World Health Organization adopts new targets to measure Non-Communicable Disease
Non-Communicable Diseases (NCDs), illnesses including cancer, diabetes, cardiovascular disease and chronic lung disease, are potent killers, claiming more than 35 million lives per year around the world--about 62 percent of all deaths. By 2030, they will be the largest contributor to disability.
On November 9, 2012, a little more than a year following the UN High Level Meeting on NCDs, the World Health Organization’s (WHO) member states adopted-- for the first time ever--nine targets and twenty-five indicators that are intended to measure progress against NCDs. The purpose is to develop strategies and programs to reduce avoidable deaths and disability NCDs cause by 2025.
The surprise landmark agreement over targets and indicators followed more than a year of sometimes contentious discussions over this “monitoring framework,” and involved a careful balancing of prevention, diagnosis, treatment and care. The full framework draft organizes the targets into three main categories: premature mortality, risk factors and national systems response. The negotiations also agreed upon a somewhat smaller set of indicators for nations to “voluntarily” adopt based upon the same nine targets. The framework is expected to be formally ratified without changes by the World Health Assembly in May 2013.
The premature mortality target, which had already been adopted by the World Health Assembly at its May 2012 meeting, is to achieve a 25 percent relative reduction in overall mortality from the four main NCDs, has two indicators on probability of dying of an NCD and cancer prevalence. The framework targets six ‘risk factors’: curbing the harmful use of alcohol, avoiding physical inactivity, lowering blood glucose levels and reducing obesity, decreasing blood pressure, cutting salt intake and ending tobacco use.
Among the many positive aspects of the framework, there is significant attention paid to adolescent health issues. Fully eight of the indicators begin measuring at age 18, another four specify beginning in adolescence, one (on alcohol use per capita) begins at age 15 and two more deal with the health of children. This is critical, since behaviors that increase the risk of NCDs, such as alcohol and tobacco use, physical inactivity and poor eating habits frequently begin or accelerate in adolescence or earlier.
Another positive is the attention paid to alcohol abuse. This well-known risk factor for NCDs gets its own target, and three separate allied indicators. In addition to consumption, there are indicators also for heavy episodic “binge” drinking, and morbidity and mortality from alcohol.
Also, the new framework does not shy away from difficult topics such as unhealthy food and beverages. Among the indicators to make the cut was one for the adoption of national targets limiting saturated fatty acids and eliminating partially hydrogenated vegetable oils, as well as another on measuring the proportion of total energy intake from saturated fatty acids. There is an indicator for daily salt intake, too. One of the biggest surprises of the negotiations has to be the inclusion of an indicator on marketing of unhealthy foods to children (the UN process operates by consensus and while an early version had included this provision, later versions had omitted it). The new indicator is for “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.”
According to some observers in Geneva, there was a significant amount of last-minute persuasion necessary to get to yes. And the U.S. delegation, led by HHS Director of the Office of Global Affairs Nils Daulaire reportedly played a highly constructive role, bringing other national delegations along on alcohol, blood pressure, HPV vaccines, diabetes and obesity, among other issues.
As with any good compromise, the framework document leaves out some important things. For example, aside from targets for limiting marketing of harmful foods and beverages, and Hepatitis B vaccine administration, the framework is largely silent on childhood health and NCDs. There are no good data to justify leaving out measuring NCDs in children (to be fair, there are no reliable data to justify including children, either). In fact, there is strong anecdotal evidence, from the United States, Mexico and elsewhere, that risk factors for NCDs, including obesity, are showing up at younger ages all over the world. Apparently there was no one at the table in Geneva making the case for children, and this is a flaw in the framework.
The Political Declaration on NCDs adopted at the UN High Level Meeting clearly noted the role of social determinants in the tidal wave of NCDs sweeping the planet; there is no way to separate poverty and lack of education from the ever-increasing levels of NCDs. Despite this, the framework has no targets or indicators to measure these important influencers in the NCD crisis.
Also left out of the framework is the important task of hiring and training appropriate health staff to prevent, diagnose and treat NCDs. Sometimes known as “health systems strengthening,” this critical set of activities will be essential if the international community seeks to reduce the global burden of disease caused by NCDs. Finally, the framework’s only nod to the different way NCDs affect women and men is the inclusion of one indicator to measure screening for cervical cancer between ages 30-49. There is a great deal more – including on breast cancer screening – to be done to prevent and treat NCDs in women.
With this thorny agreement out of the way, the NCD movement now turns to the equally difficult subject of adopting an overall action plan for preventing and controlling NCDs. Some of the issues left out of the framework could conceivably turn up in WHO’s NCD action plan, the next draft of which may emerge as early as February 2013. Finally, WHO and the international community will need to grapple soon with tracking all of these targets and indicators, either by giving this task to existing parts of the WHO, or by creating some new mechanism. Given the funding and staffing issues already facing WHO, and the deafening silence from donor nations on “new resources for NCDs,” either method is fraught.
The Public Health Institute (PHI) has been engaged in advocacy around global health and NCDs for the past several years, based upon the organization’s long history in NCD prevention, both in the United States and globally. PHI staff in 2012 are making important progress in tobacco control, inappropriate alcohol use, nutrition, cancer surveillance, and asthma, among other areas.
This original blog post, written by Jeff Meer, Special Advisor for Global Health Policy and Development, PHI, can be viewed here.