not justified with evidence Availability of an accepted treatment for patients with recognized disease Not discussed Facilities for diagnosis and treatment should be available Available and referral pathways are described in the chapter ‘Referral procedures for persons with abnormal test results’ (page 10) Availability of a recognizable latent or early symptomatic stage Not discussed Availability of a suitable test or examination Screening tool and its administration discussed in page 5 The test should be acceptable to the population Not discussed The natural history of the condition should be known Not discussed Agreed policy to say whom to treat as patients Described in the Chapters ‘cut-off values for blood pressure and laboratory investigations’ and ‘Interpretation of results’ (page 9) Cost effectiveness Not discussed Should be a continuous process Discussed under the chapter ‘Monitoring and evaluation’ (page 13) TABLE 43: EVIDENCE OF ADOPTION OF WHO KEY PRINCIPLE ON SCREENING BY THE GUIDELINE FOR SCREENING CKDU IN SRI LANKA Overall, four out of ten key principles on screening by the WHO are reflected on the contents of the Sri Lankan document. However, it should be noted that the Sri Lankan document has been prepared to describe the methodology of the screening process, rather than to justify the establishment of a screening programme for CKDu in the country. Nevertheless, having such a technical justification would have improved the quality of the Sri Lankan publication. Conclusion: There was insufficient evidence to suggest that the content of WHO publications had been adopted in the reviewed guideline document ‘Screening Guidelines for Chronic Kidney Disease Sri Lanka 2017’. 3.9.1.6. Second of the two Sri Lankan guideline documents reviewed for evidence of adoption of contents of WHO publications: ‘Pain Management Guideline for Adults with Cancer 2017’ ‘Pain Management Guideline for Adults with Cancer 2017’ is the second Sri Lankan guideline document reviewed for evidence of adoption of content of WHO publications. The publication by the National Cancer Control Programme of Sri Lanka had a list of references and also in-text citations, making it feasible to accurately evaluate the evidence of the adoption of the content of WHO publications, Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 143 leading to changes in policy. In addition, other relevant WHO publications published before 2017 but are not mentioned in the reference list of the Sri Lankan document were also analysed to assess the influence of the WHO publications on the Sri Lankan document. ‘Cancer pain relief’ (1996) - WHO was the other most relevant publication thus selected to compare with the Sri Lankan document. Findings: The WHO reference was used as the sole source of information to describe the principles of pharmacological treatment of pain which is described as the backbone for treatment of pain (page 10). However, there was no evidence on any references from other relevant WHO publications. Conclusion: Adoption of WHO publication contents in the Sri Lankan document ‘Pain Management Guideline for Adults with Cancer 2017’ has been moderate. Out of the six documents reviewed for evidence of adoption of content of WHO publications, one action plan document, the ‘National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020’ showed a very high adoption of content from relevant WHO publications. Sri Lankan policy document ‘National policy and strategic framework for cancer prevention and control’ showed high levels of adoption of content from WHO publications. “Pain management guideline for adults with cancer 2017” showed a satisfactory level of adoption of content from WHO publications. “National policy on health care quality and safety’ (2015) showed a very low level of adoption of content form WHO publications and ‘Screening Guidelines Chronic Kidney Disease Sri Lanka 2017’, showed very minimal evidence of adoption of content from WHO publications. Evaluation of Sri Lankan policy document ‘National policy on health care quality and safety’ (2015) did not reveal any evidence of adoption of content from WHO publications. The fact that three Sri Lankan documents: a policy document, a strategic plan and a guideline demonstrating evidence of high levels of adoption of content from WHO publications shows that Sri Lanka trusts reputation of WHO publications as credible sources of health information with high level of authoritativeness. 3.9.2. Quantitative survey In the quantitative survey, opinions were asked of the target audiences with medical backgrounds if the content of WHO publications have led to changes in policy, clinical practices or individuals’ behaviour in Sri Lanka. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 144 Yes No Total No: % No: % Health ministry officials 49 (84%) 16 (16%) 65 Health ministry national technical consultants 21 (91%) 2 (09%) 23 Members of medical professional colleges 64 (89%) 8 (11%) 72 Medical research community 58 (84%) 11 (16%) 69 TABLE 44: RESPONSE TO THE QUESTION “HAS THE CONTENT OF WHO PUBLICATIONS LED TO CHANGES IN POLICY, CLINICAL PRACTICES OR INDIVIDUAL BEHAVIOURS IN SRI LANKA?” Over 80% of respondents in all medical related target audiences agreed that WHO publications have led to changes in policy, clinical practices or individual behaviours in Sri Lanka. Health ministry national technical consultants who are in national technical units, agreed most at 91%. It is significant to note that in medical research community, where the WHO publication reach was comparatively low (TABLE 13), agreement to that WHO publications have let to changes in policy, clinical practices or individual behaviours is high. Section end summary box 9: Evidence of adoption of the content of WHO publications leading to changes in policy, clinical practice or individuals’ behaviour. 1. In the Sri Lankan policy document ‘National policy and strategic framework for cancer prevention and control’ there are ample evidence of adoption of content from WHO publications and they has been referred to a greater extent in preparing the National policy on cancer control and prevention. 2. Adoption of the content of WHO publications leading to changes in the Sri Lankan policy could not be well established in the Sri Lankan document ‘National policy on health care quality and safety’ (2015). 3. Evidence indicates that the adoption of the contents of WHO publications in the Sri Lankan strategic plan “National health strategic plan for preventive sector 2016 – 2025” is at a very low level. 4. Adoption of the content of relevant WHO publications in compiling the ‘National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016 – 2020’ is very high. Evidence of adoption indicates that the two documents are almost blueprints. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 145 5. Evidence of the adoption of the content of WHO publications in the reviewed guideline document ‘Screening Guidelines Chronic Kidney Disease Sri Lanka 2017’ is scarce. 6. Adoption of WHO publication contents in the Sri Lankan document ‘Pain Management Guideline for Adults with Cancer 2017’ is satisfactory. Over 80% of respondents in the quantitative survey from all medical related target audiences agreed that WHO publications have led to changes in policy, clinical practices or individual behaviours in Sri Lanka. A very high majority of the medical related target audiences (Health ministry officials, Health ministry national technical consultants, Medical professional colleges, Medical research community) agreed that WHO publications have been used as an authoritative source of health information in Sri Lanka. 3.10. The extent to which the language, format and mode of dissemination of WHO publications influence their use as reference and authoritative source. TABLE 45: RESPONSE TO THE QUESTION “HAVE WHO PUBLICATION BEEN USED AS REFERENCE AND AUTHORITATIVE SOURCE IN SRI LANKA?” Yes No Total No: % No: % Health ministry officials 51 (88%) 7 (12%) 58 Health ministry national technical consultants 21 (91%) 2 (09%) 23 Members of medical professional colleges 59 (82%) 13 (18%) 72 Medical research community 60 (87%) 9 (13%) 69 A very high majority of the medical related target audiences agreed that WHO publications have been used as an authoritative source of health information in Sri Lanka. Section end summary box 10: The extent to which the language, format and mode of dissemination of WHO publications influence their use as reference and authoritative source. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 146 3.11. Recommendations on how WHO can foster better use of health information in Sri Lanka? Respondents were asked to give up to three responses how WHO can foster better use of health information in Sri Lanka. Many suggested having emailing lists to update on new releases. There were several responses on the formats of the publications: requesting more ‘infographs’ and charts and requests to reduce the write ups and technical contents. The following TABLE 46 provides concise presentation of opinions given by the respondents. 1 2 3 By YouTube videos Documentary movies Pop ups Having an online repository for the publications for the country New updates to be shared by an email (have subscribers) and send updates (text, email) Publish only few articles a year, may be as a big compiled book Have an index of an Year's publications/ have a calendar Why do you want to make the world a better place? Get the opinion from the public Include local consultants By using podcasts publishing summary books publishing country specific documents Wider dissemination through professional bodies SLMA and colleges Dissemination through unions AMS, GMOA and NU, Dissemination summary at hospital directors forum or NHDC Some publications with key messages in two local languages Considering capacity of peripheral areas when preparing guidelines Auditing the use of guidelines Dissemination through networks enhancement of communication between WHO and post graduate institute of medicine, Colombo making publication guideline of updates in WHO web or app make professional group to share the information Make sure web links are always available Make search facilities more user friendly Having a portal with a link to different publications in the Ministry of Health web site e.g. NCD. Health systems, Environmental and Occupational Health, etc. Making key messages TABLE 46: OPINIONS EXPRESSED BY THE RESPONDENTS ON WAYS WHO CAN FOSTER BETTER USE OF HEALTH INFORMATION IN SRI LANKA Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 147 Make available a link for all NCD related research articles Aware the officials on latest publication via email Aware the officials on latest publication via work shops Collaboration with relevant officials in ministry of health Disseminating it to the relevant authorities via email or hard copy Conduct workshops to disseminate it Assess the data and provide information on the gaps identified and suggestions for improvement Develop a repository of documents which are relevant and useful in the country context Available these publications at the Ministry of Health Website Regular usage as a reference material THROUGH SOCIAL MEDIA content should be very practical the docs should be very reader friendly include pictographs and images Patients and public need to be involved and engaged Regular reviews on the outcome and impact of the target information Monitoring and evaluation from bottom up approach By providing training to relevant healthcare staff By using local media such as TV and Radio By using social media (this is already in use I suppose) Develop in three language Hard copies targeting different target groups need to be available to all Made available Sinhala translations Inform the intended users by providing web links etc. Share the facts and figures with the relevant officers in the Ministry of Health Publish in Sinhala. Distribute hard copies to relevant sectors Prepare simple and short publications provide hard copies to institutions Book introduction or launching in Sri Lanka inviting the relevant stakeholders Link to appear in health institution web sites Distribute /Make available a catalogue for easy reference with the link Compile an Email list of those interested and inform them like in infolep, CDC, etc. Easy access to the website organising short courses in country and outside the country letting experienced the best practices Giving correct information to Health workers working with the community. Make aware the target audience on the available products periodically arrange publications by sections and display in a common platform Arrange country specific ones separately and common ones separately Make online search to find a required document easier Make a comprehensive list of publications in the website State the year of publication in online information, specifically fact sheets etc Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 148 wide dissemination more advocacy lessons learned or case histories disseminating publications widely making the WHO library accessible to researchers making a repository of WHO publications in reputed local libraries and keeping the material updated Giving wide publicity to their publications Having an all in one web site to publish health information related to different indicators where the users are given the ability to search for each country Use of Infographics Summary of each chapter How WHO can foster better use of health information  Wider dissemination and greater outreach to all public health institutions in every member state.  By carrying out needs assessments and impact assessments o Needs assessments • Helps to clarify what are needs of publications. • What is the information product is intended to achieve, lead or support. • What is the intended change expected from the information product. • The intended target audience/s. • Appropriate media and style of communication. o Impact evaluation/impact assessment • Impact evaluation is essential for promoting good practice. • As a measure of use and uptake of WHO information can track download page view data, bibliometrics and altmetrics.  People / users/ target audiences has to be trained how to find the health information they look for / they want. o People think that google has all of the information. o People fail terribly trying to find out good quality information. o It takes only few minutes to identify good quality publications. Suggestions by WHO HQ and SEARO publication staff through the Qualitative study through Survey Monkey form how WHO can foster better use of health information Identification and documenting/ publicizing the target group will contribute immensely at improving the reach of the publications. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 149 CHAPTER 4: CONCLUSIONS AND RECOMMENDATIONS Reach of WHO publications to the Sri Lankan reader 1. WHO publication process has a well-organized method of identification of target audiences. However, the review revealed that indicating the target audience in the publication is not a regular practice in the WHO publications which adversely affect WHO publications reaching the intended target audiences. 1.1. It is recommended that for each publication, the intended target audiences to be identified at the initial stage of publication development and displayed /indicated in the publication to improve the reach of WHO publication to the intended target audiences. Any future revision of WHO publication policy to include this as a directive. 2. The extent of reach of WHO publications to Sri Lankan authorities appears to be in the moderate to low range based on the evaluation of the publications of Sri Lanka Ministry of Health policies, strategic plan and guideline documents though this evaluation was affected by shortcomings/ non-availability of referencing in the Sri Lankan publications. 2.1. A main suggestion to improve the situation was found to be promoting referencing by providing citation/ how to cite the source document at the beginning of the WHO publication. This recommendation will also contribute to more objective evaluation of evidence of reach, usefulness and use of WHO publications, in the future. 3. Reach of WHO publications to the officials in the Ministry of Health depends on two factors. The category of professional and the type of WHO publication. The category of professional: among technical consultants, particularly Health Ministry national technical consultants the reach was shown to be average to high. Other categories including medical research community the reach was low. While reach of NCD related publications was high, those of health systems appeared to be low. 3.1. It is recommended to identify novel strategies to disseminate WHO publications to increase the reach and accessibility to the intended target audiences. 3.2. Create an email base of target audiences (current/ prospective/ intended) and send the relevant target audiences an email notification in a fixed time gap or whenever a new publication is published. However, sending bulk and general notifications to all audiences is not recommended. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 150 4. Online mode was the popular mode of distribution of the WHO publications reaching Health Ministry officials and Health Ministry national technical consultants. Majority of medical research community either actively searched online for WHO publications or noticed them accidently online. More than half of the members from Health Ministry officials were of the opinion that making WHO publications online only will improve the reach of the WHO publications to the Sri Lankan reader. Majority of the other three target groups with a medical background (Health Ministry national technical consultants, medical research community and members of medical professional colleges) were of opinion that making WHO publications online only will hinder the reach of WHO publications to the Sri Lankan reader. 4.1. Adopting innovative ways of boosting the dissemination of online versions of WHO publications are recommended as oppose to printed publications. This will improve both the reach of WHO publications to Sri Lankan reader leading to improved use of WHO publications in Sri Lanka. 4.2. Mode of dissemination of the WHO publications should be customized according to the target groups to improve the reach of WHO publications to specific target groups in Sri Lanka. 5. Reach of WHO Sri Lanka country office Facebook uploads to the Sri Lankan general public appears to be low. Social media engagement by Sri Lankans also appears to be poor. 5.1. Proactive use of social media platform is recommended to reach the Sri Lankan general public. Creating Facebook pages with regular and frequent uploads and actively increasing the friends and followers will promote the reach of Sri Lankan general public through social media via Facebook. Usefulness of WHO publications to the Sri Lankan reader 1. Most of the selected WHO publications which were reviewed did not clearly demonstrate that the publication has used country specific needs assessment or global strategies and prioritizations in the publication. This may be a limiting factor of usefulness of WHO publications to individual countries including Sri Lanka. “Working towards achieving Sustainable Development Goals” is one of the best examples from reviewed WHO publications which demonstrated responsiveness to global strategies and priorities, thus high in usefulness. 1.1. It is recommended that future WHO publications should respond to global strategies and priorities. They also should be based on needs assessments which will improve the usefulness of WHO publications to the reader. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 151 2. Overwhelming majority of the members of four target groups with a medical background responded that WHO publications respond to and meet their priority information needs. This indicates that WHO publications which are based on health information needs of the reader will achieve higher usefulness to the reader. 2.1. It is recommended that future WHO publications should focus to address readers priority information needs which will improve the usefulness of WHO publications to the reader. 3. Use of English language and technicality of English used in WHO publications does not adversely affect the usefulness of WHO publications in Sri Lanka. 4. Publications with lesser technical contents and use of more reader friendly formats, including infographics appears to be more appealing to the Sri Lankan reader. 4.1. Making WHO publications concise and use of modern communication methods and techniques are recommended which will improve the usefulness of WHO publications to the Sri Lankan reader. 5. Near 100% agreement was expressed by Health Ministry officials and Health Ministry national technical consultants that WHO publications are of high quality. They responded by very strongly agreeing that WHO publications are very high/ high in perceived credibility, authoritativeness, trustworthiness and reputability, the four dimensions of quality. Use of WHO publications by the Sri Lankan reader 1. The reviewed WHO publication, “Global Action Plan for the Prevention and Control of Non- communicable Diseases 2013 – 2020” had a greater influence and impact on the formulation of the “National Multi-sectoral Action Plan for Prevention and Control of Non-communicable Diseases in Sri Lanka”. 1.1. Organized introducing of WHO publications to relevant target groups is recommended as it was found to improve the use of WHO publications as evidenced by the use of “Global Action Plan for the prevention and Control of Non-Communicable Diseases 2013–2020” in Sri Lanka. 2. Evidence of perceived influence and impact of WHO publications on some of the reviewed Sri Lankan Ministry of Health published policy, strategic plan and guideline documents was limited due to lack of a list of references to assess the extent of perceived influence and comparative advantage of WHO publications in relation to the ones by other stakeholders. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 152 3. Review of Sri Lankan Ministry of Health published policy, strategic plan and guideline documents for their references to WHO publications revealed that the extent to which the relevant WHO publications have been used as authoritative sources of health information is very high in NCD and cancer prevention related publications. 4. Greater majority of the target audiences with a medical background agreed that WHO publications are used as authoritative sources of health information in Sri Lanka. 5. WHO publications on tobacco control and NCD prevention and control have made significant contributions to public health in Sri Lanka. 6. WHO publications on Health Promotion and related to Health Economics does not show a significant contribution to public health in Sri Lanka. 6.1. It is recommended that Health Promotion and Health Economics related information needs to be identified as priority areas in Sri Lanka to promote the use of relevant WHO publications in Sri Lanka. 7. Review of Sri Lanka Ministry of Health published policy, strategic plan and guideline documents revealed that there is ample evidence that the content of WHO publications have been adopted leading to changes in policy, clinical practice and practices of people in Sri Lanka. 8. Majority of the target audiences with a medical background agreed that the content of WHO publications have led to changes in policy, clinical practice or individual behaviours in Sri Lanka. 9. Majority of respondents agreed that WHO publications are used as authoritative sources of health information in Sri Lanka. 10. Sri Lankan readers’ awareness of available WHO publications and available health information and how to find them appears to be poor leading to low use of WHO publications in Sri Lanka. 10.1. It is recommended to develop a training module to train Sri Lankan target audiences how to find health information they look for, to promote the use of WHO publications in Sri Lanka. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 153 ABBREVIATIONS CKD Chronic Kidney Disease CKDu Chronic Kidney Disease Unknown Etiology FCTC Framework Convention on Tobacco Control FHB Family Health Bureau GMOA Government Medical Officers’ Association GoSL Government of Sri Lanka HPB Health Promotion Bureau HQ Head Quarters HRH Human Resources for Health HS Health Systems IARC International Agency for Research in Cancer ICT Information and Communication Technology IHR International Health Regulations MoH Ministry of Health and Indigenous Medical Services of Sri Lanka (formerly, Ministry of Health, Nutrition and Indigenous Medicine) NCCP National Cancer Control Programme NCD(s) Non-Communicable Disease(s) NPTCCD National Programme for Tuberculosis Control and Chest Diseases PGIM Postgraduate Institute of Medicine PKDL Post Kala-Azar Dermal Leishmaniasis PoD Prevention of Disability PwC PricewaterhouseCoopers (Pvt) Ltd. RDHS Regional Director of Health Services SDG Sustainable Development Goals SEAR(O) South East Asia Region/al Office SLMA Sri Lanka Medical Association SMS Short Message Service SPMC State Pharmaceutical Manufacturing Cooperation ToR Terms of Reference TRIPS Agreement on Trade-Related Aspects of Intellectual Property Rights UHC Universal Health Coverage UNAIDS United Nations Programme on HIV and AIDS URL Uniform Resource Locator WHO World Health Organization WHO IRIS World Health Organization Institutional Repository for Information Sharing WTO World Trade Organization Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 154 DISCLAIMER Our Services were performed and this Report was developed in accordance with Agreement for Performance of Work (APW) signed with World Health Organisation (WHO – “Client”) dated 19 July 2019 and are subject to the terms and conditions referred therein. We are providing no opinion, conclusion or other form of assurance with respect to our work and we did not verify or audit any information provided to us. This information has been prepared solely for the use and benefit of, and pursuant to a client relationship exclusively with, WHO. PwC disclaims any contractual or other responsibility to others based on its use and, accordingly, this information may not be relied upon by anyone other than WHO. Evaluation of Impact of WHO Publications Related to Non-Communicable Diseases (NCDs) and Health Systems in Sri Lanka - 2013 – 2019 155