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National capacity for prevention and control of noncommunicable diseases in WHO South-East Asia Region

Results from NCD country capacity survey 2017

March 2018

Noncommunicable Disease (NCD) Document Repository: https://extranet.who.int/ncdccs/documents/

National capacity for prevention and control of noncommunicable diseases in WHO South-East Asia Region. Results from NCD country capacity survey 2017

ISBN: 978 92 9022 617 8

© World Health Organization 2018

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Suggested citation. National capacity for prevention and control of noncommunicable diseases in WHO South-East Asia Region. Results from NCD country capacity survey 2017. New Delhi: World Health Organization, Regional Office for South-East Asia; 2018. Licence: CC BY-NC-SA 3.0 IGO.

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iii

Contents

List of figures and tables v

Acknowledgements vi

List of abbreviations and acronyms vii

Regional Director’s foreword ix

Executive summary x

1 Introduction 1

2 Methods 2

Data collection review and validation 2

Questionnaire 2

Analysis 2

Limitations 3

3 Results 4

1 Public health infrastructure, partnerships and multisectoral collaboration for NCDs 4

Governance structures 4

NCD unit, branch or department 4

Multisectoral coordination mechanisms, building coalitions and partnerships 5

Partnerships with non-State actors 6

Funding mechanisms 12

Implementation of fiscal interventions 14

2 Plans, policies and strategies 15

Inclusion of NCDs in overarching national health plans and development plans 16

Integrated NCD policy/strategy/action plan 16

Scope of integrated NCD policies/strategies and action plans 17

Disease-specific NCD plans 17

Risk factor-specific NCD plans 18

Selected cost-effective policies for NCDs and their related risk factors 19

Campaigns to increase awareness on diet and physical activity 19

3 National capacity for early detection, treatment and care of NCDs within the health systems 19

Availability of evidence-based guidelines/protocols: 20

Availability of basic technologies for early detection, diagnosis and monitoring of NCDs 20


iv

Availability of medicines and vaccines in primary health care facilities in the public sector 24

Availability of specific procedures for treating NCDs in the public health care system 27

4 Health information systems and surveillance 30

Setting time-bound targets and indicators 30

Responsibility of surveillance of NCD and risk factors 30

Civil registration and vital statistics systems reporting mortality by cause 31

Availability and scope of cancer registries 31

Disease-specific registries: diabetes registries 32

Patient information systems 32

Surveys to assess service availability and readiness for NCDs 33

Population-based survey to assess NCD risk factors among youth 33

Population-based surveys to assess NCD risk factors among adults 34

4 Discussions 35

Public health infrastructure, partnerships and multisectoral collaboration for NCDs 35

Status of policies, strategies and action plans relevant to NCDs and their risk factors 37

Capacity for NCD early detection, treatment and care within the health system 39

Evidence-based guidelines, standards, protocols and referral criteria 39

Early detection and diagnosis, and treatment of major NCDs at the primary care level 39

Diagnosis and treatment of major NCDs in secondary and tertiary levels of care 40

Health information systems, surveillance, and the surveys for NCDs and their risk factors 40

5 Conclusions 42

6 References 43

Annex

1. Questionnaires 45

2. Glossary 71


v

List of figures and tables

Figure 1: Availability of governance structures and financing for different NCD activities 5

Figure 2: Existence of integrated or disease/risk factor- specific policies, plans or strategies, 2017 16

Figure 3: Availability of technologies for early diagnosis and monitoring of selected NCDs in public sector facilities 21

Figure 4: Availability of technologies for early diagnosis and monitoring of selected NCDs in private sector facilities. 22

Figure 5: Reported availability of essential medicines for prevention and control of NCDs in primary care facilities in the public sector, 2017 25

Figure 6: Reported availability of specific procedures for treating NCDs or their complications in the public sector health-care facilities, 2017 28

Figure 7: Reported status of national surveillance systems for NCDs in South-East Asia, 2017 32

Table 1: Intersectoral coordination mechanisms in Member States of the WHO SEA Region, 2017 7

Table 2: Status of health expenditure in the WHO South-East Asia Region, 2017 12

Table 3: Major sources for regular funding for NCDs as reported by countriesin 2017 NCD CCS survey 13

Table 4: Reported general availabilityb of different NCD medications at the primary health care level in public sector, NCD CCS Survey 2017 27

Table 5: Status of NCD risk-factor surveys among youth in the SEA Region 34

Table 6: Status of NCD risk-factor surveys among adults in the SEA Region. 34


vi

Acknowledgements

This report was prepared by Dr Manju Rani, Regional Adviser for NCD and Tobacco Surveillance, from the NCD and Tobacco Surveillance team of the Department of Noncommunicable Diseases and Environmental Health at the South-East Asia Regional Office of the World Health Organization. Mr Naveen Agarwal from the NCD and Tobacco Surveillance team contributed in the compilation of the report by assisting the data collection process, preparation of specific graphs, and in formatting the report. Editorial and design support was provided by Mr Gautam Basu (Assistant Reports Officer) and Mr Subhankar Bhowmik (Graphic Art Associate) based in the South-East Asia Regional Office of WHO.

Contributions to the report were made by the following colleagues based in the South-East Asia Regional Office of WHO in the Department of Noncommunicable Diseases and other departments: Dr Thaksaphon Thamarangsi, Dr Phyllida Travis, Dr Palitha Mahipala, Dr Gampo Dorji, Dr Jagdish Kaur, Dr Angela Padmini de Silva, Dr Nazneen Anwar, Ms Klara Tisocki, Mr Lluis Vinals Torres, Dr Manisha Shridhar and Mr Mark Landry. In addition, contributions are acknowledged from colleagues at WHO headquarters, in particular Ms Leanne Riley, Dr Hebe Gouda and Ms Melanie Cowan, who coordinated the overall administration and compilation of data for 2017 Country Capacity Survey at the global level.

Sincere thanks to all WHO Member States for their assistance in reporting data to WHO, which made the compilation of these data and indicators possible.


vii

List of abbreviations and acronyms

ACE angiotensin-converting enzymes

CCS country capacity survey

CHE current health expenditures

CRD chronic respiratory diseases

CVD cardiovascular diseases

CRVS civil registration and vital statistics

EPI Expanded Programme on Immunization

GDP gross domestic product

GYTS Global Youth Tobacco Survey

GSHS Global Student-based School Health Survey

HPV human papilloma virus

IARC International Agency for Research on Cancer

LMIC lower-middle income countries

MoE Ministry of Education

MoH Ministry of Health

MoHFW Ministry of Health and Family Welfare

MoPH Ministry of Public Health

NCDs noncommunicable diseases

NMAP National Multisectoral Action Plan

PA physical activity

PEN Package of Essential Noncommunicable disease interventions

SARA service availability and readiness assessment

SEAR South-East Asia Region

SEARO South-East Asia Regional Office of WHO

SDG Sustainable Development Goals

SHI social health insurance

SRS Sample Registration System

SSB sugar and sweetened beverages

STEPs STEPwise approach to surveillance

THE total health expenditure

TOR terms of reference

WHO World Health Organization

WHO FCTC World Health Organization Framework Convention on Tobacco Control

UN United Nations


viii


ix

Regional Director’s foreword

Noncommunicable diseases (NCD) represent a serious threat to the economic and social development of the WHO South-East Asia Region. Sixty-four per cent of all deaths in South-East Asia are NCD-related, half of which occur during the economically productive ages of 30 and 70 years. Premature death from noncommunicable diseases has become a major public health challenge in Region. It is predicted that the NCD burden may raise further especially among low- and lower-middle income countries, which may be least prepared to deal with them. Hence I have declared the control and prevention of NCDs as one of my key Flagship Priorities.

While the Global and Regional Plans of Action as well as the resolution A/RES/68/300 and outcome document adopted by United Nations General Assembly on 10 July 2014 have set out the roadmap to tackle NCDs, we cannot afford to be complacent with

regard to our efforts towards NCD prevention and control. Hence, as part of our efforts to track the progress towards reducing morbidity and mortality from NCDs, WHO conducted in 2017 its sixth national NCD Capacity Survey to generate detailed information from countries on their current capacities related to NCD infrastructure, policy action, surveillance and health systems response.

These results are particularly relevant and timely. While the results reveal significant areas of progress especially in terms of developing NCD policies and plans, they also highlight persisting challenges and uneven progress across the countries in the Region. These challenges include weak multisectoral coordination, difficulties in putting plans and strategies into action, inadequate information systems, and fiscal and regulatory measures still falling short of best recommendations.

This report is intended to call attention to the urgent need to accelerate national efforts and invest more resources to fulfil national commitments; failing which the social, human and economic costs associated with noncommunicable diseases will overwhelm our systems and economies and challenge the Region’s ability to successfully pursue the 2030 Sustainable Development Agenda.

Dr Poonam Khetrapal Singh Regional Director WHO South-East Asia


x

Executive summary

Noncommunicable diseases (NCDs), including cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases, and their key risk factors – tobacco, harmful use of alcohol, unhealthy diet and physical inactivity – remain the leading cause of death in the South-East Asia Region of WHO. NCDs are currently responsible for 8.9 million deaths annually in South-East Asia (64% of all deaths in the Region) out of which 4.4 million deaths are premature between the ages of 30 and 69 (31.5 of total deaths and 49.2 of all NCD-related deaths) and accounts for 29% of all premature deaths globally (1). NCDs, thus, represent a serious threat to the economic and social development of the Region.

Since 2001, WHO has been carrying out NCD Country Capacity Surveys (CCS) periodically to develop country capacity profiles, monitor the progress, and identify gaps and unmet needs in each country. Since 2013, WHO has been implementing this survey every two years. This report summarizes the status of national capacity to prevent and control NCDs in the WHO South-East Asia Region based on the results from 2017 NCD CCS survey—the sixth national capacity survey since 2001. NCD CCS survey is a qualitative survey, with administration of a web-based questionnaire hosted on WHO website to collect data from NCD focal point(s) or designated officials within the Ministry of Health or national institutes or agencies responsible for NCDs in the WHO Member States. The data for 2017 was collected between January and July 2017. 100% response rate was achieved, with all the 11 countries completing and submitting the questionnaires within the given deadline. Given that there are only 11 countries in the Region, the data are presented mainly in a qualitative form, rather than as percentages or other statistical measures.

The questionnaire (Annex 1) comprised of four modules:

¤ Public health infrastructure, partnerships and multisectoral coordination;

¤ Policies, strategies, and action plans;

¤ Health information systems and surveillance; and

¤ Health system capacity for detection, treatment and care.

The survey results highlight several areas where substantial progress has been made in the Region in the past 4 to 5 years and areas that still need attention.

Areas of major progress:

¤ Governance and financing: ALL the 11 countries have

¢ established a dedicated NCD unit, branch, or a department;

¢ provided government financial allocation for all the eight key functions of NCD prevention and control.

¢ Introduced taxation for alcohol and tobacco (except one country)

¤ Policies and strategies: ALL the 11 countries have

¢ included the NCD agenda in their overall health sector plan and national development agenda;


xi

¢ developed multisectoral national NCD prevention and control plans, strategies or action plans which address all the four key NCD risk factors and early detection and treatment of all the four major NCDs. However, in some countries, these are still in the process of official endorsement.

¤ Early detection, treatment and care of NCDs within health systems: ALL the 11 countries have

¢ reported having recently updated evidence-based guidelines/protocols for cardiovascular diseases and diabetes;

¢ reported general availability of equipment for height and weight, and blood pressure measurement in primary care facilities;

¢ reported availability of at least one group of anti-hypertensive medication in the primary health care facilities in the public sector. Thiazide diuretics are the most commonly reported anti-hypertensive medication.

¤ Health information system, monitoring, surveillance:

¢ All countries except Indonesia and Timor-Leste reported the existence of civil registration and vital statistics systems for mortality data;

¢ All countries except India and DPR Korea reported doing integrated risk factor survey among youth (as part of GSHS) in the last three years;

¢ All the countries except Bangladesh, India and Maldives reported doing at least one nationwide integrated risk factor survey among adults in the last five years.

Areas needing attention:

¤ Governance:

¢ Establishing, strengthening, and evaluating the performance of multisectoral governance mechanism,

¢ Strengthening NCD unit/branch by ensuring adequate staffing with technical expertise and capacity,

¢ Improving the levels of funding for NCD prevention and control,

¢ strengthening of regulatory and financial reform capacity to further strengthen fiscal policies on tobacco and alcohol, and hopefully for other unhealthy foods including sugar-sweetened beverages and foods high in salt and trans-fats based on recommended best practices.

¤ Policies and strategies:

¢ Strengthening implementation of NCD policies and plans,

¢ Involvement of multisectoral coordination committees or groups in regular monitoring and evaluation of these policies and plans,

¢ Obtaining high-level endorsement of policies and plans where still pending.

¤ Early detection, treatment and care of NCDs within health systems:

¢ Ensuring regular availability of anti-hypertensive and anti-diabetic medications and regular assessment tools in all the primary health care facilities,


xii

¢ Increasing the availability of insulin,

¢ Increasing the availability of drugs for treatment of bronchial asthma (especially corticosteroid inhalers),

¢ Increasing the availability of nicotine replacement therapy and palliative care,

¢ Institutionalizing cancer screening programmes especially for cancers of public health importance with availability of sensitive and specific screening tests. The current systems in most of the countries rely on opportunistic screening with very low coverage.

¤ Health information systems, monitoring and surveillance:

¢ Establishing and expanding coverage and completeness of mortality registration systems as part of civil and vital registration systems,

¢ Financing and Institutionalizing periodic integrated NCD risk factor surveys as an integral and essential part of national health information systems. Two of the countries (India and Maldives) never did a nationwide NCD risk factor survey, while Bangladesh did the last survey in 2010, more than five years ago.

Survey results presented above should be interpreted taking into account some of the major limitations. First of all, the questionnaires provided only a high-level overview of national capacities for prevention and control of NCDs, and as such do not capture all the specific circumstances of each country and do not allow for a comprehensive situation analysis of each subject covered. Second, the quality of the collected data depends on the breadth of the consultation process among key informants, and reflects the perspectives and knowledge level of informants at the time they completed the survey.

These limitations notwithstanding, the results are still very useful because they provide information on the status of essential infrastructure, surveillance, policy and health services.


1

1 Introduction

Noncommunicable diseases (NCDs), including cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases, and their key risk factors — tobacco, harmful use of alcohol, unhealthy diet and physical inactivity — remain the leading cause of death in the South-East Asia Region of WHO. NCDs are currently responsible for 8.9 million deaths annually in South-East Asia (64% of all deaths in the Region) out of which 4.4 million deaths occur prematurely between the ages of 30 and 69 (31.5% of total deaths and 49.2% of all NCD-related deaths) and account for 29% of all premature deaths globally (1).

The WHO South-East Asia Region comprises 11 countries with a total population of 1.9 billion or about 26% of the total global population. There are no high-income countries in the Region. Only two countries, Maldives and Thailand comprising less than 5% of the total regional population are classified as upper-middle-income countries. The rest of the countries are classified as lower-middle-income countries with the exception of Nepal and the Democratic People’s Republic (DPR) of Korea which are classified as low-income countries (2).

Recognizing the critical public health importance of addressing NCDs for overall social and economic development, the 2030 Agenda for Sustainable Development Goals (SDGs), adopted at United Nations Summit on Sustainable Development in September 2015, explicitly included a goal to reduce the premature mortality from NCDs by one third by 2030 (3). Achieving these targets for NCD prevention and control requires a multisectoral and concerted action at the national level.

In 2001, WHO conducted the first NCD Country Capacity Survey (NCD CCS) to assess the national capacity for NCDs prevention and control by collecting detailed comparative information on the progress made by countries in addressing and responding to NCDs (4). The survey was repeated in 2005, in 2010, in 2013 and in 2015. Since 2013, WHO has been implementing this survey every two years, and the survey tool used in the assessment has evolved over time taking into account the evolving nature of NCD epidemic and the national response.

This report summarizes the status of national capacity to prevent and control NCDs in the WHO South-East Asia Region based on the results from 2017 NCD CCS survey — the sixth national capacity survey since 2001. It assesses the progress made over time, where possible, by comparing the results with 2013 and 2015 survey data. The report also identifies limitations and challenges for national capacity for NCD prevention and control and highlights the areas that urgently need prioritization and additional strengthening.


2

2 Methods

Data collection review and validation

The NCD CCS survey is a qualitative survey, with administration of a web-based questionnaire hosted on WHO website to collect data from NCD focal point(s) or designated officials within the Ministry of Health or national institutes or agencies responsible for NCDs in the WHO Member States. In the last week of January 2017, each country received their unique web log-in details to access the website and the identified focal points were requested to submit their completed questionnaires through the WHO website by end of July 2017. To improve the quality and breadth of information provided, the questionnaire completion instruction requested that a team of people, led by the NCD focal point, complete the responses so that topic-specific experts could provide more detailed information. Additionally, for validation and verification of responses, Member States were requested to upload supporting documentation for selected questions such as the existence of a multisectoral policy or plan or screening or treatment guidelines.

The submitted information was thoroughly reviewed by the WHO Secretariat at the Regional Office and later at headquarters in terms of completeness and consistency (with the responses in the previous rounds of survey, as well as internally with other responses within this survey) and validated responses against existing data sources and supporting documentation provided. Where discrepancies were noted between the country response and other sources, a clarification request was sent to the country by the Regional Office of WHO. Similarly, if the review revealed missing documentation or incomplete questions, the focal point was asked to supply the missing information.

Questionnaire

The questionnaire (Annex 1) comprised four modules:

1. Public health infrastructure, partnerships and multisectoral coordination;

2. Policies, strategies, and action plans;

3. Health information systems and surveillance; and

4. Health system capacity for detection, treatment and care.

The questionnaire included a set of detailed instructions on how to complete it and a glossary defining the terms used in it.

Analysis

All the 11 Member States of the WHO South-East Asia Region submitted their responses by mid-April 2017, and went through several rounds of validation and re-submissions between mid-April and July. Data were downloaded directly from the web-based platform to an excel file. Initial data cleaning was performed by the WHO Secretariat to ensure consistency between responses to a question and its sub-questions. Given that there are only 11 countries in the Region or only 11 data


3

points for aggregate regional analysis, the data are presented mainly in a qualitative form, rather than percentages or other statistical measures such as mean or median. Non-positive responses (i.e. “no”, “don’t know”, and item left unanswered) were treated equally and specifically mentioned where relevant.

Trends in national capacity for NCDs were presented in a qualitative manner by comparing the results from this survey with the surveys conducted in 2010, 2013 and 2015, wherever comparative questions were asked in all the four surveys. The results were examined in relation to the objective and key recommendations made to WHO Member States in the Global and Regional Action Plan (5, 6) as well as the progress monitoring indicators adopted in 2015 on the progress achieved in the implementation of the four time-bound commitments included in the 2014 United Nations Outcome Document on NCDs (7).

Limitations

The results of the 2017 Country Capacity Survey should be interpreted taking into account certain limitations. First, the questionnaire designed as a global tool provides only a high-level overview of national capacities for prevention and control of NCDs, and as such cannot capture all the specific circumstances of each country; nor does it allow for a comprehensive situation analysis of each subject covered. For example, while the survey can identify the existence of fiscal interventions for NCDs and their risk factors, it does not provide enough information to determine whether those interventions are sufficient to bring about the desired public health impact.

Second, the Country Capacity Survey is coordinated by a focal point for NCDs designated by the national authority, which was expected to identify and consult key informants for each of the survey modules. The quality of the collected data depends on the breadth of this consultation process, and reflects the perspectives and knowledge level of informants at the time they completed the survey. Finally, while the present round of survey featured an expanded validation process, there were still substantial numbers of questions (e.g. availability of medicines, diagnostics, etc.) for which no independent verification mechanisms were available. These limitations notwithstanding, the results should still be very useful because they provide information on essential infrastructure, surveillance, and the policy and health service component for the control and prevention of NCDs.


4

3 Results

All the results presented below are dated 31 July 2017, when the data collection process was closed. Any changes in the situation in any Member State since have not been taken into account.

1 Public health infrastructure, partnerships and multisectoral collaboration for NCDs

Governance structures

Highlights:

¤ All countries in the WHO SEA Region reported having a unit, branch, or department responsible for NCDs in their Ministry of Health.

¤ All countries with the exception of Bangladesh and Maldives reported having a dedicated nationwide multisectoral commission, agency or mechanism to oversee NCD engagement, policy coherence and accountability in sectors other than health.

¤ General government revenues were reported to be the single largest source of regular funding for prevention and control of NCDs in all the countries, regardless of income level. However, given the overall low level of government spending on health, these budget allocations may not be adequate.

¤ All countries reported the implementation of at least one fiscal intervention related to NCDs (most common being tobacco/alcohol taxation).

NCD unit, branch or department

Since 2010, all countries in the WHO South-East Asia Region, except Nepal, have been reporting having a unit, branch or department in their ministry of health with the responsibility for NCDs. Nepal established the same in 2016 with 11+ full-time or equivalent staff members. Hence, in 2017, all countries reported having such a unit (Figure 1).

The reported full-time technical staff in the NCD unit ranged from 2 to 5 in DPR Korea, Maldives and Sri Lanka; to 6–10 in India and Timor-Leste; to 11 or more in Bangladesh, Bhutan, Indonesia, Myanmar, Nepal and Thailand. The 2017 Survey represents substantial improvement in NCD staffing capacity since 2010, especially in some countries such as Bangladesh, Nepal and Timor-Leste.


5

Figure 1: Availability of governance structures and financing for different NCD activities

Yes No Don't know Not reported

0 1 2 3 4 5 6 7 8 9 10 11

For health promotion

Tax on alcohol

Tax on tobacco

Tax on SSB

Tax on unhealth food

Subsidies for health food

Tax to promote PA

Primary prevention

Health promotion

Early detection/ screening

Healthcare/ treatment

Surveillance, monitoring…

Capacity building

Palliative care

Separate unit/dept/branch

Multisectoral commission,agency or mechanism

Fund

sea

rmar

ked

Cou

ntry

impl

emen

ting

any

fisca

l int

erva

tions

Fund

s al

loca

ted

ingo

vern

men

t bu

dget

for

NC

Dca

paci

tyin

MO

H

Number of countries in the WHO SEA Region

Multisectoral coordination mechanisms, building coalitions and partnerships

Multisectoral coordination mechanisms in the WHO South-East Asia Region at a glance:

¤ Seven out of 11 countries reported having an ‘operational’ multisectoral mechanism; India and Timor-Leste reported a mechanism ‘under development’.

¤ Cross-departmental or inter-ministerial committees were the most commonly reported mechanism for multisectoral coordination.

¤ A health sector representative chaired these mechanisms except in India and Nepal.

¤ Only three countries reported membership of the private sector and four countries reported an NGO to be a member.

¤ Limited information on the legitimacy, powers, resources and effectiveness of these mechanisms in influencing NCD policy and programme outcomes.

Encouragingly, both the sector-wide and the NCD-specific plans in all the SEA Region countries emphasize the importance of multisectoral coordination and identify relevant stakeholders.

In 2017, seven out of 11 countries in the Region reported having an “operational” multisectoral coordination mechanism and partnership to oversee NCD engagement, policy coherence and accountability of sectors beyond health. While Bangladesh and Maldives did not report having


6

any multisectoral coordination mechanism, India and Timor-Leste reported that its multisectoral coordination mechanism is “under development”.

Cross-departmental or inter-ministerial committees were the most commonly reported mechanism for multisectoral coordination. In most instances, the mechanism was chaired by a health sector representative (minister, secretary or director-general). Only India and Nepal reported the mechanism to be chaired a Cabinet Secretary/Chief Secretary1.

The supporting documentation provided by the Member States with the survey provides some details of the composition, roles and responsibilities (Table 1). The reported key stakeholders for partnerships included other non-health government ministries (8/8), academic (7/8), nongovernmental organizations (6/8), UN agencies (4/8), and other international organizations (4/8). Three out of eight countries also reported membership of the private sector (3/8).

Partnerships with non-State actors

Effective governance for NCD at the national level requires the development of effective partnerships and coalitions to generate the demand for change and to catalyse political action. The range of actors and stakeholders for noncommunicable disease control are complex and include food manufacturers and retailers, tobacco and alcohol industries, civil associations, disease/condition-specific advocacy groups such as national diabetic associations, and professional associations.

The multisectoral coordination mechanisms in some of the Member States (e.g. DPR Korea, India, Myanmar, Sri Lanka and Thailand) officially included membership of nongovernmental organizations (NGOs), in others it was confined to only government ministry representatives (e.g. Bhutan, Indonesia and Nepal) (Table 1). In addition, the countries may not be well equipped to develop partnerships or engage effectively with such a complex and wide range of actors that may often have conflicting interests. In the current survey, almost six out of eight Member States that reported having multisectoral coordination mechanism reported having partnerships with NGOs, and only three countries (India, Myanmar and Thailand) with the private sector. However, functional mechanisms to deal with non-traditional stakeholders, such as food manufacturers, do not seem to be well established in any of these countries.

1 Cabinet or Chief Secretaries generally oversee all the sectors/department in a government, while sector-specific secretary such as health secretary are responsible for the only health department.


7

Tabl

e 1:

Inte

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atio

n m

echa

nism

s in

Mem

ber

Stat

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f th

e W

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SEA

Reg

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201

7

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Ch

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Mem

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ship

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Ban

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or

NC

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to

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; he

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ealth

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Min

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12 m

embe

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ting

mul

tiple

go

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(e.

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Dep

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ent

of Y

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in M

oE,

Dep

t. o

f Tr

ade,

Dep

t. o

f Re

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2010

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in 2

010,

the

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icit

ToR,

incl

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g To

Rs f

or

each

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owev

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activ

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and

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, so

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ng C

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prev

entio

n an

d co

ntro

l of

NC

Ds

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inet

Se

cret

ary.

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ealth

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cret

ary,

M

oHFW

as

Mem

ber

Secr

etar

y

Secr

etar

ies

of 3

9 co

ncer

ned

depa

rtm

ents

m

entio

n in

NM

AP;

can

ca

ll ot

her

secr

etar

ies,

ot

her

stak

ehol

ders

an

d U

N a

genc

ies

as

appr

opria

te.

Prop

osed

to

be

set

up in

NM

AP

(201

7–20

24)

Prop

osed

as

a m

echa

nism

/pla

tfor

m

for

coor

dina

ted

mul

tisec

tora

l en

gage

men

t an

d ac

tion;

key

fu

nctio

ns a

re d

efin

ed; m

eetin

g fr

eque

ncy

not

defin

ed.

Inte

r-min

iste

rial

Com

mitt

ee f

or

prev

entio

n an

d co

ntro

l of

NC

Ds

Secr

etar

y,

MoH

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odal

off

ice

from

co

ncer

ned

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istr

ies/

depa

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ents

; can

cal

l re

pres

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of

othe

r un

ion

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istr

ies,

ac

adem

ia, C

SO, p

rivat

e se

ctor

Prop

osed

to

be

set

up in

NM

AP

(201

7–20

24)

Key

obj

ectiv

e is

to

syne

rgiz

e,

harm

oniz

e, a

nd f

acili

tate

im

plem

enta

tion

of t

he a

ctiv

ities

en

visa

ged

in N

MA

P. N

MA

P de

scrib

es

the

func

tions

.


8

Co

un

try

Nam

e o

f in

ters

ecto

ral

mec

han

ism

Ch

air

Mem

ber

ship

Yea

r o

f es

tab

lish

men

tC

om

men

ts

Tech

nica

l Adv

isor

y G

roup

s (T

AG

)Pr

opos

ed t

o be

se

t up

in N

MA

P (2

017–

2024

)

To p

rovi

de s

uppo

rt t

o ot

her

mec

hani

sms

(i.e.

Inte

rmin

iste

rial

com

mitt

ee a

nd S

tand

ing

Com

mitt

ee

of S

ecre

tarie

s); t

he f

unct

ion

are

defin

ed.

Hea

lth P

rom

otio

n Bo

ard/

Soci

ety

of In

dia

Prop

osed

to

be

set

up in

NM

AP

(201

7–20

24)

Ind

on

esia

Hea

lthy

Peop

le

Mov

emen

tO

ther

gov

ernm

ent

min

istr

ies,

UN

age

ncie

s,

acad

emia

Att

ache

d do

cum

ent

was

in B

ahas

a,

no o

ther

info

rmat

ion

is r

epor

ted

in

CC

S Su

rvey

.

Mal

div

esN

one

repo

rted

Mya

nm

arTe

chni

cal S

trat

egy

Gro

up f

or N

CD

sD

G,

Dep

artm

ent

of p

ublic

he

alth

, M

inis

try

of

Hea

lth a

nd

Spor

ts

36 m

embe

rs in

clud

ing

DG

pub

lic h

ealth

, m

embe

r fr

om d

iffer

ent

depa

rtm

ents

of

MoH

, re

pres

enta

tive

from

M

oE, D

epar

tmen

t of

Spo

rts

and

Phys

ical

Edu

catio

n;

repr

esen

tativ

e fr

om U

N

agen

cies

, Int

erna

tiona

l an

d na

tiona

l NG

Os

and

Civ

il So

ciet

y O

rgan

izat

ion

2017

Has

def

ined

ter

ms

of r

efer

ence

s.

Oth

er t

han

MoE

, no

othe

r no

n-he

alth

de

part

men

t is

rep

rese

nted

.

TSG

NC

Ds

is o

ne o

f th

e TS

Gs

form

ed

unde

r M

yanm

ar H

ealth

Sec

tor

Coo

rdin

atin

g C

omm

ittee

(M

HSC

C)

whi

ch is

larg

er c

oord

inat

ing

body

ch

aire

d by

Uni

on M

inis

ter

for

Hea

lth &

Spo

rts.

MH

SCC

com

pris

es

repr

esen

tativ

es f

rom

diff

eren

t en

titie

s in

clud

ing

rele

vant

min

istr

ies,

ING

Os/

NG

Os,

CSO

s an

d so

on.

Nat

iona

l Roa

d Sa

fety

C

ounc

il (N

RSC

)C

haire

d by

Vic

e-Pr

esid

ent

Mem

bers

incl

udin

g re

pres

enta

tives

fro

m

Min

istr

y of

Hea

lth a

nd

othe

r re

leva

nt m

inis

trie

s.

June

201

4Fu

nctio

ns a

re d

efin

ed.


9

Co

un

try

Nam

e o

f in

ters

ecto

ral

mec

han

ism

Ch

air

Mem

ber

ship

Yea

r o

f es

tab

lish

men

tC

om

men

ts

Cen

tral

Tob

acco

C

ontr

ol C

omm

ittee

Cha

ired

by U

nion

M

inis

ter

of H

ealth

and

of

ficia

ls f

rom

rel

evan

t ot

her

min

istr

ies.

2011

Func

tions

are

def

ined

.

Nep

alN

atio

nal S

teer

ing

Com

mitt

ee f

or N

CD

sC

hief

Se

cret

ary,

G

ovt.

of

Nep

al,

Secr

etar

y M

oH a

s M

embe

r Se

cret

ary

18 m

embe

rs a

re

prop

osed

incl

udin

g ch

air

and

mem

ber

secr

etar

y re

pres

entin

g 17

gov

ernm

enta

l de

part

men

ts in

clud

ing

natio

nal p

lann

ing

com

mis

sion

.

Prop

osed

to

be

set

up in

NM

AP

(201

4-20

20)

Cab

inet

end

orse

d fo

rmat

ion

of

com

mitt

ee w

ith d

efin

ed T

oRs.

No

repr

esen

tatio

n of

priv

ate

sect

or, C

SO,

etc.

Nat

iona

l Com

mitt

ee

for

cont

rol a

nd

prev

entio

n of

NC

Ds

Secr

etar

y of

Hea

lth;

Chi

ef,

cura

tive

divi

sion

se

rvic

e pr

ovis

ion

as M

embe

r Se

cret

ary

Prop

osed

to

be

set

up in

NM

AP

(201

4–20

20)

Expe

cted

to

prov

ide

a pl

anni

ng

and

mon

itorin

g an

d in

form

atio

n ex

chan

ge f

orum

for

the

min

istr

ies

invo

lved

in im

plem

enta

tion

of N

MA

P

Coo

rdin

atio

n co

mm

ittee

for

con

trol

an

d pr

even

tion

of

NC

Ds

Chi

ef

spec

ialis

t,

cura

tive

serv

ice

divi

sion

Prop

osed

to

be

set

up in

NM

AP

(201

4–20

20)

ToR

defin

ed in

NM

AP,

but

whe

ther

an

y ad

min

istr

ativ

e or

der

issu

ed t

o ap

poin

t th

e co

mm

ittee

is n

ot k

now

n.

Ad

hoc

com

mitt

ees

for

cont

rol a

nd p

reve

ntio

n of

NC

Ds

Prop

osed

to

be

set

up in

NM

AP

(201

4–20

20)

Ad

hoc

com

mitt

ee m

ay b

e fo

rmed

by

coor

dina

tion

com

mitt

ee t

o de

velo

p sp

ecifi

c pr

oduc

ts r

equi

red

in t

he

cour

se o

f im

plem

enta

tion

of M

SAP


10

Co

un

try

Nam

e o

f in

ters

ecto

ral

mec

han

ism

Ch

air

Mem

ber

ship

Yea

r o

f es

tab

lish

men

tC

om

men

ts

Regi

onal

and

dis

tric

t N

CD

pre

vent

ion

and

cont

rol c

omm

ittee

s

Prop

osed

to

be

set

up in

NM

AP

(201

4–20

20)

Coo

rdin

ate

enfo

rcem

ent

of

regu

latio

ns r

elat

ed t

o al

coho

l, to

bacc

o, d

iet,

roa

d sa

fety

and

ot

her

heal

th p

rom

otin

g re

gula

tions

, s

harin

g of

exp

erie

nces

, adv

ocat

e im

plem

enta

tion

of M

SAP

Sri L

anka

Nat

iona

l Hea

lth C

ounc

ilPr

opos

ed t

o be

set

up

in

natio

nal p

olic

y &

str

ateg

ic

fram

ewor

k fo

r pr

even

tion

& c

ontr

ol o

f N

CD

s, 2

009

Supr

eme

body

for

inte

r-min

iste

rial/

inte

rsec

tora

l coo

rdin

atio

n,

mul

tisec

tora

l par

tner

ship

s, p

rogr

ess

of im

plem

enta

tion

of N

atio

nal N

CD

po

licy

Nat

iona

l NC

D S

teer

ing

Com

mitt

eeSe

cret

ary

of

Min

istr

y of

H

ealth

and

N

utrit

ion

Hig

h-le

vel r

epre

sent

atio

n fr

om a

ll re

leva

nt

gove

rnm

ent

agen

cies

(f

inan

ce, t

rade

, ag

ricul

ture

, urb

an

plan

ning

, edu

catio

n,

just

ice,

pov

erty

al

levi

atio

n, s

ocia

l w

elfa

re a

nd o

ther

re

leva

nt a

genc

ies

and

deve

lopm

ent

part

ners

in

clud

ing

loca

l and

in

tern

atio

nal N

GO

s.

Sam

e as

abo

vePr

opos

ed t

o fu

nctio

n as

nat

iona

l m

onito

ring

body

on

natio

nal N

CD

po

licy

impl

emen

tatio

n

Will

mee

t ev

ery

two

mon

ths,

ac

coun

tabl

e to

Min

iste

r of

Hea

lthca

re

and

Nut

ritio

n

Func

tion

are

defin

ed in

NC

D p

olic

y (2

009)

doc

umen

t

Nat

iona

l Adv

isor

y Bo

ard

for

Non

com

mun

icab

le

Dis

ease

s

DG

, Min

istr

y of

Hea

lth

and

Nut

ritio

n

Hig

h-le

vel t

echn

ical

re

pres

enta

tion

from

re

leva

nt p

rofe

ssio

nal

bodi

es.

Adv

isor

y bo

dy o

n N

atio

nal N

CD

Pol

icy

impl

emen

tatio

n


11

Co

un

try

Nam

e o

f in

ters

ecto

ral

mec

han

ism

Ch

air

Mem

ber

ship

Yea

r o

f es

tab

lish

men

tC

om

men

ts

Tech

nica

l Wor

king

G

roup

on

NC

Ds

Dire

ctor

NC

D8–

10 m

embe

rs

Thai

lan

dEx

ecut

ive

Com

mitt

ee

of T

haila

nd H

ealth

y Li

fest

yle

Stra

tegi

c Pl

an (

Phas

e 2)

(al

so

calle

d N

atio

nal N

CD

Pr

even

tion

and

Con

trol

Pl

an (

2017

-21)

; can

ap

poin

t su

bcom

mitt

ees

as a

ppro

pria

te

Min

iste

r of

Pu

blic

Hea

lth43

mem

bers

incl

udin

g ch

airp

erso

n—in

clud

ing

mem

bers

fro

m 1

3+

diff

eren

t go

vern

men

t m

inis

trie

s, C

SO, a

nd U

N

agen

cies

Dec

1, 2

016

via

MoP

H o

rder

no

2233

/255

9

Task

ed w

ith f

ive

key

func

tions

in

clud

ing

form

ulat

ing

dire

ctio

n an

d st

rate

gies

to

supp

ort

NC

D p

reve

ntio

n an

d co

ntro

l, m

onito

ring

& e

valu

atio

n.

Tim

or-

Lest

eN

one

repo

rted

Repo

rted

as

“und

er d

evel

opm

ent”

, no

fur

ther

det

ails

pro

vide

d.


12

Funding mechanisms

Overall health expenditures in South-East Asia: Predominance of private out-of-pocket expenditures

In 2017, the current health expenditures (CHE)2 as percentage of gross domestic product (GDP) ranged from 2.6% in Bangladesh to 11.5% in Maldives. The domestic private expenditures account for more than 70% of current health-care expenditure in the three largest countries of the SEA Region – Bangladesh (74%), India (74%), Myanmar (74%) and Nepal (71%) (8). Most of the domestic private expenditures are “out-of-pocket” expenditures putting the population at risk of catastrophic health expenditures and being driven into poverty, especially from chronic illnesses.

Table 2: Status of health expenditure in the WHO South-East Asia Region, 2017

Country Current health expenditure (CHE) per capita in US$

Current health expenditure (CHE) as % gross domestic product (GDP)

Domestic private health expenditure (PVT-D) as % current health expenditure (CHE)

Out-of-pocket (OOP) as % of current health expenditure (CHE)

Bangladesh 32 2.6 74 72

Bhutan 91 3.5 21 20

India 63 3.9 74 65

Indonesia 112 3.3 61 48

Maldives 944 11.5 18 16

Myanmar 59 4.9 74 74

Nepal 44 6.1 71 60

Sri Lanka 118 3.0 45 38

Thailand 217 3.8 21 12

Timor-Leste 72 3.1 10 10

Source: World Health Organization, 2017. Global Health Expenditure Database (GHED). As accessed and downloaded on March13,2018 from http://apps.who.int/nha/database/ViewData/Indicators/en

Allocation of government budget to identified NCD activities

All the countries in the WHO SEA Region reported allocating funding in their government budget for all the eight key NCD and risk factor activities or functions, which were explicitly enquired about in the questionnaire (Figure 1). These eight NCD activities and functions include: primary prevention; health promotion; early detection or screening; health care and treatment; surveillance, monitoring and evaluation; capacity-building; palliative care; and research. Only DPR Korea reported not allocating government budget for palliative care. However, given the overall low level of general government expenditure on heath as percentage of current health expenditure as shown in Table 2, the total

2 Since the introduction of SHA 2011, current health expenditure (excluding capital, which is a one-off expenditure that will be “consumed” for several years) instead of total health expenditure are reported.


13

current budget allocation may not be sufficient to address the expanding NCD epidemic in most countries.

Major sources of regular funding

General government revenues

All countries reported general government revenue as the single largest source of regular funding for NCDs and their risk factors (Table 3).

International donors

International donors seem to be an important source of regular funding for NCDs in the SEA Region. Seven countries (Bangladesh, Bhutan, DPR Korea, Myanmar, Nepal, Sri Lanka and Timor-Leste) reported international donors as the second largest source of funding. Thailand mentioned international donors as “other source”. Notwithstanding this, the international funding for NCDs still remains negligible.

While the implementation of programmes for communicable diseases and maternal and child health in LMICs owe much to the financial and technical assistance of external donors, less than 3% of global development assistance for health currently goes to NCDs (9). Despite mounting international advocacy, the future of the international financing for NCDs is still unpredictable.

Health insurance

With the implementation of social health insurance (SHI) mechanism for health financing in some countries such as Indonesia (since 2014), Maldives and Thailand, health insurance is also emerging as an important mechanism or channel of regular funding for NCDs, though in majority of these countries, general tax revenues are used to fund these schemes with very low contributions from members. None of the countries, even the ones with an SHI system with fairly large coverage, mentioned health insurance as their first largest mechanism. Indonesia, Maldives and Thailand mentioned health insurance as their second largest mechanism of funding, after general government revenues. Three other countries (Sri Lanka, Myanmar and Timor-Leste) mentioned health insurance as “other” source of regular funding.

Domestic donors and earmarked taxes on alcohol, tobacco, etc. are mainly reported as ”other” sources of funding by five countries out of 11 countries.

Table 3: Major sources for regular funding for NCDs as reported by countries in 2017 NCD CCS survey

Country Largest source Next largest Others

Bangladesh Government revenue International donors

Bhutan Government revenue International donors

DPR Korea Government revenue International donorsa


14

Country Largest source Next largest Others

India Government revenue None National donors, earmarked taxes on tobacco and alcohol

Indonesia Government revenue Health insurance Ear-marked taxes on tobacco and alcohol

Maldives Government revenuea Health insurancea International donorsa

Myanmar Government revenue International donors National donors, ear-marked taxes on tobacco and alcohol, Help age international

Nepal Government revenuea International donors Health insurancea

Sri Lanka Government revenue International donors Health insurance, national donors, ear-marked taxes on tobacco and alcohol

Thailand Government revenue Health insurance International and national donors, ear-marked taxes on tobacco and alcohol, Private companies

Timor-Leste Government revenue International donors Health insurance, national donors

a: response was changed post-survey completion

Implementation of fiscal interventions

Countries were explicitly asked if they have been implementing any of the six specific fiscal interventions mainly related to taxation (taxation on alcoholic beverages; on tobacco (excise and non-excise); on sugar-sweetened beverages; on food high in fat, sugar or salt; taxation incentives to promote physical activity) or price subsidies (for healthy foods). Countries were also given the option to specify any other fiscal intervention not captured by these six specific interventions.

With the exception of DPR Korea, all countries reported implementing taxation on alcohol and tobacco (Figure 1). DPR Korea has other price-setting mechanisms in place as all the tobacco and alcohol production is state-owned3.

India increased the taxes on aerated beverage with sugar from 18% to 21%, though the tax increase was applied evenly on mineral water and was not done exclusively for sugar sweetened beverages (10) (Figure 1), In addition, in February 2017, Maldives increased import duties on energy and fizzy drinks by 58%, Thailand is planning to introduce taxes on sugar-sweetened beverages (has gazetted the tax but not started the implementation). India also reported providing subsidies for promoting healthy foods mainly in the form of subsidies for production, storage and distribution of fruits and

3 Tobacco Control Law of DPR Korea (Decree number 1176 on June 24th, 2016), Pyongyang, DPR Korea.


15

vegetables under the India Horticulture Mission. India also reported providing taxation incentives for promoting physical activities. DPR Korea also reported subsidies for healthy food, but the data could not be validated.

None of the countries reported levying taxes on unhealthy food high in fat, sugar or salt.

Earmarking of tax revenues from alcohol or tobacco for NCD or health promotion activities

While all countries reported levying taxation for alcohol and tobacco as mentioned above, only five countries (Bangladesh, Indonesia, India, Nepal and Thailand) reported earmarking a part of these revenues, especially from tobacco, for NCD or health promotion activities (Figure 1).

Indonesia does not earmark alcohol taxes, but regulates tobacco taxes under Act No. 28 of 2009 (implementation started in 2014) and Government Regulation no. 55 of 2016 for local tax, both of which state the tariff for tobacco tax as 10% of the excise tax. A minimum of 50% of the tobacco tax revenue at provincial or district level is proposed to be allocated for public health services including for prevention and control of NCDs and enforcement of regulation. The procedure for allocation of funding is regulated under Ministry of Health Regulation no. 40 of 2016.

2 Plans, policies and strategies

Highlights:

¤ All SEA Region countries reported inclusion of NCDs in their current national health plan and is being reflected in the national development agenda (except Myanmar).

¤ All SEA Region countries reported having multisectoral national NCD policy, strategy or action plans which address all the four major risk factors (tobacco, harmful use of alcohol, physical activity and unhealthy diets), and early detection, care and management of all the four major NCDs (CVD, cancers, diabetes, chronic respiratory diseases).

¤ All SEA Region countries reported having time-bound national targets and indicators for NCDs based on nine global targets from the WHO Global Monitoring Framework.

¤ Some countries also reported having a disease- or risk-factor specific strategy or plan in addition to an integrated NCD plan/strategy.

Information was elicited regarding the presence of both integrated (defined as addressing one or more risk factors or diseases) and topic-specific policies, strategies, or action plans for noncommunicable diseases overall as well as for four major NCDs (CVD, cancers, diabetes mellitus, and chronic respiratory disease) and for four major risk factors.

Ministries of health were asked to name the policy and indicate if the plan was currently operational or under development. Additionally, this component covered cost-effective policies for NCDs, such as policies to reduce population salt consumption, to eliminate industry produced trans-fats (the partially hydrogenated vegetable oils) in the food supply, and to reduce impact on children of


16

marketing of unhealthy foods and non-alcoholic beverages high in saturated fats, trans-fatty acids, free sugars, or salt.

Inclusion of NCDs in overarching national health plans and development plans

All Member States reported inclusion of NCDs in the outcomes and outputs of their national health plans as well as national development plans (except Myanmar which reported “don’t know” for national development plan. Myanmar also reported the same in 2015) (Figure 2).

Figure 2: Existence of integrated or disease/risk factor-specific policies, plans or strategies, 2017

0 1 2 3 4 5 6 7 8 9 10 11

Salt policy

Fat /Transfat policy

Marketing of foods policy

Unhealthy diet policy

Tobacco control policy

Physical activity policy

Overweight/obesity policy

Alcohol policy

Oral health policy

CRD policy

Diabetes policy

Cancer policy

CVD policy

Integrated National NCD policy/plan/strategy

Time-bound national targets

NCDs in national development agenda

NCDs in national health plan

Sele

cted

cos

t-ef

fect

ive

p olic

ies

Polic

ies/

Plan

s fo

rSp

ecifi

c Ri

sk f

acto

rSp

ecifi

c ke

y N

CD

s

NC

Ds

rele

vent

polic

ies,

str

ateg

ies

and

actio

n pl

ans


Available Not available Don't know Not reported

Integrated NCD policy/strategy/action plan

Encouragingly, all countries in the SEA Region reported having an integrated and operational national NCD policy/strategy/action plan (Figure 2), though in Bangladesh, India, Indonesia and Myanmar, the plans were still under finalization and awaiting official endorsement at the time of the survey.


17

This is a progress since 2013–2015, when two of the countries did not report having an operational integrated plan. .

Scope of integrated NCD policies/strategies and action plans

All countries reported these strategies/plans to cover all the four major risk factors (harmful use of alcohol, tobacco, unhealthy diet, and physical inactivity) and covering early detection, care and treatment of all the four major NCDs (CVD, cancers, diabetes, and chronic respiratory diseases). Finally, all the countries, with the exception of DPR Korea and Timor-Leste, also reported plans to cover palliative care as well.

Additionally, all countries described their integrated plans to be multistakeholder and multisectoral in nature, with the exception of Bangladesh and DPR Korea, which did not provide any response for the “multistakeholder option”.

Disease-specific NCD plans

Cardiovascular diseases

India and Thailand reported delivery of services for cardiovascular diseases through their integrated national programmes, the National Programme for Control of Cancer, Diabetes, CVD and stroke (NPCDCS) and National Service Development Plan, respectively. Other countries mainly include strategies and plan for CVD control in their integrated plans only (Figure 2).

Cancers

Seven of the 11 Member States reported having a specific plan or strategy for cancer control – either a general strategy covering all cancers (e.g. Bangladesh, Myanmar, Sri Lanka) or a strategy for specific cancers (e.g. Bhutan). India and Thailand reported their cancer services through the integrated programme as mentioned above for CVD. Four countries (DPR Korea, Indonesia, Nepal and Timor-Leste) did not report any cancer-specific plan or programme, though their integrated NCD plans cover cancer control and prevention (Figure 2).

Diabetes

Bhutan was the only country that reported having a diabetes-specific workplan. India and Thailand reported delivering diabetes services through their integrated programme as mentioned above. Other countries have included diabetes control strategies as part of their integrated NCD control and prevention policies (Figure 2).

Chronic respiratory diseases

Two of the Member States reported having a special plan or strategy for chronic respiratory disease either in operation (1) or under development (1) (Figure 2). Thailand also reported inclusion of chronic respiratory disease in their integrated programme – National Service Development Plan. India reported plans “under development” for inclusion of chronic respiratory diseases and chronic kidney diseases as part of their integrated national programme (NPCDCS).


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Oral health

In all, four countries reported specific oral health policies and programmes. India and Timor-Leste reported national oral health programmes (operational since 2012) and Timor-Leste Strategic Plan for Oral Health (2015–2020), respectively. Thailand included oral health services as part of National Service Development Plan. Nepal also reported having national oral health policy in the past, but not in effect currently (Figure 2).

Other NCD diseases

Many countries reported plans and strategies covering other noncommunicable diseases as well. Mental health was the common disease group, reported by four Member States (Bhutan, India, Maldives and Timor-Leste). In addition, Bangladesh and Nepal (National Road Safely Action Plan 2013-2020) reported having a national plan on road safety. India and Nepal reported having plans and strategies for disabilities — specifically blindness and deafness in India, and for disability overall in Nepal. Thailand reported having specific plans and strategies for stroke and chronic kidney diseases.

Risk factor-specific NCD plans

Tobacco

Tobacco was the most common risk factor, for which all Member States reported a specific strategy/plan. While some countries provided the names of their tobacco control strategies and plans, such as Bangladesh (Tobacco Strategic Plan of Action), India (National Tobacco Control Programme), Indonesia (Roadmap Tobacco Control Programme), Myanmar (Tobacco Control Strategy and Plan), others (Bhutan, DPR Korea, Maldives, Nepal, and Timor-Leste) provided the names of their tobacco control law rather than a specific plan/strategy to implement that law. In addition, all the countries included tobacco control in their overall NCD prevention and control plan.

Alcohol

Six (Bhutan, India, Myanmar, Nepal, Sri Lanka and Thailand) out of 11 Member States reported specific strategies and plans for alcohol, though some of them mentioned names of the alcohol control legislation rather than policies/strategies (Figure 2).

Overweight

India and Indonesia mentioned specific policies and strategies for reduction of overweight/obesity. India reported Food Safety and Standards Authority of India (FSSAI) guidelines on children’s food and Ministry of Women and Child Development (MoWCD) guidelines on junk food as the specific policies for reduction of overweight and obesity. In addition, all the Member States included the component of reduction of overweight and obesity as part of the integrated NCD plans.

Promotion of physical activity

Bhutan, India, Indonesia, Sri Lanka, Thailand mentioned special guidelines/policies for promotion of some form of physical activities, while others indicated their integrated NCD plans where they have articulated strategies for the promotion of physical activity.


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Diet

Six (Bhutan, India, Indonesia, Maldives, Sri Lanka, Thailand) countries out of 11 mentioned specific policies/strategies for diet and listed their national nutrition programmes/policies

Selected cost-effective policies for NCDs and their related risk factors

Policies to reduce impact on children of marketing of food and non-alcoholic beverages

Three countries (India, Maldives and Thailand) reported implementing policies to reduce the impact of marketing of food and non-alcoholic beverages high in saturated fats, trans-fatty acids, free sugars, or salt through government legislation. While the government was responsible for overseeing enforcement and complaints in India and Maldives, Thailand reported an independent regulator to be responsible for the same. In addition, none of the countries reported taking steps to address the effect of cross-border marketing of food and non-alcoholic beverages on children.

Policies to limit saturated fatty acids and eliminating industrially produced trans-fats

Only two countries (Bhutan and India) reported implementing national policies that limit saturated fatty acids and virtually eliminate industrially produced trans-fat in the food supply.

Policies to reduce population salt consumption

Four countries (Bhutan, DPR Korea, India and Thailand) reported having polices to reduce population salt consumption. While all these four countries reported public awareness campaigns to reduce salt consumption; product reformulation by industry across the food supply was reported by India and Thailand; and regulation of salt content of food and nutrition labelling was reported by Bhutan, India and Thailand.

Campaigns to increase awareness on diet and physical activity

All countries reported implementing national public awareness programmes or campaigns in the last five years, though some countries did not provide supporting documents to validate their claim (DPR Korea, Maldives, Sri Lanka and Thailand). Similarly, all countries except Bangladesh reported implementing awareness campaigns for physical activities, though it could not be validated for four of the countries (Bhutan, DPR Korea, Maldives and Sri Lanka) based on submitted documents.

3 National capacity for early detection, treatment and care of NCDs within the health systems

The 2017 NCD Capacity Survey assessed the capacity of their health system related to NCD prevention, early detection, and treatment and care at the primary health care level in the public and private sector. Specific questions were asked to assess the availability of protocols to treat major NCDs and the availability of the tests, procedures and equipment related to NCDs within the health system.


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Highlights:

¤ All SEA Region countries reported having evidence-based guidelines/protocols for cardiovascular disease and diabetes that have been updated in the past 2 years, though only six countries reported them to be used in at least 50% of health facilities .

¤ All SEA Region countries reported general availability of equipment for measurement of height, weight, and blood pressure in both public and private health facilities (where relevant).

¤ While the basic equipment (e.g. glucometers) for diabetes is reported to be generally available in public primary care facilities (with the exception of DPR Korea and Timor-Leste), the more advanced tests (Hb1ac, etc.), blood cholesterol testing are available in only few countries at primary health care level.

¤ All SEA Region countries reported availability of at least one group of anti-hypertensive medication in primary health care facilities in public sector.

¤ Availability of drugs for diabetes, bronchial asthma, and tobacco cessation at primary care facilities is much more limited.

¤ All SEA Region countries reported screening programs for cervical cancer, and all but one reported for breast cancer. However, the screening programs are mainly opportunistic in nature and have low coverage in most of the countries.

Availability of evidence-based guidelines/protocols:

All the countries in the Region reported having evidence-based guidelines/protocols for cardiovascular diseases and diabetes that have been updated within the last two years (between 2015 and 2017) and include referral criteria. However, only six countries reported them being used in at least 50% of health facilities. Five countries [Bangladesh (reported as “don’t know”), Indonesia, Nepal, Sri Lanka and Timor-Leste] reported them being used in less than 50% of the health facilities.

For cancer and chronic respiratory diseases also, the majority of the Member States, with the exception of DPR Korea (reported “don’t know” for cancer), and Maldives4 (reported negative for both cancer and CRD) reported having these evidence-based protocols updated within the last one to four years.

In terms of nature of these evidence-based guidelines and protocols, four countries (Bhutan, Indonesia, Nepal and Timor-Leste) provided reference of their PEN protocols, and the rest referred to other NCD management guidelines.

Availability of basic technologies for early detection, diagnosis and monitoring of NCDs

Figure 3 and 4 shows the general availability of basic technologies for early detection, diagnosis and monitoring of NCDs in the public and private sector, respectively.

4 Even though Maldives did not have the guidelines at the time of survey, Maldives is engaged in developing standard treatment guidelines or a wide array of diseases including CRDs and cancers. Maldives is also adopted PEN protocol in 2017, and is now rolling out throughout the country.


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Figure 3: Availability of technologies for early diagnosis and monitoring of selected NCDs in public sector facilities

0 1 2 3 4 5 6 7 8 9 10 11

Peak flow measurementspirometry

Urine strips for albumin assay

Total cholesterol measurement

Urine strips for glucoseand ketone mesaurement

Foot vascular status by doppler

Foot vibrationperception by tuning fork

Dilated fundus examination

HbA1c test

Oral glucose tolerance test

Blood glucose measurement

Blood presure measurement

Measuring height

Measuring weight

Chr

onic

resp

irato

rydi

seas

eC

VD

mgm

tD

iabe

tes

mel

litus

Bloo

dpr

essu

reBM

I


Generally available Generally not available Don't know Not reported


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Figure 4: Availability of technologies for early diagnosis and monitoring of selected NCDs in private sector facilities.

0 1 2 3 4 5 6 7 8 9 10 11

Peak flow measurementspirometry

Urine strips for albumin assay

Total cholesterol measurement

Urine strips for glucoseand ketone mesaurement

Foot vascular status by doppler

Foot vibrationperception by tuning fork

Dilated fundus examination

HbA1c test

Oral glucose tolerance test

Blood glucose measurement

Blood presure measurement

Measuring height

Measuring weight

Chr

onic

resp

irato

rydi

seas

eC

VD

mgm

tD

iabe

tes

mel

litus

Bloo

dpr

essu

reBM

I



Note: DPR Korea and Timor-Leste has no private facilities and is shown under ‘not reported’


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Equipment for measurement of height and weight

All the countries reported the general availability of equipment for measurement of height and weight in both public and private health facilities. DPR Korea and Bhutan do not have significant number of private health facilities and hence no response was recorded for both these countries.

Basic technologies for early detection diagnosis and monitoring of diabetes

Overall while the basic equipment (e.g. glucometer) is reported to be generally available in primary care facilities, the more advanced technologies and tests (e.g. oral glucose tolerance test, Hb1ac, dilated fundus examination) are reported to be available in only few countries (Figure 4). Based on country responses, it is difficult to assess if the availability is more in the public or private sector primary care facilities.

Blood testing equipment (glucometer): All countries reported general availability of blood glucose testing equipment in primary care facilities in the public sector with the exception of DPR Korea and Timor-Leste. A similar response was observed for the private sector, though Bhutan and DPR Korea and Maldives either did not respond for the private sector or mentioned “don’t know”, mainly due to the insignificant role of the private sector in health care service delivery in these countries5.

Urine strips for glucose and ketone measurement: The availability of urine strips for glucose and ketone measurement was reported to be less than the availability for blood glucose testing. Five countries (Bangladesh, India, Indonesia, Nepal and Sri Lanka) reported it to be available in both public and private facilities, while Thailand reported it only in public health facilities.

The availability of other technologies was reported to be much more limited. Only Nepal and Sri Lanka reported oral glucose tolerance test in public facilities. None of the countries reported its availability in the private facilities. Similarly, for glycosylated haemoglobin (HB1ac), only Thailand reported its availability in the public sector, while Sri Lanka and India reported it to be available in the private sector only.

Dilated fundus examination is important for early detection of diabetic eye disease. Only Sri Lanka reported its availability in both public and private facilities, while Thailand reported it only in public facilities.

Foot vibration perception testing by tuning fork is important for early diagnosis of diabetic neuropathy and prevention of diabetic foot amputation, a major complication of diabetes. Only four countries (India, Nepal, Sri Lanka and Thailand) reported general availability in both public and private health facilities. Similarly, only Nepal and Sri Lanka reported the availability of the foot vascular status assessment by Doppler in both public and private health facilities.

Basic technologies for early detection, diagnosis and monitoring of cardiovascular disease

Encouragingly, all countries reported general availability of blood-pressure measuring instruments at the primary care level in all Member States in both public and private health facilities (Figure 3 and 4).

5 In Maldives, even though the private sector is very extensive in the capital city (Male), it is negligible in atolls.


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Total cholesterol is included as a risk factor in estimation of total CVD risks score, though the general availability of blood cholesterol testing was reported to be much lower. Only Bangladesh, Indonesia and Sri Lanka reported blood cholesterol testing at the primary health care level in both public and private sector (Figure 3 and 4). In Myanmar, total cholesterol measurement is available at all township hospitals and some Rural Health Centers in public sector. Thailand reported it to be generally available only in public facilities while Nepal reported the general availability of cholesterol testing in private facilities only.

Urine strips for albumin assay: Less than 50% of the countries (Bangladesh, India, Nepal and Sri Lanka) reported the availability in both public and private, while Bhutan and Thailand reported availability in public facilities only (Figure 3 and 4).

Basic technologies for asthma and chronic obstructive pulmonary disease

Peak flow spirometry: Only three countries – Indonesia, Nepal and Sri Lanka – reported general availability of peak flow spirometry at primary care level in both public and private sectors. The other Member States either report not generally available or offer a “don’t know” response.

Availability of medicines and vaccines in primary health care facilities in the public sector

Countries were enquired about “general availability” of medicines in the primary health care facilities in the public sector. “General availability” implied that medicines are available in 50% or more of health facilities. Table 4 and Figure 5 provide a summary of general availability of different NCD essential medicines in SEA Region countries.

HPV vaccination programme

Cervical cancer is an important public health issue in most of the SEA Region countries. HPV vaccination is still in the early stages of implementation in the SEA Region. Only five countries (Bangladesh, Bhutan, Indonesia, Nepal and Thailand) reported introduction of HPV vaccination for girls. Out of these five countries, only Bhutan, which also introduced the vaccine much earlier in 2010, reported coverage of 70% of more. The remaining four countries started the programme only recently in 2016 or 2017 (Thailand) and reported coverage of 10% or less. Though not reported in the survey, Sri Lanka also later reported introducing the vaccine in the public sector in 2017 with vaccination of school girls in many districts. Three of the countries have targeted 9–10-year-old girls for vaccination. However, Indonesia is providing them to one-year-old girls, and Bhutan is targeting all girls up to 18 years of age. The EPI programme in Myanmar has plans to initiate HPV vaccination in 2019.

Availability of anti-diabetic medications

Information was collected on general availability (defined as availability of a drug or practice or procedure in 50% of more of health facilities) of oral hypoglycemic agents (metformin and sulphonylureas) and insulin. Metformin is generally the first-line drug of treatment for DM-2 especially among overweight patients. Similarly sulphonylureas (glimepiride, glipizide, etc.) are used as drugs of first choice alone or in combination with metformin for type-2 diabetes. Insulin is the only drug that can be used for type-1 diabetes and is often required for type-2 diabetes not controlled with diet, exercise and/or oral hypoglycemic drugs.


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Figure 5: Reported availability of essential medicines for prevention and control of NCDs in primary care facilities in the public sector, 2017

0 1 2 3 4 5 6 7 8 9 10 11

NRT

Benzathine penicillin inj.

Oral morphine

Bronchodilator

Steroid inhaler

Sulphonylurea(s)

Metformin

Insulin

Statins

Aspirin (100 mg)

Beta Blockers

CC blockers

Thiazide diuretics

ACE inhibitors

Qui

ttin

gsm

okin

g

Rheu

mat

icH

eart

Dis

ease

Palli

ativ

eca

reBr

onch

od d

rugs

Ant

idia

betic

dru

gsO

ther

CV

D d

rugs

Ant

ihyp

erte

nsiv

e dr

ugs




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Timor-Leste and Bangladesh were the only countries in the SEA Region that did not report availability of any antidiabetic drug in 50% of more of health facilities. On the other hand, four countries – India, Indonesia, Sri Lanka and Thailand – reported general availability of all the three antidiabetic medications.

Metformin is the most commonly available anti-diabetic drug in the SEA Region, reported to be available in all SEA Region countries except Bangladesh and Timor-Leste.

Availability of sulfonylureas and insulin is much more limited. Only five countries (India, Indonesia, Myanmar, Sri Lanka and Thailand) reported sulfonylureas to be generally available. India, Indonesia, Maldives, Sri Lanka and Thailand reported insulin to be generally available in primary health care facilities in the public sector.

Availability of anti-hypertensive medications

Information was asked about general availability of four major groups of anti-hypertensive medications – thiazide diuretics, angiotensin converting enzyme inhibitors (ACE), calcium channel blockers and beta blockers.

In general, there seems to be good availability of the anti-hypertensive medications in the Region. All countries reported availability of at least one group of anti-hypertensive medication. Thiazide diuretics are the most commonly reported anti-hypertensive medication. Overall, six countries (India, Indonesia, Nepal, Sri Lanka, Thailand and Timor-Leste) reported availability of all the four categories of anti-hypertensives; Bangladesh and Myanmar reported availability of three groups of anti-hypertensives; and Bhutan, DPR Korea and Maldives reported availability of two of the anti-hypertensive medications.

Availability of other medications for cardiovascular diseases

Low-dose aspirin (75 mg–100 mg) is recommended as part of the PEN package for prevention of CVD in patients being evaluated at high risk of CVD event. All countries except Bhutan reported the general availability of low-dose aspirin (100 mg) in primary health care facilities in the public sector.

The general availability of statins – the cholesterol lowering drugs – was reported to be lower compared with anti-hypertensive medications. Only six countries – India, Indonesia, Maldives, Myanmar, Sri Lanka and Thailand – reported them to be generally available in public sector facilities.

Drugs for chronic respiratory diseases

All countries reported availability of bronchodilator drugs except DPR Korea and Thailand. However, DPR Korea later confirmed availability of bronchodilator drugs in the primary health care system. However, the availability of steroid inhalers, a key drug used in treatment of bronchial asthma, seems to be very limited, reported to be available only in Indonesia and Sri Lanka.

Availability of benzathine penicillin

This is a long-acting penicillin for prophylaxis of rheumatic heart disease — a public health problem in many SEA Region countries. All the countries reported it to be available in the PHCs in the public sector except Bangladesh (reported as “don’t know”) and Maldives (gave no response).


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Availability of oral morphine

None of the countries reported availability of oral morphine, which may be used for relief of severe pain as part of palliative care, in the PHC facilities in the public sector. Notwithstanding the non-availability of the morphine in PHC facilities, many countries provide morphine in secondary and tertiary care hospitals for palliative care.

Nicotine replacement therapy (NRT)

None of countries reported availability of NRT, which is used for tobacco cessation, in the PHC facilities in the public sector.

Table 4: Reported general availabilitya of different NCD medications at the primary health care level in public sector, NCD CCS Survey 2017

CountryHPV

vaccina-tion

Anti-diabetic

Anti- hyperten-

siveCVD CRD

Benza-thine peni-

cillin

Oral mor-phine

NRT

Bangladesh Yes No 3 groups Yes Yes DK No No

Bhutan Yes Partial 2 groups No Yes Yes No No

DPR Korea No Partial 2 groups Yes Yesa Yes No No

India No Yes All 4 groups Yes Yes Yes No No

Indonesia Yes Yes All 4 groups YesYes

inhalersYes No No

Maldives No Partial 2 groups Yes Yes NR No No

Myanmar No Partial 3 groups Yes Yes Yes No No

Nepal Yes Partial All 4 groups Yes Yes Yes No No

Sri Lanka Yesa Yes All 4 groups YesYes

inhalersYes Yesb No

Thailand Yes Yes All 4 groups Yes No Yes No No

Timor-Leste No Partialb All 4 groups Yes Yes Yes No No

a: general availability means when a drug or vaccine is available in 50% or more of health facilities/pharmacies

b: countries initially responded ‘no’ in the survey, however after the completion of the survey, clarified that these medicines are available in the countries.

DK: Don’t know; NR: Not reported

Availability of specific procedures for treating NCDs in the public health care system

Figure 6 summarizes the general availability of selected procedures for treating NCDs or their complications in the public sector health-care facilities.

Retinal photocoagulation

Retinal photocoagulation is required for treatment of diabetic retinopathy, but its availability in the public health care system seems to be limited (Figure 6). Only five countries (Bhutan, DPR Korea, Indonesia, Nepal and Thailand) reported availability of such services in their public health care system, though the responses need to be validated.


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Figure 6: Reported availability of specific procedures for treating NCDs or their complications in the public sector health-care facilities, 2017


0 1 2 3 4 5 6 7 8 9 10 11

Rheumatic heart disease mgmt

Chemotherapy

Radiotherapy

Palliative care for NCD patients

Renal replacement

by transplantation

Renal replacement

therapy by dialysis

Retinal photocoagulation

Thrombolytic therapy

Stenting

Coronary bypass

CVD risk stratification

RHD

Can

cer

Dia

bete

s m

ellit

usC

VD

man

agem

ent

Number of countries in WHO SEA Region

Thrombolytic therapy for acute MI, coronary bypass and stenting

Five Member States (Bhutan, Indonesia, Nepal, Sri Lanka and Thailand) reported availability of all the three services, namely, thrombolytic therapy, stenting and coronary bypass. Bangladesh and Timor-Leste reported the availability of none of these services. DPR Korea reported stenting and coronary bypass to be available, but provided no response for thrombolytic therapy. India reported the availability of only thrombolytic therapy, while Maldives reported availability of only stenting (Figure 6). All these responses need further validation. Thrombolytic therapy, stenting and coronary bypass services are available in selected tertiary care hospitals in Myanmar.

Management of cardiovascular disease

Use of cardiovascular risk stratification for management of patients at high risk for heart attack of stroke: All Member States except Bangladesh reported using CVD risk stratification, though


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the proportion of facilities using risk stratification varied from less than 25% (Indonesia, Maldives, Nepal and Timor-Leste) to more than 50% (Myanmar, Sri Lanka and Thailand). All the countries that reported using CVD risk stratification used WHO/ISH risk charts for scoring, except Thailand.

Provision of stroke services in public health care system: All the countries except three (Indonesia, India and Nepal) reported the provision of care for acute stroke to be generally available in the public sector. Similarly, all the countries except four (Bangladesh, Indonesia, India and Nepal) reported availability of rehabilitation services for stroke patients (Figure 6). However, these responses need to be further validated.

Rheumatic fever and rheumatic heart disease: Only five countries (DPR Korea, Myanmar, Nepal, Thailand and Timor-Leste) reported having a register of patients who have had rheumatic fever and rheumatic heart disease (Figure 6). All of these five countries reported having systems for follow-up/recall to deliver long-term penicillin prophylaxis.

Cancers

Cancer screening programmes for early detection: All Member States reported screening programmes for cervical cancer. Similarly, all countries reported screening programmes for breast cancer with the exception of Nepal. However, in the majority of the Member States, the screening programmes were reported to be opportunistic and coverage was either not known or reported to be rather low. For example, for breast cancer, Nepal reported no screening programme, six countries reported the programme to be opportunistic screening, while the remaining five (DPR Korea, India, Indonesia, Sri Lanka, Thailand and Timor-Leste) reported to be organized population-based screening.

India and Thailand reported the highest screening coverage for breast cancer (>70%); Indonesia and Sri Lanka reported the coverage to be in the range of 10%-50%; and four countries reported it to be less than 10%. Bangladesh and DPR Korea did not report coverage levels. These coverage data need further validation. The age range reported for screening varied across the Region. Only Maldives6 reported mammography as the initial screening method for breast cancer, while the others reported it to be clinical breast examination.

Cervical cancer: While six Member States reported visual inspection as the initial screening method, the remaining five (Bhutan, Maldives, Sri Lanka, Thailand and Timor-Leste) reported using PAP smear as the initial screening method. The reported coverage was low, with only Bhutan, India, Thailand reporting it to be more than 50%, which needs to be validated further as the actual coverage may be much lower.

Availability of palliative care for patients with NCD in the public health systems: Only four countries (Bhutan, DPR Korea, Maldives and Thailand) reported palliative care to be available in the primary health care system. All of these four countries also reported palliative care to be available in the community or home-based care system as well.

Renal replacement therapy

This is required for end-stage renal disease caused by diabetes or any other cause. There seems to be good availability of dialysis services, with only three countries (Bangladesh, Myanmar and Timor-Leste)

6 This needs to be further confirmed and validated.


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reporting non-availability of these services in the public sector. However, as expected, the availability of renal replacement therapy by transplantation was more limited, and reported to be available only in Bhutan, Indonesia, Nepal, Sri Lanka and Thailand. The responses need to be validated further.

4 Health information systems and surveillance

The information systems and surveillance module asked questions on the routine collection of mortality data, the existence of cancer and diabetes registries and risk factor surveillance activities. Figure 7 summarizes the reported status of key surveillance issues in South-East Asia.

Highlights:

¤ All SEA Region countries reported having a set of time-bound targets and indicators in national NCD plans.

¤ The administrative or institutional responsibility for NCD surveillance is either embedded within the unit/division of MOH responsible for overall health information and surveillance issues or shared across several offices within MOH.

¤ All SEA Region countries except Indonesia and Timor-Leste reported the existence of civil and vital statistics system, though the coverage and completeness of mortality registration is much less than desired.

¤ All countries except India and DPR Korea reported doing integrated risk factor survey among youth (as part of GSHS) in the last three years;

¤ All the countries except Bangladesh, India and Maldives reported doing at least one nationwide integrated risk factor survey among adults in the last five years.

Setting time-bound targets and indicators

An important element of a modern health policy approach is the setting and monitoring of quantifiable goals and targets to generate a sense of political urgency and to hold various stakeholders accountable. Whereas in 2015, two of the Member States – Bangladesh and Myanmar – did not report having time-bound targets/indicators, in 2017, all Member States reported having a set of time-bound targets and indicators based on WHO’s global monitoring framework in the national NCD plans.

Responsibility of surveillance of NCD and risk factors

Having clear institutional roles and responsibilities may facilitate efficient execution of specific functions and help to fix accountability.

Surveillance or regular monitoring of NCD and risk factors relies on multiple platforms of data collection (e.g. civil and vital registration systems for mortality and population-based surveys for risk factors) and requires both financial, technical expertise and human resources. While it is impossible for


31

one organizational unit to collect all the relevant surveillance data, having a dedicated organizational unit may ensure coordination and cooperation with other relevant department or units responsible for data (e.g. with civil and vital registration organization for mortality data, organizational entities for conducting national surveys, national health insurance agencies, etc.).

Six countries (Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, and Timor-Leste7) reported having an office/department or administrative division within the MoH responsible for surveillance but not exclusively dedicated to NCD surveillance.

Four countries (Bangladesh, Bhutan, India and Thailand) reported responsibility of NCD surveillance being shared across several offices/departments or administrative divisions within the ministry of health.

Only one country (DPR Korea) reported having an office/department/administrative division within the MoH exclusively dedicated to NCD surveillance.

Civil registration and vital statistics systems reporting mortality by cause

All countries, except Indonesia and Timor-Leste, reported having a system for routinely collecting mortality data by cause of death, and reported having a civil registration and vital statistics system (CRVS). In addition, four countries (Bangladesh, India, Maldives and Thailand) also reported having a sample registration system in addition to CRVS. Indonesia was the only country in the Region that reported having only a sample registration system, but no CRVS.

The latest year for which mortality data were reported varied from 2013 (India), 2014 (Bangladesh, Indonesia) to 2016 (Maldives). All the countries reported that the mortality data can be disaggregated by age and gender, and seven countries also reported that the data can be disaggregated by other sociodemographic factors. However, this needs to be validated further.

Availability and scope of cancer registries

Cancer registries allow longitudinal monitoring of cancer patients and facilitate estimation of cancer incidence and period-specific survival and mortality rates of different cancers.

All countries except Timor-Leste reported having a cancer registry: three of them (Indonesia, Nepal and Thailand) reported having a population-based registry, six reported having hospital-based cancer registries, while India reported having a cancer registry in the “other” category. Half of them (Bhutan, India, Nepal, Sri Lanka and Thailand) reported these registries to be national in scope and the other half (Bangladesh, Indonesia, Maldives, Myanmar, DPR Korea) reported them to be subnational in scope. However, even in the countries that reported having a population-based registry or a national registry, the coverage may be limited. The latest year for which data were reported to be available varied from 2010 (Sri Lanka), 2012 (Thailand and Indonesia), 2013 (Myanmar), 2014 (Nepal) and 2015 (Bhutan, India, Maldives, DPR Korea). Bangladesh reported the data to be available for 2016.

7 While Timor-Leste reported having an exclusive NCD surveillance unit earlier, during 2nd round of validation after close of survey, it was confirmed by country that NCD surveillance is integrated into the Health Management Information System, Ministry of Health.


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Figure 7: Reported status of national surveillance systems for NCDs in South-East Asia, 2017

0 1 2 3 4 5 6 7 8 9 10 11

Number of countries in WHO SEA Region


Survey conducted

Available

Electronic medical records

Available

Available

National

sub-national

Data availability

CRVSSA

RA

Patie

ntIn

form

atio

nSy

stem

sD

iabe

tes

regi

stry

Can

cer

regi

stry

Cau

se o

f de

ath

regi

stra

tion

Disease-specific registries: diabetes registries

Six of the 11 countries (Bangladesh, Bhutan, Indonesia, Maldives, DPR Korea, and Thailand) reported having a hospital-based (except Maldives which reported “other” type) diabetes registry. Of these, Bhutan, DPR Korea and Thailand reported these registries to be national in scope, while the remaining three countries (Bangladesh, Maldives and Indonesia) reported it to be subnational. All of these countries except Bhutan reported updating of the chronic complication status in the registries as the patient complication status changes. The last year of available data varied from 2015 to 2016. The actual coverage achieved in these registries need to be validated further.

Patient information systems

All countries reported having a system for recording patient information that includes NCD status. Five of the countries (Bangladesh, Indonesia, India, Maldives and Thailand) reported this system to be the electronic medical/health records system. All countries reported the coverage of these systems


33

to be national, except India, which reported coverage to be subnational. However, this issue needs to be validated further, as many of the countries reporting electronic medical record system may actually be mixed systems (paper and electronic). Nepal did not provide any response, but seems to have paper-based systems with some electronic health record system.

Surveys to assess service availability and readiness for NCDs

Six of the countries (Bangladesh, Bhutan, Indonesia, Sri Lanka (ongoing), Myanmar and Nepal) reported conducting a survey to assess service availability and readiness for NCDs either standalone (Health facility audit for PEN delivery or as part of SARA assessment) or conducted between 2014 (Bangladesh, Indonesia), 2015 (Myanmar, Nepal), 2016 (Bhutan) and 2017 (Sri Lanka). All of them reported the coverage of the survey to be national in nature. Nepal did not provide any validation document and did not report on the coverage of survey.

Population-based survey to assess NCD risk factors among youth

Almost all the countries reported doing a national integrated risk factor survey among youth (13–17-year-olds) in the last three years with the exception of India and DPR Korea. These integrated risk factor surveys were mainly conducted as part of Global Student-based School Health Surveys (GSHS) supported technically and financially by WHO and CDC Atlanta. These surveys covered the harmful use of alcohol, tobacco consumption, fruit and vegetable consumption, physical activity, and overweight/obesity. In addition, almost all the countries in the SEA Region, with the exception of India and DPR Korea, have conducted youth tobacco surveys as part of the WHO-CDC sponsored initiative of the Global Youth Tobacco Survey (GYTS).

Though four of the countries reported doing these surveys every 3–5 years, and others reported to be doing them on an ad hoc basis, these surveys were mostly donor-driven and externally-funded by WHO/CDC. Table 5 shows the different round of adolescent integrated risk factor surveys done in the SEA Region as part of GSHS and GYTS.

Table 5: Status of NCD risk-factor surveys among youth in the SEA Region

Integrated (GSHS) Tobacco-specific (GYTS)

Bangladesh 2014 2004~ 2007 2013

Bhutan 2016 2004 2006 2009 2013

DPR Korea None None

India 2007 2004 2006 2009

Indonesia 2007 2015 2006 2009 2014

Maldives 2009 2014 2004 2007 2011

Myanmar 2007 2016 2004 2007 2011 2016

Nepal 2015 2001 2007 2011

Sri Lanka 2008 2016 1999 2003 2007 2011 2015

Thailand 2008 2015 2005 2009 2015

Timor-Leste 2015 2006 2009 2013

~ subnational


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Population-based surveys to assess NCD risk factors among adults

Similar to youth surveys, most of the countries have undertaken population-based risk factor surveys either as integrated risk factor surveys (popularly known as STEP surveys as part of a WHO supported initiative) or as standalone adult tobacco surveys as part of the WHO-CDC supported initiative of the Global Adult Tobacco Surveys (GATS). With few exceptions (India and Indonesia), the surveys are highly dependent on external technical and financial support, and few countries have been able to do them every 3–5 years as planned, ever since the initiative started in early 2000.

Table 6: Status of NCD risk-factor surveys among adults in the SEA Region.

Integrated (STEPs) Tobacco-specific (GATS)

Bangladesh 2002 2006~ 2010 2009 2017*

Bhutan 2004~ 2007~ 2014

DPR Korea 2005~ 2007~ 2008~ 2016 2013# 2017#

India 2006~ 2007~ 2009 2016

Indonesia 2001 2003~ 2006~ 2013 2011

Maldives 2004~ 2011~

Myanmar 2004~ 2009 2014

Nepal 2003~ 2005~ 2008 2013

Sri Lanka 2003~ 2006 2014

Thailand 2004^ 2009^ 2014–15^ 2009 2011

Timor-Leste 2014

~ subnational

* ongoing

^ National Health Examination Surveys # tobacco-specific surveys, but not using the standard protocol of GATS


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4 Discussions

The following section discusses the key findings of the 2017 Country Capacity Survey organized around the four sub-sections as in the “results” section. The survey results highlight priorities for work in the Region and can serve as a starting point to identify successful experiences that can be replicated in other countries. The discussions take into account the time-bound commitments made by Member States in the outcome document of the Second High-Level Meeting of the United Nations General Assembly (7).

Public health infrastructure, partnerships and multisectoral collaboration for NCDs

The results of the 2017 Survey suggest the availability of minimal operational governance infrastructure in most countries in the Region, as all countries reported having a dedicated unit, branch or a department for NCDs that is staffed by at least one full-time professional as well as the availability of funding for the core activities or functions needed to address these diseases.

Having a dedicated unit/department for NCD prevention and control may provide a clear institutional identity and visibility to the control and prevention of NCDs within the ministry of health. It will also serve as a source of in-depth technical expertise and advice on NCDs to the minister of health and other divisions and departments in the government both within and outside the ministry of health.

Although these results seem to show progress in the right direction, they do not reveal whether the financial or human resources are sufficient in quality or quantity to cope with the burden of NCDs and their risk factors in each country. For example, the reported full-time technical staff in the NCD unit ranged from 2–5 in DPR Korea, Maldives and Sri Lanka; to 6–10 in India and Timor-Leste; and 11 or more in Bangladesh, Bhutan, Indonesia, Myanmar, Nepal and Thailand. This substantial variation in size and capacity of these organization or structures across countries did not necessarily reflect the public administration complexity or population size of the country. The question only enquired about the availability of such units at the “national” level. Having only “national” structures may be highly inadequate, especially in larger countries such as India, Indonesia and Bangladesh, and more so in countries with a federal governance structure. Anecdotal and other published evidence from countries still suggest that building a sustainable infrastructure consistent with the magnitude of the NCDs continues to be a challenge.

The Country Capacity Survey also revealed that seven out of the 11 countries have a dedicated, nationwide operational multisectoral commission, agency or mechanism to oversee NCD engagement, policy coherence and accountability in sectors other than health. Two countries – India and Timor-Leste – reported such mechanisms under development. Maldives established the same after the completion of the survey in late 2017. Effective regulation of the lifestyles and other environmental determinants of NCDs require interventions across multiple sectors and stakeholders. Hence, one of the key dimensions of governance of NCD response is the establishment of multisectoral coordination mechanisms, building coalitions and partnerships across different stakeholders within and outside the government, as recognized in the Political Declaration of the High-Level Meeting of the UN General Assembly (7) and in the global (5), regional (6) and national action plans of some countries. Such


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efforts are especially important in view of new 2030 Agenda for Sustainable Development and the Sustainable Development Goals-3 on health and well-being, which, for the first time, includes specific targets related to NCDs and their risk factors (3).

The survey data do not assess the effectiveness of these multisectoral coordination mechanisms, or the extent to which these mechanisms influence national strategies, plans and regulations for NCDs. In addition, the legal basis of these mechanisms is not very clear, as most of them have been proposed as part of national multisectoral plans, and it is not clear if that is followed by any specific administrative order or other directive to appoint these committees.

While the roles and responsibilities are explicitly defined in some countries (the most common supporting documents shared were multisectoral plans for control and prevention of NCDs), the powers and legitimacy of decision-making and resources of these coordination mechanisms are unclear.

The majority of the countries reported general government revenues as their main source of funding. Earmarked taxes were reported by only five countries and ranked third or lower in terms of importance. These results suggest that there is some leeway to increase mobilization of funds through fiscal policies and reforms. Such a strategy has been proposed as a funding mechanism for development (11) and as a way to reduce out-of-pocket payments to health services, as a recommendation within the WHO Framework Convention on Tobacco Control (WHO FCTC) (12) and the guidelines for implementation of its Article 6 (13).

Fiscal interventions not only represent a potential source of funding for NCD control and prevention, but is also considered as one of the most effective strategies for reducing consumption of products that have an adverse effect on population health, such as tobacco, alcohol, sugar-sweetened beverages, and food high in trans-fat and salt. In fact, excise taxes on tobacco and alcohol are among the 15 highly cost-effective interventions recommended by WHO to address NCDs and their risk factors (14). Two of the progress indicators established by WHO that monitor progress in NCD control are increase in taxes for tobacco and alcohol (15). Taxes must be levied to make products sufficiently more expensive, and must be adjusted periodically to account for inflation and income growth, to achieve the goal of reducing the consumption of these products and consequently mitigate the associated morbidity and mortality burden.

All countries in the SEA Region except DPR Korea8 reported taxing tobacco and alcohol and a smaller number also taxed (India, Maldives) or are in the process of taxing (Thailand) other products such as sugar-sweetened beverages. None of the countries reported levying taxes on foods high in fat, sugar or salt. Although the survey results show that these taxes exist, they do not provide any information about the type of taxation (excise tax, value-added tax, sales tax, etc.), the proportion of the product’s price represented by the tax, or whether these taxes are being adjusted periodically for inflation and income growth, among other practices, to ensure that taxation contributes to the public health targets.

With regard to tobacco, data from the WHO report on the global tobacco epidemic (GTCR), 2017: Monitoring tobacco use and prevention policies (16) shows that from the Region, only Bangladesh achieved the global benchmark of taxes being 75% of the retail price of the most-sold cigarette

8 DPR Korea is a tax free country. It has no tax system and all tobacco products are sold at a price fixed by government (article 23 of Tobacco Control Law), which is being raised gradually over the years.


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brands. Four countries (Indonesia, Maldives, Sri Lanka and Thailand) levy taxes that account for 51% to 75% of the retail price, while India, Myanmar, Nepal and Timor-Leste apply taxes that represent 50% or less of the retail price of the most-sold brand of cigarettes (16).

Similarly for alcohol, even though all countries in the Region except DPR Korea9, reported taxes on alcohol, it is not known whether these taxation policies seek to limit the availability and consumption of alcohol. For example, data from the WHO Global Status Report on Alcohol and Health 2014 (17, 18) show none of the countries from the SEA Region adjusted their taxes on alcohol beverages according to inflation. Furthermore, the WHO Global Strategy to reduce the harmful use of alcohol (19) recommends combining taxation with other pricing policies such as setting minimum prices or banning volume discounts. Without such supplemental restrictions, the alcohol industry can compensate for the tax burden by offering promotion of alcohol (17, 19).

The results show that there is the need for continued strengthening of regulatory and financial reform capacity in the Region in order to further strengthen fiscal policies on tobacco and alcohol, and hopefully for other unhealthy foods, including sugar-sweetened beverages and foods high in salt and trans-fats, based on the recommended best practices, so that the desired impact on public health can be achieved.

Status of policies, strategies and action plans relevant to NCDs and their risk factors

The 2017 Survey confirms that progress has been made in the Region in terms of policies, strategies and action plans for the prevention and control of NCDs. NCDs are integrated in the national health plans of all the countries and have been reflected in the national development agenda in almost all countries, thus improving the position and visibility of these issues within the broader policy framework. Inclusion in national development plans is particularly important in the context of the 2030 Agenda for Sustainable Development (3) as it signals recognition of the impact of NCDs on economic and social development (20).

In addition, all the countries in the Region reported having integrated multisectoral policies, strategies and action plans for NCDs addressing all the four major risk factors and early detection and treatment of all the four major NCDs. The results are encouraging as this implies that all the countries have met the time-bound commitment which proposes to “by 2015, consider developing or strengthening national multisectoral policies and plans” on NCDs (7). Since most common noncommunicable diseases share common risk factors, and the risk factors also tend to cluster around individuals, it is more effective and logical to have integrated NCD policies or plans rather than disease-specific (e.g. CVD, diabetes, etc.) or risk factor-specific policies. However, more detailed disease- or risk factor-specific policies may be developed under the overall umbrella of an integrated NCD strategy or plan.

However, the survey does not provide detailed information on the implementation status of the reported policies. By way of example, while all the 11 countries reported having an integrated multisectoral plan only eight countries reported having a nationwide multisectoral commission, agency or mechanism for NCDS. The results indicate that although the importance of multisectoral work in addressing NCDs and their risk factors is reflected in policies, plans and strategies, the availability of formal entities to operationalize this approach remains limited.

9 Please see earlier footnote on DPR Korea


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Likewise, although all countries reported having a specific policy, strategy or action plan or national law for tobacco, and all reported addressing this issue within an integrated multisectoral NCD policy or plan, only one country (Nepal) has implemented three of the four “best buys” for tobacco control at the highest level of achievement10 as defined by WHO (16). Hence, implementation of national laws consistent with the mandates and guidelines of the WHO FCTC remains a priority in order to allow full and coordinated implementation of all its measures to maximize the positive impact on public health.

Regarding the harmful use of alcohol, the Global Strategy to reduce harmful use of alcohol (18) establishes 10 areas of political action11. Among them, three are considered highly cost-effective interventions, or “best buys”: reduce the physical availability of alcohol, restrict all form of advertising (direct and indirect), and implement pricing policies (18). These three indicators are also included in the NCD global progress monitor 2017 (15). Although all the countries reported integration of control of harmful use of alcohol in their national multisectoral NCD control plan and six countries (Bhutan, India, Myanmar, Nepal, Sri Lanka and Thailand) reported additional specific strategies and plans for alcohol control, only one country (Maldives) reported “full achievement” for all three indicators based on the 2016 Global Survey on Alcohol and Health (15).

All countries except Thailand reported implementing diet awareness campaigns in the last five years, though it could not be validated for three of the countries (DPR Korea, Maldives, and Sri Lanka). Similarly, all countries except Bangladesh reported implementing awareness campaigns for physical activities, though it could not be validated for four of the countries based on the submitted documents. However, few countries reported implementation of more effective interventions involving legislation or regulation. Only four countries reported policies to reduce population salt consumption; however, these could be validated for only two countries (India and Thailand). India and Thailand were also the only two countries that reported having legislation for product reformulation by industry across the food supply spectrum. Furthermore, only two countries, India and Bhutan, reported policies to limit saturated fat and virtually eliminate transfats and only India reported that these policies were backed by government legislation. Similarly, only India, Maldives and Thailand reported having policies to reduce the impact on children of marketing of foods and non-alcoholic beverages with high calorie content and low nutritional value, all backed by government legislation as per WHO recommendations (21).

These findings, along with the need to strengthen fiscal policies, underscore the importance of boosting the regulatory capacity of Member States as an essential public health function for addressing NCDs and their risk factors. WHO has developed several tools to facilitate these efforts at the country level, such as resource tool on alcohol taxation and pricing policies (22), and the WHO Technical Manual on Tobacco Tax Administration (23), and recommendations on regulating the marketing of foods and non-alcoholic beverages to children (21).

10 The highest level of achievement of the “best buys” for tobacco control is defined by WHO as follows:

• All indoor public places and workplaces and public trans port are completely smoke-free (or at least 90% of the popu lation is covered by subnational legislation).

• Packaging contains a large warning (average of at least 50% coverage on the front and back of the package) with all appropriate characteristics.

• All forms of direct and indirect advertising are banned.

• Taxes are more than 75% of the retail sale price.

11 The Global Strategy to reduce the harmful use of alcohol inclu des 10 recommended target areas for policy action: leadership, awareness, and commitment; health services response; com munity action; drunk-driving policies and countermeasures; availability of alcohol; marketing of alcoholic beverages; pri cing policies; reducing the negative consequences of drinking and alcohol intoxication; reducing the public health impact of illicit alcohol and informally produced alcohol; and monitoring and surveillance (16)


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Capacity for NCD early detection, treatment and care within the health system

In the out come document of the second meeting of the United Nations General Assembly, countries committed to strengthen and guide their health systems to address the prevention and control of NCDs and their under lying social determinants through people-centered primary health care and universal health coverage by 2016 (7).

Evidence-based guidelines, standards, protocols and referral criteria

All countries in the Region reported developing and updating evidence-based guidelines/protocols for cardiovascular diseases and diabetes within the last two years (between 2015 and 2017). However, only six countries reported implementing those guidelines in at least 50% of health facilities. Fewer countries reported implementing evidence-based guidelines for cancers and respiratory diseases. The implementation of evidence-based guidelines, protocols, and standards are essential in providing high-quality care, and reducing unjustifiable variability in clinical practice. Similarly, while almost all the Member States reported inclusion of criteria for referral in their guidelines/protocols and standards, it is not known how far these referral criteria are implemented by different levels of health facilities.

Early detection and diagnosis, and treatment of major NCDs at the primary care level

Most of the countries reported availability of basic technologies such as equipment for measurement of height, weight and blood pressure. Fewer countries reported availability of other basic technologies such as glucometers for blood glucose testing, urine strips for albumin assay, or blood cholesterol testing. Availability of more compact tests such as HB1ac, dilated fundus exam, and testing for foot vascular status was even more limited as reported by 1–4 Member States. The majority of countries reported that the main essential medicines for NCDs are available in at least 50% of primary care facilities in the public health system. Exceptions were oral morphine and nicotine replacement therapy, as none of the countries reported them to be available in at least 50% of the primary health care facilities.

Although the responses to the survey seem to point in the right direction regarding the availability of medicines and basic technologies for NCDs, certain limitations must be taken into account when interpreting these results. The evaluation of whether drugs and technologies are available in at least 50% of primary care facilities is eminently subjective. Most countries in the Region lack an information system capable of reporting on this topic, which means the responses provided are largely based on subjective knowledge or perceptions of the respondents. Some countries have conducted SARA in recent years, and the results of which will be useful in further validating the observed responses. Furthermore, the survey questions are not designed to evaluate important aspects such as the affordability, suitability or competencies to prescribe these medicines, or patient adherence to the therapy. Nevertheless, the survey provides valuable information to identify gaps and to set priorities.

With regard to cancer, almost all the countries reported screening programmes for cervical cancer (11/11) and for breast cancer (10/11). However, most screening programmes continue to be opportunistic with either unknown or very low coverage. Furthermore, there is room for improvement in the availability of screening services for other types of cancer, especially oral cancer — one of the most common cancers in the Region. Finally it should be noted that in order to be effective, screening programmes require high-quality diagnostic tests, and proper follow-up management of


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any lesions identified. Neither aspect could be evaluated through this survey, which requires more in-depth study.

Regarding CVD, the survey included some items designed to assess country capacity in terms of access to essential medicines for the prevention of heart attacks and strokes in case of high cardiovascular risk. Ensuring availability of these drugs is one of the targets of the Global Monitoring Framework (24) and one of the strategies listed as highly cost-effective interventions in the recently updated Global Action Plan for NCD Prevention and Control (14). Although the essential medicines necessary for primary and secondary prevention of cardiovascular episodes were reported as being generally available by a high proportion of countries in the Region, there is limited use of cardiovascular risk stratification in the public sector. Only three countries in 2017 reported offering such risk stratification in 50% or more of the primary care facilities. Despite limitations inherent in the survey, the result suggests that a substantial gap exists and confirms the need to promote total cardiovascular risk assessment for the individuals. To support these efforts, WHO has developed a cardiovascular risk assessment form, which was reported to be used by the majority of the countries in the Region, wherever CVD risk assessment has been introduced.

Finally there is a significant shortfall in access to palliative care in the Region. This is the NCD related function or activity for which the fewest countries report having funding, and oral morphine is least likely to be available in the public health system.

Diagnosis and treatment of major NCDs in secondary and tertiary levels of care

The survey revealed a substantial gap in the availability of procedures for NCD treatment (retinal, renal, cardiac and stroke treatment) at the secondary and tertiary levels of care. Only about half of the countries reported availability of thrombolytic therapy for treatment of acute myocardial infarction and retinal photocoagulation. The growing demand of these highly specialized and costly services represent a great challenge for the health systems not only for the secondary and tertiary levels, but also at primary level where the efforts towards prevention of NCD complications should be reinforced.

Health information systems, surveillance, and the surveys for NCDs and their risk factors

The Political Declaration of the High-Level Meeting of the United Nations General Assembly held in 2011 (25) and subsequent resolutions established a clear mandate for NCD surveil lance as a core public health function. In this regard, the nine voluntary time-bound targets and 25 indicators of the WHO Global Monitoring Frame work (GMF) (24) and the progress indicators developed to inform reporting to the United Nations General As sembly (15, 26) are especially noteworthy. The frame work and the establishment of time-bound reporting commitments constitute a roadmap for strengthen ing surveillance at the country level and provide a mechanism to ensure accountability. They will be re inforced by the development of a monitoring frame work for the SDGs, which for the first time include a goal and targets related to NCDs and their risk factors (3).

As one of the four time-bound commitments adopted in the outcome document of the second meeting of the United Nations General Assembly in 2014 (7), countries pledged to establish national


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targets and indicators by 2015, taking into account the WHO Global Monitoring Framework. The survey results presented above show that all the countries in the SEA Region had national time-bound targets and indicators for NCDs and their risk factors as per the WHO GMF. However, based on analysis of national plans provided by the countries as supporting documents, few countries have the availability of baseline data for those indicators and fewer have clear mechanisms and systems in place to measure those indicators during the timeframe of those plans. The relationship of the indicators listed in the national plans with interventions available or expected to become available is not clear in the majority of the countries.

National surveillance system for NCDs and their risk factors should produce data periodically, systematically and sustainably and in a standardized fashion. In general, NCD surveillance systems should be able to obtain data through at least four main information sources: civil and vital registration, population-based surveys, NCD registries (e.g. cancer registries), and health services information system. The information systems of the national health insurance system can serve as an excellent source of data related to NCDs, especially in countries with high or near universal health insurance coverage (in the SEA Region, these countries include Thailand, Maldives and Indonesia). Given the multisectoral nature of interventions required to control NCDs, the surveillance system can also rely on data collected outside of the health sector (e.g. information on taxes, legislations, and mortality data via civil and vital registration systems). It should also be examined how far the information gathered is being used to inform development and evaluation of policies.

With regard to mortality data, while all the Member States (except Indonesia and Timor-Leste) reported having a system to collect mortality data by cause of death on routine basis, the coverage, completeness and accuracy of cause of death reported therein is very poor in most of the countries, with the best situation observed in Thailand and Sri Lanka, where the coverage is in the range of 50% to 70%. Few countries have meaningful reliable mortality data by cause to monitor the SDG indicator on NCD, i.e. premature mortality from the four major NCDs.

All countries except Timor-Leste reported having a cancer registry: three countries reported having population-based cancer registries; and six countries reported having hospital-based registries. While hospital-based registries are a good starting point, only population-based registries can generate incidence data for this group of diseases. Cancer incidence is one of the key indicators included in the GMF to evaluate the impact of both primary prevention interventions and those geared to reduce exposure to risk factors such as tobacco, alcohol or unhealthy diets. The majority of countries in the SEA Region does not have complete and accurate cancer incidence data and rely on estimates produced by IARC.

Most Member States reported conducting population-based surveys for NCD risk factors in both adults (mostly as part of WHO STEP survey initiative) and young people (mostly as part of WHO-CDC Global School Health Initiative). However, analysis of representativeness (national), periodicity (at least every five years), year of latest data collection (within last five years), and availability of both physical and biochemical measurements of reported surveys revealed many large countries in the Region (e.g. India and Bangladesh) not meeting the benchmark of doing high-quality surveys every five years.


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5 Conclusions

The results of 2017 Country Capacity Survey suggest the following actions for strengthening the capacity and response of the countries of the WHO South-East Asia Region for the prevention and control of NCDs and their risk factors:

1. Strengthening and operationalizing multisectoral mechanisms and prioritizing full implementation of integrated multisectoral policies/strategies or action plans as almost 10 of the 15 most cost-effective recommendations require coordinated multisectoral actions by relevant ministries and support from civil society.

2. Strengthen the institutional and regulatory capability of the country health authorities to establish regulations pertaining to the risk factors (tobacco, alcohol, regulating salt content), including the development of fiscal policies – especially raising taxes for tobacco, alcohol and food high in salt, sugar and trans-fats – as an essential element for the implementation of 10 out of 15 highly cost-effective interventions recommended by WHO for addressing the NCDs and their risk factors.

3. Strengthen national surveillance system for NCDs and their risk factors which are capable of producing timely, systematic and standardized data through key information sources: civil registration and vital statistics system, population-based surveys, NCD registries, social health insurance information system (where exists), and health facility-based information system (especially for data on drug availability and drug use). Ensure adequate financing for key surveillance activities.

4. Prioritize regular measurement and monitoring of national indicators for NCDs and their risk factors as well as time-bound national targets.

5. Strengthen national screening programmes for the main types of cancer in order to achieve effective coverage with high-quality screening tests.

6. Promote implementation of evidence-based clinical practice guidelines, standards, or protocols for the leading NCDs and improve the availability of essential medicines and technologies for the diagnosis and treatment of NCDs.

7. Promote assessment of total cardiovascular risk for individuals at the primary care level to improve management of patients with or at high risk of cardiovascular disease.

8. Improve access to palliative care by strengthening policy frameworks, strategies or plans, as well as expanding the availability of opioids and provision of ambulatory and community-based palliative care.


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6 References

1. World Health Organization. Global burden of diseases 2015. Geneva. http://www.who.int/healthinfo/global_burden_disease/estimates/en/index1.html - accessed 22 November 2017.

2. World Bank. https://data.worldbank.org/income-level/lower-middle-income - accessed 28 March 2018.

3. United Nations. Transforming our world: the 2030, Agenda for Sustainable Development. New York: UN; 2015. Seventieth session. Document A/RES/70/1. https://goo.gl/lNSx6V - accessed 22 November 2017.

4. Alwan AD, Maclean D, Mandil A. Assessment of national capacity for noncommunicable disease prevention and control: the report of a global survey. Geneva: World Health Organization, 2001. http://apps.who.int/iris/bitstream/10665/67305/1/WHO_MNC_01.2.pdf - accessed 22 November 2017.

5. World Health Organization. Global action plan for the prevention and control of NCDs 2013-2020. Geneva. http://www.who.int/nmh/events/ncd_action_plan/en/ - accessed 22 November 2017.

6. WHO Regional Office for South-East Asia. Action plan for the prevention and control of noncommunicable diseases in South-East Asia, 2013-2020. http://www.searo.who.int/entity/noncommunicable_diseases/documents/sea_ncd_89/en/ - accessed 22 November 2017.

7. United Nations. Outcome document of the high-level meeting of the General Assembly on the comprehensive review and assessment of the progress achieved in the prevention and control of noncommunicable diseases. Sixty-eighth session (Document A/68/L.53). New York: UN, 2014. https://goo.gl/SniGle - accessed 22 November 2017.

8. World Health Organization. Global Health Expenditure Database (GHED). 2017. As accessed and downloaded on March13,2018.

9. Nugent RA, Fiegl AB. Where have all the donors gone? Scarce donor funding for non-communicable diseases. Center for Global Development Working Paper 228. 2010, Center for Global Development Washington DC.

10. Government of India. 2016. Ministry of Finance. Amendments in the Ist Schedule to the Central Excise Tariff Act, 1995. Delhi, India. http://www.cbec.gov.in/resources/htdocs-cbec/ub1617/do-ltr-jstru1-revised.pdf;jsessionid=6D80BB5D1B6F22E31DA9A47C2CE11C53 - accessed 29 March 2018.

11. United Nations General Assembly. Addis Ababa Action Agenda of the Third International Conference on Financing for Development (Addis Ababa Action Agenda). Resolution A/ RES/69/313. New York: UN, 2015. http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/69/313&Lang=E - accessed 22 November 2017.

12. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: WHO, 2003. http://www.who.int/fctc/ - accessed 22 November 2017.


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13. World Health Organization. Guidelines for the implementation of Article 6 of the FCTC. Geneva: WHO, 2003. http://www.who.int/fctc/guidelines/adopted/Guidelines_article_6.pdf - accessed 22 November 2017.

14. World Health Organization. Draft Updated Appendix 3 of the WHO Global NCD Action Plan 2013-2020. WHO Discussion Paper (version dated 25 July 2016). Geneva. http://www.who.int/ncds/governance/discussion-paper-updating-appendix3-25july2016-EN.pdf - accessed 22 November 2017.

15. World Health Organization. Noncommunicable Diseases Progress Monitor 2017. Geneva: WHO, 2017. http://www.who.int/nmh/publications/ncd-progress-monitor-2017/en/ - accessed 22 November 2017.

16. World Health Organization. WHO report on the global tobacco epidemic, 2017: monitoring tobacco use and prevention policies. Geneva: WHO, 2017. http://apps.who.int/iris/bitstream/10665/255874/1/9789241512824-eng.pdf - accessed 22 November 2017.

17. World Health Organization. Global status report on alcohol and health, 2014. Geneva: WHO, 2014. http://www.who.int/substance_abuse/publications/global_alcohol_report/en/ - accessed 22 November 2017.

18. World Health Organization. Global Information System on Alcohol and Health (GISAH). Geneva. http://www.who.int/substance_abuse/activities/gisah/en/ - accessed 22 November 2017.

19. World Health Organization. Global strategy to reduce the harmful use of alcohol. Geneva, 2010. http://www.who.int/substance_abuse/publications/global_strategy_reduce_harmful_use_alcohol/en/ - accessed 22 November 2017.

20. World Health Organization. NCDs, poverty and development. Geneva. http://bit.ly/23YRdN5 - accessed 22 November 2017.

21. World Health Organization. Set of recommendations on the marketing of foods and non-alcoholic beverages to children. Geneva: WHO; 2010. http://whqlibdoc.who.int/publications/2010/9789241500210_eng.pdf - accessed 22 November 2017.

22. Sornpaisarn B, Shield KD, Österberg E, Rehm J, eds. Resource tool on alcohol taxation and pricing policies. Geneva: World Health Organization, 2017. http://www.who.int/substance_abuse/publications/tax_book/en/ - accessed 22 November 2017.

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24. World Health Organization. Noncommunicable Diseases Global Monitoring Framework: Indicator Definitions and Specifications. Geneva: WHO. http://bit.ly/1PfWV6n - accessed 22 November 2017.

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2017 Country profile of capacity and response to noncommunicable diseases (NCDs)

Modules:

I Public health infrastructure, partnerships and multisectoral collaboration for NCDs and their risk factors

II Status of NCD-relevant policies, strategies and action plans

III Health information systems, monitoring, surveillance and surveys for NCDs and their risk factors

IV Capacity for NCD early detection, treatment and care within the health system

Annex 1: Questionnaires


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Purpose

¤ The purpose of this survey is to gauge your country’s capacity for responding to noncommunicable diseases. It will guide Member States, WHO Regional Offices and WHO HQ in planning future actions and technical assistance required to address NCDs and their risk factors. This is also the basis for ongoing assessment of changes in country capacity and response.

¤ The information collected through this survey will also be used to produce some of the indicators that Member States have agreed to monitor and will be held accountable to the United Nations General Assembly (UNGA) and World Health Assembly (WHA);

¤ Use of standardized questions allows comparisons of country capacities and responses. We have divided this survey into four modules, assessing four key aspects of NCD prevention and control.

¤ The four main types of noncommunicable diseases are cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructed pulmonary disease and asthma) and diabetes.

¤ The main risk factors for NCDs are harmful use of alcohol, tobacco use, unhealthy diet, and physical inactivity. Capacity assessment related to some specific risk factors is also captured in other topic-specific assessments – e.g. for tobacco through the WHO Report on the Global Tobacco Epidemic.

Process

¤ The survey is intended to assess national level capacity and response to NCDs. If responsibility for health is decentralized to sub-national levels, it can also be applied at sub-national levels.

¤ A focal point or survey coordinator will need to be identified to coordinate and ensure survey completion. However, in order to provide a complete response, a group of respondents with expertise in the topics covered in the modules will be needed. Please use the table provided to indicate the names and titles of all of those who have completed the survey and which sections they have completed. Please also add any additional information on other sources you may have consulted in developing your response.

¤ Please note that while there is space to indicate “Don’t Know” for most questions, there should be very few of these. If someone is filling in numerous “Don’t Knows”, another person who is more aware of this information should be found to complete this section.

¤ In order to validate responses, documentation will be requested for affirmative responses throughout the questionnaire. Please make every effort to provide electronic copies of the requested documentation. If documentation has been provided previously and is available in the NCD Document Repository (https://extranet.who.int/ncdccs/documents), please indicate this. If you are unable to provide electronic copies through the provided links, please ask your regional focal point for an alternative means to submit documentation.


47

Information on those who completed the survey

Who is the focal point for completion of this survey?

Name: __________________________________

Position: ________________________________

Contact Information: __________________________________________________________________

Sections completed: __________________________________________________________________

Name and contact information of others completing survey

Sections completed

Additional information sources consulted:


48

I: Public health infrastructure, partnerships and multisectoral collaboration for ncds and their risk factors

This module includes questions related to the presence of a unit or division in the ministry of health dedicated to NCDs and risk factors, staff and funding. It also includes an assessment of the existence of fiscal interventions as incentives to influence health behaviour and/or to raise funds for health-related activities. Finally, it assesses the existence of a formal multisectoral mechanism to coordinate NCD-related activities in sectors outside of health. Responses to these questions enable reporting against NCD Global Action Plan process indicators and UN High Level Meeting national commitment progress indicators.

(1) Is there a unit/branch/department in the ministry of health or equivalent with responsibility for NCDs and their risk factors?

Yes No Don’t Know

IF NO: Go to Question 2

(1a) Please indicate the number of full-time-equivalent technical/professional staff in the unit/branch/department.

□ 0

□ 1

□ 2-5

□ 6 - 10

□ 11 or more □ Don’t know

(2) Is there funding allocated in the government budget for the following NCD and risk factor activities/functions?

(i) Primary prevention Yes No Don’t Know

(ii) Health promotion Yes No Don’t Know

(ii) Early detection/screening Yes No Don’t Know

(iv) Health care and treatment Yes No Don’t Know

(v) Surveillance, monitoring and evaluation Yes No Don’t Know

(vi) Capacity building Yes No Don’t Know

(vii) Palliative care Yes No Don’t Know

(viii) Research Yes No Don’t Know

If at least one Yes to above questions:

(2a) What are the major sources of regular funding for NCDs and their risk factors?

More than one can apply, rank order them where: 1=Largest source; 2=Next largest; 3=Others

General government revenues

Health insurance

International Donors

National Donors


49

Earmarked taxes on alcohol, tobacco, etc.

Other (specify) _____________________

Don’t Know

(3) Is your country implementing any of the following fiscal interventions? (for taxes, please respond “Yes” only if excise taxes and/or special VAT/sales tax rates are applied)

taxation on alcoholic beverages Yes No Don’t Know

taxation on tobacco (excise and non-excise taxes) Yes No Don’t Know

taxation on sugar sweetened beverages Yes No Don’t Know

taxation on foods high in fat, sugar or salt Yes No Don’t Know

price subsidies for healthy foods Yes No Don’t Know

taxation incentives to promote physical activity Yes No Don’t Know

others (specify) Yes No Don’t Know

If Yes to at least one of the above, other than price subsidies:

(3a) Are any of these funds earmarked for health promotion or health service provision?

Yes No Don’t Know

(4) Is there a national multisectoral commission, agency or mechanism to oversee NCD engagement, policy coherence and accountability of sectors beyond health?

Yes No Don’t Know

IF NO: Go to MODULE II

(4a) Indicate its stage:

□ Operational

□ Under development

□ Not in effect

□ Don’t know

If Operational or under development:

(4b) Please provide name: __________________________________________________________

(4c) Which of the following are members? (Check all that apply)

□ Other Government Ministries (non-health, e.g. ministry of sport, ministry of education)

□ United Nations Agencies

□ Other international institutions

□ Academia (including research centres)

□ Nongovernmental organizations/community-based organizations/civil society

□ Private Sector

□ Other (specify) __________________________

□ Don’t know


50

IF “Private Sector” is one of the members:

(4d) Is the tobacco industry’s participation to the consultations and decision making process excluded from the national multisectoral commission?

Yes No Don’t Know

II: Status of ncd-relevant policies, strategies, and action plans

This module includes questions relating to the presence of policies, strategies, or action plans - the questions differentiate between integrated policies/strategies/action plans that address several risk factors or diseases, and policies/strategies/action plans that address a specific disease or risk factor. Additional questions address the existence of specific policies related to the cost-effective interventions for NCDs. Responses to these questions enable reporting against NCD Global Action Plan process indicators and UN High Level Meeting national commitment progress indicators.

(1a) Are NCDs included in the outcomes or outputs of your current national health plan?

Yes No Don’t Know

(1b) Are NCDs included in the outcomes or outputs of your current national development agenda?

Yes No Don’t Know

(2) Are there a set of time-bound national targets for NCDs based on the 9 voluntary global targets from the WHO Global Monitoring Framework for NCDs?

Yes No Don’t Know

If Yes:

(2a) Are there a set of national indicators for these targets based on the indicators from the WHO Global Monitoring Framework for NCDs?

Yes No Don’t Know

II A: Integrated policies, strategies, and action plans

(3) Does your country have a national NCD policy, strategy or action plan which integrates several NCDs and their risk factors?

Please note that disease- and risk factor-specific policies, strategies, and action plans will be reported in other questions later in this module.

Yes No Don’t Know


If yes:

Is it a policy/strategy? Yes No Don’t Know

Is it an action plan? Yes No Don’t Know

Is it multisectoral? Yes No Don’t Know

Is it multi-stakeholder? Yes No Don’t Know


51

Please provide the following information about the policy, strategy or action plan:

(3a) Title: _____________________________________________________

(3b) Does it address one or more of the following major risk factors?

Harmful use of alcohol Yes No Don’t Know

Unhealthy diet Yes No Don’t Know

Physical inactivity Yes No Don’t Know

Tobacco Yes No Don’t Know

(3c) Does it include early detection, treatment and care for:

Cancer Yes No Don’t Know

Cardiovascular diseases Yes No Don’t Know

Chronic respiratory diseases Yes No Don’t Know

Diabetes Yes No Don’t Know

(3d) Does it include palliative care for patients with NCDs?

Yes No Don’t Know

(3e) Indicate its stage:

□ Operational


□ Not in effect

□ Don’t know

If Operational:

(3e-i) What was the first year of implementation? ________________________

(3e-ii) What year will it expire? _________________________________________

II B: Policies, strategies, action plans for specific key noncommunicable diseases

The questions in this sub-section only refer to policies, strategies and action plans that are specific to key NCDs. If your integrated policy, strategy or action plan addresses the NCD, you do not need to re-enter that information.

(4) Is there a policy, strategy, or action plan for cardiovascular diseases in your country?

Yes No Don’t Know


If yes:




52

(4a) Write the title _________________________________________________________________

(4b) Indicate its stage:

□ Operational


□ Not in effect

□ Don’t know

If Operational:

(4b-i) What was the first year of implementation? ______________________________________

(4b-ii) What year will it expire? _______________________________________________________

(5) Is there a policy, strategy, or action plan for cancer or some particular cancer types in your country?

Yes for all cancers or cancer in general

Yes but only for specific cancers (specify: ___________________________)

No

Don’t Know


If yes, provide the following for the general cancer policy/strategy/action plan or, if there isn’t one, for the most important specific cancer policy/strategy/action plan:



(5a) Write the title _________________________________________________________________


□ Operational


□ Not in effect

□ Don’t know

If Operational:



(6) Is there a policy, strategy, or action plan for diabetes in your country?

Yes No Don’t Know


If yes:




53

(6a) Write the title _________________________________________________________________


□ Operational


□ Not in effect

□ Don’t know

If Operational:



(7) Is there a policy, strategy, or action plan for chronic respiratory diseases in your country?

Yes No Don’t Know


If yes:



(7a) Write the title _________________________________________________________________


□ Operational


□ Not in effect

□ Don’t know

If Operational:



(8) Is there a policy, strategy, or action plan for oral health in your country?

Yes No Don’t Know


If yes:



(8a) Write the title _________________________________________________________________


□ Operational


□ Not in effect

□ Don’t know


54

If Operational:



(9) Is there a policy, strategy, or action plan for another non-communicable disease of importance in your country?

Yes No Don’t Know


If yes:



Please provide the following information about the policy / strategy / action plan. If there is more than one, please provide the information for the most recent one.

Please specify which NCD: ____________________________________________________________

(9a) Write the title _________________________________________________________________


□ Operational


□ Not in effect

□ Don’t know

If Operational:



II C: Policies, action plans, strategies for NCD risk factors

The questions in this sub-section only refer to policies, strategies and action plans that are specific to an NCD risk factor. If your integrated policy, strategy or action plan addresses the risk factor, you do not need to re-enter that information.

(10) Is there a policy, strategy, or action plan for reducing the harmful use of alcohol in your country?

Yes No Don’t Know


If yes:



(10a) Write the title _________________________________________________________________


55


□ Operational


□ Not in effect

□ Don’t know

If Operational:

(10b-i) What was the first year of implementation? __________________________________

(10b-ii) What year will it expire? ____________________________________________________

(11) Is there a policy, strategy, or action plan for reducing overweight/obesity in your country?

Yes No Don’t Know


If yes:



(11a) Write the title _________________________________________________________________


□ Operational


□ Not in effect

□ Don’t know

If Operational:



(12) Is there a policy, strategy, or action plan for reducing physical inactivity and/or promoting physical activity in your country?

Yes No Don’t Know


If yes:



(12a) Write the title _________________________________________________________________


□ Operational


□ Not in effect

□ Don’t know


56

If Operational:



(13) Is there a policy, strategy, or action plan to decrease tobacco use in your country?

Yes No Don’t Know


If yes:



(13a) Write the title _________________________________________________________________


□ Operational


□ Not in effect

□ Don’t know

If Operational:



(14) Is there a policy, strategy, or action plan for reducing unhealthy diet related to NCD and/or promoting a healthy diet in your country?

Yes No Don’t Know


If yes:



(14a) Write the title _________________________________________________________________


□ Operational


□ Not in effect

□ Don’t know

If Operational:




57

II D: Selected cost-effective policies for NCDs and related risk factors

NB: Only selected policies are captured here as information on some policy measures, e.g. for tobacco and alcohol, are included in other assessment tools.

(15) Is there a policy and/or plan on NCD-related research including community-based research and evaluation of the impact of interventions and policies?

Yes No Don’t Know


If Yes:

(15a) Indicate its stage:

□ Operational


□ Not in effect

□ Don’t know

(16) Is your country implementing any 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?

Yes No Don’t Know


If yes:

16a) Are the policies:

□ Voluntary/self-regulating

□ Government legislation

□ Don’t know

(16b) Who is responsible for overseeing enforcement and complaints?

□ Government

□ Food Industry

□ Independent regulator

□ Other, please specify: _______________

(16c) Do they include steps taken to address the effects of cross-border marketing of food and non-alcoholic beverages on children?

Yes No Don’t Know

(16c-i)) If yes, please provide details: __________________________________________________

(17) Is your country implementing any national policies that limit saturated fatty acids and virtually eliminate industrially produced trans-fats (i.e. partially hydrogenated vegetable oils) in the food supply?

Yes No Don’t Know



58

(17a) If yes, are the policies:



□ Don’t know

(18) Is your country implementing any policies to reduce population salt consumption?

Yes No Don’t Know


(18a) Are these targeted at:

Product reformulation by industry across the food supply Yes No Don’t Know

Regulation of salt content of food Yes No Don’t Know

Public awareness programme Yes No Don’t Know

Nutrition labeling Yes No Don’t Know

(18b) If yes to product reformulation or regulation of salt content, is the policy:



□ Don’t know

(19) Has your country implemented any national public awareness programme on diet within the past 5 years?

Yes No Don’t Know


(19a) If yes, please provide details of the public awareness programme(s):

______________________________________________________________________________

(20) Has your country implemented any national public awareness programme on physical activity within the past 5 years?

Yes No Don’t Know

IF NO: Go to MODULE III

(20a) If yes, please provide details of the public awareness programme(s):

______________________________________________________________________________

III: Health information systems, monitoring, surveillance and surveys for NCDs and their risk factors

The questions in this module assess surveillance relating to the mortality, morbidity and risk factor reporting systems of each country and whether NCD mortality, morbidity and risk factor data were included in their national health reporting systems. Responses to these questions enable reporting against NCD Global Action Plan process indicators and UN High Level Meeting national commitment progress indicators.


59

(1) In your country, who has responsibility for surveillance of NCDs and their risk factors?

□ An office/department/administrative division within the MOH exclusively dedicated to NCD surveillance

□ An office/department/ administrative division within the MOH not exclusively dedicated to NCD surveillance

□ Responsibility is shared across several offices/departments/administrative divisions within the MOH

□ Coordination is by an external agency, such as an NGO or statistical organization

□ No one has this responsibility

□ Don’t know

III A: Data included in the national health information system

(National health information system refers to the annual or regular reporting system of the National Statistical Office or Ministry of Health)

(2) Does your country have a system for collecting mortality data by cause of death on a routine basis?

Yes No Don’t Know


IF YES:

(2a) Is there a civil/vital registration system?

Yes No Don’t Know

(2b) Is there a sample registration system?

Yes No Don’t Know

(2c) What is the latest year for which data are available? _______________________________

(2d) Can the data collected be disaggregated by:

Age Yes No Don’t Know

Gender Yes No Don’t Know

Other sociodemographic factor Yes No Don’t Know

(3) Does your country have a cancer registry?

Yes No Don’t Know


IF YES:

(3a) Are the data collected population-based, hospital-based, or other?

□ population-based

□ hospital-based

□ Other (specify: _____________)

□ Don’t know


60

(3b) Is the coverage of the registry national or subnational?

□ National (covers the whole population of the country)

□ Subnational (covers only the population of a defined region, not the whole country)

□ Don’t know

(3c) What is the latest year for which data are available?

______________________________________________________________________________

(4) Does your country have a diabetes registry?

Yes No Don’t Know


IF YES:

(4a) Are the data collected population-based, hospital-based, or other?

□ population-based

□ hospital-based

□ Other (specify: _____________)

□ Don’t know

(4b) Is the coverage of the registry national or subnational?


□ Subnational (covers only the population of a defined region, not the whole country)

□ Don’t know

(4c) Does the registry include data on any chronic complications which are updated as the patient’s complications status changes?

Yes No Don’t Know

(4d) What is the latest year for which data are available?

______________________________________________________________________________

(5) Does your country have a system for recording patient information that includes NCD status?

Yes No Don’t Know


IF YES:

(5a) Is it an electronic medical records/health records system?

Yes No Don’t Know

(5b) What is the coverage of the system?


□ Subnational (covers only the population of a defined region or regions or only certain segments of the population)

□ Don’t know


61

(6) Has your country conducted a survey of facilities to assess service availability and readiness for NCDs?

Yes No Don’t Know


(6a) Year of last survey _____________________________________________________________

(6b) Coverage of last survey:

National Subnational Don’t know


62

III B: Risk factor surveillance

(7a) Harmful alcohol use

(7b) Low fruit and vegetable consumption

(7c) Physical inactivity (7d) Tobacco use

(7) Have population-based surveys of risk factors (may be a single RF or multiple) been conducted in your country for any of the following: (Please fill in all columns, start in the first row, going left to right, and then continue left to right across the second row.)

For the questions on surveys on adolescents, please include here only surveys specifically targeting adolescents (i.e. do not repeat adult surveys that may have covered part of the adolescent age range).

Yes No Don’t know

IF NO: Go to next column.

IF YES:

i) Was there a survey on adolescents?

Yes No Don’t know

IF YES:

(i-1) Was it: National Subnational Don’t know

(i-2) How often is the survey conducted?

Ad hoc Every 1 to 2 years Every 3 to 5 years Other Don’t know

i-3) When was the last survey conducted? (give year) _____

(ii) Was there a survey on adults? Yes No Don't know

IF YES:

(ii-1) Was it:


(ii-2) How often is the survey conducted?


(ii-3) When was the last survey conducted? (give year) _____

Yes No Don’t know


IF YES:

(i) Was there a survey on adolescents?

Yes No Don’t know

IF YES:

(i-1) Was it: National Subnational Don’t know



(i-3) When was the last survey conducted?

(give year) _____


IF YES:

(ii-1) Was it:





Yes No Don’t know


IF YES:


Yes No Don’t know

IF YES:

(i-1) Was it: Measured Self-reported Don’t know

(i-2) Was it:



Ad hoc

Every 1 to 2 years

Every 3 to 5 years

Other

Don’t know

(i-4) When was the last survey conducted? (give year) _____


IF YES:

(ii-1) Was it:

Measured Self-reported Don’t know

(ii-2) Did it assess physical activity for work/in the household, for transport and during leisure time?

Yes No Don't know

(ii-3) Was it:




(ii-5) When was the last survey conducted?

(give year) _____

Yes No Don’t know


IF YES:


Yes No Don’t know

IF YES:

(i-1) Was it:




(i-3) When was the last survey conducted? (give year) _____


IF YES:

(ii-1) Was it:






63

(7) cont.(7e) Raised blood glucose/diabetes

7f) Raised total cholesterol

(7g) Raised blood pressure/

Hypertension

(7h) Overweight and obesity

(7i) Salt/Sodium intake

Yes No Don't know


IF YES:

(i) Was it:


(ii) Was it:


(iii) How often is the survey conducted?


(iv) When was the last survey conducted?

(give year) _____

Yes No Don't know


IF YES:

(i) Was it:


(ii) Was it:





(give year) _____

Yes No Don't know


IF YES:

(i) Was it:


(ii) Was it:





(give year) _____

Yes No Don't know


IF YES:


Yes No Don't know

IF YES:

(i-1) Was it:


(i-2) Was it:




(i-4) When was the last survey conducted?

(give year) _____


IF YES:

(ii-1) Was it:


(ii-2) Was it:




(ii-4) When was the last survey conducted?

(give year) _____

Yes No Don't know

IF NO: Go to MODULE IV.

IF YES:

(i) Was it:

Measured by 24-hr urine collectionMeasured by 12-hr urine collectionMeasured by spot urine collectionMeasured by combination of methodsSelf-reportedDon’t know

(ii) Was it:





(give year) _____


64

IV: Capacity for NCD early detection, treatment and care within the health system

The questions in this module assess the health care systems capacity related to NCD early detection, treatment and care within the health care sector. Specific questions focus on availability of guidelines or protocols to treat major NCDs, and the tests, procedures and equipment related to NCDs within the health-care system. It also assesses the availability of palliative care services for NCDs. Responses to these questions enable reporting against NCD Global Action Plan process indicators and UN High Level Meeting national commitment progress indicators.

(1) Please indicate whether evidence-based national guidelines/protocols/standards are available for the management (diagnosis and treatment) of each of the major NCDs through a primary care approach recognized/approved by government or competent authorities. Where guidelines/protocols/standards are available, please indicate their implementation status, when they were last updated and whether they contain standard criteria for the referral of patients from primary care to a higher level of care (secondary/tertiary).

Cardiovascular Disease

Diabetes CancerChronic

Respiratory Disease

1a) Are they available?

Yes

No

Don't Know

Yes

No

Don't Know

Yes (specify cancer types)

No

Don't Know

Yes

No

Don't Know

1b) Are they being utilized in at least 50% of health care facilities

Yes

No

Don't Know

Yes,

No

Don't Know

Yes,

No

Don't Know

Yes No

Don't Know

1c) When were they last updated?

1d) Do they include referral criteria?

Yes

No

Don't Know

Yes

No

Don't Know

Yes

No

Don't Know

Yes

No

Don't Know


65

(2) Indicate the availability of the following basic technologies for early detection, diagnosis / monitoring of NCDs in the primary care facilities of the public and private health sector where: Generally available=1; Generally not available = 2, Don’t know = 3.

Availability in the primary care facilities of the public health

sector (1, 2, or 3)

Availability in the primary care facilities of the private health

sector (1, 2, or 3)

Overweight and obesity

(2a) Measuring of weight

(2b) Measuring of height

_____

_____

_____

_____

Diabetes mellitus

(2c) Blood glucose measurement

(2d) Oral glucose tolerance test

(2e) HbA1c test

(2f) Dilated fundus examination

(2g) Foot vibration perception by tuning fork 2h) Foot vascular status by Doppler

(2i) Urine strips for glucose and ketone measurement

_____

_____

_____

_____

_____

_____

_____

_____

Cardiovascular disease

(2j) Blood pressure measurement

(2k) Total cholesterol measurement

(2l) Urine strips for albumin assay

_____ _____ _____

_____

_____

_____

Asthma and chronic obstructive pulmonary disease

(2m) Peak flow measurement spirometry_____ _____

* Generally available: in 50% or more health care facilitiesGenerally not available: in less than 50% health care facilities


66

(3) Please indicate if there is a national screening program targeting the general population for the following cancers and, if yes, provide details.

Cancers

Initial screening method (indicate only one, the most widely used)

Population targeted by the program

Type of program Screening coverage

Breast

□ Yes

□ No

□ Don’t know

If NO: Go to next row

□ Clinical breast exam

□ Mammography screening

□ Don’t know

Women aged …….. to …….

Other, specify:

□ Don’t know

□ Organised population-based screening

□ Opportunistic screening

□ Don’t know

□ Less than 10%

□ 10% to 50%

□ more than 50% but less than 70%

□ 70% or more

□ Don’t know

Cervix

□ Yes

□ No

□ Don’t know


□ Visual inspection

□ PAP smear

□ HPV test

□ Don’t know

Women aged …….. to …….

Other, specify:

□ Don’t know



□ Don't Know

□ Less than 10%

□ 10% to 50%


□ 70% or more

□ Don’t know

Colon

□ Yes

□ No

□ Don’t know


□ Faecal test

□ Colonoscopy/ sigmoidoscopy

□ Don’t know

People aged …….. to …….

Other, specify:

□ Don’t know



□ Don’t know

□ Less than 10%

□ 10% to 50%


□ 70% or more

□ Don’t know

Other cancer type(s)

Specify: _______

□Yes

□No

□Don’t know

(4) Please indicate if early detection of the following cancers by means of rapid identification of the first symptoms is integrated into primary health care services and if there is a clearly defined referral system from primary care to secondary / tertiary care for suspect cases (in low- and middle-income countries this set of measures may be designated as an “early diagnosis” programme):

Breast Cervix Colon Other cancer types (specify: ______)

Program/guidelines to strengthen early diagnosis of first symptoms at primary health care level

□ Yes

□ No

□ Don’t know

□ Yes

□ No

□ Don’t know

□ Yes

□ No

□ Don’t know

□ Yes

□ No

□ Don’t know


67

Breast Cervix Colon Other cancer types (specify: ______)

Clearly defined referral system from primary care to secondary and tertiary care

□ Yes

□ No

□ Don’t know

□ Yes

□ No

□ Don’t know

□ Yes

□ No

□ Don’t know

□ Yes

□ No

□ Don’t know

(5) Is there a national HPV vaccination programme under implementation?

Yes No Don’t know

If NO: Go to Question 6.

If yes, please provide the following details of the programme:

(5a) Who is targeted by the programme?

Girls aged ____ to ____

Other (specify: ____________)

Don’t know

(5b) What year did the programme begin? __________

(5c) What is the immunization coverage of the programme?

□ Less than 10%

□ 10% to 50%


□ 70% or more

□ Don’t know

(6) Describe the availability of the medicines below in the primary care facilities of the public health sector, where: Generally available=1; Generally not available = 2, Don’t know = 3.

Generic drug name Availability*

(6a) Insulin

(6b) Aspirin (100 mg)

(6c) Metformin

(6d) Thiazide Diuretics

(6e) ACE Inhibitors

(6f) Calcium channel Blockers

(6g) Beta Blockers

(6h) Statins

(6i) Oral morphine

(6j) Steroid inhaler

(6k) Bronchodilator


68

(6l) Sulphonylurea(s)

(6m) Benzathine penicillin injection

(6n) Nicotine Replacement Therapy

*Generally available: in 50% or more pharmacies Generally not available: in less than 50% of pharmacies

(7) Indicate the availability* of the following procedures for treating NCDs in the publicly funded health system, where: 1=Generally available; 2=Generally not available; 3=Don’t know.

Procedure name Availability

(7a) Retinal photocoagulation

(7b) Renal replacement therapy by dialysis

(7c) Renal replacement by transplantation

(7d) Coronary bypass

(7e) Stenting

(7f) Thrombolytic therapy (streptokinase) for acute myocardial infarction

*Generally available: reaches 50% or more patients in need Generally not available: reaches less than 50% of patients in need

(8) Detail the availability of cancer diagnosis and treatment services in the public sector:

Service Availability*

Cancer centres or cancer departments at tertiary level

□ Generally available

□ Generally not available

□ Don’t know

Pathology services (laboratories) □ Generally available


□ Don’t know

Cancer surgery □ Generally available


□ Don’t know

Subsidized chemotherapy □ Generally available


□ Don’t know

Radiotherapy □ Generally available


□ Don’t know


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(9) How many pathology laboratories for cancer diagnosis are there in the country?

(If you don’t know the exact number, just give an interval, for example “between 2 and 5”.)

Number of public laboratories: ___________ Don’t know

Number of private laboratories: ___________ Don’t know

Palliative care for patients with NCDs:

(10) Indicate the availability* of palliative care for patients with NCD in the public health system:


(10a) In primary health care facilities:

Generally available

Generally not available

Don’t know

(10b) In community or home-based care:

Generally available


Don’t know

Cardiovascular disease:

(11) What proportion of primary health care facilities are offering cardiovascular risk stratification for the management of patients at high risk for heart attack and stroke?

none

less than 25%

25% to 50%

more than 50%

Don’t know

If more than none:

(11a) Which CVD risk scoring chart is used?

WHO/ISH risk prediction charts

Others (specify ___________)

Don’t know

(12) Indicate the availability* of services for stroke in the public health system:



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(12a) Provision of care for acute stroke:

Generally available


Don’t know

(12b) Rehabilitation for stroke patients:

Generally available


Don’t know

(13) Is there a register of patients who have had rheumatic fever and rheumatic heart disease?

Yes

No

Don’t know

IF YES:

(13a) Are there systems for follow-up/recall to deliver long-term penicillin prophylaxis?

Yes

No

Don’t know


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Annex 2: Glossary

Academia: Refers to educational institutions, especially those for higher education.

Broadcast media: Media which is broadcast to the public through radio and television.

Cancer: A generic term for a large group of diseases that can affect any part of the body. Other terms used are malignant tumours and neoplasms. One defining feature of cancer is the rapid creation of abnormal cells that grow beyond their usual boundaries, and which can then invade adjoining parts of the body and spread to other organs.

Cancer registry: A systematic collection of data about cancer cases in a certain region or a certain hospital. The first aim is to count cancer cases to get an idea of the magnitude of the problem. WHO advises national coverage by population-based registry in small countries only.

Capacity building: The development of knowledge, skills, commitment, structures, systems and leadership to enable effective action.

Cardiovascular diseases: A group of disorders of the heart and blood vessels that includes coronary heart disease, cerebrovascular disease, peripheral arterial disease, rheumatic heart disease, congenital heart disease, deep vein thrombosis and pulmonary embolism.

Cardiovascular risk assessment: Use of risk prediction charts to indicate the risk of a fatal or non-fatal major cardiovascular event in the next 5 to 10 years. Based on the assessment people can be stratified into different levels of risk, which will help in management and follow up.

Chronic respiratory diseases: Diseases of the airways and other structures of the lung. Some of the most common are: asthma, chronic obstructive pulmonary disease, occupational lung diseases and pulmonary hypertension.

Civil registration: The system by which a government records the vital events of its citizens and residents, such as births, deaths and marital status, and cause of death.

Collaboration: A recognized relationship between different groups with a defined purpose.

Community: A specific group of people, often living in a defined geographical area, who share a common culture, values and norms, and are arranged in a social structure according to relationships which the community has developed over a period of time. Members of a community exhibit some awareness of their identity as a group, and share common needs and a commitment to meeting them.

Cross-border marketing: Marketing originating in one country that crosses national borders through broadcast media and internet, print media, sponsorship of events and programmes or any other media or communication channel. It includes both in-flowing and out-flowing cross-border marketing.


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Diabetes: A disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces.

Early detection/screening: Measures performed in order to identify individuals who have early stages of a disease (with apparent symptoms in the case of early detection and without in the case of screening).

Earmarked taxes: Taxes which are collected and used for a specific purpose.

Fiscal interventions: Measures taken by the government such as taxes and subsidies.

Free sugars: Monosaccharides and disaccharides added to foods by the manufacturer, cook or consumer, plus sugars naturally present in honey, syrups and fruit juices.

Full immunization coverage: The proportion of people in the population targeted by the programme who actually received the full dose(s) of vaccine.

General government revenue: The money received from taxation, and other sources, such as privatization of government assets, to help finance expenditures.

Health: A state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity. A resource for everyday life which permits people to lead an individually, socially and economically productive life. A positive concept emphasizing social and personal resources as well as physical capabilities.

Health behaviour: Any activity undertaken by an individual, regardless of actual or perceived health status, for the purpose of promoting, protecting or maintaining health, whether or not such behaviour is objectively effective towards that end.

Health care and treatment: The diagnosis and treatment of diseases.

Health care facility: Facilities which provide health services. They may include mobile clinics, pharmacies, laboratories, primary health care clinics, specialty clinics, and private and faith-based establishments.

Health promotion: The process of enabling people to increase control over, and to improve their health.

Healthy diet: A healthy diet throughout the life-course helps prevent malnutrition in all its forms as well as a range of noncommunicable diseases (NCDs) and conditions. The exact make-up of a healthy, balanced diet will vary depending on the individual needs (e.g. age, gender, lifestyle, degree of physical activity). For adults, a healthy diet contains fruits, vegetables, legumes, nuts and whole grains and should be limited in free sugars, salt, total fat, saturated fats and free of industrial trans-fats.

International donors: Organizations which extend across national boundaries and which give funds for projects of a development nature.

Intervention: Any measure whose purpose is to improve health or alter the course of disease.


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Legislation: A law or laws which have been enacted by the governing bodies in a country.

Marketing: Any form of commercial communication or message that is designed to, or has the effect of, increasing the recognition, appeal and/or consumption of particular products and services. It comprises anything that acts to advertise or otherwise promote a product or service.

Multisectoral: Involving different sectors, such as health, agriculture, education, finance, infrastructure, transport, trade, etc.

Multisectoral collaboration: A recognized relationship between part or parts of different sectors of society (such as ministries (e.g. health, education), agencies, non-governmental agencies, private for-profit sector and community representation) which has been formed to take action to achieve health outcomes in a way that is more effective, efficient or sustainable than might be achieved by the health sector acting alone.

Multi-stakeholder: Involving stakeholders from across the public sector, civil society, NGOs and the private sector.

National Cancer Screening Programme: A government-endorsed programme where screening is offered. NGO-led programmes or national recommendations to go for screening at one’s own cost, do not qualify as national screening programmes.

National focal point, unit or department:

i. National focal point: the person responsible for the prevention and control of chronic diseases in a ministry of health or national institute.

ii. Unit or department: a unit or department with responsibility for NCD disease prevention and control in a ministry of health or national institute.

National health reporting system, survey and surveillance:

i. National health reporting system: The process by which a ministry of health produces annual health reports that summarize data on, for example, national health human resources, population demographics, health expenditures, and health indicators such as mortality and morbidity. Includes the process of collecting data from various health information sources, e.g. disease registries, hospital admission or discharge data.

ii. National survey: A fixed or unfixed time interval survey on the main chronic diseases, or major risk factors common to chronic diseases.

iii. Surveillance: The systematic collection of data (through survey or registration) on risk factors, chronic diseases and their determinants for continuous analysis, interpretation and feed-back.

National integrated action plan: A concerted approach to addressing a multiplicity of issues within a chronic disease prevention and health promotion framework, targeting the major risk factors


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common to the main chronic diseases, including the integration of primary, secondary and tertiary prevention, health promotion and diseases prevention programmes across sectors and disciplines.

National policy, strategy, action plan:

i. Policy: A specific official decision or set of decisions designed to carry out a course of action endorsed by a political body, including a set of goals, priorities and main directions for attaining these goals. The policy document may include a strategy to give effect to the policy.

ii. Strategy: a long-term plan designed to achieve a particular goal.

iii. Action plan: A scheme of course of action, which may correspond to a policy or strategy, with defined activities indicating who does what (type of activities and people responsible for implementation), when (time frame), how and with what resources to accomplish an objective.

National protocols/guidelines/standards for chronic diseases and conditions:

A recommended evidence-based course of action to prevent a chronic disease or condition or to treat or manage a chronic disease or condition aiming to prevent complications, improve outcomes and quality of life of patients.

NGO: Non-governmental organization.

Noncommunicable diseases (NCDs): The four main types of noncommunicable diseases are cardiovascular diseases (such as heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructed pulmonary disease and asthma) and diabetes.

Noncommunicable diseases prevention and control: All activities related to surveillance, prevention and management of the chronic noncommunicable diseases.

Not in effect: Any policy, strategy or plan of action which has been previously developed and is no longer under development, but for various reasons is not being implemented.

Nutrition labelling: A description intended to inform consumers of the nutritional properties of food. Nutrition labelling consists of two components: (a) nutrient declaration; (b) supplementary nutrition information.

Operational: A policy, strategy or plan of action which is being used and implemented in the country, and has resources and funding available to implement it. Also applies to a multisectoral commission/mechanism which is functional and meets on a regular basis.

Palliative care: Palliative care is an approach that improves the quality of life of patients (adults and children) and their families who are facing problems associated with life-threatening illness. It prevents and relieves suffering through the early identification, correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual.


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Partnership for health: An agreement between two or more partners to work cooperatively towards a set of shared health outcomes.

Price subsidies: Economic benefit provided by the government (such as a tax allowance or duty rebate) to keep the price of healthy foods low.

Primary health care: Refers to core functions of a nation’s health system. Encompassing front-line health service delivery (primary care) as well as health system structure; governance and financing; the intersectoral policy environment; and social determinants of health, primary health care provides essential health interventions according to a community’s needs and expectations.

Primary prevention: Measures directed towards preventing the initial occurrence of a disease or disorder.

Print media: Communicating with the public through printed materials such as magazines, newspapers and billboards.

Product reformulation by industry: Refers to the process of changing the composition of processed foods to be healthier and reduce the salt content.

Public awareness programme: A comprehensive effort that includes multiple components (messaging, grassroots outreach, media relations, government affairs, budget, etc.) to help increase public understanding about the importance of an issue.

Public health sector: Publicly funded health care sector.

Rehabilitation: A set of measures that assist individuals who experience, or are likely to experience, disability to achieve and maintain optimal functioning in interaction with their environments.

Risk factors associated with noncommunicable diseases

The four main risk factors for NCDs are tobacco use, harmful use of alcohol, unhealthy diet and low levels of physical activity.

Sample registration system: A method and procedure for estimating vital statistics in national and regional populations by intensively registering and verifying vital events in population samples. For instance, in India more than 4,000 rural and 2,000 urban sample units, with a total of more than 6 million persons, i.e., less than 1% of the total national population, are included in a sample registration system that provides a reasonably reliable picture of the national pattern of vital events at a cost that is feasible and reasonable.

Saturated fats: Fats found in animal products, including meat and whole milk dairy products, as well as certain plant oils like palm, palm kernel and coconut oils.

Screening: Measures preformed across an apparently healthy population in order to identify individuals who are at high risk or in the early stages of disease, but do not yet have symptoms.


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Screening coverage: The proportion of people in the population targeted by the programme who actually received screening in the time frame defined by the programme. (For example, if a country recommend mammography screening every 2 years for women aged 50 to 60. The screening coverage is the number of women aged 50 to 60 who benefitted from mammography thanks to the programme in the past 2 years, divided by the total number of women aged 50 to 60 in the country.)

Self-regulation: In this context refers to when a group or private sector entity governs or polices itself without outside assistance or influence.

Target: A specific aim to be achieved, should be time bound, and define a ‘desired’, ‘promised’, ‘minimum’ or ‘aspirational’ level of achievement.

Taxation incentives to promote physical activity: Involve removing the tax (or a portion of the tax) in order to promote increased use of goods or services to encourage physical activity.

Trans-fatty acids (trans fats): A form of fatty acids. While trans fats do occur in tiny amounts in some foods, almost all the trans fats come from an industrial process that partially hydrogenates (adds hydrogen to) unsaturated fatty acids. Trans fats, then, are a form of processed vegetable oils.

Under development: Something which is still being developed or finalized and is not yet being implemented in the country.

VAT/Sales Tax: “Value-added tax” (VAT) is a “multi-stage” tax on all consumer goods and services applied proportionally to the price the consumer pays for a product. Although manufacturers and wholesalers also participate in the administration and payment of the tax all along the manufacturing/distribution chain, they are all reimbursed through a tax credit system, so that the only entity who pays in the end is the final consumer. Most countries that impose a VAT do so on a base that includes any excise tax and customs duty. Example: VAT representing 10% of the retail price. Some countries, however, impose sales taxes instead. Unlike VAT, sales taxes are levied at the point of retail on the total value of goods and services purchased.

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