13.1 Prevention and control of NCD

On this page

• documents
• issues before the Assembly
• PHM comment pre debate (including statement)
• PHM report of debate
• PHM comment post debate

Documents

• Document EB130/2012/REC/1, resolutions EB130.R6 and EB130.R7 
• See WHO Watch report of discussion of NCDs (all aspects) at EB130
• PHM Statement to the Committee

Issues before the Assembly

In 2011 two high levels meetings on NCDs were held: a Global Ministerial Conference on Healthy lifestyles and NCDs in Moscow in April 2011; and High Level Meeting of the UN General Assembly on Prevention and Control of NCDs in New York in September 2011. The World Health Assembly is invited to note the outcomes on these two meetings A65/6 and provide further guidance.

The Political Declaration on NCDs that was endorsed at the New York HLM called on WHO to present, 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 process, to monitor trends and to assess progress made in the implementation of national strategies and plans on NCDs;
• recommendations for a set of voluntary global targets for the prevention and control of NCDs.options for strengthening and facilitation multi-sectoral actions for the prevention and control of NCDs through partnership.

 In relation to these three items, the WHO Secretariat developed documents A65/6, A65/6 Add.1, and A65/7, and the Health Assembly is invited to note the reports, to share views and to provide further guidance.

In addition, the WHA is invited to note reports on the implementation of the Global NCDs Strategy

(A65/9) and Action Plan (A65/8).

Outcomes of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases and the First Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control.

• Documents A65/6 and A65/6 Add.1

• EB130/R7

• See WHO Watch Comment on this item at EB130

Options and a timeline for strengthening and facilitating multisectoral action for the prevention and control of noncommunicable diseases through partnership.

• Documents A65/7 and A65/7 Add.1
• This item arises from the GSAP see below

Implementation of the global strategy for the prevention and control of noncommunicable diseases and the action plan.

• Document A65/8 
• See full GSP&CNCDs (from page 82)
• See WHO Watch comment on this item at EB130 

PHM pre-debate comment

While there is rhetorical recognition of the larger scale issues of trade and industry practices in this report it seems there is very little action on this front. The implications of ISDS for tobacco control and food regulation and the implications of ever tighter IP protection for affordable access to medicines are self evident. But WHO has completely avoided them. Furthermore, the significance of neoliberal economic policies in widening inequalities have not been addressed.

WHA resolution

WHA59.26 on international trade and health highlights a number of crucial issues in relation to trade and health, and the WHO’s role in capacity strengthening in this area. Global level action and coordination is needed to address some of the trade related determinants of NCDs (WTO, Codex), including the introduction of an international code on marketing of unhealthy foods, and drinks (including alcohol) to children. Because the factors that shape NCDs lie outside the reach of health policy, the 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. Such approach to preventing NCDs should go beyond education, housing and agriculture to also include the structural determinants of health. We urge Member States to explicitly recognize the role of trade policies in the spread of NCD risk factors and commit to ensure that future trade treaties do not increase such risks.

A continuing concern in relation to NCDs is the sustained focus on partnerships and engaging in multi-sector consultations. The private sector – whilst a very important actor for policy implementation – appears to be embedded throughout the processes . This is an important concern for food and nutrition, but also alcohol. The continued failure by WHO to distinguish between public interest NGOs (PINGOs) and Business interest NGOs (BINGOs) compounds this issue. The UN High Level Meeting “civil society hearing” which included representatives from the food and alcohol industry was a case in point.

The WHO Director General, in her report to the WHA on progress on WHO Reform and governance (A65/5), states that member states have agreed to the following principle: “the development of norms, standards, policies and strategies, which lies at the heart of WHO’s work, must continue to be based on the systematic use of evidence and protected from influence by any form of vested interest.” It is important for WHO to adopt this principle in determining future policy and governance and action on NCDs.

Also in keeping with recommendations made in the WHO reform paper (A65/5): WHO should also develop a framework to guide interactions with all stakeholders on the prevention and control of NCDs, at both the national and global levels.

WHO should provide technical support and expert advice to member states on the implementation of fiscal, legislative and regulatory measures to improve food and nutrition. This should involve technical support to finance ministries on the administration of national food tax and regulatory systems and administration, as well as the production of manuals and toolkits.

PHM statement to Committee A

PHM Report of debate around NCDs

The Assembly received wide inputs from Member States around 5 global voluntary targets and proposed the inclusion of  additional targets including  targets on mortality, raised blood pressure, tobacco, salt and physical activity, obesity, fat intake, alcohol, and health systems (access to essential medicines for NCDs). Other suggestions include recommendations by:
·         India to include suicide rate reduction as a feasible indicator for mental diseases;
·         Salvador to include indicator on renal failure
·         Tanzania to include target on alcohol abuse and gender based violence.
·         Mongolia to include HPV vaccinations as an indicator, as well as vaccinations against some cancers.

Philippines called for WHO to strike efficient balance between prevention and treatment; whilst Thailand proposed better access to medicines, indoor pollution and child obesity. In addition, Thailand and Norway called for broader approach (rather than solely access to medicines) and called for action to manage conflicts of interest.

Bangladesh and the Member States from the African Region called for attention to the double-burden of communicable and non-communicable diseases faced by many countries.

On the other hand, the International Alliance of Patients Organisations said the targets are too focused on prevention and not enough on treatment. Therefore, IAPO proposed including access to treatment as a target.

A statement by PHM and Churches Action for Health called for more commitment from Member States and WHO to work on trade and health. On the multi-stakeholder partnerships, PHM called for transparency and integrity at global and national level to be observed in these relationships.

A number of member states and observers (such as the International Federation of the Red Cross and Red Crescent, and World Heart Federation) called for Member States to commit to including NCDs in the Rio+20 and a post-MDGs agenda.

Health Action International (HAI) urged member states called for access to effective generics medicines and ensure availability and affordability of medicines.

A draft decision proposed by the delegations of Australia, Barbados, Brazil, Norway, Russian Federation, Switzerland, Thailand and USA was debated but members could not reach immediate agreement. Therefore, the discussion was suspended and an informal drafting group set up to work on the proposed resolution. The group was chaired by Barbados, and had a total of 13 Member States. The group met for a total of 8.5 hours over three sessions in an attempt to reach consensus. The group proposed that in recognition of the fact that setting of targets is both technical and political, there is the need for Regional Committees and other regional constituencies to be involved in the target setting process. Secondly, a range of indicators were brought forward and discussed. There was sufficient agreement that the mortality target should be adopted by this WHA in order to report to the UN General Assembly in September.

The revised resolution presented by the drafting group was adopted by the Assembly. 

Decision of WHA on Prevention and control of noncommunicable diseases: follow-up to the Highlevel meeting of the United Nations General Assembly on the Prevention and Control of Non-communicable diseases (in Second Report of Committee A)

PHM post debate commentary

NCDs constitute a huge and growing burden of disease.

Their causation can be understood in terms of genes (salt and fat appetite), behaviour (smoking and diet) and social determinants (market choices, urban design).  The current direction in which WHO is moving is likely to lead to a focus on biomedical and behavioural causes to the exclusion of structural causes. In view of the close association of NCDs prevalence with socio-economic inequality, relying solely on the pharmaceutical and behavioural strategies reflects a discounting of the equity and social justice dimensions of the public health challenge.

In the Moscow conference and the NY Summit the focus has been on the leading risk factors and associated behaviours. This is reasonable, to a degree.  However, an effective strategy needs to be broadly based and to address the structural and environmental factors which shape those behaviours. Smoking is shaped by powerful marketing; diet is shaped by marketing and price relativities; inactivity is shaped by town planning.  The behavioural approach without the social determinants approach is less effective and not sustainable.   

Much of the policy commentary on NCDs is couched in the language of partnerships and multi-stakeholder collaboration. This appears to mean collaboration with the food industry to promote more health oriented marketing and collaboration with town planners without confronting the urban land speculators who shape their decisions. This approach has the benefit of conflict avoidance but the disadvantage that it is unlikely to achieve structural change.

Like the tobacco industry the food industry, from farm to supermarket, is dominated by transnational corporations. A strategy which avoids the challenges of regulating transnational corporations is destined to fail. Engaging with trade negotiators is the first step to regulating transnational corporations. However, while WHO talks about multi-stakeholder strategies the US and Europe are spinning a web of ‘WTO plus’ trade agreements which are deliberately structured to prevent the regulation of TNCs. One of the leading tools in this purpose is the principle of ‘investor protection’ through investor state dispute settlement. This allows transnational corporations to sue governments whose regulations have the effect of diminishing the value of their investment (most notoriously applied in the Phillip Morris suit against Australia’s plain packaging laws).

WHO’s donor countries have refrained from supporting WHO’s work on trade and health coherence as mandated by WHO59.26. Indeed some of the main donors are the same countries which are driving investor protection provisions in trade agreements. The structured conflict of interest in the financing dialogue is blatant.

There is also a risk that the narrow focus on four specific diseases will contribute to a vertical disease focused approach to management rather than a more broadly based primary health care approach. The professional and institutional capabilities which are needed to care for patients with the four NCDs have much in common with a range of other chronic diseases. These include continuity of care, quality management, monitoring and follow up, effective links between primary and more specialised services and quality, safe, efficacious and affordable medications and devices. The management of NCDs should be progressed within a broadly based approach to health system strengthening, universal access and primary health care.

It is not clear what a new ‘platform’ for NCDs might look like; one scenario appears to involve a new ‘global fund’ for NCDs with funds mobilisation and disbursement focused on NCDs or more narrowly on pharmaceutical and behavioural prevention and on disease focused management.

The multi-stakeholder partnership approach needs to be approached carefully in relation to the transnational pharmaceutical corporations. Pharmaceutical approaches to prevention, management and cure have great potential for health gain and great potential for increasing profits and returns to executives and shareholders. Both with respect to rational drug use and affordable access to necessary medicines the interests of the large pharmaceutical corporations (and their host countries) diverge from those of public health.  Most of the donor countries have chosen not to support WHO’s role in the rational use of medicines over the last three decades. Indeed the ceiling on assessed contributions was first imposed as a sanction against WHO for its work on essential drugs lists. In a time of financial crisis the export earnings of big pharma constitute a valuable contribution to the trade balance.

Reliance on the patent mechanism to incentivise drug development necessarily involves high prices under patent protection and as a consequence, inequitable barriers for poor people and poor countries seeking to access quality, safe and efficacious medicines. The three main solutions to this problem currently in operation are compulsory licensing, donor supply and differential pricing. Talk of an NCDs ‘platform’ suggests an approach to mobilising donor funds to support access to NCD medicines. The policy questions here are complex but WHO’s capacity to take an evidence based approach to these questions is compromised by the clear conflicts of interests around the policy positions taken by those donors who also host large transnational pharmaceutical corporations.

Determination of an appropriate policy, funding and regulatory regime to address the NCDs crisis does not lie with WHO alone. However, WHO has a responsibility to reach out to other sectors to explain the epidemiological and social justice dimensions and to offer evidence based analysis and options.  Freeing WHO from donor hostage is a necessary condition for it to be able discharge this responsibility.