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Progress on the Prevention and Controlof Noncommunicable Diseases

in the Western Pacific RegionCountry 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 20132.1. Public health infrastructure, partnerships and

multisectoral collaboration for NCDs2.2. Status of NCD-relevant policies, strategies and action plans2.3. Health information systems, surveillance and surveys for NCDs2.4. Capacity for early detection, treatment and care of NCDs

within the health system

3. Regional response and progress in country capacity3.1. Regional response3.2. Progress in country capacity for prevention and control of NCDs: 2004–2013

4. Mapping the status of the action plan indicators for NCDs4.1. Action plan indicators4.2. Preparedness for reporting on the nine voluntary global targets

5. Key findings and recommendations5.1. Public health infrastructure, partnerships and multisectoral collaboration5.2. Status of policies, strategies and action plans5.3. Health information systems, surveillance and surveys5.4. Capacity for early detection, treatment and care within the health system5.5. Regional preparedness for monitoring progress in meeting the objectives of the global action plan and the nine global voluntary targets5.6. Recommendations

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TABLE OF CONTENTS

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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 theNorthern 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.

Progress on the Prevention and Control of Noncommunicable Diseases in the Western Pacific Region Country capacity survey 2013 iii

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

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ABBREVIATIONS & ACRONYMS

community-based organizationchronic respiratory disease cardiovacular disease(WHO) Framework Convention on Tobacco Controlhigh-income countrylow- and middle-income countrymultisectoral actionnoncommunicable diseasenoncommunicable disease country capacity surveynongovernmental organizationnicotine replacement therapyPackage of Essential NCD Interventions Pacific island countriesWHO STEPwise approach to surveillancetobacco advertising, promotion and sponsorshipWorld Health Organization

CBOCRDCVDFCTCHICLMICMSANCDNCD CCSNGONRTPENPICSTEPSTAPSWHO

Progress on the Prevention and Control of Noncommunicable Diseases in the Western Pacific Region Country capacity survey 2013 v

EXECUTIVE SUMMARY

Following 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.

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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.

Progress on the Prevention and Control of Noncommunicable Diseases in the Western Pacific Region Country capacity survey 2013 1

1. INTRODUCTION

Noncommunicable 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).

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NONCOMMUNICABLE DISEASE (NCD) COUNTRY CAPACITY SURVEY 20132.

The 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)

AustraliaBrunei DarussalamHong Kong SAR, ChinaJapan

Macao SAR, ChinaNew ZealandRepublic of KoreaSingapore

China MalaysiaCambodiaLao People’s Democratic Republic

MongoliaPhilippinesViet Nam

Northern Mariana IslandsPalauPapua New GuineaSamoa

Solomon IslandsTokelauTongaTuvaluVanuatuWallis and Futuna

American Samoa Cook Islands Fiji French Polynesia

GuamKiribatiMarshall Islands Micronesia (Federated States of)Nauru New CaledoniaNiue

*: 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.

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Coun

trie

s rep

ortin

g

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.


Coun

trie

s rep

ortin

g

100%

75%

50%

25%

0%Taxation on alcohol Taxation on high sugar content food

and non-alcoholic beveragesTaxation on tobacco

Fig. 2. Fiscal interventions for prevention and control of NCDs


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.

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trie

s rep

ortin

g

100%

75%

50%

25%

0%Cancer Diabetes CRDCVD

Fig. 3. Disease-specific NCD policies, strategies or action plans


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 inactivity compared to PICs and HICs.


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 useReducing 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







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







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.

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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

10

Public sector (%)

LMIC N=7

Measurement of weight

Measurement of height

Blood pressure measurement

Blood glucose measurement

Peak flow measurementspirometry

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

HICN=8

Private sector (%) Availability of trained staff (%)

100

100

100

100

100

100

50

100

100

88

88

88

100

100

100

100

ActivityPIC

N=21

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

HICN=8

88

88

88

88

88

88

38

75

75

63

63

75

88

88

88

75

PIC N=21

LMIC N=7

100

100

100

71

43

71

14

43

29

43

57

43

57

57

57

43

HICN=8

88

88

100

100

88

100

38

88

88

63

75

75

100

100

100

75

PIC N=21

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

HICN=8

Covered by health insurance or publicly

funded(%)

On the list of essential medicines**(%)

100

100

100

100

100

100

100

75

100

100

100

PIC N=21

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

HICN=8

100

100

100

100

100

100

100

100

100

100

80

PIC N=21

LMIC N=7

71

86

86

86

71

71

86

71

57

86

14

HICN=8

100

100

100

100

100

100

100

100

100

100

100

PIC N=21

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

12

Coun

trie

s rep

ortin

g

100%

75%

50%

25%

0%Renal

replacement therapy

Radiotherapy ChemotherapyRetinal 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 NCDs


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 CAPACITY3.

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.

14

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 surveyNumber of tools sentNumber of responsesResponse rate

Number of countries with an intergrated NCD policy/strategy or action planNumber of countries with policies, strategies, plans specific to:

Tobacco control Harmful use of alcoholNutritionPhysical activityOverweight and obesityCancer

NCD policy and programme infrastructure

Surveillance and monitoring

Number of countries with surveillance for: Tobacco useHarmful use of alcoholUnhealthy dietPhysical activityDiabetesHypertensionOverweight and obesityDyslipidaemiaCancer

Clinical interventions

Number of countries with with clinical protocols or guidelines for:

Tobacco dependenceDiabetesCancer

Availability of statinsNumber of countries with end-stage care

20043728

76%

20103735

94%

20133736

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

16

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 = 3Complete TAPS

ban = 5*

23

CVD = 27Diabetes = 33Cancer = 26

CRD = 23Tobacco 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

* Data made available from the tobacco control programme, with updates from countries.

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

Not

es: (

*) =

Fro

m 2

013

WH

O re

port

on

the

glob

al to

bacc

o ep

idem

ic, T

able

1.1

.6 S

umm

ary

of M

POW

ER m

easu

res,

Wes

tern

Pac

ific,

pp.

118

–119

MSA

: m

ultis

ecto

ral a

ction

pla

n; T

APS:

tob

acco

adv

ertis

ing,

pro

moti

ons

and

spon

sors

hips

; CV

D: c

ardi

ovas

cula

r di

seas

es;

Diab

: di

abet

es;

CA:

canc

er;

CRD:

chr

onic

res

pira

tory

dise

ase;

Tob

dep

: to

bacc

o de

pend

ence

; Mor

t: m

orta

lity;

Alc

: alc

ohol

; PA:

phy

sical

acti

vity

; Tob

use

: tob

acco

use

; BP:

blo

od p

ress

ure;

Ob:

obe

sity;

P: p

rese

nt; P

i: pr

esen

t and

impl

emen

ted;

-: ab

sent

; Ud:

und

er d

evel

opm

ent;

?: u

nkno

wn;

M

: sta

ndar

d m

et; m

: sta

ndar

d no

t met

; /: n

ot in

clud

ed;

Ad: a

dults

onl

y; A

l: ad

oles

cent

s on

ly; S

n: s

ubna

tiona

l onl

y; S

r: se

lf-re

port

ed o

nly

Coun

try/

Area

ACTI

ON

PLA

N IN

DICA

TOR

Aust

ralia

Brun

ei D

arus

sala

mHo

ng K

ong

SAR,

Chi

naJa

pan

Mac

ao S

AR, C

hina

New

Zea

land

Repu

blic

of K

orea

Sing

apor

e

12

3a3b

3c*

3d4

6

MSA

plan

NCD

un

itPo

licy

Alc

PAIn

door

Ban

TAPS

Diet

CVD

Diab

CACR

DTo

b de

pM

ort

Evid

ence

-bas

ed g

uide

lines

NCD

surv

eilla

nce

and

mon

itorin

g

Alc

PASa

ltTo

b us

eBP

Diab

Ob

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

HIG

H-IN

COM

E CO

UN

TRIE

SP 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

Cam

bodi

aCh

ina

Lao

Peop

le’s

Dem

ocra

tic R

epub

licM

alay

siaM

ongo

liaPh

ilipp

ines

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 AdPA

CIFI

C IS

LAN

D CO

UN

TRIE

S AN

D AR

EAS

Amer

ican

Sam

oaCo

ok Is

land

sFi

jiFr

ench

Pol

ynes

iaGu

amKi

rbati

Mar

shal

l Isla

nds

Mic

rone

siaN

auru

New

Cal

edon

iaN

iue

Nor

ther

n M

aria

na Is

land

sPa

lau

Papu

a N

ew G

uine

aSa

moa

Solo

mon

Isla

nds

Toke

lau

Tong

aTu

valu

Vanu

atu

Wal

lis a

nd F

utun

aTo

tal

- 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 PAd

, Sn

P - 30

P P P Ad P P Al Sn P Ad P Al P Ad P P P PAd

, 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 PAd

, 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 PAd

, Sn

Ad Ad 25

LOW

- AN

D M

IDDL

E-IN

COM

E CO

UN

TRIE

S

18

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.

20

Table 9. Set of nine voluntary global targets and 25 indicators for the prevention and control of NCDs

Framework element

Premature mortality from noncommunicable diseases

Target Indicator

Mortality and morbidity(1) A 25% relative reduction in risk of premature mortality from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases

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

Additional indicator (2) Cancer incidence, by type of cancer, per 100 000 population

Behavioural risk factors

Harmful use of alcohol7

(2) At least 10% relative reduction in the harmful use of alcohol,8 as appropriate, within the national context

(3) Total (recorded and unrecorded) alcohol per capita (aged 15+ years old) consumption within a calendar year in litres of pure alcohol, as appropriate, within the national context(4) Age-standardized prevalence of heavy episodic drinking among adolescents and adults, as appropriate, within the national context(5) Alcohol-related morbidity and mortality among adolescents and adults, as appropriate, within the national context

Physical inactivity (3) A 10% relative reduction in prevalence of insufficient physical activity

(6) Prevalence of insufficiently physically active adolescents, defined as less than 60 minutes of moderate to vigorous intensity activity daily(7) Age-standardized prevalence of insufficiently physically active persons aged 18+ years (defined as less than 150 minutes of moderate-intensity activity per week, or equivalent)

Salt/sodium intake (4) A 30% relative reduction in mean population intake of salt/sodium9

(8) Age-standardized mean population intake of salt (sodium chloride) per day in grams in persons aged 18+ years

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

(9) Prevalence of current tobacco use among adolescents(10) Age-standardized prevalence of current tobacco use among persons aged 18+ years

7 Countries will select indicator(s) of harmful use as appropriate to national context and in line with WHO’s global strategy to reduce the harmful use of alcohol and that may include prevalence of heavy episodic drinking, total alcohol per capita consumption, and alcohol-related morbidity and mortality, among others.8 In WHO’s global strategy to reduce the harmful use of alcohol the concept of the harmful use of alcohol encompasses the drinking that causes detrimental health and social consequences for the drinker, the people around the drinker and society at large, as well as the patterns of drinking that are associated with increased risk of adverse health outcomes.9 WHO’s recommendation is less than 5 grams of salt or 2 grams of sodium per person per day.

4.2. Preparedness for reporting on the nine voluntary global targets

The NCD comprehensive global monitoring framework includes a set of nine voluntary global targets and 25 indicators (Table 9). Table 10 attempts to provide a snapshot of the status of countries in the Region to report on seven of the nine NCD voluntary global targets.


10 Countries will select indicator(s) appropriate to national context.11 Individual fatty acids within the broad classification of saturated fatty acids have unique biological properties and health effects that can have relevance in developing dietary recommendations.

Raised blood pressure

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

(11) Age-standardized prevalence of raised blood pressure among persons aged 18+ years (defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg) and mean systolic blood pressure

Diabetes and obesity10 (7) Halt the rise in diabetes and obesity

(12) Age-standardized prevalence of raised blood glucose/diabetes among persons aged 18+ years (defined as fasting plasma glucose concentration ≥ 7.0 mmol/l (126 mg/dl) or on medication for raised blood glucose)(13) Prevalence of overweight and obesity in adolescents (defined according to the WHO growth reference for school-aged children and adolescents, overweight – one standard deviation body mass index for age and sex, and obesity – two standard deviations body mass index for age and sex) (14) Age-standardized prevalence of overweight and obesity in persons aged 18+ years (defined as body mass index ≥ 25 kg/m² for overweight and body mass index ≥ 30 kg/m² for obesity)

Additional indicators

(15) Age-standardized mean proportion of total energy intake from saturated fatty acids in persons aged 18+ years.11

(16) Age-standardized prevalence of persons (aged 18+ years) consuming less than five total servings (400 grams) of fruit and vegetables per day(17) Age-standardized prevalence of raised total cholesterol among persons aged 18+ years (defined as total cholesterol ≥5.0 mmol/l or 190 mg/dl); and mean total cholesterol concentration

Biological risk factors

Framework element Target Indicator

Table 9. Set of nine voluntary global targets and 25 indicators for the prevention and control of NCDs (cont.)

22

Framework element Target Indicator

Source: Western Pacific Regional action plan for the prevention and control of noncommunicable diseases (2014–2020); pp. 9–11. http://www.wpro.who.int/noncommunicable_diseases/about/NCDRAP_2014-2020_full.pdf

Drug therapy to prevent heart attacks and strokes

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

(18) Proportion of eligible persons (defined as aged 40 years and older with a 10-year cardiovascular risk ≥30%, including those with existing cardiovascular disease) receiving drug therapy and counseling (including glycaemic control) to prevent heart attacks and strokes

Essential noncommunicable disease medicines and basic technologies to treat major noncommunicable diseases

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

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

Additional indicators

(20) Access to palliative care assessed by morphine equivalent consumption of strong opioid analgesics (excluding methadone) per death from cancer(21) Adoption of national policies that limit saturated fatty acids and virtually eliminate partially hydrogenated vegetable oils in the food supply, as appropriate, within the national context and national programmes(22) Availability, as appropriate, if cost-effective and affordable, of vaccines against human papillomavirus, according to national programmes and policies (23) Policies to reduce the impact on children of marketing of foods and non-alcoholic beverages high in saturated fats, trans fatty acids, free sugars, or salt(24) Vaccination coverage against hepatitis B virus monitored by number of third doses of Hep-B vaccine (HepB3) administered to infants(25) Proportion of women between the ages of 30–49 screened for cervical cancer at least once, or more often, and for lower or higher age groups according to national programmes or policies

National systems response

Table 9. Set of nine voluntary global targets and 25 indicators for the prevention and control of NCDs (cont.)


Table 10. Readiness of countries and areas to report on seven of the nine WHO voluntary targets *

Country/Area Voluntary target

++++++++

ASIARelative

reduction in

premature mortality

(25%)

Relative reduction in harmful

alcohol use (10%)

Relative reduction in physical inactivity

(10%)

Relative reduction

in salt/sodium intake (30%)

Relative reduction in tobacco use (30%)

Relative reduction in containment

of raised blood

pressure (25%)

Halt the rise in

diabetes (0%)

Halt the rise in

obesity (0%)

HIGH-INCOME COUNTRIESAustraliaBrunei DarussalamHong Kong SAR, ChinaJapanMacao SAR, ChinaNew ZealandRepublic of KoreaSingapore

+-++++++

++++++++

SRSRSRSR-+

SR+

++++++++

++++-+++

++++-+++

++++++++

LOW- AND MIDDLE-INCOME COUNTRIESCambodiaChinaLao People’s Democratic RepublicMalaysiaMongoliaPhilippinesViet Nam

-+-+++-

+++++++

+++++++

SNSRSNSN++

SN

+++++++

+++++++

+++++++

+++++++

PACIFIC ISLAND COUNTRIES AND AREASAmerican SamoaCook IslandsFijiFrench PolynesiaGuamKiribatiMarshall IslandsMicronesia (Federated States of)NauruNew CaledoniaNiueNorthern Mariana IslandsPalauPapua New GuineaSamoaSolomon IslandsTokelauTongaTuvaluVanuatuWallis and Futuna

+++- +++++++-+-+-+++--

++++ ++++++++++++++

SN+-

++++ +++

SN++++++++++

SN++

--

SR-?-

SR-----

SR-+------

++++ +++

SN++++++++++

SN+ +

SR+++

SR++

SN+++-+++++

SNSN++

SR++

SR SR++

SN+++-++++++

SN++

SR+++

SR++

SN+++-+++ +++

SN++

Total27 Natl-33

SN-1Natl-34

SN-2Measured

Natl-5Measured

SN-4SR-9

Natl-34SN-2

Measured Natl-29

Measured SN-3SR-2

Natl-29SN-2SR-3

Natl-31SN-2SR-2

*: based on country reports of mortality data and NCD risk factor surveys in adults (+): capable of reporting; (-): not capable of reporting; SN: subnational data only; SR: self-reported; ?: unknown

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KEY FINDINGS AND RECOMMENDATIONS

5.1. Public health infrastructure, partnerships and multisectoral collaboration

The national public health infrastructure for NCD prevention and control was strengthened across the entire Region. However, income status was correlated with source of funding for NCD prevention and control, with HICs predominantly funded by general government sources and LMICs supported largely by international donors. LMICs’ reliance on external funding implies less sustainability and probably less control over how funds are allocated. Both factors may have deleterious impact on NCD prevention and control in the long term.

Tobacco and alcohol taxation were the most frequently reported fiscal interventions for NCD prevention and control. Implementation of fiscal interventions to influence health behaviours was higher in HICs than LMICs and PICs. However, LMICs and PICs utilized fiscal interventions to raise revenues.

5.2. Status of policies, strategies and action plans

Overall, HICs have more operational policies/strategies and plans compared to LMICs. However, the differences are not marked, and indicate an overall enhancement in policy implementation capacity in the Region.

The influence of external policy drivers, such as the WHO FCTC, was evident in assessing the status of NCD-relevant policies, strategies and plans. Tobacco-specific policies, strategies or action plans were reported by 89% of countries and areas, as compared to 69% for diet and nutrition, 61% for physical inactivity and harmful use of alcohol, and 58% for overweight and obesity. This suggests the effectiveness of the international treaty model in shaping the policy environment to reduce the risk of NCDs.

5.3. Health information systems, surveillance and surveys

Substantial gains in capacity for NCD risk factor surveillance highlight the practical utility of the WHO STEPS tool, which can be adapted to diverse country situations. Risk factor survey data obtained from actual physical and biochemical measurements rather than self-reporting, was higher in LMICs and PICs compared to HICs.

Given the current surveillance capacity, the Region can report on most of the indicators and targets for the global comprehensive monitoring framework and the nine indicators to measure progress towards the global action plan. However, several indicators are not covered under the existing surveillance mechanisms.

5.


5.4. Capacity for early detection, treatment and care within the health system

Improvements in clinical capacity can be attributed, in part, to the dissemination of PEN, which provides a simple and affordable clinical perspective for NCD prevention and control, even in the most basic settings. However, implementation of tobacco cessation guidelines and the availability of NRT lag behind other primary care interventions for NCD prevention and control. This highlights a strategic gap in action, given the ubiquitous nature of tobacco consumption in the Region, its tremendous impact on NCDs and the proven effectiveness of population-based cessation interventions.

Capacity gaps are more prominent with the more advanced treatment modalities and drugs, with differences across country groups reflecting the disparities in health-care system resources between countries. As the NCD epidemic matures, and more individuals transition towards the end stages of their disease, these capacity gaps will require definitive intervention, but this will be challenging without re-addressing the inequity in health-care among the various countries and areas of the Region. Ultimately, this CCS affirms the interconnectedness of NCDs with socioeconomic progress.

5.5. Regional preparedness for monitoring progress in meeting the objectives of the global action plan and the nine global voluntary targets

Regional action plan indicators were captured from the NCD CCS. Information was collated for indicators 1, 2, 3, 4 and 7, and can be used for monitoring the implementation of the action plan. Status of indicators 5 (operational status of national policies) and 6 (research on NCDs) were not collected and will be considered in the next round of the NCD CCS.

The status of reporting for 7 of the 9 global voluntary targets was compiled from the NCD CCS. Most of the countries are collecting data that will enable reporting against the global targets on mortality, tobacco use, raised blood pressure and diabetes. The report on 2014 NCD country profiles published by WHO, builds on the earlier report of 2011 and provides an updated overview of the NCD situation in each country12 .

The major gaps in reporting are cause-specific mortality and health system indicators. This report provides the regional status of data availability and gaps that will need to be addressed in the near future, to enable full reporting from all Member States.

12 Noncommunicable disease country profiles, 2014. Geneva: World Health Organization; 2014. http://www.who.int/nmh/publications/ncd-profiles-2014/en/ (accessed 12 July 2014).

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5.6. Recommendations

1. National intersectoral mechanisms are useful for strengthening multisectoral action plans. LMICs and PICs should explore fiscal mechanisms more aggressively, including the allocation of a portion of alcohol and tobacco tax revenues for NCD programmes. There is a need to highlight the urgency of moving the NCD agenda above health into the realm of national and regional development.

2. The potential for applying models similar to international treaties such as the WHO FCTC to curtail the harmful use of alcohol and unhealthy eating should be considered.

3. NCD surveillance systems need to be more efficient and timely in monitoring NCD prevention and control, and in meeting the reporting requirements. Surveillance for NCD risk factors can become part of routine health surveillance/surveys instead of stand-alone surveys.

4. The surveillance capacity of countries 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 medicines and basic technologies for NCDs.

5. It is expected that cause-specific mortality and health system indicators will be strengthened as part of the overall health information systems. New measures such as salt intake and alcohol consumption need more work compared with behavioural risk factors, which are better assessed.

6. Designing service delivery models for NCD management with strengthening of primary care facilities within a continuum of care can improve NCD management. Tobacco cessation services need to be scaled up.

progress on the prevention and control of noncommunicable diseases … · 2019-09-10 · progress...

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