Addressing NCDs in Low and Middle Income Countries Special Interest Group

The special interest group for non-communicable diseases (NCDs) in low- and middle-income countries (LMICs) is 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.

Our work focuses 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

We are keen to welcome new members to the group. If you are interested please do get in touch with one of the co-chairs: Katy Scammell (kscam@hotmail.com), or David McConologue (dmcconalogue@yahoo.com).

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 reduce d 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.

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.

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.

  • Increase excise taxes and prices on tobacco products and alcoholic beverages

  • Implement plain/standardized packaging and/or large graphic health warnings on all tobacco packages

  • Enact and enforce comprehensive bans on tobacco advertising, promotion and sponsorship and restrictions on exposure to alcohol advertising (across multiple types of media)

  • Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public places, public transport

  • Implement effective mass media campaigns that educate the public about the harms of smoking/tobacco use and second-hand smoke

  • Enact and enforce restrictions on the physical availability of retailed alcohol (via reduced hours of sale)

  • Reduce salt intake through the reformulation of food products to contain less salt and setting target levels for the amount of salt in foods and meals

  • Reduce salt intake through a behaviour change communication and mass media campaign

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 (here) includes a 13 point plan to tackle NCDs globally.

Background:

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 multisectoral policies and plans, accelerating the reduction of risk factors, and strengthening health systems.

The WHO published a Global Action Plan for the prevention and control of NCDs (2013–2020)which was endorsed during the Sixty-sixth WHO World Health Assembly in 2013 and is due to be updated. 

Global Targets

The following targets for voluntary action by governments were agreed at the 2013 World Health Assembly in Resolution WHA66/10 and have formed the basis for subsequent monitoring of progress. Reported progress is published by WHO regularly and the targets themselves will be updated periodically.

  1. A 25% relative reduction in the overall mortality from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases.

  2. At least 10% relative reduction in the harmful use of alcohol, as appropriate, within the national context.

  3. A 10% relative reduction in prevalence of insufficient physical activity.

  4. A 30% relative reduction in mean population intake of salt/sodium.

  5. A 30% relative reduction in prevalence of current tobacco use in persons aged 15+ years.

  6. A 25% relative reduction in the prevalence of raised blood pressure or contain the prevalence of raised blood pressure, according to national circumstances.

  7. Halt the rise in diabetes and obesity.

  8. At least 50% of eligible people receive drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes.

  9. An 80% availability of the affordable basic technologies and essential medicines, including generics, required to treat major noncommunicable diseases in both public and private facilities.

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.  

 

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 

 

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

 

WHO Global Action Plan 2013 - 2020 (due to be updated)

https://apps.who.int/iris/bitstream/handle/10665/94384/9789241506236_eng.pdf?sequence=1

 

WHO report on tackling NCDs effectively and efficiently:  Saving Lives; Spending Less, A strategic response to NCDs, Geneva, 2018: 

WHO-NMH-NVI-18.8-eng.pdf

 

WHO report on Best Buys for NCDs and other interventions: 

https://apps.who.int/iris/handle/10665/259232  

 

WHO briefs and posters on NCDs available in the six UN languages:

https://www.who.int/ncds/un-task-force/policy-briefs/en/ 

 

Policy implementation experience: 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 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 (here):

https://www.who.int/ncds/un-task-force/en/ 

 

The Disease Control Priorities (3) 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 

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 

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