How to combat the NCD epidemic

Despite long-standing international commitments, progress to reduce noncommunicable diseases has been frustratingly slow. With governments due to meet again about NCDs in 2018, how can they tackle this growing global problem?

19th March 2018

A child smokes after primary school in Yogyakarta, Indonesia. Smoking among Indonesian children has been rising, with an estimated 20 million child smokers under the age of 10. Globally, tobacco is estimated to kill seven million people prematurely each year. © Ulet Ifansasti/Getty Images

How to combat the NCD epidemic

Despite long-standing international commitments, progress to reduce noncommunicable diseases has been frustratingly slow. With governments due to meet again about NCDs in 2018, how can they tackle this growing global problem?

By Ala Alwan Regional Director Emeritus, Eastern Mediterranean Region, World Health Organization (WHO)

Noncommunicable diseases (NCDs) – like heart disease, stroke, cancer, chronic lung disease and diabetes – are now the leading causes of mortality worldwide. They are responsible for around 40 million deaths every year – about 70 per cent of global mortality.

Often, NCDs affect people during the most productive period of their life. WHO estimates that about 17 million people die from NCDs each year before the age of 70. Of those, more than nine million people die before they reach 60.

More than 40 per cent of deaths due to NCDs are caused by cardiovascular diseases, and more than 20 per cent by cancers. Meanwhile, the incidence of diabetes is increasing worldwide, affecting more than 425 million adults. In many countries, half of people remain undiagnosed and untreated until their condition progresses and they develop complications like cardiovascular diseases. Diabetes and high blood pressure are in turn the main causes of end-stage kidney disease. Left undiagnosed and untreated, diabetes is also a leading cause of vascular disease, lower extremity amputation and visual impairment and blindness.

NCDs particularly affect people in low- and middle-income countries (LMICs). About 80 per cent of deaths due to NCDs occur in LMICs. In some countries, up to 50 per cent of these deaths occur prematurely. Chronic lung disease, including chronic obstructive pulmonary disease and asthma, are an increasing problem in LMICs. Asthma is the most common chronic condition in children, affecting millions worldwide.

NCDs cause poverty, and poverty contributes to NCDs. The loss of productivity and family income due to premature death, disability and morbidity has a negative impact on socio-economic development, and it impedes poverty-reduction initiatives.

The socio-economic consequences of NCDs are compounded by the high costs of treatment, which represent a serious financial risk to people with NCDs, and their families. It is estimated that every year more than 100 million people are driven below the poverty line because of catastrophic health expenditures. Health systems in low-income countries and many middle-income countries are overwhelmed by the increasing healthcare costs of these conditions.

NCDs share common preventable risk factors related to lifestyle, such as tobacco use, unhealthy diet, physical inactivity, the harmful use of alcohol, and air pollution. Tobacco use causes cardiovascular disease, diabetes, chronic respiratory disease and many cancers, and is estimated to kill around seven million people every year. Based on current trends, that number will rise to eight million by 2030.

Unhealthy dietary trends are a major risk factor for cardiovascular disease, diabetes and many common cancers. Obesity is increasing in all countries. Most adolescents and a substantial proportion of adults, particularly in high-income countries, are insufficiently physically active. This puts them at increased risk of NCDs, and of overall mortality.

Alcohol-related harm, which can result from increased alcohol consumption and certain drinking patterns, is a risk factor for cardiovascular disease and several cancers. Meanwhile, air pollution is emerging as an important public health problem and an underlying cause for more than five million deaths a year. Air pollution causes a variety of health problems, particularly heart disease, chronic lung disease and cancers.

Global initiatives to combat NCDs
In May 2000, the World Health Assembly (WHA) endorsed a global strategy for the prevention and control of NCDs. The strategy noted that the rapid rise of NCDs represents one of the major challenges to global development in the 21st century. The strategy predicted that by the year 2020, NCDs are expected to account for 73 per cent of deaths, compared with 60 per cent in 1998.

WHA’s strategy was based on an extensive review of evidence and international experience conducted between 1998 and 2000. The strategic directions adopted were guided by the lessons learned from existing knowledge. The strategy focused on the four most prominent groups of NCDs (mentioned above) that were responsible for about 80 per cent of premature NCD deaths. Action to prevent the vast majority of these deaths and the overall disease burden of NCDs should therefore focus on controlling the risk factors in an integrated manner, and providing better healthcare for those with already established conditions.

The strategy had three components:

  • a surveillance component to map NCDs and to track and analyse their behavioural risk factors, as well as their social, economic and political determinants, with particular reference to poor and disadvantaged populations;
  • a prevention component to reduce the level of exposure to the common risk factors and their determinants;
  • a management component to strengthen healthcare for people with NCDs and reinforce the capacity of health systems to respond to the increasing needs.

The strategy also emphasised the critical importance of other arms of government. It stated that more health gains in terms of prevention are achieved by influencing public health policies in domains like trade, finance, agriculture, food and urban development than by changing health policy alone. Tackling issues outside the health sector and placing prevention and health promotion high on the public agenda was a major strategic direction.

In 2003, the WHO Framework Convention on Tobacco Control was endorsed by Member States and became the first international treaty negotiated under WHO’s umbrella. It was also one of the most widely and rapidly ratified treaties in the history of the UN.

Work on developing technical guidance to reduce the key risk factors continued. In 2004, the WHA endorsed the Global Strategy on Diet, Physical Activity and Health. Then, in 2010, the WHA adopted the strategy on the harmful use of alcohol, following extensive consultation with Member States and other stakeholders.

The work done in implementing the global strategy, coupled with mounting evidence of the socio-economic consequences of NCDs, and increasing recognition of the critical role of governments in addressing the epidemic, led the UN General Assembly (UNGA) to host the first high-level meeting on NCDs in September 2011. It was a major breakthrough. Attended by 34 heads of state and government, it was only the second time the UNGA had met on a health issue. World leaders adopted a political declaration that outlined the actions to be taken to tackle NCDs at international and national levels.

The political leaders acknowledged that the global burden of NCDs constitutes one of the major challenges to socio-economic development and threatens the achievement of internationally agreed development goals. The declaration considered that responding to the challenge is a whole-of-government and whole-of-society responsibility. It adopted a comprehensive list of recommendations and measures that countries committed to take to respond to the global challenge. The commitments covered four broad areas of action: governance; surveillance and monitoring; reducing risk factors; 
and healthcare.

To realise the commitments made in 2011, the WHA endorsed a plan with nine voluntary targets for achievement in 2025. Countries were urged to develop their own national targets for 2025 based on the nine global targets, while taking into account their own circumstances and needs.

The Sustainable Development Goals (SDGs) represent another important milestone in the global struggle against NCDs, as they include a specific target (3.4) on NCDs. All countries are expected to reduce premature deaths from NCDs by a third by 2030.

The menu of policy options recommended in the global strategy plan and the UNGA political declaration represents a comprehensive roadmap for action. It consists of a set of prioritised interventions that are evidence based, cost effective, high impact and affordable in all countries, irrespective of income. The interventions, sometimes called ‘public health best buys’ include: implementing tobacco control measures like taxation, health warnings, bans on advertising and smoking in public places; increasing excise taxes on alcoholic drinks, and restricting advertising and the physical availability of alcohol in retail stores; reducing salt intake through reformulation of food products, awareness, public education, and front-of-pack labelling; treatment of high blood pressure and diabetes, drug therapy and counselling to people who have had a heart attack or stroke or with a high risk of cardiovascular disease; and early detection of common curable cancers.

In July 2014, the UNGA convened the second high-level meeting on NCDs in New York. The objective was to assess the progress made by countries in implementing the recommendations of the 2011 political declaration and the best buys. The meeting concluded that progress made by countries and other stakeholders in implementing the roadmap was insufficient and highly uneven. This slow progress is confirmed by the ongoing assessment conducted by WHO in collaboration with countries.1

Why such slow progress?
Several factors impede countries from scaling up actions to make real investments in the most promising and proven interventions. First, there is weak political will in translating the declared commitments into sustained investments, and in financing NCD programmes.

This is despite the increased awareness generated by the 2011 UNGA meeting and its declaration. The lack of adequate action is seen across the board: in countries, international agencies (including UN agencies) and civil-society networks, as well as funding agencies and philanthropic organisations. The lack of adequate funding is particularly serious in low and lower-middle-income countries where the needs are greatest and the NCD burden is progressively accelerating. NCDs unfortunately remain a low priority for donors, and in development assistance 
for health.

Second, despite the clear vision and sound roadmap, many countries lack the technical know-how, experience and capacity to turn commitments into action. These countries need substantial technical support from specialised UN agencies and global health institutions. Yet, support is often fragmented and grossly insufficient. Training and other forms of capacity-building initiatives for LMICs remain limited.

Third is the fact that low-income and many middle-income countries have serious weaknesses in their health systems and their ability to respond to the NCD challenge. Universal health coverage (UHC) – another SDG target that countries are expected to reach by 2030 – will hopefully help to address this gap, but only if countries make the right investments to achieve it. People with NCDs should have access to essential preventive, promotive, curative and rehabilitative services without being subjected to financial hardship.

Strengthening health systems is a challenge that countries and the international community need to tackle. The UN SDG monitoring scheme includes specific indicators for UHC that should provide an objective assessment of countries’ progress. Every country can make a difference in addressing gaps in areas like the health workforce, access to technologies and medicines, health information systems and financing. But low-income countries in particular will need support from technical agencies and the international community.

Intersectoral action is essential. Engagement of non-health sectors is often weak. Unless countries acknowledge NCDs as a threat to sustainable development, and until they seriously consider prevention measures as a whole-government obligation, many of the high-impact measures will not be adequately implemented. The tension that often exists between health policies and the policies of other sectors like trade, agriculture and industry is difficult to reconcile without high-level, cross-government engagement.

Finally, there are some opposing forces. The commercial determinants of health can impede action. The business community is an important stakeholder, and the private sector can make a decisive role in investing in health and in supporting preventive initiatives. However, certain industries (particularly tobacco) clearly damage health and oppose healthy lifestyle options. Other industries do not meet their commitments; some impede preventive action through their marketing and other practices. The corporate sector must do more to align its practices with public health policies. It should be accountable for meeting its commitments as a stakeholder in reducing the NCD burden. At the same time, governments should monitor the commercial determinants and take appropriate actions when necessary – like regulatory or fiscal measures to protect their populations’ health.

Hopes for the third high-level meeting?
The UNGA will hold its third high-level meeting in 2018. The world expects this meeting to provide an opportunity and recipe to scale up action against NCDs. There is no need for a new vision or a new roadmap. What is needed is a compact of countries and other stakeholders to reinvigorate consensus on more effective actions to remove the existing barriers and constraints.

UN Member States will begin negotiating the outcome document soon – in New York in June of this year. When they do, they will need to consider innovative options to tackle existing obstacles based on evidence and on concrete, transparent and objective analysis. They will also need to discuss a robust, transparent and realistic accountability mechanism to monitor progress beyond 2018.

The problems impeding action are complicated and thorny, and the potential differences and interests between countries can be extremely challenging. Reconciling and resolving differences will require talented negotiation skills. But much can be achieved, and effective solutions reached, with the strong commitment of countries, support of technical agencies, and by focusing on priorities during this important negotiation phase.

  1. WHO (2015), “How WHO will report in 2017 to the United Nations General Assembly on the progress achieved in the implementation of commitments included in the 2011 UN Political Declaration and 2014 UN Outcome Document on NCDs” (technical note), www.who.int/nmh/events/2015/technical-note-en.pdf?ua=1