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    Fighting NCDs in the post-2015 world

    It would take more than including NCD targets in the post-2015 agenda to effectively prevent incidences of these so-called "diseases of developed countries." So how can the development community rally around the fight against NCDs? We spoke to a few global health experts.

    By Anna Patricia Valerio // 10 November 2014
    Often viewed as a problem largely limited to developed countries, noncommunicable diseases such as cancer, cardiovascular and chronic respiratory diseases, and diabetes claim more lives in low- and middle-income countries than in richer nations. Of the 38 million deaths from NCDs that the World Health Organization recorded in 2012, 10.9 million came from the western Pacific, where several small island countries already have overstretched health budgets. According to an NCD road map report prepared for the Joint Forum Economic and Pacific Health Ministers’ Meeting earlier this year, NCD-related causes accounted for 70 to 75 percent of all deaths in Pacific island countries. NCDs are also the leading causes of death in all regions except Africa. But Africa, according to WHO projections, is also the region that will see the largest increases in deaths due to NCDs by 2020. And by 2030, the number of deaths from NCDs in the region is expected to exceed deaths from communicable and nutritional diseases as well as maternal and perinatal deaths. Poverty is actually closely linked with NCDs, according to WHO. For one, poorer people are more exposed to tobacco and unhealthy food, and often have limited access to health services. But the persistence of the myth that NCDs are, according to Sam Byfield, “diseases of developed countries” has made it difficult to gather donor support for curbing incidences. The lack of effective and cohesive lobbying within both the country and international level is a factor as well, noted Byfield, the coordinator for NCDs at the University of Melbourne’s Nossal Institute for Global Health. “Too often the individual disease groups are in competition for funding and attention, instead of [people] working together to highlight the common risk factors of NCDs, and interventions needed to collectively address them,” Byfield told Devex. For many in the development community, however, NCDs’ absence in the Millennium Development Goals is the primary contributor to the neglect that has prevented these diseases from inching up along what has become a longer list of health priorities. NCDs’ small slice of global health funding Despite the close link that NCDs have with poverty and the increasing burden they are placing on the developing world, donor funding for the fight against this set of diseases has historically paled in comparison with the aid that goes to other subsectors of development assistance for health. “International commitment to address NCDs has never really been commensurate with their associated burden,” Byfield said. “The relatively tiny amount of global health aid funding that gets directed to NCDs is testament to this.” In 2011, donors funneled $377.5 million to address noncommunicable diseases — the highest amount channeled toward NCDs since 1990. But this still only accounted for 1.2 percent of total development assistance for health that year, a recent report from the University of Washington’s Institute for Health Metrics and Evaluation noted. Even when the $67.8 million for tobacco control is considered, funding for addressing NCDs and their risk factors remains small. The 4.6 percent growth in health development assistance for NCDs in 2011 was driven mainly by the World Bank’s International Bank for Reconstruction and Development, which contributed $93 million to the subsector that year. That represented a $54 million increase from 2010 levels and accounted for 24.5 percent of NCD spending in 2011. Meanwhile, WHO’s contribution to NCD efforts amounted to $47 million — a 16.8 percent drop from its 2010 DAH for NCDs. Bloomberg Philanthropies, which works across more than 40 developing countries, also slashed its spending on NCDs significantly in 2011: from $81 million in 2010 to $35 million in 2011. But Bloomberg contributed the most to preventing tobacco use through investments that included supporting the passage of tobacco-related legislation and developing tobacco-use monitoring systems. Its disbursements for tobacco control peaked in 2010, at $81 million. But even at $35 million in 2011, Bloomberg spending on anti-tobacco interventions still comprised a large chunk — 51.1 percent — of total tobacco DAH. Again, this dwarfs WHO’s $6 million contribution to tobacco control — or 8.7 percent of total DAH for curbing tobacco use — in 2011. A multisector approach for a crosscutting issue For Amanda Glassman, director of global health policy and senior fellow at the Center for Global Development, “it just doesn’t seem clear that [WHO] alone could take a lead on [NCD interventions].” Glassman has been pushing to give multilateral development banks a greater role in addressing NCDs. The World Bank, for instance, could infuse reducing behavior that could contribute to the risk of NCDs into its conditional cash transfers. Maybe so. But it cannot be denied that WHO has been crucial to the NCD fight, a fact that Glassman herself has acknowledged. While IHME’s preliminary estimates show WHO’s contribution to DAH fell 0.9 percent from $2.17 billion in 2012 to $2.15 billion in 2013, the U.N. health agency is expected to have increased its spending on interventions for NCDs by 20.5 percent last year. WHO’s Framework Convention on Tobacco Control, which has been in effect for 10 years, was also the first binding international agreement centered on a chronic, noncommunicable disease. Containing provisions that include rules that govern the production, sale, distribution, advertisement and taxation of tobacco, the FCTC “has been instrumental in driving awareness, regulatory and legal reform in many countries, and providing political and normative weight to tobacco control efforts,” Byfield said. With only 10 U.N. member states that did not sign the treaty, the FCTC is also “one of the most highly and rapidly signed and ratified conventions,” according to IHME. But despite these efforts from WHO and other key actors to drive down NCDs and their risk factors, the number of smokers continues to increase, the IHME report noted. There are now 739 million daily smokers in developing countries, with 282 million living in China, also the country with the most NCD-related deaths. The crosscutting nature of NCDs has prompted WHO and other development institutions to adopt a multisector rather than just a health approach to the NCD burden. For instance, aside from direct NCD interventions, investments in education and health measures that warn about the risks of smoking could help reverse NCD prevalence. Sports programs that assist with obesity control and provide a forum for communicating broader health messaging are another example of programs that employ a different approach to NCDs, according to Byfield. Australia’s development-through-sport programs, which cite combating NCDs as one of the main objectives, are a more specific example of this, he said. In addition, other health issues — Ebola, for example — that have dominated the headlines in recent months are still somehow linked to NCDs, Glassman said. For instance, the spread of Ebola in West Africa has reinforced the need for better health systems, which, according to Byfield, would also have an impact on a country’s ability to prevent and control NCDs. Funding for sports programs and health systems, however, may not necessarily be categorized as aid to address NCDs, noted Byfield, who believes that “a nuanced approach … to understanding aid funding for NCDs” includes these investments, as well as funding for policy support, vaccinations for infectious diseases that also help prevent NCDs, and NCD research, among others. “There are few global initiatives with the title of ‘NCD’ — is this a problem?” Glassman told Devex. “Maybe, maybe not.” What’s next for NCDs? As the end of the MDGs draws near, several important issues have been pushing their way into the post-2015 development agenda. But how could NCDs fit into this ever-growing laundry list of priorities? “Unfortunately, the post-2015 agenda is incredibly crowded — if everything is a priority, then nothing is a priority,” Glassman said. “We need to be more strategic in the choice of targets, and make some basic choices. Are targets supposed to be achievable or aspirational? Will we ‘reward’ progress or reaching some threshold? Should the targets be universally measurable or not?” For Byfield, “the likely inclusion of NCDs in the post-2015 agenda is a very positive and much-needed development.” But there is a need to align the post-2015 NCD targets with those already set by the Action Plan for the Prevention and Control of NCDs 2013-2020 and the Comprehensive Global Monitoring Framework and Targets for the Prevention and Control of NCDs. One of the voluntary global targets, for example, is a 25 percent relative reduction in the risk of premature mortality from NCDs by 2025. “The post-2015 agenda should be developed with clear reference to these existing frameworks,” Byfield said. Meanwhile, Glassman recommends continuing to invest in health systems, which need to focus on both continuity of care and NCD-related outcomes. Global institutions also need to be more vocal in their advocacy for and accountability to the FCTC. “I’d like to see systematic efforts to increase tobacco taxation in multiple countries,” Glassman said. “It’s low-cost and high-impact.” Still, the absence of an FCTC-like framework for other NCD risk factors — alcohol use, for example — has led some to call for a broader treaty to holistically address NCDs, according to Byfield, who thinks that it is an “important step.” The creation of an NCD fund similar to the Global Fund to Fight AIDS, Tuberculosis and Malaria — an effort Byfield believes “will take a tremendous amount of leadership from bilateral and multilateral donors, and ongoing advocacy from civil society” — could also make the NCD cause more prominent. But again, the establishment of such a fund should be consistent with the 10-year targets that have already been set by WHO. The G-20, a forum for the governments and central bank governors of the world’s 20 major economies, could play a role in this initiative, Byfield said. After all, the G-8’s influence in driving both health commitments and cooperation — the G-8 helped facilitate the establishment of the Global Fund and the Global HIV Vaccine Enterprise — has set a precedent for this kind of leadership. “The G-20, with its broader reach and economic clout, and increased relevance due to its expanded membership — including the BRICS countries — is perfectly placed to mobilize funding for NCDs,” Byfield said. In the meantime, the emergence of the need for universal health coverage in recent global health discussions could prove to be an important component in tackling NCDs. Byfield cites the Lancet’s Global Health Blog post, which noted that “UHC might be the only realistic path to closing the NCD services gap.” “I agree with this suggestion, though emphasize the importance of simultaneously addressing the social, political and economic drivers of NCDs,” he said. Want to learn more? Check out the Healthy Means campaign site and tweet us using #HealthyMeans. Healthy Means is an online conversation hosted by Devex in partnership with Concern Worldwide, Gavi, GlaxoSmithKline, International Federation of Pharmaceutical Manufacturers & Associations, International Federation of Red Cross and Red Crescent Societies, Johnson & Johnson and the United Nations Population Fund to showcase new ideas and ways we can work together to expand health care and live better lives.

    Often viewed as a problem largely limited to developed countries, noncommunicable diseases such as cancer, cardiovascular and chronic respiratory diseases, and diabetes claim more lives in low- and middle-income countries than in richer nations.

    Of the 38 million deaths from NCDs that the World Health Organization recorded in 2012, 10.9 million came from the western Pacific, where several small island countries already have overstretched health budgets. According to an NCD road map report prepared for the Joint Forum Economic and Pacific Health Ministers’ Meeting earlier this year, NCD-related causes accounted for 70 to 75 percent of all deaths in Pacific island countries.

    NCDs are also the leading causes of death in all regions except Africa. But Africa, according to WHO projections, is also the region that will see the largest increases in deaths due to NCDs by 2020. And by 2030, the number of deaths from NCDs in the region is expected to exceed deaths from communicable and nutritional diseases as well as maternal and perinatal deaths.

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    About the author

    • Anna Patricia Valerio

      Anna Patricia Valerio

      Anna Patricia Valerio is a former Manila-based development analyst who focused on writing innovative, in-the-know content for senior executives in the international development community. Before joining Devex, Patricia wrote and edited business, technology and health stories for BusinessWorld, a Manila-based business newspaper.

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