Progress on the Prevention and Control of Noncommunicable Diseases
in the Western Pacific Region
Country capacity survey 2013
Progress on the Prevention and Control of Noncommunicable Diseases
in the Western Pacific Region
Country capacity survey 2013
WHO Library Cataloguing-in-Publication Data
Progress on the prevention and control of noncommunicable diseases in the Western Pacific Region: country capacity survey 2013
1. Chronic diseases – epidemiology, prevention and control.
2. Non-communicable diseases. 3. Regional health planning. I. World Health Organization Regional Office for the Western Pacific.
ISBN 978 90 9061 694 8 (NLM Classification: WT 500)
© World Health Organization 2014
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Acknowledgements Preface
Abbreviations and Acronyms Executive summary
1. Introduction
2. Noncommunicable disease (NCD) country capacity survey 2013 2.1. Public health infrastructure, partnerships and
multisectoral collaboration for NCDs
2.2. Status of NCD-relevant policies, strategies and action plans 2.3. Health information systems, surveillance and surveys for NCDs 2.4. Capacity for early detection, treatment and care of NCDs
within the health system
3. Regional response and progress in country capacity 3.1. Regional response
3.2. Progress in country capacity for prevention and control of NCDs: 2004–2013
4. Mapping the status of the action plan indicators for NCDs 4.1. Action plan indicators
4.2. Preparedness for reporting on the nine voluntary global targets 5. Key findings and recommendations
5.1. Public health infrastructure, partnerships and multisectoral collaboration
5.2. Status of policies, strategies and action plans
5.3. Health information systems, surveillance and surveys 5.4. Capacity for early detection, treatment and care within
the health system
5.5. Regional preparedness for monitoring progress in meeting the objectives of the global action plan and the nine global voluntary targets
5.6. Recommendations
ii iii iv v
1 2 3 6 8 9 13 13 14 16 16 19 24 24 24 24 25 25 26
TABLE OF CONTENTS
ACKNOWLEDGEMENTS
This report was developed by the World Health Organization (WHO) Regional Office for the Western Pacific. WHO wishes to acknowledge the support and cooperation of the following national focal points who provided the completed survey tool:
Dottie Siavii (American Samoa) Sally Goodspeed (Australia) Christel Leemhuis (Australia) Ong Sok King (Brunei Darussalam) Prak Piseth Raingsey (Cambodia) Liangyou Wu (China)
Karen Tairea (Cook Islands) Isimeli Tukana (Fiji)
Melle Solène Bertrand (French Polynesia) Roselie Zabala (Guam)
Ching Cheuk Tuen Regina (Hong Kong SAR, China) Hiroyuki Noda (Japan)
Koorio Tetabea (Kiribati)
Phisith Phoutsavath (Lao People’s Democratic Republic) Chan Tan Mui (Macao SAR, China)
Zainal Ariffin Omar (Malaysia) Feisul Idzwan Mustapha (Malaysia) Russell Edwards (Marshall Islands) Julia Alfred (Marshall Islands)
Marcus Samo (Federated States of Micronesia) Khishgee Majigzav (Mongolia)
Setareki Vatucawaqa (Nauru) Bernard Rouchon (New Caledonia) Louise Delaney (New Zealand) Jane Chambers (New Zealand) Grizelda VL Mokoia (Niue)
Roxanne Diaz (Commonwealth of the Northern Mariana Islands)
Edolem Ikerdeu (Palau)
Vicki Wari (Papua New Guinea) Maria Elizabeth Caluag (Philippines) Chang-Kyu, Park (Republic of Korea) Take Naseri (Samoa)
Noorul Fatha (Singapore)
Geoffrey Kenilorea (Solomon Islands) Petelo Alapati Tavite (Tokelau) Siale ‘Akau’ola (Tonga)
Julie Elisala (Tuvalu) Len Tarivonda (Vanuatu) Luong Ngoc Khue (Viet Nam)
Flament Florence (Wallis and Futuna)
World Health Organization:
Dr Bayandorj Tsogzolmaa, Dr Andrew Colin Bell, Ms Marie Clem Carlos, Ms Melanie Cowan,
Dr John Juliard Go, Ms Regina Guthold, Ms He Jing, Mr Peter Hoejskov, Mr Phonesavanh Keomanysone, Dr Sam Ath Khim, Dr Lai Duc Truong, Dr Sonia McCarthy, Dr Ada Moadsiri, Ms Leanne Riley,
Dr Hai-Rim Shin, Dr Paulinus Sikosana, Dr Chun Paul Soo, Mr Oscar Vic Sto. Niño, Dr Cherian Varghese, Mr Saula Volavola, Dr Temo Waqanivalu and Dr Wu Yanwei.
The draft version was prepared by Dr Annette David and the report was reviewed by Professor Donald Matheson and Professor Ruth Bonita.
PREFACE
The last few years have seen significant momentum in noncommunicable disease (NCD) prevention and control, and this is one of the priorities for the Western Pacific Region.
Member States have endorsed the Western Pacific Regional Action Plan for the Prevention and Control of Noncommunicable Diseases 2014-2020, which includes a set of nine voluntary global targets for NCDs to be achieved by 2025. Progress towards these targets, as well as implementation of the Action Plan will be regularly monitored.
WHO uses country capacity surveys to monitor and assess countries’ responses to NCDs. This report presents the results of the 2013 survey of countries and areas in the Region, as well as readiness to report on the global targets.
I am pleased to note substantial progress in the areas of infrastructure for NCD prevention and control, development of national policies and multisectoral action plans, management of NCDs at the primary health care level and surveillance. However, there is more to be done, as NCDs remain a health and economic challenge for the Region.
WHO will continue to support Member States in working towards achievement of the nine voluntary global targets for the prevention and control of NCDs.
Shin Young-soo, MD, Ph.D.
Regional Director
ABBREVIATIONS & ACRONYMS
community-based organization chronic respiratory disease cardiovacular disease
(WHO) Framework Convention on Tobacco Control high-income country
low- and middle-income country multisectoral action
noncommunicable disease
noncommunicable disease country capacity survey nongovernmental organization
nicotine replacement therapy
Package of Essential NCD Interventions Pacific island countries
WHO STEPwise approach to surveillance
tobacco advertising, promotion and sponsorship World Health Organization
CBO CRD CVD FCTC HIC LMIC MSA NCD NCD CCS NGO NRT PEN PIC STEPS TAPS WHO
EXECUTIVE SUMMARY
F
ollowing the Political Declaration of the High-level Meeting of the United Nations General Assembly on the Prevention and Control of Non-communicable Diseases in September 2011, WHO and its Member States developed the WHO Global Action Plan for the Prevention and Control of NCDs 2013–2020. The sixty-fourth Regional Committee for the Western Pacific endorsed the Western Pacific Regional Action Plan for the Prevention and Control of Noncommunicable Diseases 2014–2020. The regional plan is fully aligned to the global plan and provides guidance in the regional context.Tracking implementation of these action plans at the global, regional and national levels is crucial for monitoring the progress of noncommunicable disease (NCD) prevention and control programmes.
Moreover, Member States’ implementation of the United Nations General Assembly’s political declaration will be evaluated every three years.
Adequate national capacity is essential for progress in preventing and controlling NCDs. The World Health Organization (WHO) periodically assesses national capacity for NCD prevention and control through the global NCD country capacity survey (NCD CCS). In the Western Pacific Region, surveys were conducted in 2004, 2010 and 2013. The response rate in 2013 was 97%, with 36 out of 37 countries and areas responding.
This report, compiled from the 2013 NCD CCS and other information, provides an overview of the status and progress in national capacity for NCD prevention and control in the Western Pacific Region. For the analysis, countries and areas in Asia were grouped as high-income countries (HICs) or low- and middle-income countries (LMICs), based on the World Bank classification. Meanwhile, Pacific island countries and areas (PICs) were considered as one group.
There was improvement in NCD infrastructure over time in the Region. All of the 36 participating countries and areas reported having an NCD unit within the Ministry of Health or its equivalent in 2013, compared to only 48% (14 of 29) in 2004. The major sources of funding for NCD prevention and control in HICs (8 of 8) and LMICs (4 of 7) are from general government sources, while funding for PICs comes from international donors (17 of 21).
Of the 36 countries and areas participating in the Western Pacific Region NCD CCS, 92% or 33 have an NCD policy, strategy and/or action plan. NCD policies in 86% of PICs (18 of 21) address all four risk factors; tobacco use, physical inactivity, the harmful use of alcohol, and unhealthy diets;
whereas, only 57% of LMICs (4 of 7) address all risk factors.
Among the four most prominent NCDs—namely cardiovascular diseases, cancers, chronic respiratory diseases and diabetes—cancer is the most frequently addressed by specific national NCD policies (25 of 36 participants). For diabetes mellitus, 67% of PICs (14 of 21) have a policy compared with 29% of LMICs (2 of 7) and 38% of HICs (3 of 8). Among risk factors, tobacco control was the most commonly addressed through policies (31 of 36). While LMICs and PICs indicated they have risk factor reduction policies, implementation varies widely.
Although 94% of countries (34 of 36) report having a system that can generate mortality data, coverage of deaths and quality of certification of deaths by cause is low in LMICs and PICs. All HICs and LMICs, and 75% of PICs, have NCD risk factor data available within the past five years.
The majority of respondent countries have evidence-based national guidelines/protocols/
standards for the management of NCDs and tobacco dependence. However, the utilization of these guidelines lags in all disease categories. Basic tests such as height and weight measurements, blood pressure and blood glucose level are available at the primary care level in the public and private sectors of all countries in the Region. Availability of tests for early detection of cancer is very limited in LMICs and PICs. Availability of essential NCD medications is higher in HICs than LMICs and PICs. The inequities in essential drug availability for NCDs across country groups are most marked for nicotine replacement therapy, steroid inhalers and morphine.
From 2004 to 2013, there has been substantial progress in country capacity for NCD prevention and control. In 21 of the 22 parameters of the NCD CCS, positive changes occurred over the three data collection periods (2004, 2010 and 2013). Recent mandates in global and regional NCD prevention and control are likely to have contributed to improvements in national capacity.
An attempt was made to assess the status of countries against the limited set of action plan indicators used for monitoring global and regional NCD action plans. The findings of this mapping will help to develop further guidance for priority areas in countries.
WHO has been working with countries to support the development of national multisectoral plans for NCD prevention and control, set national targets aligned to the global voluntary targets, strengthen national NCD surveillance frameworks, implement cost-effective interventions to reduce tobacco use, reduce harm from alcohol, reduce salt consumption, control the marketing of unhealthy foods and beverages to children, and support health systems to provide comprehensive management of NCDs.
Enhanced country capacity to assess the status of indicators for NCD prevention and control in the Region will help to prioritize and scale up interventions. Periodic publication of the results of country capacity surveys will help to closely monitor the progress in preventing and controlling NCDs, as well as provide further guidance for priority areas in countries.
1. INTRODUCTION
N
oncommunicable diseases (NCDs) are the leading cause of death in the Western Pacific Region, accounting for more than 80% of all deaths. In 2008, half of all deaths due to NCDs in low- and middle-income countries (LMICs) of the Region occurred among individuals who were less than 70 years of age, compounding health-care costs with productivity losses, and widening the equity gap.1 A study by the World Economic Forum and Harvard School of Public Health indicates that in 2010, cardiovascular disease (CVD) alone cost the Western Pacific Region US$ 107.1 billion; productivity losses were US$ 50.8 billion.2 Clearly, the NCD crisis requires urgent and comprehensive action.Following on commitments made by heads of states and governments in the Political Declaration of the High-level Meeting of the United Nations General Assembly on the Prevention and Control of Non-communicable Diseases,3 the World Health Organization (WHO) and its Member States developed the WHO Global Action Plan for the Prevention and Control of NCDs 2013–2020. The global action plan provides a menu of policy options aimed at attaining nine voluntary global targets, including a 25% relative reduction in premature deaths from NCDs by 2025.
The Western Pacific Regional Action Plan for the Prevention and Control of NCDs 2014–2020 was developed with full alignment to the global action plan and was endorsed at the Sixty-fourth Regional Committee Meeting in 2013.4
Enhanced national capacity is essential for strengthening NCD prevention and control. WHO conducts periodic assessments of national capacity for NCD prevention and control in all Member States through the use of a global survey known as the NCD country capacity survey (NCD CCS).
In the Western Pacific Region, surveys were carried out in 2004, 2010 and 2013. Such periodic assessments allow countries and WHO to monitor progress and achievements.
This report summarizes the findings from the 2013 NCD CCS, which was implemented from April to September 2013. Progress in country capacity from 2004 to 2013 is also presented. An attempt has been made to map the status of countries in the Region against the limited set of indicators in the NCD action plan. The preparedness of countries to report on the nine voluntary global targets was also assessed.
This report provides the current status of monitoring the implementation of the NCD Regional action plan. The information in the report can also provide further directions to prioritize NCD prevention and control programmes in countries.
1 Global status report on noncommunicable diseases 2010. Geneva: World Health Organization.; 2010.
2 Bloom DE, Cafiero ET, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, et al. The global economic burden of noncommunicable diseases. Geneva: World Economic Forum; 2011.
3 United Nations General Assembly resolution A/RES/66/2. http://www.who.int/nmh/events/un_ncd_summit2011/
political_declaration_en.pdf?ua=1 (accessed 08 July 2014).
4 Western Pacific Regional Action Plan for the Prevention and Control of Noncommunicable Diseases (2014–2020).
Manila: WHO Regional Office for the Western Pacific; 2013. http://www.wpro.who.int/noncommunicable_diseases/
about/WP_RAPNCD_2014-2020.pdf (accessed 08 July 2014).
NONCOMMUNICABLE DISEASE (NCD) COUNTRY CAPACITY SURVEY 2013
2.
T
he 2013 NCD CCS was carried out to assess the capacity of countries to respond to the NCD epidemic. The survey was administered through an electronic questionnaire tool in MS Excel, which used standardized questions to allow comparisons across countries and regions.Data were collected from April to September 2013, through the collaborative efforts of national NCD focal points, WHO country offices and WHO Regional Office for the Western Pacific. Countries identified a focal point and a group of national experts to complete the questionnaire. Thirty-six out of the 37 countries and areas (97%) in the Western Pacific Region completed the questionnaire, except Pitcairn Islands. The number of actual responses per question varied among countries. The results are presented under the following four domains:
• public health infrastructure, partnerships and multisectoral collaboration for NCDs;
• status of NCD-relevant policies, strategies and action plans;
• health information systems, surveillance and surveys for NCDs; and
• capacity for early detection, treatment and care of NCDs within the health system.
Data were extracted from the country questionnaires and compiled into a regional database.
Descriptive statistics and charts were derived and, when appropriate, comparisons between the groupings of countries were highlighted. Progress in NCD country capacity over the years was assessed using the 2004, 2010 and 2013 data. The findings depict an overview of reported capacity and progress across time.
The global and regional NCD action plans are monitored through a limited set of indicators. Using the information from the survey, the status of these indicators was mapped. Even though the survey was not primarily meant to capture the preparedness to report on the nine voluntary global targets, an assessment was done using the available information.
The WHO Western Pacific Region has 37 countries and areas. The 21 PICs are grouped as one to reflect the commonalities and the collective actions for NCD prevention and control in the Pacific. Other countries are grouped by income status, based on the World Bank’s classification of countries,5 into two broad groups: high-income countries (HICs; N=8) and low- and middle- income countries (LMICs; N=7). This grouping of countries has been used throughout this report to present the findings (Table 1).
5 World Bank list of economies. Washington, DC: The World Bank; 2014. http://siteresources.worldbank.org/DATASTA- TISTICS/Resources/CLASS.XLS (accessed 07 July 2014).
Table 1. Grouping of countries and areas in the Western Pacific Region
High-income*countries (HIC, N=8)
Low- and -middle income* countries
(LMIC, N=7) Pacific island countries & areas (PIC, N=21) Australia
Brunei Darussalam Hong Kong SAR, China Japan
Macao SAR, China New Zealand Republic of Korea Singapore
China Malaysia Cambodia Lao People’s Democratic Republic Mongolia
Philippines Viet Nam
Northern Mariana Islands Palau
Papua New Guinea Samoa
Solomon Islands Tokelau
Tonga Tuvalu Vanuatu
Wallis and Futuna American Samoa
Cook Islands Fiji
French Polynesia Guam
Kiribati
Marshall Islands
Micronesia (Federated States of) Nauru
New Caledonia Niue
*: Income classification based on the World Bank’s income categories as of February 2014: http://data.
worldbank.org/about/country-classifications
To assess the progress over time, questions in 2004, 2010 and 2013 were retained as much as possible. Data were mostly categorical (e.g. presence or absence of a resource) or absolute counts (e.g. number of strategic plans that address NCD risk factors). Detailed information regarding the scope, status of implementation, and monitoring of policies and programmes was not captured.
There was no independent validation of the responses, except for cancer registries that were validated using the information available with the International Agency for Research on Cancer, Lyon, France.
The assessment of capacity is a complex process. This survey represents the starting point for such an assessment but, in itself, it is not all encompassing and cannot address all facets of national capacity. Additional information may be used to augment and expand the findings of the survey.
Mapping the status against the NCD action plan indicators and the readiness to report on the nine voluntary global targets was an exploration on the use of data. While this does not give the full picture, it can provide guidance for strengthening and advancing the monitoring and surveillance of NCD prevention and control programmes.
2.1. Public health infrastructure, partnerships and multisectoral collaboration for NCDs
This domain queried countries about having a designated NCD unit/branch/department within the Ministry of Health (or its equivalent), the designated unit’s responsibilities and areas covered, funding for activities and functions in the area of NCDs, sources of funding, fiscal interventions for the prevention and control of NCDs, mechanisms for partnerships/collaboration, key stakeholders in partnerships, and content areas covered by partnerships.
Countries reporting
100%
75%
50%
25%
0%
Health insurance Earmarked taxes on
alcohol, tobacco, etc. International donors
HIC (N=8) LMIC (N=7) PIC (N=21)
General government revenues
Fig. 1. Main sources of funding for the prevention and control of NCDs Infrastructure and funding
Thirty-six countries and areas in the Western Pacific have an NCD unit within the Ministry of Health (or its equivalent). Eighty-three per cent (30/36) have at least one full-time staff working on NCDs, and 97% stated that other government ministries or departments also address NCDs and/or risk factors. Responsibilities for the NCD unit are consistent across countries, with 94% of countries (34/36) reporting that planning, coordination of implementation, and monitoring and evaluation are within the scope of their work. Rehabilitation services are the least reported technical area taken care of by the NCD unit.
Primary prevention and health promotion, early detection and screening are the most frequently reported NCD activities/functions with funding, while rehabilitation services are the least funded.
Overall, HICs more commonly report funding for all activities/functions. Gaps in funding are pronounced in the areas of surveillance, monitoring and evaluation (30/36), and capacity-building (28/36). All HICs (8/8) have 100% funding whereas only 86% of LMICs (6/7) and 76% of PICs (16/21) have funding for NCD surveillance activities.
The distribution of major funding sources for NCDs varies across the different groupings of countries and areas (Fig. 1). General government revenues remain a major funding source in most countries, particularly in all HICs. Funding in PICs has an equally high reliance on government revenues and international donations. The contributions of health insurance and excise taxes are rather low in all countries and areas.
All HICs report taxation on tobacco as a fiscal intervention. Eighty-six per cent of LMICs (6/7) and 81% of PICs (17/21) also have tobacco taxation. Taxation on alcohol as a fiscal intervention was reported by 88% of HICs (7/8), 43% of LMICs (3/7) and 76% of PICs (16/21). Taxation on food with high sugar content and non-alcoholic beverages was reported in 24% of PICs (5/21) (Fig. 2). Fiscal interventions for influencing behaviours were used predominantly in HICs.
Countries reporting
100%
75%
50%
25%
0% Taxation on alcohol Taxation on high sugar content food
and non-alcoholic beverages Taxation on tobacco
Fig. 2. Fiscal interventions for prevention and control of NCDs
HIC (N=8) LMIC (N=7) PIC (N=21)
Partnerships and collaboration
Most countries and areas in the Region (33/36) have partnerships and collaborate for implementing key activities related to NCD prevention and control. A cross-departmental or interministerial committee is the main mechanism for partnerships/collaborative work in 88% of HICs (7/8) and 81% of PICs (17/21), whereas 86% of LMICs (6/7) utilize a joint task force.
Eighty-one per cent of all countries (29/36) reported that they had established a formal multisectoral mechanism for coordinating NCD policies. However, only about a third of LMICs (2/7) and PICs (7/21) reported that these were operational.
The most commonly identified key stakeholders in NCD partnerships are other government ministries (33/36), nongovernmental organizations (NGOs)/community-based organizations (CBOs) and civil society (31/36). PICs and LMICs usually include United Nations agencies and other international institutions as key stakeholders, while HICs commonly include the academia, including research centres and private sector partners. Other key stakeholders identified include faith-based, professional and welfare organizations, groups representing specific ethnic subpopulations, the military, agricultural associations, school-based groups and organizations of tribal leaders.
The majority of countries have included tobacco and harmful use of alcohol as the main areas for partnerships. PICs have also considered unhealthy diet, physical inactivity, diabetes and overweight/obesity as priorities.
Countries reporting 100%
75%
50%
25%
0% CVD Cancer Diabetes CRD
Fig. 3. Disease-specific NCD policies, strategies or action plans
HIC (N=8) LMIC (N=7) PIC (N=21)
2.2. Status of NCD-relevant policies, strategies and action plans
National policies, strategies and action plans
In the Western Pacific, 92% of countries and areas (33/36) have an NCD policy, strategy and/or action plan. Eighty-eight per cent of countries and areas with an NCD policy, strategy and/or action plan (29/33) describe their plan as being multisectoral.
All LMICs, 88% of HICs (7/8) and 86% of PICs (18/21) have included NCDs in their national health plan. Sixty-two per cent of PICs (13/21), 57% of LMICs (4/7) and 13% of HICs (1/8) reported the inclusion of NCDs in their national development agenda.
About 86% of PICs (18/21) address all four behavioural risk factors (tobacco, harmful use of alcohol, unhealthy diet and physical inactivity) in their NCD policy, strategy or action plan, compared to only 57% of LMICs (4/7).
Noncommunicable disease-specific policies, strategies and action plans
Cancer is the most common NCD addressed by specific national policies, strategies or action plans, followed by diabetes mellitus. For diabetes, 67% of PICs (14/21) have a policy or strategy compared to 29% of LMICs (2/7) (Fig. 3). While policies are available, their implementation varies widely among the four diseases (cardiovascular diseases, cancers, chronic respiratory diseases and diabetes), with cancer policies being more operational than others.
Risk factor-specific policies, strategies and action plans
Over 80% of all countries and areas in the Region identify tobacco use as the major risk factor that is most frequently tackled by a specific policy, strategy or plan. However, the survey data are insufficient to determine if the tobacco-related policies/strategies/plans are aligned with the WHO Framework Convention on Tobacco Control (FCTC) articles. A majority of countries also report having policies/strategies or plans that address unhealthy diet, regardless of country/
area grouping. Fewer LMICs have national policies for alcohol, overweight/obesity and physical
Percentage of settings with NCD risk factor interventions (N=8) Health-care
facility Community School Workplace Household Reducing harmful use of alcohol
Reducing overweight/obesity Reducing physical inactivity Reducing tobacco use Reducing NCD-related unhealthy diet
38 63 63 88 38
63 75 75 88 63
63 75 75 88 63
50 63 63 88 38
38 50 63 63 38 High-income countries
Percentage of settings with NCD risk factor interventions (N=7) Health-care
facility Community School Workplace Household Reducing harmful use of alcohol
Reducing overweight/obesity Reducing physical inactivity Reducing tobacco use Reducing NCD-related unhealthy diet
43 29 29 86 43
43 43 29 86 43
43 43 29 71 57
43 29 29 86 43
29 29 29 43 43 Low- and middle-income
countries
Percentage of settings with NCD risk factor interventions (N=7) Health-care
facility Community School Workplace Household Reducing harmful use of alcohol
Reducing overweight/obesity Reducing physical inactivity Reducing tobacco use Reducing NCD-related unhealthy diet
52 38 57 81 48
62 57 67 86 71
62 57 62 86 76
57 48 57 86 71
48 48 33 48 62 Pacific island countries
Table 2. Interventions for risk factors for NCDs in different settings
A review of the operational status of NCD risk factor-specific policies/strategies/plans indicates that more HICs implement these. Risk factor-specific NCD policies, strategies and plans are more commonly implemented in community and school settings.
Table 2 presents the various settings through which major NCD risk factors are addressed.
Prevention of tobacco use is the most common risk factor intervention in different settings.
Promotion of physical activity is inadequate in almost all settings in LMICs and PICs.
Other settings identified by respondents as implementation venues included health-care facilities, communities, schools, workplaces and households.
Additional strategies for the prevention and control of NCDs
Growing evidence on what works in effectively preventing and controlling NCDs indicates that there are promising interventions in several policy areas. Four of these policy areas are given below:
• reducing the impact of marketing non-alcoholic beverages and foods high in saturated fats, trans-fatty acids, free sugars or salt to children;
• implementing the International Code of Marketing of Breast-Milk Substitutes;
• formulating policies that limit saturated fatty acids and virtually eliminate industrially produced trans-fats (i.e. partially hydrogenated vegetable oils) in the food supply; and
• reducing salt consumption in populations.
In the Region, 89% of countries and areas have policies that promote breastfeeding (32/36) but only 17% (6/36) have policies for the elimination of trans-fats. Policies to reduce the impact of marketing on children are present in 50% of HICs, 14% of LMICs and 48% of PICs. Policies that promote reduction of salt consumption in the population are also present in 75% of HICs (6/8) but in only 29% of LMICs (2/7) and 38% of PICs (8/21).
2.3. Health information systems, surveillance and surveys for NCDs Mortality data
Thirty-four of the 36 countries and areas (94%) have a system that is able to generate mortality data by cause of death on a routine basis. Thirty-two of the 34 countries and areas (94%) reported that they have a civil or vital registration system. Of these, 12 countries and areas also have a sample registration system, while one country reported having a sample registration system only.
A medical practitioner certifies the cause of death in 91% of countries and areas with a civil/vital registration system (29/32), and in all countries with a sample registration system (13/13). Deaths outside medical facilities were included in the civil registration system in 43% of LMICs (3/7), 81%
of PICs (17/21) and 100% of HICs (8/8).
Mortality data with medical certification of cause of death, including deaths reported outside medical facilities, with age and sex disaggregation and updated within the past three years are available in 100% of HICs (8/8), 57% of LMICs (4/7) and 71% of PICs (15/21).
Cancer registries
All HICs (8/8), 71% of LMICs (5/7) and 86% of PICs (18/21) reported having a cancer registry.
Population-based cancer registration is available in all HICs, 57% of LMICs and 33% of PICs.
Risk factor surveillance
The majority of countries and areas in the Region conduct surveys for the behavioural risk factors of NCDs. Adult surveys are slightly more frequently reported than adolescent surveys, although overall, the prevalence of NCD risk factors was high in both population groups.
HIC (N=8)
Implementation (%) CVD
Diabetes Cancer CRD
Tobacco dependence
25 38 38 25 38
71 100
71 57 57
43 57 43 29 29
67 81 57 57 48
52 48 24 29 10 Protocol
(%) Implementation
Protocol (%)
(%) Implementation
Protocol (%) (%)
LMIC (N=7) PIC (N=21)
88 100 100 75 100
Table 3. Availability of evidence-based clinical guidelines and status of their full
implementation for the management of major NCDs and tobacco dependence
CVD cardiovascular disease; CRD chronic respiratory disease
Thirty-eight per cent of HICs (3/8), 57% of LMICs (4/7) and 52% of PICs (11/21) have data available for all the NCD behavioural risk factors for the past five years. While government funds are used in all HICs (8/8) for all adult and adolescent risk factor surveys, 57% of LMICs (4/7) and 76% of PICs (16/21) report that they had support from international donors.
Overall, surveys on salt intake are the least reported by countries and areas in the Western Pacific Region (9 out of 17 reporting countries and areas) and also the least obtained through biochemical measurement. However, the inclusion of the salt measurement module into current STEPS surveys will provide more information on salt intake in the Region.
2.4. Capacity for early detection, treatment and care of NCDs within the health system
WHO advocates a comprehensive approach to NCD prevention and control. This requires a combination of primary prevention and health promotion, detection of risk factors, management of risk factors and diseases, support for self-help and self-care, provision of home-based care and rehabilitation services for the chronically ill, integrated into the three levels of health-care.
The components of the spectrum of care for NCDs are well integrated into all levels of health-care in HICs. Support for self-help and self-care, home-based care and rehabilitation services are provided in half of the LMICs and PICs.
Availability and utilization of evidence-based clinical guidelines for the treatment of NCDs and tobacco dependence
The majority of respondent countries have evidence-based national guidelines/protocols/standards for the management of the major NCD disease categories and tobacco dependence. However, full implementation of these guidelines lags behind across all disease categories (Table 3).
Clinical guidelines
Public sector (%) LMIC
N=7 Measurement of weight
Measurement of height Blood pressure measurement Blood glucose measurement Peak flow measurement spirometry
Urine strips for albumin assay Acetic acid visualization Cervical cytology Fecal occult blood test or fecal immunological test Bowel cancer screening by exam or conoloscopy Breast cancer screening by palpation
Mammogram
Total cholesterol measurement Oral glucose tolerance test HbA1c test
Foot vibrarion perception by tuning fork or foot vascular status by Doppler
100 100 100 71 43 71 29 57 14 43 86 57 57 57 43 43 N=8HIC
Private sector (%) Availability of trained staff (%)
100 100 100 100 100 100 50 100 100 88 88 88 100 100 100 100 Activity
N=21PIC 90 90 100
95 62 71 24 67 71 52 95 48 81 57 71 52
LMIC N=7 100 100 100 71 43 71 43 43 29 43 86 43 57 57 57 43 N=8HIC
88 88 88 88 88 88 38 75 75 63 63 75 88 88 88 75
N=21PIC LMIC
N=7 100 100 100 71 43 71 14 43 29 43 57 43 57 57 57 43 N=8HIC
88 88 100 100 88 100
38 88 88 63 75 75 100 100 100 75
N=21PIC 71 71 76 67 33 48 24 43 38 24 71 29 52 38 38 38
95 95 95 90 67 81 38 67 67 62 86 38 81 52 71 52
Table 4. General availability* and capacity for early detection, diagnosis and monitoring
of NCDs at the primary health care level*Generally available: in 50% or more health-care facilities
Availability of basic tests and procedures for early detection, diagnosis/monitoring of NCDs at the primary health care level
Ensuring that primary health care facilities have the equipment and capacity to perform these critical functions is essential for NCD prevention and control.
Basic tests such as height and weight measurements, blood pressure and blood glucose are available at the primary care level in both the public and private sectors of all countries in the Region. Tests for the early detection of cancer are limited in LMICs and PICs. Acetic acid visualization, used for screening cervical cancer, is available in 20–30% of LMICs and PICs, while HICs use cervical cytology.
Peak flow measurement spirometry, needed to diagnose chronic obstructive respiratory disease, is not widely available at the primary care level in LMICs and PICs. While countries report the presence of trained staff, the extent of their skills and competencies, and availability in sufficient numbers are not known (Table 4).
General availability* (%) LMIC
N=7 Insulin
Aspirin (100mg) Metformin Thiazide diuretics Angiotensin-converting enzyme inhibitors Calcium-channel blockers Statins
Oral morphine Steroid inhaler Bronchodilator
Nicotine replacement therapy N=8HIC
Covered by health insurance or publicly
funded(%)
On the list of essential medicines**(%)
100 100 100 100 100 100 100 75 100 100 100
N=21PIC 86 81 90 90 86 81 86 71 76 90 29
LMIC N=7 100 100 100 100 100 100 100 85 71 100
14 N=8HIC
100 100 100 100 100 100 100 100 100 100 80
N=21PIC LMIC
N=7 71 86 86 86 71 71 86 71 57 86 14 N=8HIC
100 100 100 100 100 100 100 100 100 100 100
N=21PIC 62 62 67 67 67 67 62 62 67 67 19
84 84 89 89 89 84 84 79 84 89 16 71
86 86 86 71 86 71 29 43 86 29
Table 5. General availability* of medicines in the public health sector, and financing and inclusion in national list of essential medicines
* Generally available: in 50% or more pharmacies
** Inclusion of medicines in the list of essential medicines is not applicable in some HICs (Australia, Japan and Republic of Korea) and PICs (French Polynesia and New Caledonia).
Availability of medicines in the public health sector
Over 80% of countries and areas confirmed that essential medications for treating NCDs, such as insulin, aspirin, metformin, thiazide diuretics, calcium-channel blockers, statins and bronchodilators, were available in public health centres. Moreover, in over three fourths of countries and areas, these medications were covered by insurance and were on the essential drugs formulary. In contrast, nicotine replacement therapy (NRT) was reported as available in the public health sector by less than half of the respondent countries and areas. Furthermore, health insurance covered NRT in only one third of respondent countries and areas, and less than one fourth reported that NRT was included in their essential drugs list.
HICs more frequently confirmed the availability of essential medications for NCDs as compared to LMICs and PICs. The inequities in essential drug availability for NCDs across country groups are most marked for NRT, steroid inhalers and morphine (Table 5).
Medicines
Countries reporting 100%
75%
50%
25%
0% Renal
replacement therapy
Radiotherapy Chemotherapy Retinal
photocoagulation Coronary bypass
or stenting
Fig.4. Availability of more complex treatment modalities and community
or home care for people with advanced or end-stage NCDsHIC (N=8) LMIC (N=7) PIC (N=21)
Availability of more complex procedures for treating NCDs and community/home care for people with advanced or end-stage disease
On average, less than half of respondent countries and areas have more complex procedures and/
or treatment modalities readily available in the public health sector. However, when disaggregated by country grouping, there are notable gaps between HICs and the LMICs and PICs across all complex procedures. Without exception, HICs far more frequently report the availability of these complex procedures, which require highly specialized skills, infrastructure and equipment (Fig. 4).
Community or home care for people with advanced/end-stage NCDs is available in 75% of HICs, 29% of LMICs and 71% of PICs.
REGIONAL RESPONSE AND
PROGRESS IN COUNTRY CAPACITY
3.
3.1. Regional response
The Western Pacific Regional Action Plan for the Prevention and Control of Noncommunicable Diseases 2014–2020, which is fully aligned to the global action plan, will provide guidance for countries in the Region to scale up NCD prevention and control efforts.
WHO has been working with countries to support implementation of the regional action plans.
Technical support is tailored to the country context and varies from advocacy for national policy to subnational demonstration programmes.
WHO has supported the development of national NCD multisectoral action (MSA) plans and two countries have endorsed a multisectoral plan. In three countries, MSA plans are in the final stages of approval. All PICs have developed a national crisis response package and established national targets aligned to the global targets, with the addition of a “Tobacco-free Pacific” target (less than 5% tobacco use in adults) by 2025.
Ten Member States implemented NCD interventions under “Actions that make a difference”, which helped to operationalize the “very cost-effective interventions”. In addition to salt reduction programmes in various Member States, including reductions in the salt content of bread by 10%
in Mongolia and by 15% for a popular brand of noodles in Fiji, a regional salt reduction network is being initiated to share good practices and disseminate the salt advocacy pack.
Cities, schools and workplaces implemented NCD programmes in advance of national programmes.
An approach called “Action for healthier families” has been introduced to link and strengthen community and primary health-care activities for NCDs and maternal and child health. The Western Area Health Initiative in China has been a platform for multiple NCD interventions.
WHO supported the uptake of the WHO PEN in 20 countries and areas in the Region. A knowledge network on NCD management was initiated in June 2014.
The reports of STEPS surveys and Global School-based Student Health Surveys were finalized in 10 countries. WHO provided support to eight countries for strengthening cancer registration. In the Pacific, WHO has been actively engaged in discussions around establishing a Monitoring Alliance for NCD Action, which will help countries to strengthen NCD surveillance.
The 2013 NCD CCS paints an optimistic picture of the Western Pacific Region with regard to infrastructure and partnerships, policies, surveillance and clinical interventions for NCD prevention and control. Overall, the capacity gaps between HICs, LMICs and PICs are narrowing, with the largest gains made in NCD infrastructure and policies, surveillance capacity and basic clinical interventions.
3.2. Progress in country capacity for prevention and control of NCDs:
2004–2013
WHO conducted the NCD CCS in the Western Pacific Region in 2004, 2010 and 2013. Although the questionnaires were not identical, some of the questions on key parameters remained constant.
These allowed for a comparison of changes over time, depicted in Table 6.
The response rate to the survey increased over time from 76% in 2004 to 97% in 2013. Among the questions in the NCD CCS across this time period, 22 parameters were identical and used for comparison. Positive changes were seen in 21 of the 22 parameters over the three data collection periods.
The magnitude of change was greatest for the parameters in the surveillance and monitoring section. This may be due to the scaling-up of the WHO STEPwise approach to surveillance (STEPS) survey in the Region, and to the recent developments to track progress in NCD prevention and control, including the nine voluntary global targets.
The roll-out of the Package of Essential NCD Interventions (PEN), especially in the Pacific, may have contributed to the reported increases in the use of clinical guidelines, availability of essential drugs such as statins and expansion of care models for end-stage NCD patients.
Countries and areas in the Western Pacific are investing in capacity and infrastructure enhancements for NCD prevention and control. The global and regional priority for NCD prevention and control in recent years would have contributed to these improvements in national capacity.
Country capacity indicators over time, 2004, 2010, 2013 Year of survey
Number of tools sent Number of responses Response rate
Number of countries with an intergrated NCD policy/strategy or action plan
Number of countries with policies, strategies, plans specific to:
Tobacco control Harmful use of alcohol Nutrition
Physical activity Overweight and obesity Cancer
NCD policy and programme infrastructure
Surveillance and monitoring
Number of countries with surveillance for:
Tobacco use
Harmful use of alcohol Unhealthy diet Physical activity Diabetes Hypertension
Overweight and obesity Dyslipidaemia
Cancer
Clinical interventions
Number of countries with with clinical protocols or guidelines for:
Tobacco dependence Diabetes
Cancer
Availability of statins
Number of countries with end-stage care
2004 37 28 76%
2010 37 35 94%
2013 37 36 97%
Change + + +
14 (50%) 15 (54%) 22 (79%) 12 (43%) 17 (61%) 9 (32%)
– 12 (43%)
32 (91%) 28 (80%) 29 (83%) 19 (54%) 23 (66%) 21 (60%) 18 (51%) 23 (66%)
36 (100%) 33 (92%) 31 (86%) 22 (61%) 25 (69%) 23 (64%) 21 (58%) 26 (72%)
+ + + + + + + +
17 (61%) 13 (46%) 12 (43%) 12 (43%) 18 (64%) 17 (61%) 15 (54%) 10 (29%) 15 (54%)
31 (89%) 29 (83%) 30 (86%) 27(77%) 28 (80%) 29 (83%) 30 (86%) 25 (71%) 31 (86%)
36 (100%) 34 (94%) 35 (97%) 36 (100%)
34 (94%) 34 (94%) 35 (97%) 31 (86%) 31 (86%)
+ + + + + + + + +
– 18 (64%) 12 (43%)
– 12 (34%)
20 (57%) 33 (94%) 23 (66%) 24 (69%) 14 (40%)
23 (64%) 33 (92%) 26 (72%) 31 (86%) 23 (64%)
+ + + +
Table 6. Comparison of country capacity indicators in 2004, 2010 and 2013, Western
Pacific Region
Number of countries with an operational policy, strategy or action plan to reduce unhealthy diets and/or promote healthy diets
MAPPING THE STATUS OF THE ACTION PLAN INDICATORS FOR NCDs
Number 1
Action plan indicator
Number of countries with at least one operational multisectoral national policy, strategy or action plan that integrates several noncommunicable diseases (NCDs) and shared risk factors in conformity with the global/regional NCD action plans 2013–2020
Number of countries that have operational NCD unit(s)/ branch(es)/
department(s) within the Ministry of Health, or equivalent
Number of countries with an operational policy, strategy or action plan to reduce the harmful use of alcohol, as appropriate, within the national context Number of countries with an operational policy, strategy or action plan to reduce physical inactivity and/or promote physical activity
Number of countries with an operational policy, strategy or action plan, in line with the WHO Framework Convention on Tobacco Control, to reduce the burden of tobacco use
Number of countries that have evidence-based national guidelines/protocols/
standards for the management of major NCDs through a primary care approach, recognized/approved by the government or competent authorities
Number of countries that have an operational national policy and plan on NCD-related research, including community-based research and evaluation of the impact of interventions and policies
Number of countries with NCD surveillance and monitoring systems in place to enable reporting against the nine voluntary global NCD targets
2 3a 3b 3c
3d 4
5
6
29
36 16 23
100% indoor smoke- free policies = 3
Complete TAPS ban = 5*
23
CVD = 27 Diabetes = 33
Cancer = 26 CRD = 23 Tobacco dependence = 23
Not included in the questionnaire Not included in the
questionnaire
Table 7. Status of the action plan indicators in the Western Pacific Region
4.
4.1. Action plan indicators
In response to the Political Declaration of the High-level Meeting of the United Nations General Assembly on the prevention and control of NCDs in 2011, the Sixty-sixth World Health Assembly called on WHO “…to develop, in consultation with Member States and other relevant partners, a limited set of action plan indicators to inform reporting on progress, which build on the work under way at regional and country levels, are based on feasibility, current availability of data, best available knowledge and evidence, are capable of application across the six objectives of the action plan,…”
WHO has developed a set of nine action plan indicators, agreed upon by Member States, to monitor implementation of the global and regional NCD action plans. Table 7 presents the status of these indicators in the countries and areas of the Region, based on the 2013 NCD CCS. Table 8 presents a more detailed situation by each indicator.
Status in 2013
Table 8. Status of countries and areas by action plan indicators
Notes: (*) = From 2013 WHO report on the global tobacco epidemic, Table 1.1.6 Summary of MPOWER measures, Western Pacific, pp. 118–119 MSA: multisectoral action plan; TAPS: tobacco advertising, promotions and sponsorships; CVD: cardiovascular diseases; Diab: diabetes; CA: cancer; CRD: chronic respiratory disease; Tob dep: tobacco dependence; Mort: mortality; Alc: alcohol; PA: physical activity; Tob use: tobacco use; BP: blood pressure; Ob: obesity; P: present; Pi: present and implemented; -: absent; Ud: under development; ?: unknown; M: standard met; m: standard not met; /: not included; Ad: adults only; Al: adolescents only; Sn: subnational only; Sr: self-reported only
Country/Area
ACTION PLAN INDICATOR Australia Brunei Darussalam Hong Kong SAR, China
Japan Mac ao SAR, China New Zealand Republic of Korea Singapore
123a3b3c*3d46 MSA planNCD unit
Policy AlcPA
Indoor Ban TAPSDietCVDDiabCACRDTob depMortEvidence-based guidelinesNCD surveillance and monitoring AlcPASaltTob useBPDiabOb
P P P P P Ud P Ud P P P P P P P P Ud P P P - P Ud Ud P - P P P P P P
M M / m / M m m
M m / m / M m m
Ud - P P P P P p P Pi Pi Pi - Pi Pi Pi P Pi Pi Pi Pi Pi Pi Pi Pi Pi Pi Pi Pi Pi Pi Pi - Pi Pi Pi - Pi Pi Pi Pi Pi Pi Pi Pi Pi Pi Pi P P P P P P P P P - P P Al P P P
HIGH-INCOME COUNTRIES
P P P P P P P P
Sr Sr Sr Sr - P Sr P
P P P P P P P P P P P P - P P P P P P P - P P P P P P P P P P P
Cambodia China Lao People’s Democratic Republic Malaysia Mongolia Philippines Viet Nam P P - P P P - P P P P P P P
Ud - - Ud Ud - -
- - - P P P - m m m m m m m
m m m m m m M
- - - P P P P - Pi Pi Pi Pi Pi - Pi Pi Pi Pi Pi Pi Pi Pi Pi ? Pi Pi - Pi - Pi Pi Pi - - P - Pi - Pi P Pi - P P - P P P P P P Ad P P P Ad P P Ad P P P Ad
Sn Sr Sn Sn P P Sn
P P P P P P P P P P P P P P P P P P P P P P P Ad P P P Ad PACIFIC ISLAND COUNTRIES AND AREAS American Samoa
Cook Islands Fiji French Polynesia Guam Kirba
ti Marshall Islands Micronesia Nauru New Caledonia Niue Northern Mariana Islands Palau Papua N
ew Guinea
Samoa Solomon Islands Tok
elau Tonga Tuvalu Vanuatu Wallis and Futuna Total - P P P P P P P P P P P P Ud P P P P P UD P 29 P P P P P P P P P P P P P P P P P P P P P 36 - - P P P - P P - P P P P Ud - P - P P - - 16 - - P P P P P - - P P P P - - P - P P Ud P 23 / m m / / m m m m / m / m m m m / m m m / 3
/ m m / / m m m m / m / m m m m / m M M / 5
- - P P P P P Ud - P P P P - Ud P - P P Ud P 23 Pi Pi Pi Pi ? Pi Pi Pi - P Pi - Pi - Pi - - Pi Pi Pi Pi 27 Pi Pi Pi Pi Pi Pi Pi Pi - P Pi - Pi Pi Pi Pi - Pi Pi Pi Pi 33 Pi - Pi Pi Pi - Pi Pi - P Pi Pi Pi - - - Pi Pi Pi 26 - Pi Pi Pi ? Pi Pi Pi - P Pi ? Pi - Pi - - - Pi Pi Pi 23 Pi Pi - Pi Pi - Pi ? - P Pi Pi Pi - - - - P Pi 23 P P P P P P P P P P P - P P P P P P P P P 34 P P P P P P P P P P P - P P P P P P
Ad, Sn P - 30
P P P Ad P P Al Sn P Ad P Al P Ad P P P P
Ad, Sn Ad Ad 25
- - - - ? - Sr - - - - - Sr - P - - - - 5 P P P P P P P Sn P P P P P P P P P P
Ad, Sn P Ad 33
Sr P P P Sr P P Sn P P P - P P P P P Sn Sn P P 29
Sr P P Sr Sr P P Sn P P P - P P P P P P Sn P P 29
Sr P P P Sr P P Sn P Ad P - P Ad P P P P
Ad, Sn Ad Ad 25
LOW- AND MIDDLE-INCOME COUNTRIES
Indicator 1
At present, 29 of the 36 respondent countries and areas have at least one operational multisectoral national policy, strategy or action plan that integrates several NCDs and shared risk factors. Four other countries are in the development phase.
Indicator 2
All 36 respondent countries and areas have an operational NCD unit/branch/department or its equivalent within the Ministry of Health. This underscores the widespread recognition of NCDs as a critical public health issue by all countries and areas in the Region.
Indicator 3
For risk factor-specific policies, 15 of the 36 countries and areas have an operational policy, strategy or action plan to reduce the harmful use of alcohol. More HICs are implementing alcohol-related policies/strategies/plans than LMICs.
A total of 23 countries and areas have operational policies/strategies/plans that address physical inactivity. About 88% of HICs (7/8), 43% of LMICs (3/7) and 62% of PICs (13/21) are already implementing these policies/strategies/plans.
For subindicator 3c, data from the WHO report on the Global Tobacco Epidemic 20136 were used, with updates where provided. This report only includes information from Member States.
In addition, only Member States who met the WHO FCTC standard for 100% smoke-free public places (three countries) and a complete ban on tobacco advertising, promotion and sponsorship (five countries) were included.
For subindicator 3d, 23 countries and areas have operational policies/strategies/plans to address unhealthy diets, and another five are working on the mechanism for implementing their policies/
strategies/plans.
Indicator 4
The majority of respondent countries have evidence-based national guidelines/protocols/
standards for the management of the major NCD categories and tobacco dependence. However, the utilization of these guidelines is suboptimal across all disease categories.
6 WHO Report on the Global Tobacco Epidemic, 2013: Enforcing bans on tobacco advertising, promotion and sponsorship. http://apps.who.int/iris/bitstream/10665/85380/1/9789241505871_eng.pdf?ua=1 (Accessed 01 August 2014)
Indicator 5
There was no section that addressed NCD-related research in the CCS questionnaire and no data are available at this time for this indicator.
Indicator 6
For surveillance, the majority of countries and areas in the Western Pacific Region collect data that will enable reporting against the global targets on mortality, tobacco use, blood pressure and diabetes. However, surveillance capacity needs to be enhanced to permit reporting against the global targets on salt/sodium intake, harmful alcohol use, physical activity levels, obesity, drug therapy to prevent heart attack and stroke, and essential NCD medicines and basic technologies.
