National capacity for prevention and control of noncommunicable diseases in WHO South-East Asia Region

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National capacity for

prevention and control of

noncommunicable diseases in WHO South-East Asia Region

Results from NCD country capacity survey 2017

March 2018

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Noncommunicable Disease (NCD) Document Repository: https://extranet.who.int/ncdccs/documents/

National capacity for prevention and control of noncommunicable diseases in WHO South-East Asia Region. Results from NCD country capacity survey 2017

ISBN: 978 92 9022 617 8

© World Health Organization 2018

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List of figures and tables

Figure 1: Availability of governance structures and

financing for different NCD activities 5

Figure 2: Existence of integrated or disease/risk factor-

specific policies, plans or strategies, 2017 16

Figure 3: Availability of technologies for early diagnosis and

monitoring of selected NCDs in public sector facilities 21 Figure 4: Availability of technologies for early diagnosis and

monitoring of selected NCDs in private sector facilities. 22 Figure 5: Reported availability of essential medicines for prevention and

control of NCDs in primary care facilities in the public sector, 2017 25 Figure 6: Reported availability of specific procedures for treating NCDs or their

complications in the public sector health-care facilities, 2017 28 Figure 7: Reported status of national surveillance systems

for NCDs in South-East Asia, 2017 32

Table 1: Intersectoral coordination mechanisms in Member States

of the WHO SEA Region, 2017 7

Table 2: Status of health expenditure in the WHO South-East Asia Region, 2017 12 Table 3: Major sources for regular funding for NCDs as reported

by countriesin 2017 NCD CCS survey 13

Table 4: Reported general availabilityb of different NCD medications at

the primary health care level in public sector, NCD CCS Survey 2017 27 Table 5: Status of NCD risk-factor surveys among youth in the SEA Region 34 Table 6: Status of NCD risk-factor surveys among adults in the SEA Region. 34

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Acknowledgements

This report was prepared by Dr Manju Rani, Regional Adviser for NCD and Tobacco Surveillance, from the NCD and Tobacco Surveillance team of the Department of Noncommunicable Diseases and Environmental Health at the South-East Asia Regional Office of the World Health Organization. Mr Naveen Agarwal from the NCD and Tobacco Surveillance team contributed in the compilation of the report by assisting the data collection process, preparation of specific graphs, and in formatting the report. Editorial and design support was provided by Mr Gautam Basu (Assistant Reports Officer) and Mr Subhankar Bhowmik (Graphic Art Associate) based in the South-East Asia Regional Office of WHO.

Contributions to the report were made by the following colleagues based in the South-East Asia Regional Office of WHO in the Department of Noncommunicable Diseases and other departments:

Dr Thaksaphon Thamarangsi, Dr Phyllida Travis, Dr Palitha Mahipala, Dr Gampo Dorji, Dr Jagdish Kaur, Dr Angela Padmini de Silva, Dr Nazneen Anwar, Ms Klara Tisocki, Mr Lluis Vinals Torres, Dr Manisha Shridhar and Mr Mark Landry. In addition, contributions are acknowledged from colleagues at WHO headquarters, in particular Ms Leanne Riley, Dr Hebe Gouda and Ms Melanie Cowan, who coordinated the overall administration and compilation of data for 2017 Country Capacity Survey at the global level.

Sincere thanks to all WHO Member States for their assistance in reporting data to WHO, which made the compilation of these data and indicators possible.

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List of abbreviations and acronyms

ACE angiotensin-converting enzymes CCS country capacity survey

CHE current health expenditures CRD chronic respiratory diseases CVD cardiovascular diseases

CRVS civil registration and vital statistics EPI Expanded Programme on Immunization GDP gross domestic product

GYTS Global Youth Tobacco Survey

GSHS Global Student-based School Health Survey HPV human papilloma virus

IARC International Agency for Research on Cancer LMIC lower-middle income countries

MoE Ministry of Education MoH Ministry of Health

MoHFW Ministry of Health and Family Welfare MoPH Ministry of Public Health

NCDs noncommunicable diseases NMAP National Multisectoral Action Plan PA physical activity

PEN Package of Essential Noncommunicable disease interventions SARA service availability and readiness assessment

SEAR South-East Asia Region

SEARO South-East Asia Regional Office of WHO SDG Sustainable Development Goals

SHI social health insurance SRS Sample Registration System SSB sugar and sweetened beverages STEPs STEPwise approach to surveillance THE total health expenditure

TOR terms of reference

WHO World Health Organization

WHO FCTC World Health Organization Framework Convention on Tobacco Control UN United Nations

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Regional Director’s foreword

Noncommunicable diseases (NCD) represent a serious threat to the economic and social development of the WHO South-East Asia Region. Sixty-four per cent of all deaths in South-East Asia are NCD- related, half of which occur during the economically productive ages of 30 and 70 years. Premature death from noncommunicable diseases has become a major public health challenge in Region.

It is predicted that the NCD burden may raise further especially among low- and lower-middle income countries, which may be least prepared to deal with them. Hence I have declared the control and prevention of NCDs as one of my key Flagship Priorities.

While the Global and Regional Plans of Action as well as the resolution A/RES/68/300 and outcome document adopted by United Nations General Assembly on 10 July 2014 have set out the roadmap to tackle NCDs, we cannot afford to be complacent with regard to our efforts towards NCD prevention and control. Hence, as part of our efforts to track the progress towards reducing morbidity and mortality from NCDs, WHO conducted in 2017 its sixth national NCD Capacity Survey to generate detailed information from countries on their current capacities related to NCD infrastructure, policy action, surveillance and health systems response.

These results are particularly relevant and timely. While the results reveal significant areas of progress especially in terms of developing NCD policies and plans, they also highlight persisting challenges and uneven progress across the countries in the Region. These challenges include weak multisectoral coordination, difficulties in putting plans and strategies into action, inadequate information systems, and fiscal and regulatory measures still falling short of best recommendations.

This report is intended to call attention to the urgent need to accelerate national efforts and invest more resources to fulfil national commitments; failing which the social, human and economic costs associated with noncommunicable diseases will overwhelm our systems and economies and challenge the Region’s ability to successfully pursue the 2030 Sustainable Development Agenda.

Dr Poonam Khetrapal Singh Regional Director

WHO South-East Asia

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Executive summary

Noncommunicable diseases (NCDs), including cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases, and their key risk factors – tobacco, harmful use of alcohol, unhealthy diet and physical inactivity – remain the leading cause of death in the South-East Asia Region of WHO. NCDs are currently responsible for 8.9 million deaths annually in South-East Asia (64% of all deaths in the Region) out of which 4.4 million deaths are premature between the ages of 30 and 69 (31.5 of total deaths and 49.2 of all NCD-related deaths) and accounts for 29% of all premature deaths globally (1). NCDs, thus, represent a serious threat to the economic and social development of the Region.

Since 2001, WHO has been carrying out NCD Country Capacity Surveys (CCS) periodically to develop country capacity profiles, monitor the progress, and identify gaps and unmet needs in each country.

Since 2013, WHO has been implementing this survey every two years. This report summarizes the status of national capacity to prevent and control NCDs in the WHO South-East Asia Region based on the results from 2017 NCD CCS survey—the sixth national capacity survey since 2001. NCD CCS survey is a qualitative survey, with administration of a web-based questionnaire hosted on WHO website to collect data from NCD focal point(s) or designated officials within the Ministry of Health or national institutes or agencies responsible for NCDs in the WHO Member States. The data for 2017 was collected between January and July 2017. 100% response rate was achieved, with all the 11 countries completing and submitting the questionnaires within the given deadline. Given that there are only 11 countries in the Region, the data are presented mainly in a qualitative form, rather than as percentages or other statistical measures.

The questionnaire (Annex 1) comprised of four modules:

¤ Public health infrastructure, partnerships and multisectoral coordination;

¤ Policies, strategies, and action plans;

¤ Health information systems and surveillance; and

¤ Health system capacity for detection, treatment and care.

The survey results highlight several areas where substantial progress has been made in the Region in the past 4 to 5 years and areas that still need attention.

Areas of major progress:

¤ Governance and financing: ALL the 11 countries have

¢ established a dedicated NCD unit, branch, or a department;

¢ provided government financial allocation for all the eight key functions of NCD prevention and control.

¢ Introduced taxation for alcohol and tobacco (except one country)

¤ Policies and strategies: ALL the 11 countries have

¢ included the NCD agenda in their overall health sector plan and national development agenda;

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¢ developed multisectoral national NCD prevention and control plans, strategies or action plans which address all the four key NCD risk factors and early detection and treatment of all the four major NCDs. However, in some countries, these are still in the process of official endorsement.

¤ Early detection, treatment and care of NCDs within health systems: ALL the 11 countries have

¢ reported having recently updated evidence-based guidelines/protocols for cardiovascular diseases and diabetes;

¢ reported general availability of equipment for height and weight, and blood pressure measurement in primary care facilities;

¢ reported availability of at least one group of anti-hypertensive medication in the primary health care facilities in the public sector. Thiazide diuretics are the most commonly reported anti-hypertensive medication.

¤ Health information system, monitoring, surveillance:

¢ All countries except Indonesia and Timor-Leste reported the existence of civil registration and vital statistics systems for mortality data;

¢ All countries except India and DPR Korea reported doing integrated risk factor survey among youth (as part of GSHS) in the last three years;

¢ All the countries except Bangladesh, India and Maldives reported doing at least one nationwide integrated risk factor survey among adults in the last five years.

Areas needing attention:

¤ Governance:

¢ Establishing, strengthening, and evaluating the performance of multisectoral governance mechanism,

¢ Strengthening NCD unit/branch by ensuring adequate staffing with technical expertise and capacity,

¢ Improving the levels of funding for NCD prevention and control,

¢ strengthening of regulatory and financial reform capacity to further strengthen fiscal policies on tobacco and alcohol, and hopefully for other unhealthy foods including sugar- sweetened beverages and foods high in salt and trans-fats based on recommended best practices.

¤ Policies and strategies:

¢ Strengthening implementation of NCD policies and plans,

¢ Involvement of multisectoral coordination committees or groups in regular monitoring and evaluation of these policies and plans,

¢ Obtaining high-level endorsement of policies and plans where still pending.

¤ Early detection, treatment and care of NCDs within health systems:

¢ Ensuring regular availability of anti-hypertensive and anti-diabetic medications and

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¢ Increasing the availability of insulin,

¢ Increasing the availability of drugs for treatment of bronchial asthma (especially corticosteroid inhalers),

¢ Increasing the availability of nicotine replacement therapy and palliative care,

¢ Institutionalizing cancer screening programmes especially for cancers of public health importance with availability of sensitive and specific screening tests. The current systems in most of the countries rely on opportunistic screening with very low coverage.

¤ Health information systems, monitoring and surveillance:

¢ Establishing and expanding coverage and completeness of mortality registration systems as part of civil and vital registration systems,

¢ Financing and Institutionalizing periodic integrated NCD risk factor surveys as an integral and essential part of national health information systems. Two of the countries (India and Maldives) never did a nationwide NCD risk factor survey, while Bangladesh did the last survey in 2010, more than five years ago.

Survey results presented above should be interpreted taking into account some of the major limitations. First of all, the questionnaires provided only a high-level overview of national capacities for prevention and control of NCDs, and as such do not capture all the specific circumstances of each country and do not allow for a comprehensive situation analysis of each subject covered.

Second, the quality of the collected data depends on the breadth of the consultation process among key informants, and reflects the perspectives and knowledge level of informants at the time they completed the survey.

These limitations notwithstanding, the results are still very useful because they provide information on the status of essential infrastructure, surveillance, policy and health services.

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1 Introduction

Noncommunicable diseases (NCDs), including cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases, and their key risk factors — tobacco, harmful use of alcohol, unhealthy diet and physical inactivity — remain the leading cause of death in the South-East Asia Region of WHO.

NCDs are currently responsible for 8.9 million deaths annually in South-East Asia (64% of all deaths in the Region) out of which 4.4 million deaths occur prematurely between the ages of 30 and 69 (31.5% of total deaths and 49.2% of all NCD-related deaths) and account for 29% of all premature deaths globally (1).

The WHO South-East Asia Region comprises 11 countries with a total population of 1.9 billion or about 26% of the total global population. There are no high-income countries in the Region. Only two countries, Maldives and Thailand comprising less than 5% of the total regional population are classified as upper-middle-income countries. The rest of the countries are classified as lower-middle- income countries with the exception of Nepal and the Democratic People’s Republic (DPR) of Korea which are classified as low-income countries (2).

Recognizing the critical public health importance of addressing NCDs for overall social and economic development, the 2030 Agenda for Sustainable Development Goals (SDGs), adopted at United Nations Summit on Sustainable Development in September 2015, explicitly included a goal to reduce the premature mortality from NCDs by one third by 2030 (3). Achieving these targets for NCD prevention and control requires a multisectoral and concerted action at the national level.

In 2001, WHO conducted the first NCD Country Capacity Survey (NCD CCS) to assess the national capacity for NCDs prevention and control by collecting detailed comparative information on the progress made by countries in addressing and responding to NCDs (4). The survey was repeated in 2005, in 2010, in 2013 and in 2015. Since 2013, WHO has been implementing this survey every two years, and the survey tool used in the assessment has evolved over time taking into account the evolving nature of NCD epidemic and the national response.

This report summarizes the status of national capacity to prevent and control NCDs in the WHO South-East Asia Region based on the results from 2017 NCD CCS survey — the sixth national capacity survey since 2001. It assesses the progress made over time, where possible, by comparing the results with 2013 and 2015 survey data. The report also identifies limitations and challenges for national capacity for NCD prevention and control and highlights the areas that urgently need prioritization and additional strengthening.

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2 Methods

Data collection review and validation

The NCD CCS survey is a qualitative survey, with administration of a web-based questionnaire hosted on WHO website to collect data from NCD focal point(s) or designated officials within the Ministry of Health or national institutes or agencies responsible for NCDs in the WHO Member States. In the last week of January 2017, each country received their unique web log-in details to access the website and the identified focal points were requested to submit their completed questionnaires through the WHO website by end of July 2017. To improve the quality and breadth of information provided, the questionnaire completion instruction requested that a team of people, led by the NCD focal point, complete the responses so that topic-specific experts could provide more detailed information. Additionally, for validation and verification of responses, Member States were requested to upload supporting documentation for selected questions such as the existence of a multisectoral policy or plan or screening or treatment guidelines.

The submitted information was thoroughly reviewed by the WHO Secretariat at the Regional Office and later at headquarters in terms of completeness and consistency (with the responses in the previous rounds of survey, as well as internally with other responses within this survey) and validated responses against existing data sources and supporting documentation provided. Where discrepancies were noted between the country response and other sources, a clarification request was sent to the country by the Regional Office of WHO. Similarly, if the review revealed missing documentation or incomplete questions, the focal point was asked to supply the missing information.

Questionnaire

The questionnaire (Annex 1) comprised four modules:

1. Public health infrastructure, partnerships and multisectoral coordination;

2. Policies, strategies, and action plans;

3. Health information systems and surveillance; and

4. Health system capacity for detection, treatment and care.

The questionnaire included a set of detailed instructions on how to complete it and a glossary defining the terms used in it.

Analysis

All the 11 Member States of the WHO South-East Asia Region submitted their responses by mid- April 2017, and went through several rounds of validation and re-submissions between mid-April and July. Data were downloaded directly from the web-based platform to an excel file. Initial data cleaning was performed by the WHO Secretariat to ensure consistency between responses to a question and its sub-questions. Given that there are only 11 countries in the Region or only 11 data

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points for aggregate regional analysis, the data are presented mainly in a qualitative form, rather than percentages or other statistical measures such as mean or median. Non-positive responses (i.e.

“no”, “don’t know”, and item left unanswered) were treated equally and specifically mentioned where relevant.

Trends in national capacity for NCDs were presented in a qualitative manner by comparing the results from this survey with the surveys conducted in 2010, 2013 and 2015, wherever comparative questions were asked in all the four surveys. The results were examined in relation to the objective and key recommendations made to WHO Member States in the Global and Regional Action Plan (5, 6) as well as the progress monitoring indicators adopted in 2015 on the progress achieved in the implementation of the four time-bound commitments included in the 2014 United Nations Outcome Document on NCDs (7).

Limitations

The results of the 2017 Country Capacity Survey should be interpreted taking into account certain limitations. First, the questionnaire designed as a global tool provides only a high-level overview of national capacities for prevention and control of NCDs, and as such cannot capture all the specific circumstances of each country; nor does it allow for a comprehensive situation analysis of each subject covered. For example, while the survey can identify the existence of fiscal interventions for NCDs and their risk factors, it does not provide enough information to determine whether those interventions are sufficient to bring about the desired public health impact.

Second, the Country Capacity Survey is coordinated by a focal point for NCDs designated by the national authority, which was expected to identify and consult key informants for each of the survey modules. The quality of the collected data depends on the breadth of this consultation process, and reflects the perspectives and knowledge level of informants at the time they completed the survey.

Finally, while the present round of survey featured an expanded validation process, there were still substantial numbers of questions (e.g. availability of medicines, diagnostics, etc.) for which no independent verification mechanisms were available. These limitations notwithstanding, the results should still be very useful because they provide information on essential infrastructure, surveillance, and the policy and health service component for the control and prevention of NCDs.

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3 Results

All the results presented below are dated 31 July 2017, when the data collection process was closed.

Any changes in the situation in any Member State since have not been taken into account.

1 Public health infrastructure, partnerships and multisectoral collaboration for NCDs

Governance structures

Highlights:

¤ All countries in the WHO SEA Region reported having a unit, branch, or department responsible for NCDs in their Ministry of Health.

¤ All countries with the exception of Bangladesh and Maldives reported having a dedicated nationwide multisectoral commission, agency or mechanism to oversee NCD engagement, policy coherence and accountability in sectors other than health.

¤ General government revenues were reported to be the single largest source of regular funding for prevention and control of NCDs in all the countries, regardless of income level. However, given the overall low level of government spending on health, these budget allocations may not be adequate.

¤ All countries reported the implementation of at least one fiscal intervention related to NCDs (most common being tobacco/alcohol taxation).

NCD unit, branch or department

Since 2010, all countries in the WHO South-East Asia Region, except Nepal, have been reporting having a unit, branch or department in their ministry of health with the responsibility for NCDs.

Nepal established the same in 2016 with 11+ full-time or equivalent staff members. Hence, in 2017, all countries reported having such a unit (Figure 1).

The reported full-time technical staff in the NCD unit ranged from 2 to 5 in DPR Korea, Maldives and Sri Lanka; to 6–10 in India and Timor-Leste; to 11 or more in Bangladesh, Bhutan, Indonesia, Myanmar, Nepal and Thailand. The 2017 Survey represents substantial improvement in NCD staffing capacity since 2010, especially in some countries such as Bangladesh, Nepal and Timor-Leste.

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Figure 1: Availability of governance structures and financing for different NCD activities

Yes No Don't know Not reported

0 1 2 3 4 5 6 7 8 9 10 11

For health promotion Tax on alcohol Tax on tobacco Tax on SSB Tax on unhealth food Subsidies for health food Tax to promote PA Primary prevention Health promotion Early detection/ screening Healthcare/ treatment Surveillance, monitoring…

Capacity building Palliative care Separate unit/dept/branch Multisectoral commission, agency or mechanism

Funds earm arkedCountry implementing any fiscal intervationsFunds allocated in government budget for NCD capacity in MOH

Number of countries in the WHO SEA Region

Multisectoral coordination mechanisms, building coalitions and partnerships Multisectoral coordination mechanisms in

the WHO South-East Asia Region at a glance:

¤ Seven out of 11 countries reported having an ‘operational’ multisectoral mechanism;

India and Timor-Leste reported a mechanism ‘under development’.

¤ Cross-departmental or inter-ministerial committees were the most commonly reported mechanism for multisectoral coordination.

¤ A health sector representative chaired these mechanisms except in India and Nepal.

¤ Only three countries reported membership of the private sector and four countries reported an NGO to be a member.

¤ Limited information on the legitimacy, powers, resources and effectiveness of these mechanisms in influencing NCD policy and programme outcomes.

Encouragingly, both the sector-wide and the NCD-specific plans in all the SEA Region countries emphasize the importance of multisectoral coordination and identify relevant stakeholders.

In 2017, seven out of 11 countries in the Region reported having an “operational” multisectoral coordination mechanism and partnership to oversee NCD engagement, policy coherence and accountability of sectors beyond health. While Bangladesh and Maldives did not report having

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any multisectoral coordination mechanism, India and Timor-Leste reported that its multisectoral coordination mechanism is “under development”.

Cross-departmental or inter-ministerial committees were the most commonly reported mechanism for multisectoral coordination. In most instances, the mechanism was chaired by a health sector representative (minister, secretary or director-general). Only India and Nepal reported the mechanism to be chaired a Cabinet Secretary/Chief Secretary¹.

The supporting documentation provided by the Member States with the survey provides some details of the composition, roles and responsibilities (Table 1). The reported key stakeholders for partnerships included other non-health government ministries (8/8), academic (7/8), nongovernmental organizations (6/8), UN agencies (4/8), and other international organizations (4/8). Three out of eight countries also reported membership of the private sector (3/8).

Partnerships with non-State actors

Effective governance for NCD at the national level requires the development of effective partnerships and coalitions to generate the demand for change and to catalyse political action. The range of actors and stakeholders for noncommunicable disease control are complex and include food manufacturers and retailers, tobacco and alcohol industries, civil associations, disease/condition-specific advocacy groups such as national diabetic associations, and professional associations.

The multisectoral coordination mechanisms in some of the Member States (e.g. DPR Korea, India, Myanmar, Sri Lanka and Thailand) officially included membership of nongovernmental organizations (NGOs), in others it was confined to only government ministry representatives (e.g.

Bhutan, Indonesia and Nepal) (Table 1). In addition, the countries may not be well equipped to develop partnerships or engage effectively with such a complex and wide range of actors that may often have conflicting interests. In the current survey, almost six out of eight Member States that reported having multisectoral coordination mechanism reported having partnerships with NGOs, and only three countries (India, Myanmar and Thailand) with the private sector. However, functional mechanisms to deal with non-traditional stakeholders, such as food manufacturers, do not seem to be well established in any of these countries.

1 Cabinet or Chief Secretaries generally oversee all the sectors/department in a government, while sector-specific secretary such as health secretary are responsible for the only health department.

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Table 1: Intersectoral coordination mechanisms in Member States of the WHO SEA Region, 2017 CountryName of intersectoral mechanismChairMembershipYear of establishmentComments BangladeshNone reported BhutanNational Steering Committee for NCDs; has three implementation subcommittees: tobacco & alcohol; healthy settings; health services.

Minister of Health12 members representing multiple government ministries and institutions (e.g. Department of Youth and Sport in MoE, Dept. of Trade, Dept. of Revenue & Customs)

2010Established in 2010, the Committee has explicit ToR, including ToRs for each subcommittee. However, it has remained rather inactive, and efforts are being made to reinforce it. DPR KoreaMultisectoral coordination committee for NCDs

Non-health government institutions, academia, and NGOs/CSO

No supporting documents were provided in CCS survey, so no further details are available. IndiaStanding Committee of Secretaries for prevention and control of NCDs

Cabinet Secretary. Health Secretary, MoHFW as Member Secretary

Secretaries of 39 concerned departments mention in NMAP; can call other secretaries, other stakeholders and UN agencies as appropriate.

Proposed to be set up in NMAP (2017–2024)

Proposed as a mechanism/platform for coordinated multisectoral engagement and action; key functions are defined; meeting frequency not defined. Inter-ministerial Committee for prevention and control of NCDs

Secretary, MoHFWNodal office from concerned ministries/ departments; can call representatives of other union ministries, academia, CSO, private sector Proposed to be set up in NMAP (2017–2024)

Key objective is to synergize, harmonize, and facilitate implementation of the activities envisaged in NMAP. NMAP describes the functions.

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CountryName of intersectoral mechanismChairMembershipYear of establishmentComments Technical Advisory Groups (TAG)Proposed to be set up in NMAP (2017–2024)

To provide support to other mechanisms (i.e. Interministerial committee and Standing Committee of Secretaries); the function are defined. Health Promotion Board/Society of India Proposed to be set up in NMAP (2017–2024) IndonesiaHealthy People MovementOther government ministries, UN agencies, academia

Attached document was in Bahasa, no other information is reported in CCS Survey. MaldivesNone reported MyanmarTechnical Strategy Group for NCDsDG, Department of public health, Ministry of Health and Sports

36 members including DG public health, member from different departments of MoH, representative from MoE, Department of Sports and Physical Education; representative from UN agencies, International and national NGOs and Civil Society Organization

2017Has defined terms of references. Other than MoE, no other non-health department is represented. TSG NCDs is one of the TSGs formed under Myanmar Health Sector Coordinating Committee (MHSCC) which is larger coordinating body chaired by Union Minister for Health & Sports. MHSCC comprises representatives from different entities including relevant ministries, INGOs/ NGOs, CSOs and so on. National Road Safety Council (NRSC)Chaired by Vice- President

Members including representatives from Ministry of Health and other relevant ministries.

June 2014Functions are defined.

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CountryName of intersectoral mechanismChairMembershipYear of establishmentComments Central Tobacco Control CommitteeChaired by Union Minister of Health and officials from relevant other ministries.

2011Functions are defined. NepalNational Steering Committee for NCDsChief Secretary, Govt. of Nepal, Secretary MoH as Member Secretary

18 members are proposed including chair and member secretary representing 17 governmental departments including national planning commission.

Proposed to be set up in NMAP (2014-2020)

Cabinet endorsed formation of committee with defined ToRs. No representation of private sector, CSO, etc. National Committee for control and prevention of NCDs

Secretary of Health; Chief, curative division service provision as Member Secretary

Expected to provide a planning and monitoring and information exchange forum for the ministries involved in implementation of NMAP Coordination committee for control and prevention of NCDs

Chief specialist, curative service division

ToR defined in NMAP, but whether any administrative order issued to appoint the committee is not known. Ad hoc committees for control and prevention of NCDs

Proposed to be set up in NMAP (2014–2020) Ad hoc committee may be formed by coordination committee to develop specific products required in the course of implementation of MSAP

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CountryName of intersectoral mechanismChairMembershipYear of establishmentComments Regional and district NCD prevention and control committees Proposed to be set up in NMAP (2014–2020)

Coordinate enforcement of regulations related to alcohol, tobacco, diet, road safety and other health promoting regulations , sharing of experiences, advocate implementation of MSAP Sri LankaNational Health CouncilProposed to be set up in national policy & strategic framework for prevention & control of NCDs, 2009

Supreme body for inter-ministerial/ intersectoral coordination, multisectoral partnerships, progress of implementation of National NCD policy National NCD Steering CommitteeSecretary of Ministry of Health and Nutrition

High-level representation from all relevant government agencies (finance, trade, agriculture, urban planning, education, justice, poverty alleviation, social welfare and other relevant agencies and development partners including local and international NGOs.

Same as aboveProposed to function as national monitoring body on national NCD policy implementation Will meet every two months, accountable to Minister of Healthcare and Nutrition Function are defined in NCD policy (2009) document National Advisory Board for Noncommunicable Diseases

DG, Ministry of Health and Nutrition High-level technical representation from relevant professional bodies.

Advisory body on National NCD Policy implementation

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CountryName of intersectoral mechanismChairMembershipYear of establishmentComments Technical Working Group on NCDsDirector NCD8–10 members ThailandExecutive Committee of Thailand Healthy Lifestyle Strategic Plan (Phase 2) (also called National NCD Prevention and Control Plan (2017-21); can appoint subcommittees as appropriate Minister of Public Health43 members including chairperson—including members from 13+ different government ministries, CSO, and UN agencies

Dec 1, 2016 via MoPH order no 2233/2559

Tasked with five key functions including formulating direction and strategies to support NCD prevention and control, monitoring & evaluation. Timor-LesteNone reportedReported as “under development”, no further details provided.

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Funding mechanisms

Overall health expenditures in South-East Asia: Predominance of private out-of-pocket expenditures In 2017, the current health expenditures (CHE)² as percentage of gross domestic product (GDP) ranged from 2.6% in Bangladesh to 11.5% in Maldives. The domestic private expenditures account for more than 70% of current health-care expenditure in the three largest countries of the SEA Region – Bangladesh (74%), India (74%), Myanmar (74%) and Nepal (71%) (8). Most of the domestic private expenditures are “out-of-pocket” expenditures putting the population at risk of catastrophic health expenditures and being driven into poverty, especially from chronic illnesses.

Table 2: Status of health expenditure in the WHO South-East Asia Region, 2017 Country Current health

expenditure (CHE) per capita in US$

Current health expenditure (CHE) as % gross domestic product (GDP)

Domestic private health expenditure (PVT-D) as % current health expenditure (CHE)

Out-of-pocket (OOP) as % of current health expenditure (CHE)

Bangladesh 32 2.6 74 72

Bhutan 91 3.5 21 20

India 63 3.9 74 65

Indonesia 112 3.3 61 48

Maldives 944 11.5 18 16

Myanmar 59 4.9 74 74

Nepal 44 6.1 71 60

Sri Lanka 118 3.0 45 38

Thailand 217 3.8 21 12

Timor-Leste 72 3.1 10 10

Source: World Health Organization, 2017. Global Health Expenditure Database (GHED). As accessed and downloaded on March13,2018 from http://apps.who.int/nha/database/ViewData/Indicators/en

Allocation of government budget to identified NCD activities

All the countries in the WHO SEA Region reported allocating funding in their government budget for all the eight key NCD and risk factor activities or functions, which were explicitly enquired about in the questionnaire (Figure 1). These eight NCD activities and functions include: primary prevention;

health promotion; early detection or screening; health care and treatment; surveillance, monitoring and evaluation; capacity-building; palliative care; and research. Only DPR Korea reported not allocating government budget for palliative care. However, given the overall low level of general government expenditure on heath as percentage of current health expenditure as shown in Table 2, the total

2 Since the introduction of SHA 2011, current health expenditure (excluding capital, which is a one-off expenditure that will be

“consumed” for several years) instead of total health expenditure are reported.

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current budget allocation may not be sufficient to address the expanding NCD epidemic in most countries.

Major sources of regular funding General government revenues

All countries reported general government revenue as the single largest source of regular funding for NCDs and their risk factors (Table 3).

International donors

International donors seem to be an important source of regular funding for NCDs in the SEA Region. Seven countries (Bangladesh, Bhutan, DPR Korea, Myanmar, Nepal, Sri Lanka and Timor- Leste) reported international donors as the second largest source of funding. Thailand mentioned international donors as “other source”. Notwithstanding this, the international funding for NCDs still remains negligible.

While the implementation of programmes for communicable diseases and maternal and child health in LMICs owe much to the financial and technical assistance of external donors, less than 3% of global development assistance for health currently goes to NCDs (9). Despite mounting international advocacy, the future of the international financing for NCDs is still unpredictable.

Health insurance

With the implementation of social health insurance (SHI) mechanism for health financing in some countries such as Indonesia (since 2014), Maldives and Thailand, health insurance is also emerging as an important mechanism or channel of regular funding for NCDs, though in majority of these countries, general tax revenues are used to fund these schemes with very low contributions from members. None of the countries, even the ones with an SHI system with fairly large coverage, mentioned health insurance as their first largest mechanism. Indonesia, Maldives and Thailand mentioned health insurance as their second largest mechanism of funding, after general government revenues. Three other countries (Sri Lanka, Myanmar and Timor-Leste) mentioned health insurance as “other” source of regular funding.

Domestic donors and earmarked taxes on alcohol, tobacco, etc. are mainly reported as ”other”

sources of funding by five countries out of 11 countries.

Table 3: Major sources for regular funding for NCDs as reported by countries in 2017 NCD CCS survey

Country Largest source Next largest Others

Bangladesh Government revenue International donors Bhutan Government revenue International donors DPR Korea Government revenue International donors^a

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Country Largest source Next largest Others

India Government revenue None National donors,

earmarked taxes on tobacco and alcohol Indonesia Government revenue Health insurance Ear-marked taxes on

tobacco and alcohol Maldives Government revenueâ Health insuranceâ International donorsâ Myanmar Government revenue International donors National donors,

ear-marked taxes on tobacco and alcohol, Help age international Nepal Government revenue^a International donors Health insurance^a Sri Lanka Government revenue International donors Health insurance,

national donors, ear-marked taxes on tobacco and alcohol Thailand Government revenue Health insurance International and

national donors, ear-marked taxes on tobacco and alcohol, Private companies Timor-Leste Government revenue International donors Health insurance,

national donors

a: response was changed post-survey completion

Implementation of fiscal interventions

Countries were explicitly asked if they have been implementing any of the six specific fiscal interventions mainly related to taxation (taxation on alcoholic beverages; on tobacco (excise and non-excise); on sugar-sweetened beverages; on food high in fat, sugar or salt; taxation incentives to promote physical activity) or price subsidies (for healthy foods). Countries were also given the option to specify any other fiscal intervention not captured by these six specific interventions.

With the exception of DPR Korea, all countries reported implementing taxation on alcohol and tobacco (Figure 1). DPR Korea has other price-setting mechanisms in place as all the tobacco and alcohol production is state-owned³.

India increased the taxes on aerated beverage with sugar from 18% to 21%, though the tax increase was applied evenly on mineral water and was not done exclusively for sugar sweetened beverages (10) (Figure 1), In addition, in February 2017, Maldives increased import duties on energy and fizzy drinks by 58%, Thailand is planning to introduce taxes on sugar-sweetened beverages (has gazetted the tax but not started the implementation). India also reported providing subsidies for promoting healthy foods mainly in the form of subsidies for production, storage and distribution of fruits and

3 Tobacco Control Law of DPR Korea (Decree number 1176 on June 24th, 2016), Pyongyang, DPR Korea.

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vegetables under the India Horticulture Mission. India also reported providing taxation incentives for promoting physical activities. DPR Korea also reported subsidies for healthy food, but the data could not be validated.

None of the countries reported levying taxes on unhealthy food high in fat, sugar or salt.

Earmarking of tax revenues from alcohol or tobacco for NCD or health promotion activities While all countries reported levying taxation for alcohol and tobacco as mentioned above, only five countries (Bangladesh, Indonesia, India, Nepal and Thailand) reported earmarking a part of these revenues, especially from tobacco, for NCD or health promotion activities (Figure 1).

Indonesia does not earmark alcohol taxes, but regulates tobacco taxes under Act No. 28 of 2009 (implementation started in 2014) and Government Regulation no. 55 of 2016 for local tax, both of which state the tariff for tobacco tax as 10% of the excise tax. A minimum of 50% of the tobacco tax revenue at provincial or district level is proposed to be allocated for public health services including for prevention and control of NCDs and enforcement of regulation. The procedure for allocation of funding is regulated under Ministry of Health Regulation no. 40 of 2016.

2 Plans, policies and strategies

Highlights:

¤ All SEA Region countries reported inclusion of NCDs in their current national health plan and is being reflected in the national development agenda (except Myanmar).

¤ All SEA Region countries reported having multisectoral national NCD policy, strategy or action plans which address all the four major risk factors (tobacco, harmful use of alcohol, physical activity and unhealthy diets), and early detection, care and management of all the four major NCDs (CVD, cancers, diabetes, chronic respiratory diseases).

¤ All SEA Region countries reported having time-bound national targets and indicators for NCDs based on nine global targets from the WHO Global Monitoring Framework.

¤ Some countries also reported having a disease- or risk-factor specific strategy or plan in addition to an integrated NCD plan/strategy.

Information was elicited regarding the presence of both integrated (defined as addressing one or more risk factors or diseases) and topic-specific policies, strategies, or action plans for noncommunicable diseases overall as well as for four major NCDs (CVD, cancers, diabetes mellitus, and chronic respiratory disease) and for four major risk factors.

Ministries of health were asked to name the policy and indicate if the plan was currently operational or under development. Additionally, this component covered cost-effective policies for NCDs, such as policies to reduce population salt consumption, to eliminate industry produced trans-fats (the partially hydrogenated vegetable oils) in the food supply, and to reduce impact on children of

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marketing of unhealthy foods and non-alcoholic beverages high in saturated fats, trans-fatty acids, free sugars, or salt.

Inclusion of NCDs in overarching national health plans and development plans All Member States reported inclusion of NCDs in the outcomes and outputs of their national health plans as well as national development plans (except Myanmar which reported “don’t know” for national development plan. Myanmar also reported the same in 2015) (Figure 2).

Figure 2: Existence of integrated or disease/risk factor-specific policies, plans or strategies, 2017

0 1 2 3 4 5 6 7 8 9 10 11

Salt policy Fat /Transfat policy Marketing of foods policy Unhealthy diet policy Tobacco control policy Physical activity policy Overweight/obesity policy Alcohol policy Oral health policy CRD policy Diabetes policy Cancer policy CVD policy Integrated National NCD policy/plan/strategy Time-bound national targets NCDs in national development agenda NCDs in national health plan

Selected cost- effective policiesPolicies/Plans for Specific Risk factorSpecific key NCDs NCDs relevent policies, strategies and action plans

Number of countries in the WHO SEA Region Available Not available Don't know Not reported

Integrated NCD policy/strategy/action plan

Encouragingly, all countries in the SEA Region reported having an integrated and operational national NCD policy/strategy/action plan (Figure 2), though in Bangladesh, India, Indonesia and Myanmar, the plans were still under finalization and awaiting official endorsement at the time of the survey.

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This is a progress since 2013–2015, when two of the countries did not report having an operational integrated plan. .

Scope of integrated NCD policies/strategies and action plans

All countries reported these strategies/plans to cover all the four major risk factors (harmful use of alcohol, tobacco, unhealthy diet, and physical inactivity) and covering early detection, care and treatment of all the four major NCDs (CVD, cancers, diabetes, and chronic respiratory diseases).

Finally, all the countries, with the exception of DPR Korea and Timor-Leste, also reported plans to cover palliative care as well.

Additionally, all countries described their integrated plans to be multistakeholder and multisectoral in nature, with the exception of Bangladesh and DPR Korea, which did not provide any response for the “multistakeholder option”.

Disease-specific NCD plans

Cardiovascular diseases

India and Thailand reported delivery of services for cardiovascular diseases through their integrated national programmes, the National Programme for Control of Cancer, Diabetes, CVD and stroke (NPCDCS) and National Service Development Plan, respectively. Other countries mainly include strategies and plan for CVD control in their integrated plans only (Figure 2).

Cancers

Seven of the 11 Member States reported having a specific plan or strategy for cancer control – either a general strategy covering all cancers (e.g. Bangladesh, Myanmar, Sri Lanka) or a strategy for specific cancers (e.g. Bhutan). India and Thailand reported their cancer services through the integrated programme as mentioned above for CVD. Four countries (DPR Korea, Indonesia, Nepal and Timor-Leste) did not report any cancer-specific plan or programme, though their integrated NCD plans cover cancer control and prevention (Figure 2).

Diabetes

Bhutan was the only country that reported having a diabetes-specific workplan. India and Thailand reported delivering diabetes services through their integrated programme as mentioned above.

Other countries have included diabetes control strategies as part of their integrated NCD control and prevention policies (Figure 2).

Chronic respiratory diseases

Two of the Member States reported having a special plan or strategy for chronic respiratory disease either in operation (1) or under development (1) (Figure 2). Thailand also reported inclusion of chronic respiratory disease in their integrated programme – National Service Development Plan.

India reported plans “under development” for inclusion of chronic respiratory diseases and chronic kidney diseases as part of their integrated national programme (NPCDCS).

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Oral health

In all, four countries reported specific oral health policies and programmes. India and Timor-Leste reported national oral health programmes (operational since 2012) and Timor-Leste Strategic Plan for Oral Health (2015–2020), respectively. Thailand included oral health services as part of National Service Development Plan. Nepal also reported having national oral health policy in the past, but not in effect currently (Figure 2).

Other NCD diseases

Many countries reported plans and strategies covering other noncommunicable diseases as well.

Mental health was the common disease group, reported by four Member States (Bhutan, India, Maldives and Timor-Leste). In addition, Bangladesh and Nepal (National Road Safely Action Plan 2013-2020) reported having a national plan on road safety. India and Nepal reported having plans and strategies for disabilities — specifically blindness and deafness in India, and for disability overall in Nepal. Thailand reported having specific plans and strategies for stroke and chronic kidney diseases.

Risk factor-specific NCD plans

Tobacco

Tobacco was the most common risk factor, for which all Member States reported a specific strategy/

plan. While some countries provided the names of their tobacco control strategies and plans, such as Bangladesh (Tobacco Strategic Plan of Action), India (National Tobacco Control Programme), Indonesia (Roadmap Tobacco Control Programme), Myanmar (Tobacco Control Strategy and Plan), others (Bhutan, DPR Korea, Maldives, Nepal, and Timor-Leste) provided the names of their tobacco control law rather than a specific plan/strategy to implement that law. In addition, all the countries included tobacco control in their overall NCD prevention and control plan.

Alcohol

Six (Bhutan, India, Myanmar, Nepal, Sri Lanka and Thailand) out of 11 Member States reported specific strategies and plans for alcohol, though some of them mentioned names of the alcohol control legislation rather than policies/strategies (Figure 2).

Overweight

India and Indonesia mentioned specific policies and strategies for reduction of overweight/obesity.

India reported Food Safety and Standards Authority of India (FSSAI) guidelines on children’s food and Ministry of Women and Child Development (MoWCD) guidelines on junk food as the specific policies for reduction of overweight and obesity. In addition, all the Member States included the component of reduction of overweight and obesity as part of the integrated NCD plans.

Promotion of physical activity

Bhutan, India, Indonesia, Sri Lanka, Thailand mentioned special guidelines/policies for promotion of some form of physical activities, while others indicated their integrated NCD plans where they have articulated strategies for the promotion of physical activity.

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Diet

Six (Bhutan, India, Indonesia, Maldives, Sri Lanka, Thailand) countries out of 11 mentioned specific policies/strategies for diet and listed their national nutrition programmes/policies

Selected cost-effective policies for NCDs and their related risk factors

Policies to reduce impact on children of marketing of food and non-alcoholic beverages

Three countries (India, Maldives and Thailand) reported implementing policies to reduce the impact of marketing of food and non-alcoholic beverages high in saturated fats, trans-fatty acids, free sugars, or salt through government legislation. While the government was responsible for overseeing enforcement and complaints in India and Maldives, Thailand reported an independent regulator to be responsible for the same. In addition, none of the countries reported taking steps to address the effect of cross-border marketing of food and non-alcoholic beverages on children.

Policies to limit saturated fatty acids and eliminating industrially produced trans-fats

Only two countries (Bhutan and India) reported implementing national policies that limit saturated fatty acids and virtually eliminate industrially produced trans-fat in the food supply.

Policies to reduce population salt consumption

Four countries (Bhutan, DPR Korea, India and Thailand) reported having polices to reduce population salt consumption. While all these four countries reported public awareness campaigns to reduce salt consumption; product reformulation by industry across the food supply was reported by India and Thailand; and regulation of salt content of food and nutrition labelling was reported by Bhutan, India and Thailand.

Campaigns to increase awareness on diet and physical activity

All countries reported implementing national public awareness programmes or campaigns in the last five years, though some countries did not provide supporting documents to validate their claim (DPR Korea, Maldives, Sri Lanka and Thailand). Similarly, all countries except Bangladesh reported implementing awareness campaigns for physical activities, though it could not be validated for four of the countries (Bhutan, DPR Korea, Maldives and Sri Lanka) based on submitted documents.

3 National capacity for early detection, treatment and care of NCDs within the health systems

The 2017 NCD Capacity Survey assessed the capacity of their health system related to NCD prevention, early detection, and treatment and care at the primary health care level in the public and private sector. Specific questions were asked to assess the availability of protocols to treat major NCDs and the availability of the tests, procedures and equipment related to NCDs within the health system.

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Highlights:

¤ All SEA Region countries reported having evidence-based guidelines/protocols for cardiovascular disease and diabetes that have been updated in the past 2 years, though only six countries reported them to be used in at least 50% of health facilities .

¤ All SEA Region countries reported general availability of equipment for measurement of height, weight, and blood pressure in both public and private health facilities (where relevant).

¤ While the basic equipment (e.g. glucometers) for diabetes is reported to be generally available in public primary care facilities (with the exception of DPR Korea and Timor- Leste), the more advanced tests (Hb1ac, etc.), blood cholesterol testing are available in only few countries at primary health care level.

¤ All SEA Region countries reported availability of at least one group of anti- hypertensive medication in primary health care facilities in public sector.

¤ Availability of drugs for diabetes, bronchial asthma, and tobacco cessation at primary care facilities is much more limited.

¤ All SEA Region countries reported screening programs for cervical cancer, and all but one reported for breast cancer. However, the screening programs are mainly opportunistic in nature and have low coverage in most of the countries.

Availability of evidence-based guidelines/protocols:

All the countries in the Region reported having evidence-based guidelines/protocols for cardiovascular diseases and diabetes that have been updated within the last two years (between 2015 and 2017) and include referral criteria. However, only six countries reported them being used in at least 50% of health facilities. Five countries [Bangladesh (reported as “don’t know”), Indonesia, Nepal, Sri Lanka and Timor-Leste] reported them being used in less than 50% of the health facilities.

For cancer and chronic respiratory diseases also, the majority of the Member States, with the exception of DPR Korea (reported “don’t know” for cancer), and Maldives⁴ (reported negative for both cancer and CRD) reported having these evidence-based protocols updated within the last one to four years.

In terms of nature of these evidence-based guidelines and protocols, four countries (Bhutan, Indonesia, Nepal and Timor-Leste) provided reference of their PEN protocols, and the rest referred to other NCD management guidelines.

Availability of basic technologies for early detection, diagnosis and monitoring of NCDs Figure 3 and 4 shows the general availability of basic technologies for early detection, diagnosis and monitoring of NCDs in the public and private sector, respectively.

4 Even though Maldives did not have the guidelines at the time of survey, Maldives is engaged in developing standard treatment guidelines or a wide array of diseases including CRDs and cancers. Maldives is also adopted PEN protocol in 2017, and is now rolling out throughout the country.

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Figure 3: Availability of technologies for early diagnosis and monitoring of selected NCDs in public sector facilities

0 1 2 3 4 5 6 7 8 9 10 11

Peak flow measurement spirometry Urine strips for albumin assay Total cholesterol measurement Urine strips for glucose and ketone mesaurement Foot vascular status by doppler Foot vibration perception by tuning fork Dilated fundus examination HbA1c test Oral glucose tolerance test Blood glucose measurement Blood presure measurement Measuring height Measuring weight

Chronic respiratory diseaseCVD mgmtDiabetes mellitusBlood pressureBMI

Number of countries in the WHO SEA Region Generally available Generally not available Don't know Not reported

National capacity for prevention and control of noncommunicable diseases in WHO South-East Asia Region