Abstract
On 27 September 2018 the United Nations (UN) hosts another high-level meeting on non-communicable diseases (NCDs). In response to this and in preparation for attending the meeting, the International Union for Health Promotion and Education (IUHPE) has adopted a position statement: ‘Beating NCDs equitably – Ten system requirements for health promotion and the primary prevention of NCDs’. Our statement reflects a serious concern that if we expect health promotion to have any impact on the prevention and control of NCDs, then viewing health promotion as a system and investing in it adequately and sustainably is essential.
Here are our recommendations for 10 system requirements.
In each country, establish a ministerial and head-of-state-level political commitment to health promotion, health equity and NCD prevention.
Develop transparent and robust national action plans to prevent non-communicable disease and address health inequity with clear accountabilities and specific objectives.
Allocate sustainable financing for programme implementation, research and evaluation for prevention and health promotion.
Strengthen or build dedicated health promotion institutions at national and sub-national levels.
Assure mechanisms for cross-sector collaboration and co-benefits.
Appoint high level health promotion leaders in the public service.
Build and strengthen health promotion workforce competency.
Implement comprehensive health promotion and prevention plans that emphasise policies and environment changes which address social, environmental and commercial determinants of health.
Partner with non-state actors and communities.
Invest in evidence generation, guidelines, evaluation and monitoring to ensure quality and accountability.
Rationale for this manifesto
Non-communicable diseases remain the greatest health challenge of our time, the leading cause of death globally and one of the leading challenges to global development. In 2015 almost 40 million people died from NCDs including 15 million people under the age of 70 years (1). The burden is high in all nations but particularly in low- and middle-income countries and communities. Much of the burden of NCDs is explained by several major, but common and well understood risk factors (smoking, harmful use of alcohol, physical inactivity, unhealthy diet, injury and poor mental health). These risk factors are substantially preventable through comprehensive health promotion strategies with supportive, system-driven political measures and policies.
However, since the UN high level meeting on non-communicable diseases in New York in 2011 (2), the world has seen ambitious targets set, only to be met with implementation failure. Why is this? The UN Secretary-General noted a lack of commitment to bold policies as a key barrier to progress (3). Our view at the IUHPE is that it is in two key areas where progress is failing. Both are political failures rather than technical in nature: lack of commitment to equitable policy interventions, fiscal measures and environment changes; and, lack of investment in necessary health promotion and primary prevention systems.
Through the UN Political Declaration on NCDs in September 2011, heads of state committed to establish and strengthen multi-sectoral national policies and plans for NCD prevention and control. In the 2017 Report of the UN Secretary-General on progress on NCDs, the Secretary-General noted a pressing need for bolder commitments at the general assembly in 2018 to ensure that all countries stand a chance of reaching sustainable development target 3.4 by 2030 (paragraph 52) (3). The report noted a lack of commitment to effective policies at the national level in many countries as a key barrier to progress.
Solutions to NCDs and health inequity lie largely in achieving policy coherence across sectors: a cross-sectoral collaboration mechanism must be a key feature of national NCD prevention and control plans to address health and health-equity in all policies, contributing also to the Sustainable Development Goals (SDGs). The goal is to bring different sectors together to achieve synergistic cross-sectoral implementation, and the monitoring of improvements in health, equity and related benefits for other sectors.
To tackle population-wide NCD risk factors in equitable ways, national commitments need to go beyond the mere existence of policy: what’s needed is comprehensive and sustained implementation of robust NCD plans. This means going beyond the ‘easy options’ such as education for individual responsibility, towards regulatory and fiscal measures such as advertising bans and levies on products that cause harm. The World Health Organization’s Global Action Plan on NCDs (4), already details a menu of such policy options and cost-effective interventions to assist member states.
Governments must resist commercial and industry interference and intimidation and commit to implementing measures which are the most effective in protecting the health of their citizens. Too often we see comprehensive and effective measures whittled down to ‘soft’ measures in response to industry pressure.
It follows that, fundamentally optimising health promotion’s contribution requires political commitment to secure successful engagement across sectors via the head of state or equivalent, with a health minister empowered and assigned responsibility for a portfolio covering disease treatment as well as health promotion that impacts across all policies.
Addressing implementation failure requires operational change too. Adequate resourcing is essential – an obvious point but one that is often ignored. Legislation can be used to secure ongoing funding for health promotion and NCD prevention interventions – for example, a target of five percent of overall health spending would be a start. Other financing options include levies on products that cause harm (tobacco, sugary drinks, alcohol and/or junk foods). Several countries have established health promotion funds through this mechanism (5).
Policy development, research and programme implementation are greatly enhanced when appropriately resourced national and regional health promotion institutions are in place. These need to be strengthened in countries where they exist and established in countries where they do not. For the prevention of NCDs and the promotion of health to be taken seriously as a social good, the leaders of health promotion institutions should be appointed at the highest level of the public service, with an appropriate career pathway established from practitioner to high-level leader. Supportive leadership from other sectors requires broader training in ‘Health in Public Management’.
Delivery of effective health promotion requires a skilled and knowledgeable workforce with a concomitant need for global and regional professional capacity-building activities. The IUHPE’s global scheme for accreditation of health promotion courses and registration of practitioners (6) can play a significant role here.
Successful implementation of NCD policy will require strong community engagement and partnerships, including the participation of major non-governmental agencies. Community action on NCDs is enabled by the empowerment and ownership of community members, consumers and local stakeholders – volunteer groups, women’s groups, schools, youth and the media.
Finally, accountability for action on NCD prevention is essential and requires the following: investment in research and evaluation to build a strong evidence base for NCD plans; implementation of guidelines (using national context and global evidence); creation of national targets and indicators using WHO Guidance; and establishing a monitoring and accountability framework for the delivery of NCD prevention and control action plans.
Conclusion
The third UN high level meeting on NCDs, 27 September 2018, provides an opportunity for heads of state to grasp the opportunity to lead the world to a healthier future. Equity in NCD prevention and control is reliant on political leadership, policy intervention and system change. On the plus side, in 2017 the political momentum created by the linked UN agendas of the NCDs and the SDGs (7) has been encouraging, especially in visualising the synergies between health promotion achievements and the SDGs, and can pave the way to significant progress.
Addressing implementation failure and accelerating progress in achieving the NCD targets will require governments to invest in the system requirements outlined here – in short, the 10 action areas the IUHPE proposes. A commitment to these by heads of state, health ministers and other politicians will go a long way to implementing NCD prevention plans and achieving better health for all.
The full position statement can be downloaded from the IUHPE website: https://www.iuhpe.org/index.php/en/iuhpe-at-a-glance/iuhpe-official-statements