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Addressing NCDs in Low and Middle Income Countries
Please note - this Special Interest Group is no longer active
The special interest group for non-communicable diseases (NCDs) in low and middle-income countries (LMICs) was a group for public health professionals with an interest in taking action to reduce the burden of NCDs.
NCDs are one of the major health challenges of the 21st century. Although NCDs affect all countries across the globe, the burden is rising disproportionately fast in LMICs where 47% of premature deaths from NCDs occur. The impact on health and society is especially damaging in those countries whose healthcare systems are already weakened by conflict, natural disasters, epidemics and chronic under-resourcing.
The group's work focused on:
Advocating for action to address the rising burden of NCDs in LMICs
Supporting other global health SIGs with work related to NCDs
Acting as a resource to FPH and its members on knowledge related to NCDs and LMICs
A summary of the SIG's role and how this was achieved can be found here.
NCDs are chronic, long-term diseases and health conditions that are not communicable, whether through interpersonal contact or vector transmission. Globally, they are the leading cause of premature mortality and disability. The range of health conditions captured under the heading of NCDs can be large since it usually includes mental health, nutritional disorders, injuries and trauma, and violence including gender-based violence. The four leading NCDs are cardiovascular disease (CVD), respiratory disease, diabetes and cancer. Together, these account for around 70% of all NCDs.
NCD incidence and prevalence can be reduced through proven interventions that influence behavioural and metabolic/physiological risk factors. In fact, WHO estimates that at least 80% of all heart disease, stroke and diabetes and at least 40% of cancer could be prevented by tackling major risk factors. Managing these risk factors can avert onset and also reverse disease progression. For individuals, outcomes will be highly variable, and may be affected by social, metabolic, behavioural and other factors including co-morbidities, treatment compliance, and quality of health care available.
The behavioural risk factors include tobacco use, physical inactivity, unhealthy diet, and the harmful use of alcohol. These can be reduced through societal interventions such as legislation and taxation, as well as changes to individual behaviour.
The metabolic risks include raised blood pressure, overweight/obesity, hyperglycaemia (high blood glucose levels) and hyperlipidaemia (high levels of fat in the blood). These can be addressed through screening, treatment and changes to individual behaviour.
The social context in which these risk factors occur is also crucial. Therefore, effective responses to NCDs must also consider the ‘causes of the causes’ or the ‘social determinants of health’ and the huge inequalities which exist both within and between countries.
In 2018, the WHO also recognised air pollution as a major environmental risk factor for NCDs. This can be addressed through enforcing emission standards for pollutants across a range of sectors (industry, transport, waste, agriculture etc) and improving access to clean energy sources for households.
NCDs have complex inter-relationships with other disease groups and health outcomes:
Some infectious diseases can led to the development of NCDs. For example, Human Papilloma Virus (HPV), a sexually transmitted infection, can lead to cervical cancer. HIV, a transmissible disease, has effectively become a chronic disease through improved treatment options;
Mental illness, including depression and other short and long term mental health conditions can make individuals more vulnerable to risk factors for NCDs (harmful use of alcohol for example), while the experience of suffering from an NCD can have effects on individual mental health;
Alcohol and drug abuse is frequently linked to injuries, accidents and gender-based violence.
UN Political Declaration on NCDs
Global health and political leaders have been working on making and strengthening a number of commitments to address and control NCDs since 2011.
In September 2011, heads of state and government, assembled at the United Nations, committed to address the global burden and threat of NCDs with the adoption of a wide-ranging political declaration at the opening of the General Assembly’s first United Nations High-level Meeting (HLM) on NCDs.
In July 2014, during the second United Nations HLM on NCDs, ministers and representatives of states and government committed to setting national NCD targets, developing multi-sectoral policies and plans, accelerating the reduction of risk factors, and strengthening health systems.
At the September 2018 United Nations General Assembly (UNGA) countries agreed a high level statement on the importance and urgency of addressing NCDs. This statement was developed at the third United Nations HLM on NCDs and featured 13 new commitments to tackle NCDs globally.
World Health Organization: Global Action Plan on NCDs
The Global Action Plan for the prevention and control of NCDs (2013-2020) was originally endorsed during the Sixty-sixth WHO World Health Assembly in 2013.
In 2019, at the Seventy-second World Health Assembly, the period of the action plan was extended to 2030 in order to align with the 2030 Agenda for Sustainable Development. The objectives of the WHO NCD-GAP were confirmed as a contribution towards the SDG target 3.4 (which aims by 2030 to reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being).
An implementation roadmap 2023 – 2030 is expected to be presented and considered at the 75th World Health Assembly in 2022. https://apps.who.int/gb/ebwha/pdf_files/EB148/B148(7)-en.pdf
The following nine targets for voluntary action by governments were agreed at the 2013 World Health Assembly in Resolution WHA66/10 and continue to form the bases of monitoring progress (now contributing to SDG target 3.4):
- A 25% relative reduction in the overall mortality from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases.
- At least 10% relative reduction in the harmful use of alcohol, as appropriate, within the national context.
- A 10% relative reduction in prevalence of insufficient physical activity.
- A 30% relative reduction in mean population intake of salt/sodium.
- A 30% relative reduction in prevalence of current tobacco use in persons aged 15+ years.
- A 25% relative reduction in the prevalence of raised blood pressure or contain the prevalence of raised blood pressure, according to national circumstances.
- Halt the rise in diabetes and obesity.
- At least 50% of eligible people receive drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes.
- An 80% availability of the affordable basic technologies and essential medicines, including generics, required to treat major non communicable diseases in both public and private facilities.
Preventing, diagnosing and successfully controlling NCDs requires a whole of government approach in order that necessary actions beyond the health service can be identified and implemented.
Global best buys
Working with partners, the WHO has analysed a range of interventions to prevent and control NCDs at the population level in order to identify how governments can use their available resources in the most cost-effective way. These ‘best buys’ can help guide policy priorities by enabling national authorities to get the best value for money from limited resources.
The 16 ‘best buys’ can be found in the updated Appendix 3 (2017) of the WHO Global NCD Action Plan, which presents a list of 88 options for the four key risk factors for NCDs and for four key disease areas.
There is a growing range of useful resources available to support countries and organisations in their response to NCDs. Some of these are listed below with links to open access publications.
NCD Countdown 2030 is an independent mechanism for countries to monitor progress towards SDG target 3.4. A collaborative effort from WHO, NCD Alliance, Imperial College and The Lancet, every two years it publishes a report on country-specific baseline data and rates of decline in premature mortality: https://www.thelancet.com/NCD-Countdown-2030
The Lancet-UCL Annual Lecture 2019: Dr Rachel Nugent: NCDs as a Global Health Emergency. This is the lecture she gave with the slides. An excellent framing of the NCD challenge. https://www.youtube.com/watch?v=DIYUUu2R0S4
The Lancet Taskforce on NCDs and Economics: Published on April 4th 2018 by the Lancet: https://www.thelancet.com/series/Taskforce-NCDs-and-economics
UNGA 2018: the Declaration on NCDs agreed by all countries at the UN High Level Meeting in September 2018: https://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/73/2
World Health Organization
WHO Global Action Plan 2013 - 2030: https://apps.who.int/iris/bitstream/handle/10665/94384/9789241506236_eng.pdf?sequence=1
WHO report on Best Buys for NCDs and other interventions: https://apps.who.int/iris/handle/10665/259232
WHO mid-point evaluation of the implementation of the WHO GAP NCDs 2013-2020: https://www.who.int/publications/m/item/mid-point-evaluation-of-the-implementation-of-the-who-global-action-plan-for-the-prevention-and-control-of-noncommunicable-diseases-2013-2020-(ncd-gap)
WHO Director-General report on the progress achieved in the prevention and control of non-communicable diseases and the promotion of mental health: https://apps.who.int/gb/ebwha/pdf_files/EB148/B148_7-en.pdf
WHO briefs and posters on NCDs available in the six UN languages: https://www.who.int/ncds/un-task-force/policy-briefs/en/
The Interagency Taskforce on NCDs brings together representatives from across the UN system to address NCDs. The Taskforce is hosted by WHO and meets regularly. It publishes reports and updates regularly on its webpage: https://www.who.int/ncds/un-task-force/en/
A webpage of material, tax guidance and tools on tobacco from the World Bank (Stop smoking: It’s Deadly and Bad for the Economy): https://www.worldbank.org/en/topic/tobacco
And, finally, levying tobacco tax is the single most effective health policy argues the Centre for Global Development: Savedoff W et al. The single best health policy in the world: tobacco taxation, Centre for Global Development, Washington DC, 2015: https://www.cgdev.org/publication/single-best-health-policy-world-tobacco-taxes
WHO Global Assessment of Air Pollution Exposure and Burden of Disease: https://www.who.int/airpollution/publications/en/
NCD Alliance Policy Brief on Air Pollution: https://ncdalliance.org/resources/airpollution-policybrief
Climate and Clean Air Coalition https://ccacoalition.org/en
Public Health England Health Matters: Air Pollution. https://www.gov.uk/government/publications/health-matters-air-pollution
A very interesting attempt to assess policy development and implementation progress in five African countries: Juma,PA Shukri, FM et. al. (2018) NCD prevention policy process in five African countries, BMC Public Health, 2018 18(Suppl 1): 961. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-5825-7
The Disease Control Priorities project lays out its comprehensive findings on NCDs: http://dcp-3.org/resources/benefits-and-costs-non-communicable-disease-targets-post-2015-development-agenda
Universal Health Coverage and Intersectoral Action for Health: http://dcp-3.org/chapter/2549/disease-control-priorities-improving-health-and-reducing-poverty
NCD Alliance collection of short films: https://ncdalliance.org/turning-the-tide/films