From targets to action—Implementing the global monitoringframework for diabetes

International Diabetes Federation1

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Diabetes Researchand Clinical Practice

journal homepage: www.elsevier.com/locate/diabres

The momentum for change is gathering pace. Just six months

after a significant breakthrough in negotiations on a global

monitoring framework and targets, UN Member States are

ready to adopt this historic advance at the World Health

Assembly. In the traditional international world of political

negotiation this progress has been swift. The breakthrough

came in November last year with the agreement of a set of nine

global targets covering prevention and treatments – including

the landmark goal to achieve a 25% reduction in mortality

from NCDs by 2025 [1]. A major success for IDF’s campaigning

was the singling out of diabetes in the pledge to ‘‘halt the rise’’

in diabetes and obesity by 2025.

These first time-bound and worldwide targets are a major

advance. They will build awareness, drive action and support

effective assessment of government progress on NCD preven-

tion and control. However, there is concern internationally

about how the targets will be measured and the costs involved

at the local level. In this editorial, IDF assesses the implications

of these targets for diabetes prevention, treatment and

monitoring and surveillance worldwide.

1. A breakthrough in the response to diabetes

For the year following the UN Summit on NCDs in September

2011, IDF and the NCD Alliance led a campaign for a

demanding set of targets to realise the ambition of the UN

Political Declaration on NCD Prevention and Control. Building

on the lessons from the UN General Assembly Special Session

on HIV/AIDs in 2001 – where bold targets drove a decade of

action – we challenged those governments and commentators

who were pressing for a limited number of targets.

The nine agreed targets finally agreed, and specifically the

standalone target to ‘‘halt the rise in diabetes and obesity’’,

demonstrated the power of evidence-based and collective

advocacy to sustain commitment and drive action. In January

2013, the World Health Organization (WHO) Assistant Director

General for NCDs, Dr Oleg Chestnov, paid tribute to that

campaigning, describing civil society’s role in defining the

global monitoring framework and targets as ‘‘one of the key

things behind [WHO’s] success.’’ [2].

1 sara.webber@idf.org.0168-8227/$ – see front matter # 2013 Published by Elsevier Ireland Lhttp://dx.doi.org/10.1016/j.diabres.2013.04.001

IDF’s projection of 552 million with diabetes by 2030 – up

from 371 million people today, underscores the scale of the

ambition in the ‘halt the rise’ target. No government has yet

stabilised or reversed the epidemic [3]. Stopping the rapid rise

of the disease requires governments to tackle the underlying

drivers of unhealthy lifestyles. Political commitment for the

‘health in all policies’ approach across government and

sectors, ranging from education, agriculture, trade, finance,

transport, urban planning and the environment, will be a

prerequisite. Leaders will have to achieve major social

structural changes by promoting physical activity through

urban design and ensuring healthy nutrition is available to all.

The target has the potential to drive significant progress

towards achieving one of the three objectives within IDF’s

Global Diabetes Plan 2011–2021 – preventing type 2 diabetes [4].

A clear method of measuring a ‘‘halt in the rise’’ of diabetes is

still to be established, and IDF is campaigning to ensure it does

not merely measure diabetes prevalence. Attempts to reduce

diabetes prevalence to achieve this target may create perverse

incentives for governments to reduce investment in diagnosis

and treatment for people living with diabetes now – resulting in

adverse health outcomes for people with diabetes. To meet the

ambition behind the target governments need to measure the

increase in new cases, or incidence, of diabetes in a population.

Although more challenging in terms of data collection,

measuring incidence is both feasible and crucial for ensuring

the target accurately measures progress in diabetes prevention.

2. Health system capacity for treatment andcare

Securing the balance of primary prevention and treatment

within a global monitoring framework and targets was a signi-

ficant achievement. Campaigning for the right to health, IDF and

the NCD Alliance drove the target for 80% access to essential

medicines and technologies for NCDs through the negotiations

process to protect people living with these diseases today.

The 80% access target can have a major impact. Access to

affordable and high-quality essential medicines and technolo-

gies remains unacceptably low worldwide. The Millennium

td.

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Development Goal (MDG) target for essential medicines has

achieved major progress in access to HIV/AIDs and other

infectious diseases, but has not produced progress for diabetes

[5]. IDF estimates that millions of people with diabetes are living

without access to lifesaving treatment, and out of pocket

expenditures are pushing families into poverty and destitution.

In Mali, an annual supply of insulin costs the average family

approximately 38% of their family income [6]. This must change.

To meet the 80% target will require increased funding,

reform in procurement, supply and distribution within national

health systems, and the promotion of low cost generic diabetes

medicines [7]. There will need to be more examples of progress

through international cooperation – such as the extension of the

Pan American Health Organisation’s Strategic Fund for Essen-

tial Public Health Supplies. This will now provide assistance to

governments in intellectual property regulation, procurement

and funding for diabetes and NCD medicines [8].

The target to ensure 50% of eligible people (including those

with diabetes) receive multidrug therapy and counselling to

prevent heart attack and stroke will test a health systems

capacity to tackle NCDs. IDF campaigned to ensure that

glycaemic control was specified in this target, critical for

reducing the burden of complications that people with

diabetes continue to suffer from a lack of basic treatment

and care [9]. Achieving this target in many developing

countries will mean health systems have to be fully reoriented

to provide early detection of risk, on-going multidrug therapy

treatment and self-management through counselling.

Both health system response targets will require the

provision of person centered care, to improve patient adherence

to the long term treatment needs of people with diabetes and

NCDs, at primary care level [7]. Such a response poses a major

challengefor many low incomecountries,whosehealthsystems

are only equipped to provide acute care for infectious diseases.

3. Scaling up monitoring and surveillance

The global monitoring framework will demand routine assess-

ment of outcomes, prevention and national responses for

NCDs. An obstacle will be the weakness of monitoring and

surveillance for NCDs worldwide. To overcome this a concerted

effort to improve data collection, and strengthen health and

information systems in low and middle income countries, is

vital; substantial financial and technical support will have to be

provided [10]. Quantitative data and systemic monitoring has

been a cornerstone of HIV/AIDs success, and will enable civil

society to track and improve financial investment, treatment

outputs and health outcomes for diabetes and NCDs.

Disaggregated data that assesses underlying social determi-

nants – such as gender, age and education status – will also be

crucial for analysing how vulnerable groups are disproportion-

ately affected by these diseases, and increase equity in the

global response.

4. The civil society response

As WHO Member States unite in Geneva to adopt an historic

agreement IDF welcomes a new era for diabetes. Even before

the formal adoption, the application of the global monitoring

framework is beginning with governments in South East Asia

and the Western Pacific adapting targets to regional levels. As

the framework is translated from paper to action, the role of

IDF and our network of Member Associations in implementa-

tion and surveillance will be critical. Access to comprehensive

data on prevention, treatment and outcomes will enable

diabetes civil society to routinely monitor and compare

different governments’ progress.

Quantifiable targets are already making an impact. The

agreement of targets has bolstered IDF and the NCD Alliance’s

campaign to ensure diabetes and NCDs are included in the

future global development agenda after the MDGs expire in

2015. The High Level Dialogue on Health in the Post-2015

Agenda, held in Gaborone, Botswana in March 2013, reached

consensus that reducing the burden of NCDs, in line with the

25% mortality goal, is now a global priority [11]. Bold targets for

progress are strengthening the case for the right to health – and

access to lifesaving treatment – for diabetes and NCDs that has

been a missing component in the global response to date.

r e f e r e n c e s

[1] A/NCD/2, World Health Organisation. Report of theFormal Meeting of Member States to conclude thework on the comprehensive global monitoringframework, including indicators and a set of voluntaryglobal targets for the prevention and control of NCDs, 9November 2012.

[2] Dr Oleg Chestnov. ADG for noncommunicable diseases andmental health in the World Health Organisation. Commentsat the 132nd WHO Executive Board, January 2013.

[3] International Diabetes Federation. Diabetes Atlas: 5thedition: 2012 update; November 2012.

[4] International Diabetes Federation. Global Diabetes Plan2011–2021. Brussels: IDF; 2011.

[5] United Nations. Millennium Development Goal 8 – theglobal partnership for development at a critical juncture:MDG gap task force report, New York, 2010.

[6] International Insulin Foundation. Fact sheet on diabetes inSub-Saharan Africa. http://www.access2insulin.org/uploads/4/9/1/0/4910107/factsheet.pdf [last accessed20.3.2013].

[7] Hogerzeil HV, et al. Promotion of access to essentialmedicines for non-communicable diseases: practicalimplications of the UN political declaration. Lancet,published online, February 12, 2013.

[8] Pan American Health Organisation. About the PAHOStrategic Fund: background and objectives. http://new.paho.org/hq/index.php?option=com_content&view=article&id=1712%3Aabout-the-paho-strategic-fund&catid=1159%3Ahss-strategic-fund&Itemid=986&lang= fr&limitstart=1[last accessed 20.3.2013].

[9] International Diabetes Federation. IDF submission to WHOConsultation on a Comprehensive Global MonitoringFramework, Indicators and Targets for the Prevention andControl of NCDs, October 2012.

[10] World Health Organization. Concept note: application ofthe global monitoring framework for the prevention andcontrol of NCDs, 1 November 2012.

[11] World Health Organization and the United NationsChildren Fund. High level dialogue on health in the post-2015 development agenda – meeting report, March 2013.