Non-Communicable Diseases
WHO Consultations on a monitoring framework and targets for the prevention and control of NCDs
Launched 22 March 2012 Deadline: 19 April 2012
The consultation targets and indicators and all the papers are HERE: http://www.who.int/nmh/events/2012/consultation_april_2012/en/index.html
The summary of Member States Feedback on Targets are HERE http://www.who.int/nmh/events/2012/targets_feedback_summary_22032012.pdf
The Consultation on Multisectoral action for the prevention and control of NCDs through effective partnership (Launched 19 March 2012 - DEADLINE: 9 April 2012 ) is HERE http://www.who.int/nmh/events/2012/consultation_march_2012/en/index.html
EB 130, Jan 2012
Latest WHO -meeting covering noncommunicable diseases: EB130 January 2012 - agenda item 6.1: Prevention and control of non-communicable diseases. Click here for the statement made by PHM.
Background: The challenge of noncommunicable diseases
Noncommunicable diseases (NCDs), principally cardiovascular diseases, diabetes, cancers, and chronic respiratory diseases, are the leading causes of death globally, killing more people each year than all other causes combined. NCDs caused an estimated 35 million deaths in 2005. This figure represents 60% of all deaths globally, with 80% of deaths due to noncommunicable diseases occurring in low- and middle-income countries. About one fourth of global NCD-related deaths take place before the age of 60.
The combined burden of these diseases is rising fastest among lower-income countries, populations and communities, where they impose large, avoidable costs in human, social and economic terms. Patients and their families are pushed into poverty because of catastrophic health expenditures and countries are spending a large part of their health budget on chronic conditions. A recent Harvard University study estimates that over the next 20 years, non-communicable diseases will cost the global economy more than $30 trillion, representing 48 per cent of the global GDP in 2010.
Total deaths from noncommunicable diseases are projected to increase by a further 17% over the next 10 years. The rapidly increasing burden of these diseases is affecting poor and disadvantaged populations disproportionately, contributing to widening health gaps between and within countries. Despite their rapid growth and inequitable distribution, much of the human and social impact caused each year by NCD-related deaths could be averted through well-understood, cost-effective and feasible interventions.
The four ‘major’ NCDs - cardiovascular diseases, chronic respiratory diseases, diabetes and cancer - are caused to a large extent, by four behavioural risk factors that are pervasive aspects of economic transition, rapid urbanization and 21st-century lifestyles: tobacco use, unhealthy diet, insufficient physical activity and the harmful use of alcohol. The greatest effects of these risk factors fall increasingly on low- and middle-income countries, and on poorer people within all countries, mirroring the underlying socioeconomic determinants. Among these populations, a vicious cycle may ensue: poverty exposes people to behavioural risk factors for NCDs and, in turn, the resulting NCDs may become an important driver to the downward spiral that leads families towards poverty. As a result, unless the NCD epidemic is aggressively confronted in the most heavily affected countries and communities, the mounting impact of NCDs will continue and the global goal of reducing poverty will be undermined.
As the magnitude of the NCD epidemic continues to accelerate, the pressing need for stronger
However, despite abundant evidence of their negative impact, policy-makers still fail to regard NCDs as a global or national health priority. Incomplete understanding and persistent misconceptions continue to impede action. Although the majority of NCD-related deaths, particularly premature deaths, occur in lowand middle-income countries, a perception persists that NCDs afflict mainly the wealthy. Other barriers include the point of view of NCDs as problems solely resulting from harmful individual behaviours and lifestyle choices, often linked to victim ‘blaming’. The influence of socioeconomic circumstances on risk and vulnerability to NCDs and the impact of health-damaging policies are not always fully understood; they are often underestimated by some policy-makers, especially in non-health sectors, who may not fully appreciate the essential influence of public policies related to tobacco, nutrition, physical inactivity and the harmful use of alcohol on reducing behaviours and risk factors that lead to NCDs. Effective interventions, such as tobacco control measures and salt reduction, are not implemented on a wide scale because of inadequate political commitment, insufficient engagement of non-health sectors, lack of resources, vested interests of critical constituencies, and limited engagement of key stakeholders.
Reducing exposure to the risk factors for NCDs and their determinants is also not enough. Improved health care, early detection and timely treatment is another necessary aspect of reducing the impact of NCDs. However, appropriate care for people with NCDs is lacking in many settings, and access to essential technologies and medicines is limited, particularly in low- and middle-income countries and populations. Health systems need to be further strengthened to deliver an effective, realistic and affordable package of interventions and services for people with NCDs.
We need to change the way policy-makers perceive NCDs and their risk factors, and how they then act. Concrete and sustained action is essential to prevent exposure to NCD risk factors, address social determinants of disease and strengthen health systems so that they provide appropriate and timely treatment and care for those with established disease.
Sources:
WHO Global Status Report on Noncommunicable Diseases
WHO 2008-2013 Action Plan on the Global Strategy for the Prevention and Control of Noncommunicable Diseases
PHM analysis of the international response to NCDs
"The policies that promote unhealthy lifestyles throughout entire populations are made in domains beyond the direct control of health. For many decades, public health has stressed the need for collaboration with other sectors, especially for prevention. For a very long time, these were friendly sectors, almost sister sectors, like education, the environment, water supply, sanitation, and a secure and safe food supply. Today, many of the threats to health that contribute to noncommunicable diseases come from corporations that are big, rich and powerful, driven by commercial interests, and far less friendly to health"
Dr Margaret Chan, Director General of WHO [1]
The most important message concerning noncommunicable diseases is that the factors that shape the NCD epidemic lie outside the reach of health policy so that most health gains in terms of prevention will be made by influencing policies in domains such as trade, food and pharmaceutical production, agriculture, urban development, and taxation policies[2]. Addressing NCDs thus requires a Health in All Policies approach to enhance accountability for health in other sectors; an approach that can further promote health equity and more inclusive and productive societies [3].
The global response is hugely disappointing in this regard. While the importance of the social, economical, political and environmental determinants of health and the need for multisectoral action is recognized in every document you can find, global action is geared towards interventions to change individual health behaviours and multisectoral action is understood as establishing partnerships with industry. The current global response framework, the 2008-2013 Action Plan for the Global Strategy Global Strategy for the Prevention and Control of Noncommunicable Diseases [4] focuses on 'four diseases and four risk factors'; and has eliminated action on the social determinants of health in its objectives (1). Within the international community, NCDs are still too much viewed as problems solely resulting from harmful individual behaviours and lifestyle choices, often linked to victim-blaming, and the influence of socioeconomic circumstances on risk and vulnerability to NCDs and the impact of health-damaging policies are underestimated [2].
The 'four diseases and four risk factors'-framework fails to address the causes of NCDs. The strategy of identifying risks and expecting individuals to change their behaviour to minimize their exposure has proved inadequate. Genuine choice and an ability to modify risks depend on living conditions and access to resources [5]. This point was stressed by Princess Dina(Union for International Cancer Control) in her opening speech at the UN High-Level Meeting on NCDs in September 2011: "lifestyle changes, as they are called, give the impression that it is a matter of choice or preference. But when unhealthy foods are more affordable than healthy ones, when tobacco, which kills, is so easily accessible, and when facilities or space for exercise are non-existent, it becomes not a lifestyle choice but a life sentence" [6].
The Action Plan does not recognize the varying contributions of the identified risk factors to the global NCD burden and will thus not be able to respond to the different needs of people around the world, especially the most vulnerable ones. Looking at tobacco use as the risk factor for chronic obstructive pulmonary disease (COPD), it is crucial to realize that the causes for COPD have opposite patterns according to the geographic areas. In high- and middle-income countries tobacco smoke is the biggest risk factor, meanwhile in low-income countries exposure to indoor air pollution, such as the use of biomass fuels for cooking and heating, causes the COPD burden (...) The most poor women in the world do not get COPD from smoking, but from bad living conditions [7]. Averting these deaths will not be done by tobacco control, but by ensuring access to clean fuel, housing strategies etc. Such a social determinants approach further has a greater potential return on NCD prevalence, health and social equity [8].
There is an urgent need to devote more attention to the structural determinants of health, such as international trade and financial policies. In his article on international trade and NCDs, Labonté points out that trade, despite bringing potential health benefits through economic growth, is one of the major driving factors of a growing chronic disease burden [9]. Current attention towards the role of globalization and trade in the spread of risk factors for chronic diseases however is geared towards interventions to change health behaviours and on voluntary corporate responsibility. Labonté stresses the need for a more concerted approach to regulate trade-related risk factors and thus more engagement between health and trade policy sectors within and between nations. He noted that an explicit recognition of the role of trade policies in the spread of noncommunicable disease risk factors should be a minimum outcome of the September 2011 Summit, with a commitment to ensure that future trade treaties do not increase such risks. Unfortunately this did not happen.
The negligence of the importance of the socioeconomic determinants of health in shaping the NCD epidemic is further reflected in how the discourse has shifted from a 'vicious cycle' between poverty and NCDs in the Global Strategy to a 'tunnel vision'; on the negative economical impact of NCDs. The most prominent message now is that NCDs are threatening macroeconomic development [10]. This narrowing of the focus was aggravated in a way by attempts to put NCDs on the development-agenda of the General Assembly, a success story culminating in the High-Level Meeting in September 2011. Unfortunately, this has led to a mere focus on how NCDs lead to poverty, with almost no attention to the ways in which poverty contributes to NCDs (2).
In the current NCD discourse, health is regarded simply as an input to economic growth, a means to an end; and a personal responsibility rather than a public good. "The victim-blaming strategy fails to have a positive vision of health and its contribution to society" [11]. As described by McMichael and Beaglehole, there are constant tensions between the goals of different policy sectors: "tension persists between the philosophy of neoliberalism, emphasizing self-interest of marked-based economies, and the philosophy of social justice that sees collective responsibility and benefit as the prime social goal" [12]. They rightfully concluded that "the practice of public health, with its underlying community and population perspective, sits more comfortably with the latter philosophy". Health has intrinsic value and is a basic human right, and should therefore be an end of political and societal activity in itself [13]. It is a trans-national public good and should be an overarching goal in all policies [11]. However, it does not seem that states are ready to take the necessary actions on international trade regimes as this is completely left out of the declaration of the HLM.
What should be stressed in the case of health determinants and NCDs is a virtuous cycle and not a vicious one. In the Action Plan the four main risk factors are considered together to "highlight potential synergies in prevention and control", but a social determinants approach would bring about much more important synergies; not just amongst the different risk factors, but between NCDs and other global challenges. The aim needs to be to "implement policies that serve broader societal goals, such as improving wellbeing and development, which also contribute to tackling noncommunicable diseases" [5]. A virtuous circle is possible whereby improvements in health and its determinants feedback into each other, providing mutual benefits [13]. The example of providing women with clean stoves for cooking to prevent COPD points out one of the most important synergies: mitigating climate change. WHO recently reviewed the IPCC mitigation strategies in its Health in the Green Economy Initiative and concluded that "the best climate solutions address key social determinants of health and inequalities" [15]. These "best climate solutions" would also help reducing the burden of NCDs, by their so-called "health co-benefits" [16]. A report released in 2010 by the Health & Environment Alliance states that a 10% increase in the EU greenhouse gas emissions targets by 2020 (from 20% to 30%) would lead to savings of €10.5 billion to €30.5 billion per year, mostly by reducing cardiovascular disease, cancer, asthma and other respiratory or cardiac conditions [17]; exactly the conditions on which the Action Plan focuses.
Synergies can also be found in the control of the four 'major NCDs' and all the remaining conditions people can suffer from, especially those that take a chronic course. During consultations in preparation of the UN High-Level Meeting, NGOs have repeatedly pointed out the unclear boundaries between communicable and noncommunicable diseases and have stressed that we should draw lessons from the HIV/AIDS epidemic and move away from the vertical disease approach. Separate global health initiatives or funding mechanisms for vertical noncommunicable disease-specific programmes are unlikely to work. Efforts in one disease area can be used to strengthen the overall health system, thereby improving care for other conditions as well [18]. In their in their Political Declaration coming out of the UN HLM, Heads of State have "noted with concern the possible linkages between non-communicable diseases and some communicable diseases, such as HIV/AIDS, and call to integrate, as appropriate, responses for HIV/AIDS and non-communicable diseases" [19].
It is striking to see that WHO itself has pointed out the arbitrary delineation between communicable and noncommunicable diseases when it comes to treatment. In its 2002 Innovative Care for Chronic Conditions (ICCC) Framework, the term chronic conditions is used, which is said to encompass but to expand beyond the traditional 'NCDs' to include several communicable diseases such as TB and HIV/AIDS, as well as long-term mental disorders and ongoing physical/structural impairments [20]. WHO explains: "when communicable diseases become chronic problems, the delineation between noncommunicable and communicable diseases becomes artificial and unwieldy". It is emphasized throughout the framework that all these conditions place similar demands on patients, families and the health care system and that there are similar and comparable management strategies effective in addressing them. This means that the global response should not be about the control of noncommunicable diseases, but about strengthening health systems to provide quality care for chronic conditions. It has been argued that primary health care, because of its patient-centeredness and community-based approach, is best positioned to address the challenges of chronic disease prevention and management [21].
Another key issue in the treatment of chronic conditions is access to essential medicines and social security to prevent patients and families to be pushed into poverty. At the UN HLM States decided to "promote access to affordable, safe, effective and quality medicines and diagnostics and other technologies, including through the full use of trade-related aspects of intellectual property rights (TRIPS) flexibilities" [19]. While emphasizing the need for access to essential medicines, we also want to urge for caution because of clear interests of pharmaceutical companies in this issue. We do not need another 'me too' medication to treat high-blood pressure. Focusing too much on biomedical management diverts attention and resources away from other essential aspects of chronic disease care such as education, self-management and developing a health workforce [22]. We therefore urge to include the rational use of medicines in the current policy framework.
The issue of conflict of interest of the pharma industry points out the necessity to have a reflection on the 'partnership'-paradigm that is so central in the NCD discourse. NGOs, CSOs, industry and academia have been joined together under the umbrella term 'stakeholders' and have been invited to join the global debate, without any clarity on their different roles or safeguards against conflict of interest [23-26]. The Action Plan explicitly calls for the involvement of the private sector as one of the international 'partners'. Industry is seen as part of the solution and has declared its commitment to playing a full part in Civil Society's response to NCDs at the Moscow Conference [27]. We strongly believe that this proposed 'partnership'-approach is entirely the wrong strategy. There are numerous examples of the powerful sway that the tobacco, alcohol, and food industries have over international governments and how this impedes effective health policy [23]. Evidence suggests that these corporate social responsibility strategies are intended to facilitate access to government, co-opt nongovernmental organizations to corporate agendas, build trust among the public and political elite and promote untested, voluntary solutions over binding regulation [26]. While the tobacco industry is not allowed at the negotiation table because of an "intrinsic conflict of interest", the Global Alcohol Producers Group (GAP-G) was a civil-society representative at the UN HLM. Predictably, given existing evidence on efforts by the alcohol industry to prevent effective public health policies, they pushed for voluntary rather than regulatory approaches [26].
The political declaration contains no references to international legislation surrounding the marketing and taxation of alcohol, but instead urges measures favoured by industry such as partnership working, community actions, and health promotion [23]. These kind of soft actions had been previously promoted by the World Economic Forum - also sitting at the table at the HLM - stating that "the food and beverage industries have a crucial role to play in selling healthier alternatives", using the example of PepsiCo's announcement to stop selling high-sugar drinks in primary and secondary schools worldwide; and that "contemporary marketing and behavior influencing methods are undervalued in public health and should be fully incorporated into prevention programmes"[28]. It is noteworthy that evidence suggests that educational interventions are the least effective means of reducing alcohol-related harm, and that alcohol industry-funded educational programmes are ineffective and potentially counter-productive, like their counterparts funded by the tobacco industry [26]. Another interesting fact is that PepsiCo promptly decided to spend 30% more on advertising when the CEO was facing doubts from investors and industry insiders, who were concerned that her push into healthier brands had distracted the company from some core products [29]. Nevertheless, PepsiCo had secured the prime side-event slot at the UN meeting: a breakfast event from 8-10 am on the morning of the summit [23].
Other 'civil-society representatives' with a clear business interest invited at the HLM were the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), and the International Food and Beverage Alliance (IFBA) [29]. A senior director of the WEF was also part of the Civil Society Task Force set up by the President of the General Assembly. In addition, GlaxoSmithKline, Sanofi-Aventis, and the Global Alcohol Consumers Group were included within the official US delegation and drinks companies Diageo and SABMiller were coming from the UK [23]. The representatives of the food and beverage industry succeeded in deleting a specific target of reducing population salt intake to less than 5g per person per day from the draft political resolution [23].
Instead of establishing partnerships with industry, the UN and WHO need to put up firewalls between their policy making processes and the alcohol and food companies whose products stoke chronic disease and the drug and medical technology companies whose fortunes rise with every diagnosed case. In a Lancet article on conflict of interest at the UN HLM Lincoln et al have urged for the adoption of the following recommendations in the political declaration and follow-up actions to the high-level meeting on NCDs [30]:
- WHO should develop a code of conduct that sets out a clear ethical framework to identify and address conflicts of interest, eliminating those that are insurmountable and managing those regarded as acceptable after a thorough risk/benefit analysis. Article 5.3 of the WHO Framework Convention on Tobacco Control provides an example of a framework that safeguards public health policy from the influence of the tobacco industry.
- This code of conduct and ethical framework should be used to guide any interactions with the private sector in NCD prevention and control at UN, regional, or national level and to differentiate clearly between no involvement in policy development and appropriate involvement in implementation that complies with existing regulations and the principles established in the code of conduct.
- This code of conduct should be mandated at the international UN level, and adopted as good practice recommendation for action by member states.
The authors emphasized that, without such safeguards, policies and recommendations will invariably be weakened to suit the interests of powerful corporations, and this is exactly what happened. The Political Declaration does not go any further than recognizing "the fundamental conflict of interest between the tobacco industry and public health" [19]. Health was again undermined by prioritising the interests of the food and beverage industries, as well as the pharmaceutical, technology, and treatment companies, over the public good.
Because of industry influence, the political declaration coming out of the UN HLM lacks clear and measurable targets and relies only on voluntary action. Instead of the promised 'action-oriented outcome document' in General Assembly resolution 65/238, there are only vague intentions "to consider" and "work towards". This is one of the main shortcomings of the political declaration since NGOs, CSOs and academia had repeatedly stressed the urgent need to create of a small set of global goals, targets and indicators for NCDs [31]. The lessons from HIV indicate that measureable targets create accountability and spur action. Despite these messages from civil society, the proposed overarching goal to cut preventable deaths from NCDs by 25% by 2025 was not included because of opposition from the US, Canada and the EU [32]. Instead,industry has succeeded in its call for voluntary measures: the declaration calls upon WHO to prepare recommendations for a set of voluntary global targets for the prevention and control of NCDs, before the end of 2012 [19]. National leaders have embraced lame vendor-friendly voluntary solutions instead of effective regulations governing advertising, product reformulation, package labelling, government procurement, and VAT reforms [23]. The document is infused with elusive and vague terms: "may" instead of "will" and "encourage where appropriate" instead of "provide". This clearly is a great failure of the High-Level Meeting. If voluntary measures are put in place, who's going to monitor and who's really going to hold the various players, governments, industry and civil society, to account?
This voluntariness is also reflected in the lack of clear commitments to increased financing for NCD action. Member States at the HLM called for the fulfillment of all official development assistance-related commitments and declared to promote all possible means to identify and mobilize adequate, predictable and sustained financial resources, and to consider support for voluntary, cost-effective, innovative approaches for a long term financing of non-communicable disease prevention and control. This falls short of requests by civil society to include: (1) taxation on tobacco and a levy on currency transactions, (2) the integration of NCDs in overseas development assistance programmes, and (3) the inclusion of NCDs in existing global funds and initiatives [31]. We are concerned that, without clear commitments and mechanisms to increase funding for NCDs, donors will shift resources from communicable programs to noncommunicable programs instead of adding them to the existing envelopes. The double burden faced by countries should be recognized. As pointed out by Julio Frenk at the Moscow Conference, global health is not a zero‐sum game [27]. As for the Solidarity Tobacco Levy (STL) proposed by the Task Force for Innovative Financing for Health Systems and backed up by Bill Gates, we caution that the goal of taxation should be to reduce consumption only,as raised by the Indian delegation at the Moscow Conference [27]. The STL would in a way send a message of legitimizing tobacco.
Next steps
In the final paragraphs of the HLM political declaration, Heads of State call upon WHO to build on continuing efforts to develop before the end of 2012, a comprehensive global monitoring framework, including a set of indicators, capable of application across regional and country settings, including through multisectoral approaches, to monitor trends and to assess progress made in the implementation of national strategies and plans on non-communicable diseases. They further request the SG, in close collaboration with WHO and Member States, to submit to the General Assembly, at its sixty-seventh session, options for strengthening and facilitating multisectoral action for the prevention and control of non-communicable diseases through effective partnership and to present to the General Assembly at the sixty-eighth session a report on the progress achieved in realizing the commitments made in the declaration, including on the progress of multisectoral action, and the impact on the achievement of the internationally agreed development goals, including the Millennium Development Goals, in preparation for a comprehensive review and assessment in 2014 of the progress achieved in the prevention and control of non-communicable diseases.
We urge for the development of a framework to guide countries in adopting a Health in All Policies-approach, addressing the social determinants of health and looking for synergies with other global health and development challenges. We encourage the involvement of public-interest civil society organizations but do not support the push for public-private partnerships. We urge WHO to develop a code of conduct that sets out a clear ethical framework to identify and address conflicts of interest, eliminating those that are insurmountable and managing those regarded as acceptable after a thorough risk/benefit analysis to be used to guide any interactions with the private sector in NCD prevention and control at UN, regional, or national level. This code of conduct should be mandated at the international UN level [30]. Finally, we urge for a replacement of the voluntary targets by clear goals to ensure accountability.
As argued by Rasanathan and Krech in their excellent article on the social determinants of health and NCDs, commitment towards a global agenda for noncommunicable diseases is only a partial solution. As the 2015 deadline draws near, coordinated global action, keeping equity foremost, is needed on the unfinished Millennium Development Goals agenda, climate change, social protection and noncommunicable diseases. This requires a social determinants approach at global level, with aligned strategies, implementation and monitoring. [5]
Notes
(1) The Global Strategy puts forward three goals, the second of which is to "reducde the level of exposure and populations to the common risk factors for non-communicable diseases (...) and their determinants". The 3th objective of the Action Plan, which is the translation of the 2nd goal of the Global Strategy, however, does not make any reference to the underlying determinants of what is called an unhealthy lifestyle. In addition, actions on the social determinants of health are not included in the range of actions proposed for Member States under Objective 3 in the Action Plan. It is striking that the socioeconomic determinants of NCDs get so much attention throughout the document but are left out under the objective where specific action to address them could be proposed. We are left with the promotion of more attention towards the determinants, and more research and monitoring.
(2) To illustrate this, it is interesting to look at what became of the following activity planned by the Secretariat in the 2008-2013Action Plan under objective 1: "draw up a document in support of policy coherence, pointing out connections between the findings of the Commission on Social Determinants of Health and the prevention and control of noncommunicable diseases; and take forward the work on social determinants of health as it relates to noncommunicable diseases". In the report that will be presented now at the 130th EB in January, the following activity is the implementation of what the Secretariat had promised to do: "the evidence linking noncommunicable diseases with socioeconomic development, poverty and the health-related Millennium Development Goals was reviewed. A summary of the findings was included in WHO's Global status report on noncommunicable diseases 2010".
Note that while the initial idea was to depart from the social determinants of health and look at their implication for prevention and control of NCDs, it became narrowed down to how NCDs link to socioeconomic development, poverty and the MDGs. Moreover, no separate document in support of policy coherence was prepared. Instead the findings got scattered out in a 176 page document (the Global Status Report), which will most likely not reach policy makers from different government departments and thus remain dead letter.
References
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http://www.who.int/sdhconference/declaration/Rio_political_declaration.pdf
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25. Conflicts of Interest Coalition (2011). Statement of concern on lack of clarity on role of industry for June UN interactive hearing and September UN High Level Meeting 2011. Available at: http://info.babymilkaction.org/node/458
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27. WHO (2011). Summary Report of the First global ministerial conference on healthy lifestyles and noncommunicable disease control – Moscow. Available at: http://www.who.int/nmh/events/moscow_ncds_2011/conference_documents/conference_report.pdf
28. WEF (2010). Global Redesign Initiative: Ensuring Health for all. Available at: http://www3.weforum.org/docs/WEF_HE_EnsuringHealthForAll_2010.pdf
29. Esterl M, Bauerlein V (2011). PepsiCo wakes up and smells the cola. Wall Street Journal, June 28
30. Lincoln P et al (2011). Conflicts of interest and the UN high-level meeting on non-communicable diseases. Lancet Volume 378, Issue 9804, Page 6.
31. WHO (2011). Informal dialogue with CSO on the way forward to the HLM on NCDs. Available at: http://www.who.int/nmh/events/2010/un_summit_ncd/en/index.html
32. NCD Alliance website: http://www.ncdalliance.org/takeaction
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| NCDs - history of international policy declarations.ppt | 2.48 MB |
| NCDs_HistoryInternationalPolicyDeclarations.pdf | 613.25 KB |
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