Action Plan for Prevention and Control of Noncommunicable...

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ActionPlanforPreventionandControlofNoncommunicableDiseasesintheSouth‐EastAsiaRegion

DRAFT

7June2013

ActionPlanforPreventionandControlofNoncommunicableDiseasesintheSouth‐EastAsiaRegion|Draft|May2013

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SituationalAnalysis

HealthBurdenofNCDsandRiskFactors

1. Noncommunicable diseases (NCDs) — mostly cardiovascular diseases, chronicrespiratory diseases, diabetes and cancer— are top killers in South‐East Asia Region(SEAR),claiminganestimated7.9millionliveseachyear.Onethirdofthesedeathsareprematureandoccurbeforetheageof60years,ineconomicallyproductiveindividuals.In 2008, cardiovascular diseases for a quarter of all deaths, followed by chronicrespiratorydiseases (chronicobstructivepulmonarydiseaseandasthma), cancersanddiabeteswhichaccountedfor9.6%,7.8%and2.1%ofalldeaths,respectively(Figure1).Of the7.9milliondeathsdue toNCDs in2008,3.6millionweredue to cardiovasculardiseases. The commonest cardiovascular diseases in the Region are ischaemic heartdisease,strokeandhypertensiveheartdisease.Cancerclaims1.1millionliveseachyearandanestimated1.65millionnewcasesoccureachyear.Amongmales, lungcancer ismostcommonfollowedbyoralcancer,whileamongfemalestheincidenceofbreastandcervicalcancersisthehighest.Althoughmajorityofthechronicrespiratorydiseasesarepreventable, an estimated 1.4 million people died of these diseases in 2008; 80% ofthesedeathswereduetochronicobstructivepulmonarydisease(COPD).Anestimated81millionpeopleare livingwithdiabetes in theRegion.Theprevalenceofdiabetes isincreasing in both urban and rural areas. Besides the four major NCDs, many otherchronic conditions and diseases contribute significantly to the burden ofnoncommunicable disease in the Region, such as (renal, endocrine, neurological,haematological,gastroenterological,hepatic,musculoskeletal,skinandoraldiseases,andgeneticdisorders).Figure1.Percentageofdeaths,bycause,South‐EastAsiaRegion,2008

Cardiovascular diseases25%

Chronic respiratory diseases/asthma

10%

Cancers8%

Diabetes2%Other NCDs

10%

Communicable diseases, maternal & perinatal conditions, nutritional

deficiencies35%

Injuries11%


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2. The four ‘major’NCDsarecausedtoa largeextenby fourmodifiablebehaviouralriskfactors,namelytobaccouse,unhealthydiet,insufficientphysicalactivityandharmfuluseof alcohol. In the Region, 6.8% of annual deaths (equals 1 million) are attributed totobaccouse.Therearenearly250millionsmokersandanequalnumberof smokelesstobaccousersintheRegion.Theprevalenceofcurrentuseofanysmokedtobaccorangesfrom26%(India)to61%(Indonesia)inmalesandfromlessthan1%(SriLanka)to29%(Nepal) among females. In addition to smoking, use of smokeless tobacco is a majorproblem.Ninetypercentoftheworld’stobaccousersareintheSouth‐EastAsiaRegion.The prevalence of smokeless tobacco product use among males ranges from 1.3%(Thailand) to 51.4% (Myanmar); in females prevalence of smokeless tobacco productuse ranges from 4.6% (Nepal) to 27.9% (Bangladesh). The prevalence of smokelesstobaccouseamongyounggirlsandwomenintheRegionisontherise.

3. Thereisalowintakeoffruitsandvegetables,highconsumptionofsaltandwidespread

useoftransfatsintheRegion.Themeanintakeofsaltperdayvariesfrom8to13gmperday,muchhigherthantherecommendedlevelsof<5gm/day.Approximately80%ofthepopulationdoesnoteatsufficientquantitiesof fruitsandvegetablesandhalfamilliondeaths in the Region are attributed to low intake of fruits and vegetables. Annually,nearly800000deathsintheRegionareattributedtoinadequatephysicalactivity.Theprevalence of insufficient physical activity varies from 3% to 41% among males andfrom6.6%to64%amongfemales.Theprevalenceofalcoholconsumptionvaries from2%to44%amongmalesandfrom0.1%to26%amongfemales.Anestimated350000peoplediedinSEARofalcohol‐relatedcausesin2004.

4. The four behavioural risk factors described above lead to four major metabolic risk

factors (overweight/obesity, highbloodpressure, raisedblood sugar and raisedbloodlipids)thatarehighlyprevalentintheRegion.Highbloodpressure,raisedbloodglucoseandtobaccousetogetheraccountfornearly3.5milliondeathsintheRegioneveryyear.Annually, 350000deaths are attributed to overweight andobesity in theRegion.Theprevalenceof overweight varied from8% to30%amongmales, and from8% to52%amongfemales.Childhoodobesityisanemergingissue.Approximately30%oftheadultpopulation has high blood pressure, which accounts for nearly 1.5 million deathsannually. The prevalence of raised cholesterol is as high as 50% in some countries.Nearly5%ofthetotalannualdeathsintheRegionareattributedtoraisedcholesterol.

5. Apart fromthe fourmainbehavioral risk factors, infectiousandenvironmental factors

alsoincreasetheriskofnoncommunicablediseases.HouseholdairpollutionduetosolidfuelcombustionisanimportantriskfactorforCOPD.ItisestimatedthatHAPcaused3.5million premature deaths in 2010, globally. Further, emissions from solid fuelcombustion lead to outdoor air pollutionwhichmay contribute to another0.5milliondeaths (“secondhandcook‐firesmoke”). Exposure toenvironmentalandoccupationalhazards,suchasexposuretoasbestos,dieselexhaustgasesandionizingandultravioletradiation in the living and working environment can increase the risk of cancer.Similarly, indiscriminate use of agrochemicals in agriculture and discharge of toxicproducts from unregulated chemical industries may cause cancer and othernoncommunicablediseasessuchaskidneydisease.


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SocialDeterminantsandSocioeconomicImpact

6. In addition to population ageing (a non‐modifiable determinant of NCDs) NCDs aredrivenbythenegativeeffectsofglobalization(suchastradeandirresponsiblemarketingof unhealthy products), rapid urbanization, inequity and illiteracy (Figure 2).Urbanization in SEAR is occurring at a rapid rate and increased from26% in1990 to33%in2009.Itisexpectedthattheprojectedpercentageofpopulationresidinginurbanareaswillmorethandoubleby2050inmostoftheMemberStates. Severalstudies intheRegionshowthatbehavioural,anthropometricandbiochemicalriskfactorsofNCDsaremore prevalent in urban than in rural areas. Globalization has brought processedfoods and diets high in total energy, fats, salt and sugar into billions of homes in theRegion. Nearly 30% of the Region’s population remains non‐literate. Low levels ofliteracyaffecthealthbehavioursandlifestylechoices,sothatpeoplefalleasyandearlyprey to NCDs. An inverse relationship between tobacco use and education has beenobserved.StudiesinBangladesh,India,Indonesia,SriLankaandThailandhaverevealedthat both smoking and smokeless tobacco use are more prevalent among the lesseducated.Poorlevelofawarenesscanalsoresultinhighconsumptionofsalt,aswellasuseofsaturatedfatsandtransfatsandthusaggravatedevelopmentofNCDs.Thereisatwo‐waylinkbetweenNCDsandhouseholdpoverty.Povertyexposespopulationstoriskbehavioursandpoorhealthoutcomes;NCDsinturnexacerbatepovertyduetoexpensesincurred on unhealthy behaviours, expenses on health care and loss of wages. Themacroeconomic burden is also enormous and includes health care costs, loss ofproductivityduetoprematuredeathsanddecreasedgrossdomesticproduct.Figure2.Determinantsofnoncommunicablediseases


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ProgressinCountries(needstoberevisedbasedonthe2013survey)

7. A public health response to NCDs has been initiated in all 11 Member States. NineMember States have an integrated policy on NCDs. Cancer and diabetes are themosttargeted diseases for controlwhile chronic respiratorydiseases are the least covered.Guidelines on dietary counseling are available in six countries, guidelines on tobaccodependence and physical activity are available in four countries and guidelines onalcohol dependence are available in five countries. Legislative support for tobacco isavailable in 10 countries; there is alcohol legislation in five countries. Two countriesaddress diet and nutrition and only one country tackles physical inactivity throughlegislativemeasures.At leastoneNCDrisk‐factor survey (nationalor subnational)hasbeen completed in all 11 countries. Disease‐specific morbidity data are generallycollected through the routine health information system in all 11 countries;mortalitydata are included in nine countries. Disease registries for NCDs have been mostcommonly established for cancers, followed by diabetes and stroke. Mostmortality/morbiditydataanddisease‐specificregistriesarehospital‐based.AllMemberStatesprovideatleastoneNCD‐relatedserviceattheprimarycarelevelinpublichealthfacilities.This includesprimarypreventionandhealthpromotion (11countries), earlydiagnosisofNCDriskfactors(9countries),andriskfactoranddiseasemanagement(10countries).AllMemberStateshaveanessentialdrugslistandmanyoftheNCD‐relateddrugsareincludedinthenationalessentialdrugslist.

Challenges8. ThemajorchallengesthatneedtobeovercometoeffectivelyaddressNCDsincludeweak

health systems, lack of strong national and private partnerships for multisectoralactions, weak surveillance systems, limited access to prevention, care and treatmentservices for NCDs, limited human resources and insufficient allocation of funds.Additionally, lackofeffectivepartnershipsamongdifferentdevelopmentsectorsat thenationallevelisoneofthemainweaknessesintheMemberStates.LackofavailabilityofrobustsurveillanceandresearchdataonNCDsisalsoanimportantbarriertoeffectiveplanningandimplementationofNCDpreventionandcontrolprogrammesintheRegion.There are many issues with current surveillance systems, such as NCD surveillancesystemsnotbeinginstitutionalizedandrarelybeingintegratedintothenationalhealthinformation systems; lack of a comprehensive framework for surveillance andmonitoring at the national and subnational levels; no reporting on reliable mortalitystatistics due to weak civil registration systems; inadequate population‐based cause‐specific morbidity and weak mortality data collection systems; and poorly fundedsurveillanceandresearchforNCDs.Finally,thereisalackofaccesstobasicpreventionand treatment in theprimaryhealth care setting inMember States of theRegion.ThemajorinvestmentonNCDpreventionandcontrolisfortertiarycareservices,whichareavailabletoalimitednumberofpeoplelivinginurbanareas,resultinginopportunitiesforearlydiagnosisbeinglostandNCDsbeingdiagnosedat latestagesasheartattacks,strokesanddiabetescomplicationswhichrequiretertiarycare.Community‐andhome‐based palliative care are almost nonexistent. Health systems in the Region haveinadequate human resources capacity to address NCDs both in terms of number of


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health workers and their training. Existing health professionals are concentrated inurbanareasat the tertiarycare level, resulting inan inadequateworkforcecapacityattheprimarycarelevel.HealthworkersparticularlyattheprimarycarelevelhavelimitedtraininginaddressingNCDsandtheirriskfactors.FundsallocatedforNCDprogrammesare disproportionately lower than the disease burden and contribute to ineffectiveaccesstopreventionandcontrolservicefacilities.

GlobalInitiatives9. Global initiatives to address NCDs started in the year 2000,with the adoption by the

World Health Assembly of its resolution 53.17, in which the Assembly endorsed theglobalstrategyforthepreventionandcontrolofsuchdiseases,withaparticularfocusondeveloping countries. The strategy rests on three pillars: (i) surveillance; (ii) primaryprevention;(iii)strengthenedhealthcare.

10. Since2000, theWorldHealthAssembly has adopted several resolutions in support of

specific tools for the global strategy, including the WHO Framework Convention onTobacco Control in 2003, the Global Strategy on Diet, Physical Activity and Health in2004,andtheGlobalStrategytoReducetheHarmfulUseofAlcoholin2010.In2008,theAssembly endorsed the 2008–2013 Action Plan for the Global Strategy for thePrevention and Control of Noncommunicable Diseases, with a particular focus ondevelopingcountries.TheActionPlanhassixobjectivesthatincluderaisingthepriorityaccordedtosuchdiseasesindevelopmentworkattheglobalandnationallevels.

11. To draw the attention of global leaders on the rising crisis of NCDs, the UN General

Assemblyconvenedahigh‐levelmeeting inNewYork lastyear. ItwasonlythesecondtimeinhistorythattheGeneralAssemblymetwiththeparticipationofHeadsofStatesandgovernmentsonahealth issue.Themainoutcomeofthehigh‐levelmeetingoftheUN General Assembly was the adoption of the political declaration on NCDs, whichacknowledges the rapidly growingmagnitude ofNCDs in developing countries and itsincreasingly devastating health and socioeconomic impact, and calls for concrete andcomprehensiveactionsbyMemberStatesandtheinternationalcommunity.

12. Asafollow‐uptothePoliticalDeclarationoftheUNHighLevelMeetingonNCDs,WHO

led a consultative process of developing a GlobalNCDAction Plan (2013‐2020) and acomprehensivemonitoringframeworkwithindicatorsandglobalvoluntarytargets.The66thWHAinMay2013endorsedtheGlobalActionPlanaincludingindicatorsandtargetsvideitsresolutionxx.TheresolutionurgesMemberStates,toimplementtheglobalactionplanand consider the development of national NCD monitoring frameworks, with targets andindicatorsbasedonnationalsituations,takingintoaccounttheglobalonesandtoestablishandstrengthen a national surveillance and reporting system to enable reporting against the 25indicatorsand9globalvoluntarytargets.


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RegionalInitiatives13. Importantrecentregional initiatives for thepreventionandcontrolofNCDsare listed

below: November2005:RegionalpartnershipsonNCDpreventionandcontrolstrengthened

and formalized through creation of South‐East Asian Network (SEANET‐NCD) at aregionalmeetinginBondos,Maldives.

October 2006: A regional meeting on implementing the global strategy on diet,physicalactivityandhealthinSEARwasorganizedinYangon,Myanmartofacilitateregionalcountry‐levelimplementationoftheglobalstrategy.

September2007:ThesixtiethsessionoftheWHORegionalCommitteeforSouth‐EastAsia,videitsresolutiononScalingupPreventionandControlofNCDsintheSouth‐EastAsiaRegion(SEA/RC60/R4)endorsedtheRegionalFrameworkforPreventionandControlofNCDs(2007‐2012).KeyelementsoftheRegionalFrameworkinclude:epidemiologicalassessmentofNCDsand theirdeterminants;awarenessgenerationand high‐level advocacy; formulation and adoption of policy and strategic plan forintegrated prevention and control of major NCDs; capacity building; resourcemobilization;multisectoralandmultilevelactiontomodifydeterminants.

October 2007: The second meeting of SEANET‐ NCD held in Phuket, Thailanddiscussed inputs for development of a regional and global plan of action forintegratedpreventionandcontrolofNCDs.

June 2009: The thirdmeeting of SEANET‐NCD held in Chandigarh, India reviewedprogress in scalingupofNCDpreventionand control, particularly the roleof SEA‐NET.Themeetingalsodiscussedandcontributedtotheglobalrecommendationsonmarketingoffoodandnon‐alcoholicbeveragestochildren.

September 2009: The thirty‐first session of SEA‐ACHR in Kathmandu, Nepaldiscussed research priorities in NCDs and called for intersectoral collaboration incarryingoutresearchonNCDs.

September2010:Thesixty‐thirdsessionoftheWHORegionalCommitteeforSouth‐EastAsiadiscussedprogressinthepreventionandcontrolofNCDsintheRegion.

January 2011: A regional civil society meeting, with support from SEARO wasorganizedbytheNepalPublicHealthFoundationinKathmandu,Nepal.ThismeetingresultedintheKathmanduCallforActiononNCDs.

March2011:Aregionalmeetingonhealthanddevelopmentchallengesof NCDswasconducted in Jakarta, Indonesia with participation of all 11 Member States of theRegion. The meeting culminated in the Jakarta Call for Action on prevention andcontrolofNCDsandpreparationofareportonkeymessagesforUNHLM.

September 2011: The twenty‐ninth meeting of Health Ministers of the South‐EastAsia Region held in Jaipur India, passed a decision to include 10 keymessages asinputtotheUNHLMonNCDs.

April 2012: A regional consultation of Member States including partners, held inYangon, Maynmar discussed inputs to the global action plan on NCDs as well asglobaltargetsandindicators

June 2012: A regional workshop on surveillance was organized in Delhi, India tobuildaregionalpoolofexpertsinSTEPSsurveillance.


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August 2012: A regional workshop on research in integrating NCDs into primaryhealthcarewasorganizedinKandySriLankatopromoteresearchandbuildcapacityofMemberStatesinoperationsresearch.

September 2012: The sixty‐fifth session of the Regional Committee held inYogyakartaIndonesiadiscussedNCDsincludingmentalhealthasatechnicalsubjectandpassedaresolution(RC/65/5).

November2012:AregionalworkshopwasorganizedinKathmanduNepaltodevelopregionaloralhealthstrategyforSEAR.

December2012:AnexpertgroupmeetingheldinNewDelhi,Indiadiscussedsodiumreductionstrategiesandmethodstomonitorpopulationsodiumintake.

February2013:Aregionalconsultationincluding10MembercountriesdiscussedthedraftregionalNCDactionplanandtheglobalmonitoringframework,indicatorsandvoluntarytargets.

Action Plan for Prevention and Control of NCDs for MemberStatesoftheSouth‐EastAsiaRegion(2013‐2020)

14. The regional NCD action plan is consistent with the draft Global Action Plan (2013–2020)andconsolidatesfollow‐upactionsoftheoutcomesofthehigh‐levelmeetingandrecommendations of the various regional consultations with Member States. Theregionalmonitoringframework,consistentwiththeglobalone(includingindicatorsanda set of voluntary global targets for the prevention and control of NCDs), has beenintegrated into the regional action plan. Successful implementation of the planwouldneedhigh‐levelpoliticalcommitment,sustainableresourcesandconcertedinvolvementofgovernmentsandwholeofsociety.

PurposeoftheRegionalActionPlan15. This is a reference document to helpMember States in developing and implementing

nationalactionplansforreducingtheburdenofNCDswithintheexistingsocioeconomic,cultural,politicalandhealthsystemcontextsofSEARMemberStates.Itiscoherentwithmajor global strategies for prevention and control of NCDs and aims at reducing thehealthandsocioeconomicburdenofNCDs,healthinequitiesandimprovingthequalityoflifeofpeople.TheRegionalActionPlanprovidesaframeworktosupportandstrengthentheimplementationofexistingregionalresolutions,strategiesandplans.

Vision16. All people of the South‐East Asia Region enjoy the highest attainable status of health,

well‐beingandproductivityateveryage,freeofpreventableNCDs,avoidabledisabilityandprematuredeath.


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Goal17. To reducepreventablemorbidity, avoidabledisability andprematuremortalitydue to

NCDsintheSouth‐EastAsiaRegion.

GuidingPrinciples18. TheRegionalActionPlanreliesonthefollowingoverarchingprinciplesandapproaches:

Recognition of the social determinants of health, including equity, education,gender, as well as economic, cultural, and environmental factors — all of whichcontributesignificantlytothepresenceofNCDs.

Using a life‐course approach, which is key to prevention and control of NCDs,startingwithmaternalhealth,includingpreconception,antenatalandpostnatalcareand maternal nutrition; and continuing through proper infant feeding practices,includingpromotionofbreastfeedingandhealthpromotionforchildren,adolescentsandyouth;followedbypromotionofahealthyworkinglife,healthyageingandcareforpeoplewithNCDsinlaterlife.

Anall‐of‐societyapproach forNCDs thatpromotesstrategicalliancesbothwithinthe health sector and with sectors outside of health, involving governments, civilsociety,academia,theprivatesectorandinternationalorganizations.

Public health approach with emphasis on health promotion, education andprevention as well as early detection, timely treatment and quality of care forpersons who already have NCDs or who display warning signs in terms of thepresenceofriskfactors.

Reorientationofhealthsystems,includingprovidingtrainingandcapacitybuildingandpayingspecialattentiontointegratingNCDpreventionandcontrolintoprimaryhealthcare.

Evidence‐based strategies: Application of the best available evidence, based onpublic health relevance and impact, using data from surveillance and research, indevelopingandformulatingpoliciesandprogrammes.

19. Based on the global indicators and targets, the proposed indicators and targets to beachievedbyMemberStatesby2025areasfollows:


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ProposedindicatorsandtargetsforthepreventionandcontrolofNCDsforSEARMemberStates(definitionofindicatorsandproposeddatasourcesareprovidedinAnnex) Framework

elementIndicator(additionalindicatorsincludedinActionplan)

Target

Mortalityandmorbidity

Mortalityand

morbidity

Prematuremortalityfromnoncommunicablediseases

1.Unconditionalprobabilityofdyingbetweenagesof30and70fromcardiovasculardiseases,cancer,diabetesorchronicrespiratorydiseases

2.Cancerincidence,bytypeofcancer,per100000population.

(1)25%relativereductioninoverallmortalityfromcardiovasculardiseases,cancer,diabetesandchronicrespiratorydiseases

RiskFactorsForNCDs

(Behavioural)

RiskfactorsBehaviouralriskfactorsHarmfuluseofalcohol:1

(3)Total(recordedandunrecorded)percapita(aged15yearsandolder)alcoholconsumptionwithinacalendaryearinlitresofpurealcohol,asappropriate,withinthenationalcontext

(4)Age‐standardizedprevalenceofheavyepisodicdrinkingamongadolescentsandadults,asappropriate,withinthenationalcontext

(5)Alcohol‐relatedmorbidityandmortalityamongadolescentsandadults,asappropriate,withinthenationalcontext

(2)Atleast10%relativereductioninharmfuluseofalcohol,asappropriate,withinthenationalcontext2

Physicalinactivity (6)Prevalenceofinsufficientlyphysicallyactiveadolescents(definedaslessthan60minutesofmoderate‐to‐vigorousintensityactivitydaily)

(3)10%relativereductioninprevalenceofinsufficientphysicalactivity

1Countrieswillselectindicator(s)ofharmfuluseofalcoholasappropriatetonationalcontextandinlinewithWHO’sglobalstrategytoreducetheharmfuluseofalcoholandthatmayincludeprevalenceofheavyepisodicdrinking,totalpercapitaalcoholconsumption,andalcohol‐relatedmorbidityandmortality,amongothers.2InWHO‘sglobalstrategytoreducetheharmfuluseofalcoholtheconceptofharmfuluseofalcoholencompassesdrinkingthatcausesdetrimentalhealthandsocialconsequencesforthedrinker,thepeoplearoundthedrinkerandsociety.


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(7)Age‐standardizedprevalenceofinsufficientlyphysicallyactivepersonsaged18yearsorolder(definedaslessthan150minutesofmoderate‐intensityactivityperweekorequivalent).

RiskFactorsForNCDs

(Behavioural)

UnhealthydietSalt/sodiumintake

LowFruitsandvegetables

Saturatedfatintake

(8)Meanpopulationintakeofsalt(sodiumchloride)perdayingramsinpersonsaged18yearsandolder

(9)Age‐standardizedprevalenceofpersons(aged18yearsandolder)inpopulationconsuminglessthanfivetotalservings(400grams)offruitandvegetablesperday

(103)Age‐standardizedmeanproportionoftotalenergyintakefromsaturatedfattyacidsinpersonsaged18yearsandolder.

(4)30%relativereductioninmeanpopulationintakeofsalt/sodiumintake4

Tobaccouse (11)Prevalenceofcurrenttobaccouseamongadolescents

(12)Age‐standardizedprevalenceofcurrenttobaccouseamongpersonsaged18yearsandolder.

(5)30%relativereductioninprevalenceofcurrenttobaccouseinpersonsaged15yearsandolder

Biologicalriskfactors

Raisedbloodpressure

(13)Age‐standardizedprevalenceofraisedbloodpressureamongpersonsaged18yearsandolder(definedassystolicbloodpressure≥140mmHgand/ordiastolicbloodpressure≥90mmHg)andmeansystolicbloodpressure.

(6)25%relativereductionintheprevalenceofraisedbloodpressureorcontaintheprevalenceofraisedbloodpressure,accordingtonationalcircumstances

3Individualfattyacidswithinthebroadclassificationofsaturatedfattyacidshaveuniquebiologicalpropertiesandhealtheffectsthatcanhaverelevanceindevelopingdietaryrecommendations.4WHO’srecommendationislessthanfivegramsofsalt(sodiumchloride)ortwogramsofsodiumperpersonperday.


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RiskFactorsForNCDs

(Biological)

Raisedbloodglucose/Diabetes5Overweight&ObesityRaisedtotalcholesterol

(14)Age‐standardizedprevalenceofraisedbloodglucoseconcentrations/diabetesamongpersonsaged18yearsandolder(definedasfastingplasmaglucoseconcentration≥7.0mmol/l(126mg/dl)oronmedicationforraisedbloodglucoseconcentration,respectively)(15)Age‐standardizedprevalenceofoverweightandobesityinadolescents(definedaccordingtotheWHOgrowthreferenceas:overweight—onestandarddeviationbodymassindexforageandsex,andobese—twostandarddeviationsbodymassindexforageandsex)(16)Age‐standardizedprevalenceofoverweightandobesityinpersonsaged18yearsandolder(definedasbodymassindexgreaterthan25kg/m²foroverweightand30kg/m²forobesity).(17)Age‐standardizedprevalenceofraisedtotalcholesterolconcentrationamongpersonsaged18yearsandolder(definedastotalcholesterolconcentration≥5.0mmol/lor190mg/dl)andmeantotalcholesterolconcentration

(7)Halttheriseindiabetesandobesity

Nationalsystems’response

National

system

s’ Drugtherapyto

preventheartattacksandstrokes

(18)Proportionofeligiblepersons(definedasaged40yearsandolderwitha10‐yearcardiovascularriskgreaterthanorequalto30%,includingthose

(8)Atleast50%ofeligiblepeoplereceivetreatmentwithmedicinesandcounselling(includingcontrolofglycaemia)to

5Countrieswillselectindicator(s)appropriatetonationalcontext.


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withexistingcardiovasculardisease)receivingtreatmentwithmedicinesandcounselling(includingcontrolofglycaemia)topreventheartattacksandstrokes.

preventheartattacksandstrokes

Accesstoessentialmedicinesandbasictechnologiestotreatmajornoncommunicablediseases

(19)Availabilityandaffordabilityofquality,safeandefficaciousessentialmedicinesfornoncommunicablediseases,includinggenerics,andbasictechnologiesinbothpublicandprivatefacilities.

(20)Accesstopalliativecare,asassessedbymorphine‐equivalentconsumptionofstrongopioidanalgesics(excludingmethadone)perdeathfromcancer

(21)VaccinationcoverageagainsthepatitisBvirus,monitoredbynumberofthirddosesofhepatitisBvaccineadministeredtoinfants

(22)Availability,asappropriate,ifcost‐effectiveandaffordable,ofvaccinesagainsthumanpapillomavirusinfection,accordingtonationalprogrammesandpolicies

(23)Proportionofwomenbetweentheagesof30and49yearsscreenedforcervicalcanceratleastonce,ormoreoften,andforlowerorhigheragegroupsaccordingtonationalprogrammesorpolicies.

(9)80%availabilityofaffordablebasictechnologiesandessentialmedicines,includinggenerics,requiredtotreatmajornoncommunicablediseasesinbothpublicandprivatefacilities

Nationalpolicies (24)Adoptionofnationalpoliciesthatlimitsaturatedfattyacidsandvirtuallyeliminatepartiallyhydrogenatedvegetableoilsinthefoodsupply,asappropriatewithin


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thenationalcontextandnationalprogrammes

(25)Policiestoreducetheimpactonchildrenofmarketingoffoodsandnon‐alcoholicbeverageshighinsaturatedfats,trans‐fattyacids,freesugars,orsalt.


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RegionalMonitoringFramework–TargetsRegionalMonitoringFramework–(+indicatorson?HAP,oralcancer)

Unconditional probability of dying between ages

of 30 and 70 from cardiovascular diseases,

cancer, diabetes or chronic respiratory

diseases

Cancer incidence, by type of cancer, per 100

000population

Mortality&Morbidity RiskFactors NationalSystemsResponse

Harmful use of alcohol (3)

Physical Inactivity (2) Salt/Sodium Intake

Low Fruits & Vegetables Saturated Fat Intake (2)

Tobacco Use (2) Raised blood pressure

Raised blood glucose / diabetes

Overweight & Obesity (2)

Drug therapy & Counseling

Essential NCD medicines & technologies

Access to palliative care Hepatitis B Vaccine

Human Papilloma Virus Vaccine

Cervical cancer screening Policies to limit saturated fats & virtually eliminate

trans fats Marketing to children

Premature mortality

from NCDs 25%

Harmful use of alcohol

10%

Essential medicines & technologies

80% Diabetes/ obesity

0%

Physical Inactivity

10% reduction

Salt / Sodium

intake 30% reduction

Drug therapy &

Counseling 50%

Raised blood

pressure 25%

Tobacco Use 30% reduction

?Screening for cervical cancer

? Oral Cancer

? Household

Additional targets to be discussed


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PriorityActions20. Toachievetheabovetargets,thepriorityactionsforWHOandMemberStatesarelisted

alongfourkeystrategicactionareas1‐4.

ThetablesbelowprovidepriorityactionsbyWHOandMemberStatesandindicatorstomonitortheseactions.

Area 1

Advocacy, partnerships, and

leadership and management

Area 2

Health promotion and risk reduction

Area 3Health systems

strengthening for early diagnoses

and management of NCDs and their

risk factors

Area 4

Surveillance, research, and monitoring and

evaluation

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1.1 Advocacy

Partners:Parliamentarians,AllgovernmentagenciessuchasMinistriesofHealth,Finance,Trade,Education,Legal,Agriculture,Sports,Youthaffairs,Information;UNagencies,DevelopmentalPartners,CivilSociety,NGOs,Media,PrivatesectorDesiredoutcome Indicators ActionsbyWHO RecommendationsforActionsby

MemberStatesDemonstrableincreaseinpoliticalcommitmentforhealthissuesincludingNCDs

Processindicators

Percentageofgovernmentexpenditureonpreventionandcontrolofnoncommunicablediseases

NCDsincludedandprioritizedinthenationaldevelopmentplansandpolicies

StrengthenadvocacytoHeadsofState,parliamentariansandpolicymakerstogiveahighprioritytoNCDs

OffertechnicalsupporttointegrateNCDsintonationalhealth‐planningprocesses,developmentagendaandpoverty‐alleviationstrategies

Facilitatedialogueonregional&domesticresourcemobilizationandinnovativefinancing

SupportUnitedNationsCountryTeam,tointegrateNCDsintotheUnitedNationsDevelopmentAssistanceFramework(UNDAF)processes

IntegrateNCDsintohealthplanningprocessesanddevelopmentplanswithspecialattentiontosocialdeterminantsofhealth

GenerateanddisseminateevidenceontherelationshipbetweenNCDsandotherdevelopmentissuessuchaspovertyalleviation,sustainabledevelopment,foodsecurityetc

RaisepublicandpoliticalawarenessandunderstandingaboutNCDsbysocialmarketing,mass‐mediaandresponsiblemediareporting

ProvideadequateandsustainedresourcesforNCDsbyincreaseddomesticbudgetaryallocations,innovativefinancingandothermeans

MobilizetheUNCountryTeamsandlinkNCDsintotheUNDAFprocesses

StrategicActionArea1:Advocacy,partnerships,andleadershipandmanagement


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1.2PartnershipsPartners:Parliamentarians,AllgovernmentagenciessuchasMinistriesofHealth,Finance,Trade,Education,Legal,Agriculture,Sports,Youthaffairs,Information;UNagencies,DevelopmentalPartners,CivilSociety,NGOs,Media,Privatesector

Desiredoutcome Indicators ActionsbyWHO RecommendationsforActionsbyMemberStates

AllstakeholdersandpartnersengagedandhaveprioritizedNCDsintheirpoliciesandplans

Processindicators

• Nationalandsubnationalmechanism/sformultisectoralinvolvementestablishedandfunctioning

• MultisectoralnationalNCDpolicy,strategyoractionplanwhichintegratesseveralNCDsandsharedriskfactorsdevelopedandoperational

Facilitateintercountrycollaborationforexchangeofbestpracticesintheareasof“healthinallpolicies”,“whole‐of‐government”and“whole‐of‐society”approaches

Provideguidancetocountriesindevelopingpartnershipsformultisectoralactions

CoordinateactivitiesrelatedtoNCDsofvariousUNAgencies,Funds,andProgrammes

CollateandpublishregionalbestpracticesforeffectivepublicpolicydevelopmentandimplementationintheRegion

Establish/strengthenanationalmultisectoralNCDpolicyandplanwithadequatebudget

Setupaneffectivenationalmultisectoralmechanism—commission,agencyortaskforce—reportingtotheHeadofState(ordelegate),toplan,guide,monitorandevaluatetheenactmentofmultisectoralnationalNCDpoliciesandplansandtosecurebudgetaryallocations

Ensurepolicycoherenceandaccountabilityofdifferentspheresofpolicy‐makingfortheimplementationof“healthinallpolicies”and“whole‐of‐government”and“whole‐of‐society”approachesforpreventionandcontrolofNCDs

Mobilizeasocialmovementengagingandempoweringabroadrangeofactorstoshapeasystematicsociety‐widenationalresponsetoaddressNCDs,socialenvironmentalandeconomicdeterminantsofhealthandhealthequity


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1.3Leadershipandmanagement

Partners:Parliamentarians,AllgovernmentagenciessuchasMinistriesofHealth,Finance,Trade,Education,Legal,Agriculture,Sports,Youthaffairs,Information;UNagencies,DevelopmentalPartners,CivilSociety,NGOs,Media,Privatesector


HealthMinistryeffectivelyleadingandcoordinatingthenationalNCDpreventionandcontrolprogramme

Processindicators

NCDunit/departmentintheMinistryofHealthwithadequatelyskilledstaffestablished/strengthened

ExaminethecapacityofMemberStatesthroughcapacityassessmentsurveystoidentifyneeds,andtailortheprovisionoftechnicalsupport

Providetechnicalsupporttocountriesforhealthimpactassessmentofpublicpoliciesformaximizingintersectoralsynergies

DevelopappropriatetrainingprogrammestostrengthenskillsofnationalworkforceindealingwiththecomplexityofissuesneededforimplementingNCDprogrammes

Setupand/orstrengthenanationalunitonNCDsinthehealthministrywithsuitableexpertiseandresourcesfor:needsassessment,strategicplanning,policydevelopment,multisectoralcoordination,programmeimplementationandevaluation

Conductperiodicneedsassessmentofepidemiologicalandresourceneeds,includingthehealthimpactofpoliciesinsectorsbeyondhealth

StrengthenskillsandcapacityofworkforceforimplementingthenationalactionplanandtodealwiththecomplexityofissuesrelatingtoNCDsincludingmultisectoralaction,advertising,humanbehaviour,healtheconomics,foodandagriculturalsystems,law,businessmanagement,psychology,trade,commercialinfluenceandurbanplanning,etc.


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2.1ReducetobaccousePartners:MinistriesofHealth,Finance,Trade,Education,Legal,Agriculture,Information;Media;CivilSociety‐NGOs


Tobaccousereduced

Outcomeindicators

Age‐standardizedprevalenceofcurrenttobaccouseamongpersonsaged18yearsandolder

Prevalenceofcurrenttobaccouseamongadolescents

Processindicators

ComprehensivenationaltobaccocontrollegislationsinlinewiththeWHOFCTCadoptedandenforced

Providetechnicalsupporttocountriesindraftingtobaccocontrollegislations/regulations/directives,etc.

Providetechnicalsupporttocountriesforenforcementoftobaccocontrollegislation

Developanddisseminatestandardguidelinesfortobaccocessationservices

Providetrainingfortobaccocessationtohealthprofessionals

Providetechnicalsupporttocountriestoconducttobaccosurveillance

Maintainadatabaseofpictorialwarningstofacilitatesharingbetweencountries

Ensurewideaccesstoinformationonthetobaccoindustry

Compileevidenceofeffectivenessoftaxationpoliciestoreducetobaccouse

ForNon‐Parties,accelerateprocesstoaccedetotheWHOFCTC;forParties,accelerateeffectiveimplementationofWHOFCTCanditsProtocoltoEliminateIllicitTradeinTobaccoProducts

Strengthentobaccosurveillancesystemtomonitortobaccouseandpreventionpoliciesandsponsorship

Raisetaxesandinflation‐adjustedpricesontobaccoproductsinlinewithWHOFCTC(Article6)

Legislatefor100%tobaccosmoke‐freeenvironmentsinallindoorworkplaces,publictransport,indoorpublicplacesand,asappropriate,otherpublicplaces(inlinewithWHOFCTCArticle8)

Warnpeopleaboutthedangersoftobacco,includingthroughhard‐hittingmass‐mediacampaignsandlarge,clear,visibleandlegiblehealthwarnings(inlinewithWHOFCTCArticles11,12)

Implementcomprehensivebansontobaccoadvertising,promotionandsponsorship(inlinewithWHOFCTCArticles13)

StrategicActionArea2:Healthpromotionandriskreduction


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Offerhelptopeoplewhowanttostopusingtobacco(inlinewithWHOFCTCArticle14)

Protecttobaccocontrolpoliciesfromcommercialandothervestedinterestsofthetobaccoindustryinaccordancewithnationallaw(inlinewithWHOFCTCArticle5.3)

Regulatethecontentsandemissionsoftobaccoproducts,tobaccoproductdisclosuresandthemethodsbywhichtheyaretestedandmeasured.(inlinewithWHOFCTCArticle9&10)

Takemeasurestoeliminatetheillicittradeoftobaccoproducts,includingsmuggling,illicitmanufacturingandcounterfeiting(inlinewithWHOFCTCArticle15)

Prohibitsalesoftobaccoproductstoandbyminors(inlinewithWHOFCTCArticle16)

Considertakingactiontodealwithcriminalandcivilliability,includingcompensationwhereappropriateandtoofferoneanotherrelatedlegalassistance(inlinewithWHOFCTCArticle19)

Establishorstrengthennationalsurveillanceprograms,toinitiate,cooperate,andpromotetobaccocontrolrelatedresearchandtheexchangeoftobaccocontrolrelatedinformation.(inlinewithWHOFCTCArticle20)


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2.2Reduceharmfuluseofalcohol

Partners:MinistriesofHealth,Finance,Trade,Education,Legal,Agriculture,information;Media;CivilSociety‐NGOs


Harmfuluseofalcoholreduced

Outcomeindicators Total(recordedandunrecorded)

alcoholpercapita(15+yearsold)consumptionwithinacalendaryearinlitresofpurealcoholasappropriate,withinthenationalcontext

Age‐standardizedprevalenceofheavyepisodicdrinkingamongadolescentsandadultsasappropriate,withinthenationalcontext

Processindicators Comprehensivenationalalcohol

policyandlegislationinplaceforreducingharmfuluseofalcoholenacted.

Provideleadershipandtechnicalassistancetosupporttheimplementationofglobalstrategytoreduceharmfuluseofalcohol

Strengthenadvocacytoallstakeholdersforreducingharmfromalcohol

Promotenetworking&exchangeofexperiencesamongcountries

Strengthenpartnershipsandresourcemobilization

Coordinatemonitoringofalcoholrelatedharmandtheprogressthathasbeenmade

Adoptandaccelerateimplementationofglobalstrategytoreduceharmfuluseofalcohol

Strengthenawarenessofalcohol‐attributableburdenandleadership,politicalcommitmenttoreduceharmfuluseofalcohol

Regulatethecommercialorpublicavailabilityofalcoholthroughlaws,policiesandprogrammes.

Restrictorbanalcoholadvertisingandpromotions

Introducepricingpolicies,suchasexcisetaxesonalcoholicbeverages

Implementeffectivedrink‐drivingpoliciesandcountermeasures

Reducethepublichealthimpactofillicitalcoholandinformallyproducedalcoholthroughidentifiedmeasures

Reducethenegativeconsequencesofdrinkingandalcoholintoxicationandprovidingconsumerinformation

Strengthenhealthservicestoprovidepreventionandtreatmentinterventiontoindividualsand


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familiesatriskof,oraffectedbyalcohol‐usedisordersandassociatedconditions

Supportandempowercommunitiestousetheirlocalknowledgeandexpertiseinadoptingeffectiveapproachestopreventandreduceharmfuluseofalcohol

Strengthensurveillancesystemstomonitorthemagnitudeandtrendsofalcoholrelatedharm,tostrengthenadvocacy,toformulatepoliciesandtoassessimpactofinterventions


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2.3Promotehealthydiethighinfruitsandvegetablesandlowinsaturatedfats/transfats,freesugarsandsalt

Partners:MinistriesofHealth,Education,Highereducation,Finance,Trade,Legal,Foodandagriculture,information&sports;Private:Foodmanufacturers,retailers;Media;CivilSociety‐NGOs,consumer


Reducedconsumptionofunhealthydiethighinsaturatedfats/transfat,freesugarandsaltandincreasedintakeoffruitsandvegetables

Outcomeindicators Prevalenceofpersons(aged

18+years)consuminglessthanfivetotalservings(400grams)offruitandvegetablesperday

Age‐standardizedmeanproportionoftotalenergyintakefromsaturatedfattyacidsinpersonsaged18+yearsandolder

Processindicators Nationalpoliciestoreducethe

impactonchildrenofmarketingoffoodsandnon‐alcoholicbeverageshighinsaturatedfats,trans‐fattyacids,freesugarsorsaltdevelopedandenforced

Developanddisseminatemodelpolicies,legislationsandregulations(bestpractices)

Providetechnicalsupporttocountriestodevelopandimplementnationalpoliciesandregulations

AdvancetheimplementationofGlobalStrategyonDietandPhysicalActivityforHealth

ImplementWHO’ssetofrecommendationsonthemarketingoffoodsandnon‐alcoholicbeveragestochildren,includingmechanismsformonitoring

Establishregulationsandfiscalpoliciesthatpromoteconsumptionoffruitsandvegetablesandproductslowinsodiumcontent,saturatedandtransfattyacids,andfreesugars

Considereconomictools,includingtaxesandsubsidies,toimprovetheaffordabilityofhealthierfoodproductsandtodiscouragetheconsumptionoflesshealthyoptions

Carryoutpubliccampaignsthroughmassmediaandsocialmediatoinformconsumersabouthealthydiet

Promoteandsupportexclusivebreastfeedingforthefirstsixmonthsoflife,continuedbreastfeedinguntiltwoyearsandbeyondandtimelycomplementaryfeeding


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ImplementtheCodexAlimentariusinternationalfoodstandardsforthelabellingofpre‐packagedfoodsaswellastheCodexGuidelinesonNutritionLabellingtoprovideaccurateandbalancedinformationforconsumersandenablethemtomakewell‐informed,healthychoices

Populationsalt/sodiumconsumptionreduced

Outcomeindicators Meanpopulationintakeofsalt

(sodiumchloride)perpersonperday

Processindicators Adoptionofnationalpoliciesto

regulateprivatesectortoreducesalt/sodiumcontentofprocessed/packagedfood

ProvidetechnicalsupporttoMemberStatestodevelopsodiumreductionstrategies

Strengthencountrycapacitytoconductsurveysonpopulationsodiumsurveys

Dialoguewiththeprivatesectorandbuildpressuretoreducesodiumcontentofprocessedfood

DevelopandimplementsaltreductionstrategiesinlinewithWHOrecommendations

Increasecollaborationbetweensalt/sodiumreductionprogrammesandsaltiodizationprogrammesforincreasedpublichealthgainsandhigherefficiency.

Carryoutpubliccampaignstoeducateandmotivatepeopletoreducesaltconsumptiontorecommendedlevels

Regulateprivateindustrytovoluntarilyreducesaltinpackagedfoodandlabelfooditemsandmonitorcompliance.

Undertakerepresentativesurveystomeasurepopulationsalt/sodiumintake


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Artificialtransfatseliminatedandintakeofsaturatedfatsreduced

Processindicators Adoptionofnationalpolicies

thatlimitsaturatedfattyacidsandvirtuallyeliminatepartiallyhydrogenatedvegetableoilsinthefoodsupply

Developanddisseminatemodelpolicies,legislationsandregulationstoeliminateartificialtransfats

Providetechnicalsupporttocountriestodevelopnationalpoliciesandregulationstoeliminatesaturatedandtransfatsinthefoodsupplychain

Establishpoliciesandregulationstoeliminatepartiallyhydrogenatedvegetableoils(PHVO)inthefoodsupplyandlimitsaturatedfattyacids

Monitorcomplianceofprivatesectorwiththeregulations

Carryoutpubliccampaignstoeducateandmotivatepeopletoreducesaturatedfatconsumption


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2.4PromotephysicalactivityPartners:MinistriesofHealth,Finance,Trade,Education,Sports,youthaffairs,Legal,information,Localgovernment,Infrastructure/Transport,planning&urbandevelopment;Media;CivilSociety‐NGOs


Physicalinactivityreduced

Outcomeindicators1. Prevalenceofinsufficiently

activepersonsaged18yearsandolder

2. Prevalenceofinsufficientlyactiveadolescents(definedaslessthan60minutesofmoderatetovigorousintensityactivitydaily)

Developanddisseminatemodellegislationforsupportiveenvironmentsforphysicalactivity

Providesupportforestablishingcollaborationwitharchitectsandtownplannersincountriestoadvocateurbanplanningtoincreasepublicspacessupportiveofphysicalactivity

Developanddisseminateguidelinesforphysicalactivity

Facilitatesharingofbestpracticesandlessonslearnedamongcountries

Adoptandimplementnationalguidelinesonphysicalactivityforhealth

Advocatetotownplannersfordesigningincreasedpublicspacessupportiveofphysicalactivity

Establishlegislationtoensurenewhousingdevelopmentsincludesafespacesforwalkingandcycling

Carryoutmassmediaandsocialmarketingtoraiseawarenessonbenefitsofphysicalactivity

Promotephysicalactivitythroughactivitiesofdailylivingincludingthrough“activetransport”,recreation,leisureandsports.

Encouragetheevaluationofactionsaimedatincreasingphysicalactivity,tocontributetothedevelopmentofanevidencebaseofeffectiveandcosteffectiveactions


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2.5PromotehealthybehavioursandreduceNCDsinkeysettingsPartners:MinistriesofHealth,Education,Trade,Sports,youthaffairs,information,Localgovernment,Infrastructre/transport,planning/urbandevelopment;Corporatesector;Media;CivilSociety‐NGOs


ReducedriskofNCDsamongschoolchildren/studentsateducationalinstitutes,andworkforce

Processindicators1. Nationalguidelinesforhealth

promotingschools/studentsateducationalinstitutesdevelopedandadopted

2. Nationalguidelinesforworkplacewellnessprogrammesdevelopedandadopted

Developanddisseminatemodelhealthyschools/workplacepoliciesandprogrammes

DevelopanddisseminatemodelcomprehensiveworkplacewellnesspoliciesandprogrammestoreducetheriskofNCDs

Providetechnicalsupporttocountriesindevelopingandimplementingschool,workplace,policiesandprogrammes

DevelopmodelNCDcurriculaforpreventionandcontrolofNCDsincludingcounselingtechniquesaspartoftrainingofteachers

Facilitatesharingofexperiencesandbestpracticesamongcountries

AppointandtrainfocalpersonsinMOHandMinistryofeducationforhealthpromotingschools

Establishhealthpromotingschoolswithguidelinesforimplementationandmechanismsformonitoringandevaluation

Conductadvocacyandtrainingworkshopstopromotehealthybehavioursinschoolsandworkplaces

Establishhealthpromotingworkplaceswithguidelinesforimplementationandmechanismsformonitoringandevaluation

Discontinuetheexcessiveuseofsugarandsaturatedfatcontainingfoodsofferedbycafeteriaandcaterersatschoolsandworkplaces


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2.6Reducemetabolicriskfactors

Partners:MinistriesofHealth,Education,Trade,Sports,youthaffairs,information,Localgovernment,Infrastructre/transport,planning/urbandevelopment;Corporatesector;Media;CivilSociety‐NGOs


Cardio‐metabolicriskreduced

Outcomeindicators

Age‐standardizedprevalenceofoverweightandobesityinadolescents(definedaccordingtotheWHOgrowthreferenceas:overweight—onestandarddeviationbodymassindexforageandsex;andobese—twostandarddeviationsbodymassindexforageandsex)

Age‐standardizedprevalenceofoverweightandobesityinpersonsaged18yearsandolder(definedasbodymassindexgreaterthan25kg/m²foroverweightand30kg/m²forobesity).

Prevalenceofraisedtotalcholesterolamongpersonsaged18+yearsandmeantotalcholesterol

Age‐standardizedprevalenceofraisedbloodglucoseconcentrations/diabetesamongpersonsaged18yearsandolder(definedasfastingplasmaglucoseconcentration≥7.0mmol/l(126mg/dl)oronmedicationforraisedbloodglucoseconcentration,respectively)

Raisedbloodpressureamongpersonsaged18+yearsandmeansystolicbloodpressure

Activitiescontributingtoachievementofthisindicatorareincludedunder2.1,2.2,2.3,2.4and2.5

Activitiescontributingtoachievementofthisindicatorareincludedunder2.1,2.2,2.3,2.4and2.5


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2.7ReduceHouseholdAirPollution

Partners:MinistriesofHealth,Finance,Trade,Education,Legal,Agriculture,UrbanDevelopmentandhousing,Environment,Petroleum,Energy,Industries,Information,Media,CivilSociety‐NGOs


HouseholdAirPollutionreduced

Outcomeindicators

50%reductioninproportionofhouseholdswithSolidFuelUse(SFU)asprimarysourceofcooking

Processindicators

ComprehensivenationalpoliciesdevelopedforprovidingcleanerandmoreefficientfuelsasalternativetoSFUfordomesticenergyneeds

ProvidetechnicalsupporttoMemberStatesforevaluationandscaleupofimprovementsinhealththroughaccesstosustainableenergyuse

Providetechnicalsupportfordevelopingnewandrevisedindoorairqualityguidelines

StrengthenGlobalHouseholdEnergyDatabase

Facilitateresearchersandotherpartnerstointegrateguidanceandresourcesforachievinghealthimprovementsthoughefficientandaccessibleformsofenergyintootherglobalinitiatives

Supporttransitiontocleaner(energyefficient)technologiesandfuels(LPG,bio‐gas,solarcookers,electricity,otherlow‐fumefuelslike,methanol,ethanol,etc.)

Developandmaintainnationaldatabasestosupportdecision‐makingonsustainablehouseholdenergyincludinginformationonpopulationtobeserved,candidatefuels/stoves,infrastructuredevelopmentchallenges,stovesproviders,costanalyses,estimationofability/willingnesstopay(subsidyneed)asafunctionofincome

Developimplementationprogrammese.g.upgradingtheinfrastructures,strategiesforpayingforneededsubsidies

Developandimplementprogrammestoencouragegoodcookingpracticesincludingconservationofheat,reducingexposuretofumes,usingimprovedcookstovesandimprovingventilationinhomes.


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3.1Accesstohealthservices

Partners:MinistriesofHealth,Otherrelevantministries,Localgovernmentauthorities,regulatorycouncils,CivilSociety,NGOs,Pharmaceuticalagencies

Desiredoutcome

Indicators ActionsbyWHO RecommendationsforActionsbyMemberStates

Universalcoverageandequitableaccesstoprevention,earlydiagnosisandtreatmentofNCDs

Outcomeindicators Proportionofeligible

personsreceivingdrugtherapyandcounselingtopreventheartattacks,strokesandchronicrespiratorydiseases

Proportionofwomenbetweentheagesof30–49screenedforcervicalcanceratleastonce,ormoreoften

VaccinationcoverageagainsthepatitisBvirusmonitoredbynumberofthirddosesofHepatitis‐Bvaccine(HepB3)administeredtoinfants

Processindicators Availability,as

appropriate,ifcost‐effectiveandaffordable,ofHPVvaccines,accordingtonationalprogrammesand

Providesupporttocountriesinintegratingcost‐effectiveinterventionsforNCDsandtheirriskfactorsintohealthsystems,includingessentialprimaryhealthcarepackages

Deployaninter‐agencyemergencyhealthkitfortreatmentofNCDsinhumanitariandisastersandemergencies

Developanddisseminatestandardguidelines,toolsandtrainingmaterialsforearlydetection,treatmentandpalliativecaretoaddressNCDsatprimaryhealthcarecentres

Negotiatewithpharmaceuticalproducersandwholesalerstoreducecostofessentialdrugs

Facilitatetechnologytransferformanufactureofmedicines,vaccines,medical

Integrateandscale‐upcosteffectiveNCDinterventionsintothebasicprimaryhealthcarepackagewithreferralsystemtoalllevelsofcaretoadvancetheuniversalhealthcoverageagenda(ReferAnnex2forlistof‐effectiveinterventions)

Exploreviablehealthfinancingmechanismsandinnovativeeconomictoolssupportedbyevidence

IncludeessentialmedicinesandtechnologiesspecificallyforNCDs,innationalessentialmedicinesandmedicaltechnologieslists

Improveefficiencyintheprocurement,supplymanagementandaccesstoessentialNCDmedicinesandtechnologiesincludingthroughthefulluseoftrade‐relatedaspectsofintellectualpropertyrights(TRIPS)flexibilities

PromoteprocurementanduseofgenericmedicinesforpreventionandcontrolofNCDsbyqualityassuranceofgenericproducts,preferentialregistrationprocedures,genericsubstitution,financialincentivesandeducationofprescribersandconsumers

Ensuretheavailabilityoflife‐savingtechnologiesandessentialmedicinesformanagingNCDsintheinitialphaseofemergencyresponse

StrategicActionArea3:HealthsystemstrengtheningforearlydiagnosesandmanagementofNCDsandtheirriskfactors


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policies Availabilityand

affordabilityofquality,safeandefficaciousessentialNCDmedicines6,includinggenerics,andbasictechnologiesinbothpublicandprivatefacilities

Accesstopalliativecareassessedbymorphine‐equivalentconsumptionofstrongopioidanalgesics(excludingmethadone)perdeathfromcancer

technologies,andinformationtechnologiesforpreventionandcontrolofNCDs

Facilitatesharingofexperiences,bestpracticesandlessonsamongcountries

Developandimplementapalliativecarepolicyusingcost‐effectivetreatmentmodalities,includingopiodsanalgesicsforpainreliefandtraininghealthworkers

ImprovecoverageofhepatitisBvaccination Strengthenbasicfacilitiesofprimaryhealthcare

facilitiesforpreventionandearlydiagnosisofcervicalcancer

Reviewexistingprogrammes,suchasnutrition,HIV,tuberculosisandreproductivehealth,foropportunitiestointegrateservicedeliveryforpreventionandcontrolofNCDs

StrengthenreferralsystemsformanagementofNCDs

Increasecapacityofhealth‐careservicestodeliverpreventionandtreatmentinterventionsforhazardousdrinkingandalcoholusedisorders,includingscreeningandbriefinterventionsatprimarycareandothersettingsprovidingtreatmentandcareforNCDs

Facilitateaccesstopreventivemeasures,treatmentandvocationalrehabilitation,aswellasfinancialcompensationofoccupationalNCDs,suchascancerandchronicrespiratorydisease,consistentwithinternationalandnationallawsandregulationsonoccupationaldiseases

Strengtheneducationandawarenessonearlydetectionofbreastcancer

6aspirin,ACEinhibitors,longactingCCblockers,statins,metformin,insulin,oralmorphine,bronchodilator,steroidinhaler


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3.2HealthworkforcePartners:MinistriesofHealth,CivilSociety,NGOs,Academia,AcademicInstitutions,ProfessionalAssociationsDesiredoutcome Indicators ActionsbyWHO RecommendationsforActionsby

MemberStatesImprovedcompetenceofhealthworkforceforprevention,earlydiagnosesandmanagementofNCDs

Processindicators1. Percentageofprimary

healthcareworkforcetrainedinintegratedNCDpreventionandcontrol

Providetechnicalsupporttodevelopcompetency‐basedcurriculumfortrainingofhealthworkforceinNCDpreventionandcontrol,withanemphasisonprimarycare

• DeployadditionalhealthworkforceasneededtoaddresscurrentNCDburdenaswellasplanforfutureneedsinlightofpopulationageing

• Identifycompetenciesrequiredandinvestinimprovingtheknowledge,skillsandmotivationofthecurrenthealthworkforcetoaddressNCDs,includingcommonco‐morbidconditions

• IncorporatepreventionandcontrolofNCDsinthetrainingofallhealthworkers,professionalandnon‐professional(technical,vocational),withanemphasisonprimarycare

• Provideadequatemechanism(compensation)andincentivesforhealthworkers,payingdueattentiontoattractingandretainingtheminunderservicedareas

• Developcareertracksforhealthworkersthroughstrengtheningpostgraduatetraining,withaspecialfocusonNCDs,invariousprofessionaldisciplinesandcareeradvancementfornon‐professionalstaff


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3.3Community‐basedapproachesPartners:MinistriesofHealth,Otherrelevantministries,localgovernmentauthority,CivilSociety,NGOsDesiredoutcome Indicators ActionsbyWHO RecommendationsforActionsby

MemberStatesCommunities/patientsempoweredforself–care

Processindicators• Nationalguidelinesonself–

careforpreventionandmanagementofNCDsdevelopedandadopted

Developinnovativetoolsonself–careforpersonswithNCD,forexamplethroughinformationtechnology

DevelopanddisseminateguidelinesformonitoringandevaluationofcommunitybasedinitiativesforNCDpreventionandcontrol

Useparticipatorycommunity‐basedapproachesindesigning,implementing,monitoringandevaluatingNCDprogrammesacrossthelifecourseandcontinuumofcaretoenhanceandpromoteeffectivenessofanequity‐basedresponse

Developself–careguidelinesforpreventionandcontrolofNCDsinconsultationwithawidevarietyofstakeholders

Encouragetheformationofcommunitycoalitions,patientgroupsandbuildtheircapacity

Developpatienteducationmaterials Meettheneedsforlong‐termcareofpeople

withNCDs,relateddisabilitiesandcomorbiditiesthroughinnovativeandeffectivemodelsofcare(connectingoccupationalhealthservicesandcommunityhealthresourceswithprimarycareandtherestofthehealth‐caredeliverysystem

Monitor&EvaluatecommunitybasedinitiativesforpreventionandcontrolofNCDs


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4.1StrengthensurveillanceandmonitoringPartners:MinistriesofHealth,Otherrelevantministries/governmentagencies,Professionalbodies,NGOs,Academia,NationalResearchCouncil/otherresearchinstitutions,UNagencies/bilateralandmultilateraldevelopmentpartners

Desiredoutcome Indicators ActionsbyWHO(ROandCO) RecommendationsforActionsbyMemberStates

ImprovedavailabilityanduseofinformationonNCDmortality,morbidity,riskfactorsandhealthsystemresponse

Processindicators Validnationallyorsub

nationallyrepresentativemortalitystatisticsbycause/majorNCDavailable

National/subnationalpopulation‐basedorhospital‐basedcancerregistriesestablished

Nationalriskfactorsurveysusingstandardmethodsconductedeverythreetofiveyears

DevelopanddisseminatestandardtoolsandguidelinesforNCDsurveillance/surveywithfocusoncommunityandhealthfacilitiesbasedsurveillance

StrengthencapacityofnationalinstitutionsandnationalstaffinundertakingNCDsurveillance

ProcurearegionalpoolofdatacollectiontoolssuchasPDAs,BPinstrumentandothermaterialsforfacilitatingsurveillanceinMemberStates

Strengthentechnicalcapacityincountrytomanageandimplementsurveillanceandmonitoringsystemsthatareintegratedintoexistinghealthinformationsystems’capacity,withafocusoncapacityfordatamanagement,analysisandreportinginordertoensureavailabilityofhigh‐qualitydataonNCDsandriskfactors

AdaptWHOsurveillanceframeworkthatmonitorsexposure(riskfactors),outcome(morbidityandmortality),andhealthsystemresponseandimplementbasedoncountry’sneedandcapacity.

AllocateadequatefundsforNCDsurveillance

Updatelegislationpertainingtocollectionofhealthstatistics,includingvitalregistration

Strengthenvitalregistrationsystemsandcauseofdeathregistration.

IntegratesurveillanceforNCDsintoothernationalhealthsurveys

Disseminateresultsofsurveillancewidelytoallstakeholders

Usesurveillanceinformationforpolicyandprogrammedevelopment

StrategicActionArea4:Surveillance,Research,andMonitoringandEvaluation


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4.2StrengthenresearchPartners:MinistriesofHealth,Otherrelevantministries/governmentagencies,Professionalbodies,NGOs,Academia,NationalResearchCouncil/otherresearchinstitutions,UNagencies/bilateralandmultilateraldevelopmentpartners


Relevantevidencegeneratedandusedfornationalpolicyandprogrammedevelopment

Processindicators Availabilityofanational

researchagendaandaprioritizedresearchplanwithfundingforpreventionandcontrolofNCDs

ProvidetechnicalsupporttodevelopnationalNCDresearchagendaandassistinresourcemobilizationtocarryoutpriorityresearch

Strengthencapacityofnationalinstitutionsandstaffindevelopmentofresearchprotocols,analysesofdataandpreparationofscientificpeer‐reviewedmanuscripts

Fosterpartnershipsandlinkagesbetweenacademia,researchinstitutionsandhealthserviceagenciestotranslateresearchintopolicyandaction.

OrganizeintercountrymeetingsandconferencestofacilitatesharingofnewresearchfindingsamongMemberStates

AllocateadequatefundsforNCDresearch

Develop,implementandmonitoraprioritynationalresearchagendaforpreventionandcontrolofNCDs,basedonconsultationwithuniversities,WHOandotherstakeholders

Strengthennationalcapacityforresearchanddevelopment,includingresearchinfrastructure,equipmentandsuppliesinresearchinstitutions,andthecompetenceofresearcherstoconductgood‐qualityresearch

• Enhancecooperationbetweenuniversities,researchinstitutesandhealthservicestoensurespeedyutilizationofresearchfindingsandscientificbasisfordecisionmakingforNCDpolicy/programmedevelopment

• Strengthencollaborationbetweennational,regionalandinternationalresearchcentres


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4.3ImprovemonitoringandevaluationPartners:MinistriesofHealth,Otherrelevantministries/governmentagencies,Professionalbodies,NGOs,Academia,NationalResearchCouncil/otherresearchinstitutions,UNagencies/bilateralandmultilateraldevelopmentpartners


TimelyreportinganduseofinformationtoimproveNCDinterventions

Processindicators NationalNCDmonitoring

frameworkwithkeyindicatorsandtargetsadopted

Nationalprogressreportonkeynational,regionalandglobalindicatorsandtargetspublishedperiodically

AssessnationalcapacityforpreventionandcontrolofNCDsatregularintervalsandusethisinformationtopluggapsincapacity

ProvidetechnicalsupporttoMemberStatestodevelopanationalNCDmonitoringframeworkincludingindicatorsandtargets

AssistMemberStatesinpreparingnationalNCDprogressreports

FacilitateexchangeofinformationonprogressinpreventionandcontrolofamongMemberStates

DefineandadoptaminimumsetofnationaltargetsandindicatorsbasedontheglobalmonitoringframeworkformeasuringprogressofpreventionandcontrolofNCDs

Developindicatorstomeasuretheengagementofnon‐healthsectors

PreparestandardizedformatforcollectingandreportingNCDindicators

IntegrateNCDmonitoringsystemintonationalhealthandmanagementinformationsystems

DesignandconductevaluationofNCDinterventionsperiodically

Publishbiennialreports(onceevery2years)onprogressmadeinNCDpreventionandcontrolincludingreportingonkeynational,regionalandglobalindicatorsandtargets


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Annex1:Descriptionofkeyindicatorsandsourcesofdata

Indicator Purpose/Explanation Methodofestimation Possible Sources ofInformation

1.Unconditional probability of dying between ages of 30 and 70 from, cardiovascular diseases, cancer, diabetes or chronic respiratory disease

The lower age limit for the indicator of 30 years represents the point in the life-cycle where the mortality risk for the four selected chronic diseases starts to rise in most populations from very low levels at younger ages. The upper limit of 70 years was chosen for two reasons: i) to identify an age range in which these chronic diseases deaths can be truly considered premature deaths in almost all regions of the world. ii) estimation of cause-specific death rates becomes increasingly uncertain at older ages because of increasing proportions of deaths coded to ill-defined causes, increasing levels of co-morbidity, and increasing problem of age estimation in mortality and population data sources.

This indicator is calculated from age-specific death rates for the combined four cause categories (typically in terms of 5-year age groups 30–34, …, 65–69). A life table method allows calculation of the risk of death between exact ages 30 and 70 from any of these causes, in the absence of other causes of death.

A nationally representative population based system for counting all deaths and ascertainment of cause of deaths. This could be vital registration system, medical certification of cause of death or verbal autopsy based ascertainment in a representative sample of deaths.

2. Cancer incidence, by type of cancer, per 100 000 population.

Cancer incidence tracks the number of new cancers of a specific site/type occurring in the population per year,

Number of new cancers by specific type divided by total population under surveillance expressed as per 100 000 population.

Population based cancer registries.

(3) Total (recorded and unrecorded) per capita (aged 15 years and older) alcohol consumption within a calendar year in litres of pure alcohol, as appropriate, within the national context

The Global strategy defines the harmful use of alcohol as drinking that causes detrimental health and social consequences for the drinker (harmful drinking), the people around the drinker and society at large, as well as patterns of drinking that are associated with increased risk of adverse health outcomes (hazardous

Total (recorded and unrecorded) alcohol consumption in litres of pure alcohol for a calendar year divided by the estimate of population in 15+ age group as per census or UN population projections expressed as per capita.

Governmental national sales and export/ import data, data available from alcohol industry sources and the FAO, as well as the estimates of unrecorded alcohol consumption.


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(4) Age-standardized prevalence of heavy episodic drinking among adolescents and adults, as appropriate, within the national context.

drinking). Number of people indulging in episodic drinking as per definition used divided by the population surveyed in the two age groups included.

Nationally representative population based risk factor surveys in adult and adolescent age group.

(5) Alcohol-related morbidity and mortality among adolescents and adults, as appropriate, within the national context.

Indicators based on mortality and morbidity caused by alcohol consumption, such as alcohol liver cirrhosis, alcohol dependence or alcohol-induced psychoses, .

People with identified health conditions among the population surveyed expressed as percentage.

Cause of death survey as in indicator one and nationally representative population based survey that includes measurement of other disorders included in the list.

(6) Prevalence of insufficiently physically active adolescents (defined as less than 60 minutes of moderate-to-vigorous intensity activity daily)

People who are insufficiently physically active have a 20% to 30% increased risk of all-cause mortality compared to those who engage in at least 30 minutes of moderate intensity physical activity most days of the week.

Number of adolescents surveyed who are insufficiently physically active as per definition divided by the total population surveyed.

School Based Surveys like Global School Based Health Surveys that include measurement of physical inactivity.

(7) Age-standardized prevalence of insufficiently physically active persons aged 18 years or older (defined as less than 150 minutes of moderate-intensity activity per week or equivalent).

Number of people surveyed who are insufficiently physically active as per definition divided by the total population surveyed.

Population based nutrition or health examination survey that include measurement of physical inactivity including that using STEPS approach.

(8) Mean population intake of salt (sodium chloride) per day in grams in persons aged 18 years and older.

The amount of dietary salt (sodium chloride) consumed is an important determinant of blood pressure levels and of hypertension and overall cardiovascular risk. A salt intake of less than 5 grams (approximately 2g sodium) per person per day is recommended by WHO for the prevention of cardiovascular diseases, the leading cause of death globally. The gold-standard for estimating salt intake is

Total individual salt consumption (in gms) by the population surveyed divided by the total population surveyed.

Population based nutrition or health examination survey that include measurement of urinary sodium. The WHO STEPS team is currently developing a module on dietary sodium intake that will incorporate both questions to assess sources


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through 24-hour urine collection, however other methods such as spot urines and food frequency surveys may be more feasible to administer at the population level.

of sodium, and urine collection, which will facilitate the reporting against this indicator.

(9) Age-standardized prevalence of persons (aged 18 years and older) in population consuming less than five total servings (400 grams) of fruit and vegetables per day.

Adequate consumption of fruit and vegetables reduces the risk for cardiovascular diseases, stomach cancer and colorectal cancer. The consumption of at least 400g of fruit and vegetables per day is recommended as a population intake goal, to prevent diet-related chronic diseases.

Number of people surveyed who consume less than five servings of fruits and vegetables daily divided by the total population surveyed.

Population based survey including those using STEPS approach.

(107) Age-standardized mean proportion of total energy intake from saturated fatty acids in persons aged 18 years and older

Excessive dietary fat intake has been linked to increased risk of obesity, coronary heart disease and certain types of cancer. High consumption of saturated-fatty acids is widely considered a risk factor for cardiovascular disease.

Mean calories in diet provided by saturated fat in the population of 18+ population divided by the total calories consumed by the same population.

Population based dietary/nutrition surveys measuring food intake and food composition tables.

(11) Prevalence of current tobacco use among adolescents

Risks to health from tobacco use result from direct consumption of both smokeless and smoking tobacco, and from exposure to second-hand smoke. There is no proven safe level of tobacco use. All current (daily and occasional) users of tobacco are at risk of a variety of poor health outcomes across the life-course, and for NCDs in adulthood.

Number of people using any form of tobacco in the said population divided by population surveyed expressed as a percentage.

WHO under the aegis of the Global Tobacco Surveillance System has developed a set of tobacco indicators and associated questions that can be used globally in all surveys.Thesurveys include STEPS, GATS, GYTS, GSHS.

(12) Age-standardized prevalence of current tobacco use among persons aged 18 years and older.

Number of people using any form of tobacco divided by population surveyed expressed as a percentage

(13) Age-standardized prevalence of raised blood pressure among persons aged 18 years and older (defined as systolic blood pressure ≥140

Raised blood pressure is a major risk factor for coronary heart disease and ischemic as well as haemorrhagic stroke. Blood pressure must be measured, not self-reported.

Number of people surveyed who have blood pressure above the cut-offs divided by the total population surveyed.

Population based nutrition or health examination survey that include measurement of blood sugar including that using


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mmHg and/or diastolic blood pressure ≥90 mmHg) and mean systolic blood pressure.

STEPS approach ( STEP 2)

(14) Age-standardized prevalence of raised blood glucose concentrations/ diabetes among persons aged 18 years and older (defined as fasting plasma glucose concentration ≥ 7.0 mmol/l (126 mg/dl) or on medication for raised blood glucose concentration, respectively)

Diabetes, impaired glucose tolerance and impaired fasting glycaemia are risk categories for future development of diabetes and cardiovascular disease. Fasting plasma glucose values have been selected as the indicator due to wide availability in nationally representative surveys.

Number of people surveyed who have fasting blood sugar levels above the cut-offs divided by the total population surveyed.

Population based nutrition or health examination survey that include measurement of blood sugar including that using STEPS approach ( STEP 3)

(15) Age-standardized prevalence of overweight and obesity in adolescents (defined according to the WHO growth reference as: overweight - one standard deviation body mass index for age and sex, and obese - two standard deviations body mass index for age and sex)

Body mass index is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults. BMI provides the most useful population-level measure of overweight and obesity as it is the same for both sexes and for all ages of adults.

Number of people surveyed who have BMI above the cut-offs according to the WHO Growth Reference for adolescents) for overweight and obesity divided by the total population surveyed.

School Based Surveys like Global School Based Health Surveys that include anthropometry

(16) Age-standardized prevalence of overweight and obesity in persons aged 18 years and older (defined as body mass index greater than 25 kg/m² for overweight and 30 kg/m² for obesity).

Number of people surveyed who have BMI above the cut-offs for overweight and obesity divided by the total population surveyed.

Population based nutrition or health examination survey that include anthropometry including that using STEPS approach.


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(17) Age-standardized prevalence of raised total cholesterol concentration among persons aged 18 years and older (defined as total cholesterol concentration ≥5.0 mmol/l or 190 mg/dl) and mean total cholesterol concentration

Raised cholesterol levels increase the risks of heart disease and stroke.

Number of people surveyed who have total cholesterol levels above the cut-offs divided by the total population surveyed.

Population based nutrition or health examination survey that include measurement of blood cholesterol including that using STEPS approach ( STEP 3)

(18) Proportion of eligible persons (defined as aged 40 years and older with a 10-year cardiovascular risk greater than or equal to 30%, including those with existing cardiovascular disease) receiving treatment with medicines and counselling (including control of glycaemia) to prevent heart attacks and strokes.

Population-based interventions alone will not be sufficient to prevent heart attacks and strokes for people with a 10 year CVD risk of 30% or higher. People at such risk level usually have modest elevations of multiple risk factors, such as smoking, raised blood pressure, raised cholesterol and/or diabetes. To prevent heart attacks and strokes in this population, CVD risk needs to be lowered through counselling and appropriate drug therapy.

Number of persons who are receiving treatment or counselling divided by the number of people who with a 10 year CVD risk of greater than or equal to 30%.

Population based surveys. obtaining information on cardiovascular events and drug treatment when risk factor data (on blood pressure, blood sugar and blood cholesterol) are collected. The WHO/ISH risk prediction charts or a national risk prediction tool can be used to factor in the risk factor data .

(19) Availability and affordability of quality, safe and efficacious essential medicines for noncommunicable diseases, including generics, and basic technologies in both public and private facilities.

The minimum list include: medicines – at least aspirin, a statin, an angiotensin converting enzyme inhibitor, thiazide diuretic, a long acting calcium channel blocker, metformin, insulin, a bronchodilator and a steroid inhalant. Technologies – at least a blood pressure measurement device, a weighing scale, blood sugar and blood cholesterol measurement devices with strips and urine strips for albumin assay.

Number of health facilities reporting the presence of essential medicines and technologies divided by the total number of health facilities surveys in by public and private sector.

Health Facility Survey including that of private facilities. WHO’s Service Availability and Readiness Assessment (SARA) surveys provide good template for it.


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(20) Access to palliative care, as assessed by morphine-equivalent consumption of strong opioid analgesics (excluding methadone) per death from cancer

Every year, tens of millions of patients with NCDsdiseases require palliative care to relieve suffering or, when curative treatment is no longer an option, ensure the highest possible quality of life until death. Although it is considered an integral part of health services for many NCDs,, the vast majority of these patients do not have access to palliative care and face unnecessary suffering as a result.

Number of patients who consumed morphine-equivalent strong opioid analgesics divided by the total number of patients who died of cancer in that year.

WHO produces estimates of the number of deaths from cancer. The International Narcotics Control Board annually publishes consumption data for narcotic drugs, including strong opioid analgesics, as reported by countries.

(21) Vaccination coverage against hepatitis B virus, monitored by number of third doses of hepatitis B vaccine administered to infants

Preventing liver cancer via hepatitis B vaccination is classified as a “best buy” by WHO.

Number of children who have received 3 doses of Hep B vaccine divided by the children in the 12-23 age group expressed as percentage.

Prevalence surveys conducted to monitor national immunization programme coverage.).

(22) Availability, as appropriate, if cost-effective and affordable, of vaccines against human papillomavirus infection, according to national programmes and policies

Cervical cancer is caused by certain types of HPV and is the most common cancer affecting women in developing countries. Two HPV vaccines have been approved for use in many countries. Clinical trial results show that both vaccines are safe and effective in preventing infections with the two types of HPV that cause most cervical cancer and precancerous cervical lesions.

Number of countries reporting adoption of HPV vaccine in national immunization schedule policies divided by the total number of Member States that provide information on this indicator.

WHO NCD Country Capacity Survey

23) Proportion of women between the ages of 30 and 49 years screened for cervical cancer at least once, or more often, and for lower or higher age groups according to national programmes or policies.

Cervical cancer is the most common female cancer in low- and middle-income countries. The widespread use of screening in high-income countries has resulted in a dramatic decline in cervical cancer mortality over the last three decades.

Number of women in the defined age group who have been screened for cervical cancer divided by the total population of the same age group surveyed expressed as a percentage.

Nationally representative population-based surveys including STEPs/ DHS. However, the validity of self-reported screening has not been well established in low- and middle-income countries.


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24) Adoption of national policies that limit saturated fatty acids and virtually eliminate partially hydrogenated vegetable oils in the food supply, as appropriate within the national context and national programmes

Trans-fatty acids (TFA) increase the risk for coronary heart disease through their negative effect on serum lipids. In particular, the consumption of TFA from partially hydrogenated oils adversely affects multiple CVD risk factors . TFA also worsen insulin resistance, particular among predisposed individuals with risk factors (e.g. raised blood glucose, overweight and obesity, or physical inactivity).

Number of countries reporting adoption of given national policies divided by the total number of Member States that provide information on this indicator.

WHO NCD Country Capacity Survey and the WHO global nutrition policy review.

(25) Policies to reduce the impact on children of marketing of foods and non-alcoholic beverages high in saturated fats, trans-fatty acids, free sugars, or salt

Evidence from systematic reviews on the extent, nature and effects of food marketing to children conclude that advertising is extensive and other forms of food marketing to children are widespread across the world. Most of this marketing is for foods with a high content of fat, sugar or salt. Evidence also shows that television advertising influences children’s food preferences, purchase requests and consumption patterns.

Number of countries reporting adoption of given national policies divided by the total number of Member States that provide information on this indicator.


(26) Adoption of national policies to regulate the private sector to reduce in salt/sodium in processed /packaged food

The amount of dietary salt (sodium chloride) consumed is an important determinant of blood pressure levels and of hypertension and overall cardiovascular risk. Salt in processed and packaged food is becoming an important source of sodium due to changing dietary practices.

Number of countries reporting adoption of a salt reduction regulation/policy divided by the total number of Member States that provide information on this indicator.


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Annex2:

Listofcost‐effectiveoptionsforpreventionandmanagementoffourmajorNCDs

Cardiovascular disease and diabetes • Drug therapy (including glycaemic control for diabetes mellitus and control of hypertension using a

total risk approach) and counselling to individuals who have had a heart attack or stroke and to persons with high risk (≥ 30%) of a fatal and nonfatal cardiovascular event in the next 10 years*

• Acetylsalicylic acid for acute myocardial infarction* • Drug therapy (including glycaemic control for diabetes mellitus and control of hypertension using a total

risk approach) and counselling to individuals who have had a heart attack or stroke, and to persons with moderate risk (≥ 20%) of a fatal and nonfatal cardiovascular event in the next 10 years

• Detection, treatment and control of hypertension and diabetes, using a total risk approach • Secondary prevention of rheumatic fever and rheumatic heart disease • Acetylsalicylic acid, atenolol and thrombolytic therapy (streptokinase) for acute myocardial infarction • Treatment of congestive cardiac failure with ACE inhibitor, beta-blocker and diuretic • Cardiac rehabilitation post myocardial infarction • Anticoagulation for medium- and high-risk non-valvular atrial fibrillation and for mitral stenosis with

atrial fibrillation • Low-dose acetylsalicylic acid for ischemic stroke Diabetes • Lifestyle interventions for preventing type 2diabetes • Influenza vaccination for patients with diabetes • Preconception care among women of reproductive age including patient education and intensive glucose

management • Detection of diabetic retinopathy by dilated eye examination followed by appropriate laser

photocoagulation therapy to prevent blindness • Effective angiotensin-converting enzyme inhibitor drug therapy to prevent progression of renal disease • Care of acute stroke and rehabilitation in stroke units • Interventions for foot care: educational programmes, access to appropriate footwear; multidisciplinary

clinics Cancer • Prevention of liver cancer through hepatitis B immunization* • Prevention of cervical cancer through screening (visual inspection with acetic acid [VIA] (or Pap

smear (cervical cytology), if very cost-effective)6 linked with timely treatment of pre-cancerous lesions*

• Vaccination against human papillomavirus, as appropriate if cost-effective and affordable, according to national programmes and policies

• Population-based cervical cancer screening linked with timely treatment • Population-based breast cancer and mammography screening (50-70 years) linked with timely treatment7 • Population-based colorectal cancer screening, including through fecal occult blood testing, as appropriate,

at age >50, linked with timely treatment Oral cancer screening in high-risk groups (e.g. tobacco users, betel-nut chewers) linked with timely

treatment Chronic respiratory diseases • Access to improved stoves and cleaner fuels to reduce indoor air pollution • Cost-effective interventions to prevent occupational lung diseases, e.g. from exposure to silica, asbestos • Treatment of asthma based on WHO guidelines • Influenza vaccination for patients with chronic obstructive pulmonary disease


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Annex3:

Examples of collaborative division of tasks and responsibilities. Concerns a provisional list only. A division of labour is being developed by the United

Nations Funds, programmes and agencies UNDP

• Support non-health government departments in their efforts to engage in a multisectoral whole-of-government approach to noncommunicable diseases

• Support ministries of planning in integrating noncommunicable diseases in the development agenda of each Member State

• Support ministries of planning in integrating noncommunicable diseases explicitly into poverty-reduction strategies

• Support national AIDS commissions in integrating interventions to address the harmful use of alcohol into existing national HIV programmes

UNECE • Support the Transport, Health and Environment Pan-European Programme UN-ENERGY

• Support global tracking of access to clean energy and its health impacts for the United Nations Sustainable Energy for All Initiative

• Support the Global Alliance for Clean Cookstoves and the dissemination / tracking of clean energy solutions for households

UNEP • Support the implementation of international environmental conventions UNFPA • Support health ministries in integrating noncommunicable diseases into

existing reproductive health programmes, with a particular focus on (1) cervical cancer and (2) promoting healthy lifestyles among adolescents

UNICEF • Strengthen the capacities of health ministries to reduce risk factors for noncommunicable diseases among children and adolescents

• Strengthen the capacities of health ministries to tackle malnutrition and childhood obesity

UN-WOMEN • Support ministries of women or social affairs in promoting gender-based approaches for the prevention and control of noncommunicable diseases

UNAIDS • Support national AIDS commissions in integrating interventions for noncommunicable diseases into existing national HIV programmes

• Support health ministries in strengthening chronic care for HIV and noncommunicable diseases (within the context of overall health system strengthening)

• Support health ministries in integrating HIV and noncommunicable disease programmes, with a particular focus on primary health care

UNSCN • Facilitate United Nations harmonization of action at country and global levels for the reduction of dietary risk of noncommunicable diseases

• Disseminate data, information and good practices on the reduction of dietary risk of noncommunicable diseases

• Integration of the action plan into food and nutrition-related plans, programmes and initiatives (for example, UNSCN’s Scaling Up Nutrition, FAO’s Committee on World Food Security, and the maternal, infant and young child nutrition programme of the Global Alliance for Improved Nutrition)

IAEA • Expand support to health ministries to strengthen treatment components within national cancer control strategies, alongside reviews and projects of IAEA’s Programme of Action for Cancer Therapy that promote comprehensive cancer control approaches to the implementation of radiation medicine programmes


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ILO • Support WHO’s global plan of action on workers’ health, Global Occupational Health Network and the Workplace Wellness Alliance of the World Economic Forum

• Promote the implementation of international labour standards for occupational safety and health, particularly those regarding occupational cancer, asbestos, respiratory diseases and occupational health services

UNRWA • Strengthen preventive measures, screening, treatment and care for Palestine refugees living with noncommunicable diseases

• Improve access to affordable essential medicines for noncommunicable diseases through partnerships with pharmaceutical companies

WFP • Prevent nutrition-related noncommunicable diseases, including in crisis situations

ITU • Support ministries of information in including noncommunicable diseases in initiatives on information, communications and technology

• Support ministries of information in including noncommunicable diseases in girls’ and women’s initiatives

• Support ministries of information in the use of mobile phones to encourage healthy choices and warn people about tobacco use, including through the existing ITU/WHO Global Joint Programme on mHealth and noncommunicable diseases

FAO • Strengthen the capacity of ministries of agriculture in redressing food insecurity, malnutrition and obesity

• Support ministries of agriculture in aligning agricultural, trade and health policies

WTO • Operating within the scope of its mandate, support ministries of trade in coordination with other competent government departments (especially those concerned with public health), to address the interface between trade policies and public health issues in the area of noncommunicable diseases

UN-HABITAT • Support ministries of housing in addressing noncommunicable diseases in a context of rapid urbanization

UNESCO • Support the education sector in considering schools as settings to promote interventions to reduce the main shared modifiable risk factors for noncommunicable diseases

• Support the creation of programmes related to advocacy and community mobilization for the prevention and control of noncommunicable diseases using the media and world information networks

• Improve literacy among journalists to enable informed reporting on issues impacting the prevention and control of noncommunicable diseases.

UNOSDP • Promote the use of sport as a means to the prevention and control of noncommunicable diseases

WIPO • Operating within the scope of its mandate, support, upon request, relevant ministries and national institutions to address the interface between public health, innovation and intellectual property in the area of noncommunicable diseases

UNODC • To be further explored (FOOTNOTE: Including through the planned ECOSOC discussion on the UN taskforce)

INCB • To be further explored (FOOTNOTE: Including through the planned ECOSOC discussion on the UN taskforce)

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