Noncommunicable diseases, commonly referred to as NCDs — cardiovascular diseases, cancer, chronic respiratory disease, and diabetes, just to name a few — are the leading cause of mortality worldwide, responsible for a staggering 70 percent of global deaths. The vast majority — about 80 percent — occur in low- and middle-income countries, making the prevention of NCDs one of the most urgent health concerns in developing countries.
Research indicates that tackling four key risk factors — tobacco use, alcohol abuse, physical inactivity, and unhealthy diet — can prevent the vast majority of NCDs. Effectively addressing those risk factors, however, will mean adopting policies and interventions that incentivize behavior changes for entire populations.
Finding and implementing effective ways to do this is a complex task. In lower-middle-income countries, obstacles include an acute lack of funding, political will, coordination, and national health care plans specifically targeting NCD reduction, as well as a lack of access to well-functioning health care systems — particularly at primary level.
While overcoming such obstacles is possible, targeted and strategic action is needed from many different stakeholders — including governments, donors, and civil society groups. Identifying the most impactful and strategic interventions, dividing tasks according to stakeholder expertise, communicating, and working collaboratively across sectors are key to success.
“The magnitude of the problem is enormous: 80 percent of NCDs are occurring in low- and middle-income countries. But we know that if you focus on prevention and invest there early — and not when people get sick — you can get a lot of return on investment.”— Jan Kimpen, chief medical officer at Philips
“Governments realize they need to be working with different actors — whether around prevention, treatment or access,” said Katie Dain, chief executive officer of NCD Alliance, an NGO that unites 2000 civil society organizations in more than 170 countries, dedicated to improving NCD prevention and control worldwide.
“There has to be a multisector approach,” said Dain.
The role of government
Many of the most effective, high-impact interventions require strong government leadership. While this is true for most health goals, achieving Sustainable Development Goal targets for NCDs — which include reducing premature mortality from NCDs by one-third, strengthening the response to reducing the harmful use of alcohol, and achieving universal health coverage, among others — requires the cooperation and coordination between many different governmental departments that often have conflicting goals and mandates.
While a ministry of health works to reduce consumption of ultra-processed foods, a ministry of finance could be issuing licenses to companies to produce more of those same foods. Getting all departments on the same page with a joined-up approach can be extremely challenging.
“When we talk about NCDs, one of the biggest challenges is the lack of political will,” said Svetlana Axelrod, assistant director-general for NCDs and mental health at the World Health Organization.
“It’s very important that we have strong support at the political level. While this usually isn’t a problem for the department of health, high-level politicians in other departments often don’t know how much investing in health translates to an investment in other sectors, so they don’t always prioritize it.”
To overcome this challenge, NCD Alliance recommends that governments form a coordinating body or committee to help with agenda setting, interdepartmental communication, and to coordinate the actions of the various agencies toward shared goals.
According to Laura Herman, managing director of FSG — a mission-driven consulting firm for leaders in search of large-scale, lasting social change — such coordinating committees are foundational to ensuring effective progress on the issue, and delivering collective impact.
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“It needs to be someone’s job to arrange the meetings, facilitate discussions and move the group forward in terms of working groups, planning, and collecting data across sectors to understand progress,” said Herman.
“It’s really critical, and it’s difficult to get right.”
The next key step is to create a national-level plan to determine targets and goals, create strategies, and earmark funding to support those goals.
“Having national plans and targets in place forms the foundation for achieving progress,” said Dain. “Unfortunately, at the moment, less than half of all countries have these national targets or plans.”
Once goals and targets are established, there are a number of high-impact strategies that governments are uniquely positioned to implement — both in terms of prevention, and treatment: Although often unpopular with companies, and occasionally the public, government regulations that seek to reduce unhealthy behaviors are extremely effective at moving the needle on NCDs.
Such regulations might include barring smoking in restaurants and public buildings, mandating all tobacco products to be labeled with clear warnings linking use to cancer, or imposing substantial tax hikes on products such as tobacco, alcohol, processed foods or sugary drinks aimed at reducing consumption, and generating revenue to tackle NCDs.
Other important government interventions include creating more accessible, affordable, and robust primary health systems, ensuring early diagnosis of diseases, and working closely with the private sector to ensure that key medications — insulin, for example — are both available and affordable.
“WHO has outlined a number of best buys which were adopted by member states which are focused on promotion, prevention, and early diagnosis,” said Axelrod.
“It’s important the governments use these evidence-based interventions which can be implemented through their national plans.”
More on the “best buys”
The World Health Organization has outlined a number of highly cost-effective interventions — called “best buys” — that have proven to be extremely successful at moving the needle on NCDs, and if adopted early, can save billions of dollars in treatment costs. Such interventions include imposing tobacco taxes, enforcing smoke-free environments, imposing health information and warnings on labels, restricting access to retailed alcohol, and public awareness through mass media on diet and physical activity.
Enlisting civil society
However, for government interventions to effectively translate into positive health outcomes for an entire population, civil society needs to be involved from the very beginning.
“We learned that educating people in a vacuum doesn’t work,” said Beatriz Champagne, executive director at the InterAmerican Heart Foundation. “You can talk about health until you are blue in the face. To see real behavior change, there also needs to be a shift in the environment.”
But focusing only on policy change isn’t effective either. To reduce NCDs at scale, education and regulation must go hand-in-hand, said Champagne: The public needs to be educated about the disease that policymakers are trying to prevent, potential risk factors, and why regulations are necessary and important — all before the regulations come into effect.
According to Champagne, civil society can play a major role in executing effective public education campaigns.
A successful campaign to reduce smoking, for example, would probably start with a public education campaign about the risks of smoking, and why a smoke-free environment is important. The effectiveness of the education campaigned should track changes in public opinion. As people become more aware, they are more favorable toward changes that protect them from the tobacco smoke of others. Smoke-free environments legislation is always very popular, even among smokers. Once there is evidence that people’s opinions are changing about smoking and smoke-free environments, enforcing smoke-free legislation becomes easy. However, the tobacco industry frequently finds ways to thwart regulations, and to maintain their own profits, without concern for public health, she said.
Jamaica is in the process of conducting a similar public education campaign to reduce obesity, led by the country’s ministry of health and The Heart Foundation of Jamaica, called “Are you drinking yourself sick?” The campaign aims to warn the public about the large amounts of sugar in drinks such as soda and fruit juices, and the harm caused by consuming them. To get the message out, the campaign created a series of public service announcements on TV channels, as previews to movies, and on radio stations. As a follow-up, the next step will be to impose substantial tax hikes on sugary products.
“The role of civil society is really critical,” said Axelrod.
“They help create the agenda, educate the public, and put pressure on the government through advocacy. They are a critical part of this work.”
“Primary care is where people often get diagnosed, and where community health care workers raise patient awareness, so it’s a critical that primary care and screenings are accessible and affordable.”— Laura Herman, managing director of FSG
Collaborating with the private sector
While the private sector is not a monolithic entity and consists of different companies — including those responsible for making commercial products, and those in health care — it gets a bad reputation when it comes to NCDs due to lobbying efforts by tobacco, food and beverage industries to influence and discourage policymakers from implementing taxation schemes.
“Companies fight taxes tooth and nail because the whole point of the taxes is to reduce consumption of the products that are taxed,” said Champagne.
“Obviously, that’s not something companies want.”
However, the relationship between the private sector and government doesn’t have to be antagonistic. According to NCD Alliance’s Dain, some governments are experimenting with ways to incentivize companies to reduce targets on their own.
In the United Kingdom, the government gave companies a 12-month grace period prior to imposing a sugar tax, enabling food producers to reformulate products before the taxes came into effect. Brazil used a similar model to encourage companies to gradually reduce sodium content in foods over a 10-year period of time.
Nor do taxations have to negatively affect companies’ bottom lines: In Mexico, government regulation mandated taxes of 10 percent on sugar-sweetened beverages, which reduced consumption of soda, but also boosted the consumption of bottled waters sold by the same company. And in Chile, government regulation mandating clear front-of-package labeling for foods high in sugar, sodium, saturated fat and calories. This action encouraged companies to reformulate their products and make them healthier.
“Companies just need to redirect their sales strategies,” said Champagne.
Private sector actors are also responsible for creating, making, and distributing pharmaceutical products and medical equipment, and can be enlisted in collaborations aimed at making medicines more widely available and less expensive, and to strengthen primary health care systems.
According to Jan Kimpen, chief medical officer at global health technology company Philips, successful private sector engagement with the issue of NCDs in the LMIC context requires three building blocks: A passion and commitment on the part of the companies to recognize their own responsibility in the issue, a focus on prevention, and a focus on digitization. It also requires close collaboration with various stakeholders across sectors.
For the past four years, Philips has been collaborating with governments, donors, and NGOs to increase access to primary health systems in Africa, by helping to build “community life centers” in rural regions that previously lacked access to primary care facilities.
“Primary care is where people often get diagnosed, and where community health care workers raise patient awareness, so it’s a critical that primary care and screenings are accessible and affordable,” said Herman of FSG.
To keep doing this, and to keep the centers affordable, Philips had to craft a business strategy appropriate to a low-income country context. Rather than bringing in expensive MRI devices that would be difficult to service and expensive to run, it designed a number of simple, low energy, portable medical devices health care workers could use to screen patients.
“We have to work hard to be sustainable. More often than not, the private sector gives money or works in charity. But throwing money at a problem is never going to move the needle on this issue,” said Kimpen.
“We need to learn not to donate something for a good goal or a good aim, but to work on a business model that is sustainable, but are also helping the patient on the ground, helping the health care systems in the countries, as well as Philips.”
Such business models are possible, according to Kimpen. However, they require companies to be flexible, and to rethink their strategies and to design products and services that are appropriate to the LMIC context.
“The magnitude of the problem is enormous: 80 percent of NCDs are occurring in low- and middle-income countries,” said Kimpen. “But we know that if you focus on prevention and invest there early — and not when people get sick — you can get a lot of return on investment.”
“We can see progress on this issue. Since effective tobacco control measures were implemented in several countries, as part of a set of best buys to reduce NCDs, there’s been a relative reduction in the risk of premature NCD deaths by 18 percent between 2000-2016,” said WHO’s Axelrod.
“But there is still a long way to go.”
For more coverage of NCDs, visit the Taking the Pulse series here.