REVIEW ARTICLE- PLENARY SESSION
Year : 2017 | Volume
: 2 | Issue : 4 | Page : 113--117
Going beyond the health sector for prevention and control of noncommunicable diseases: Review of multisectoral actions in health policies
School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh
Noncommunicable diseases (NCDs) are a major cause of death and disability worldwide. Many of the determinants of NCDs go beyond the purview of the health sector. Hence, the involvement of nonhealth stakeholders along with the health sectors is important in the planning and implementation of programs for the prevention and control of NCDs. The current review aims to study the existing literature, thereby provide a background for further action in prevention and control of NCDs at a policy level. It was seen that the World Health Organization (WHO) Global Action Plan in 2013 led to the development of multisectoral action plans (MSAPs) in many of the member states of the WHO. However, for effective implementation of MSAPs, a strong leadership role and mechanism for partnership must be provided by the government. Furthermore, they can be strengthened by monitoring which ensures the accountability of each sector.
|How to cite this article:|
Thapar S. Going beyond the health sector for prevention and control of noncommunicable diseases: Review of multisectoral actions in health policies.Int J Non-Commun Dis 2017;2:113-117
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Thapar S. Going beyond the health sector for prevention and control of noncommunicable diseases: Review of multisectoral actions in health policies. Int J Non-Commun Dis [serial online] 2017 [cited 2019 Oct 15 ];2:113-117
Available from: http://www.ijncd.org/text.asp?2017/2/4/113/225990
Noncommunicable diseases (NCDs) are a leading cause of mortality globally, causing 38 million deaths worldwide (68%) until 2012. More than 40% of these deaths have been premature, i.e., occurring before the age of 70 years. The low- and middle-income countries face a higher burden and contribute to more than three quarters of these deaths. In the Southeast Asian (SEA) region, an estimated 7.9 million lives have been lost due to NCDs accounting for 55% of all deaths in the region. Furthermore, in 2008, the proportion of deaths due to NCDs below the age of 60 years was 34% in SEA region, compared to 23% in rest of the world. India had 55% of the total disability-adjusted life years (DALYs) from NCDs in 2016.
Taking into consideration the gravity of the burden of NCDs, the Sustainable Development Goal 17 deals with strengthening and revitalizing the partnership for sustainable development to develop coherent policies and providing an enabling environment at all levels and by all actors. The global action plan for prevention and control of NCDs 2013–2020 has emphasized on multisectoral action (MSA) as one of the overarching principles to achieve the nine voluntary global targets. Similarly, translation of research to policy and practice also needs the involvement of nonhealth sectors. Many of the determinants of health and health inequities in populations have social, environmental, and economic determinants that extend beyond the health sector and health policies. Thus, public policies involving multiple stakeholders at different levels of governance can have a significant impact on population health and health equity. The aim of the review is to study the existing literature available for MSA and to provide a background for further action for the prevention and control of NCDs at a policy level.
A “search strategy” was prepared and four databases were searched with the keywords “multisectoral action in cardiovascular diseases, diabetes, obesity, tobacco control, cancer, and alcohol.” A background paper was prepared on “Multisectoral actions to control NCDs, Tobacco and other risk factors “ and shared with all resource person in advance and before the session. The topic was also discussed in a plenary session at the World NCD Congress on November 6, 2017, at Chandigarh, India. The proceedings of the session on “Multisectoral actions to control NCDs, Tobacco and other risk factors” were recorded during the World NCD Congress 2017. The discussions that took place during the session have been included in the current paper.
Results and Proceedings
The results were obtained from four databases PubMed, CINAHL, and Web of Science, along with the WHO database, which gave 55, 230, and 63 results, respectively, which were further reviewed and a background paper was worked out. The basis of MSA for health goes back to the 1978 with the Alma-Ata Declaration that recognized concept of health for all and involvement of social and economic sectors and not merely the health sector. The Ottawa Charter for Health Promotion in 1986 took the movement further ahead by reiterating that health promotion policies must include the nonhealth sectors., In 2011, another dimension was added to NCDs with the UN Political Declaration on NCDs that recognized the importance of a leadership role and multisectoral approach at government level for the prevention and control of NCDs. The Global Coordination Mechanisms for NCDs was further established to facilitate and enhance the coordination of activities, multistakeholder engagement, and action across sectors in order to prevent and control NCDs at the local, national, regional, and global levels.
There have been many global and regional attempts for MSA in health and also in NCDs. A survey conducted by the WHO for the capacity assessment of responding countries (178) revealed that only 50% had an operational multisectoral national NCD action plan, which conforms with the global NCD action plan. Only 56% had an operational NCD unit within the Ministry of Health. The aim is to learn from the experiences of these countries and apply it to have well-designed programs with effective involvement of multiple sectors.
The session titled “Multisectoral Actions to control NCDs, Tobacco control and other risk factors” was held on November 6, 2017, as a plenary session during the World NCD Congress 2017 at Chandigarh, India. The session started with an address by the Chief Economic Advisor and Joint Secretary, Tobacco Control, Ministry of Health and Family Welfare (MoHFW), India, who said that in 2011, a new dimension came to NCDs with the UN Political Declaration of NCDs. It iterated the need of MSA and the robust mechanisms that can help achieve the goals. Former Regional Advisor, WHO Africa region, from Zimbabwe was the co-chair for the session.
The key speaker for the session was Director, NCD, MoHFW, India, who deliberated that MSA plans (MSAPs) call for specific role distribution among different sectors, to attain maximum benefit of the actions. Once the particular role of each sector is identified, engagement of sectors must follow one by one. This holds true especially for national NCD programs where leveraging of available resources must be done within each sector. Capacity building is essential for delivery of national level programs at the grass-root level.
The National Professional Officer – Tobacco Control, WHO, India, discussed MSA in tobacco control. She said that India is the third largest producer of tobacco. The Global Adult Tobacco Survey (GATS) 2009–2010 estimates nearly 275 million tobacco users in India (35%) which also includes smokeless tobacco. Consumption of tobacco is a risk factor for all the four major NCDs, i.e. diabetes, cardiovascular diseases, cancers, and chronic obstructive pulmonary disease. Therefore, tobacco costs not only the health of the nation and the workers but also leads to huge economic losses and pollutes the environment. The three pillars of tobacco control in India are the WHO Framework Convention on Tobacco Control (FCTC), Tobacco Control Act of India and Allied Laws, and National Tobacco Control Programme. India sets an example of MSA in tobacco control by involving the Ministry of Labour and Employment, Finance, Information and Broadcasting, Women and Child Development, Environment, Forest and Climate Change, Agriculture and Farmer Welfare, Railways, Human Resource Development, and Civil Aviation for tobacco control. Specific tasks have been elaborated for each sector such as placing tobacco in the highest tax bracket of 28% by the Ministry of Finance, and Skill Development Training Scheme launched for bidi rollers by the Ministry of Labour and Employment, to adoption of tobacco-free educational institution by CBSE under the Ministry of Human Resource Development. Adopting the approach of assigning specific tasks to each ministry creates an accountability mechanism to engage all stakeholders in tobacco control. In 2015, pictorial warnings were displayed to cover 85% of the tobacco package. This effort is an excellent example of a “best buy” or cost-effective, high-impact intervention for combating NCDs.
Any MSAP can be regulated at national, state, and district level. In India, where health is a state issue, many state-level innovations on tobacco control have also been implemented such as tobacco-free Durga Puja in West Bengal; tobacco-free Commonwealth Games in Delhi; undertaking of no tobacco use by all new officers joining government service, tobacco-free Anganwadi centers, tobacco-free police training center, State Tobacco Cessation Quit Lines in Rajasthan; and ban on hookah bars and e-cigarettes in Punjab among others.
The Director, Thai Health Promotion Foundation, in his presentation, discussed the case study of Thailand for multisectoral action in NCDs and tobacco control. He shared that despite the presence of good laws for the prevention and control of NCDs in Thailand, the implementation of laws needs to be further worked upon. The prevention and control of NCDs in Thailand also requires the involvement of more sectors and the community to have whole of government and whole of society approach. He also explicitly discussed the 4-quadrant model for NCD network management with the involvement of formal and informal sector in improvement and implementation of programs. He discussed the example of best practices for multisectoral action in Thailand to advocate for the Alcohol Control Act 2008 and the various activities undertaken to support the Act. One of the most important factors for the success of a multisectoral NCD program is the presence of strong and consistent leadership role provided by the government. Besides, lack of accountability to the public can be met by ensuring the accountability of each sector by the media and funding agencies which may aid in sustainability of a MSAP.
Countries are at different levels of socioeconomic development, at varying stages of epidemiologic transition, and at different levels of addressing and implementing programs for NCDs. The government of the state must not only take a leadership role but also involve active engagement of other important stakeholders at various levels. MSAPs call for specific role distribution among different sectors, to attain maximum benefit of the actions.
Multisectoral actions should involve whole-of-government, whole-of-society, and health in all policies (HiAP) approach and engage individuals, communities, families, media, private sector, religious practitioners, traditional medicine practitioners, and the industry. Behavioral risk factors as well as their social and political determinants need to be tackled through action in both health and nonhealth sectors. The concept of HiAP helps to improve accountability of policy-makers for health impacts at all levels of policy-making. It has been instrumental with tobacco control by the development of FCTC 2003. It has included supply and demand reduction of tobacco products and involves the Ministry of Health and other relevant ministries such as finance, trade or customs or trade in each country to meet minimum standards of governing the packaging, sale, advertising, and taxation of tobacco products.
India was the first country to endorse the Global Action Plan 2013–2020 and develop specific national targets and indicators that aimed at reducing premature deaths from NCDs by 25% by 2025. Sri Lanka and Nepal are among other countries in the SEA region to develop MSA plans for the prevention and control of NCDs., The four strategic areas of the National MSAP, India, are integrated and multisectoral coordination, health promotion, health systems strengthening, and surveillance, monitoring, evaluation, and research. The nodal agency for each of these areas has also been defined for accountability.
The WHO has recommended “best buys” which are a cluster of highly cost-effective interventions that forms the central plank of the global strategy to combat NCDs and cannot be achieved without MSAPs. MSAPs help in creating enabling environments, thereby making it easier for the people to adopt healthy choices. The multisectoral action plan is needed from identification of problems to addressing the problem. Aligning of health goals to the mandate of different sectors is a must for involvement of multiple sectors for the prevention and control of NCDs.
Multisectoral action in tobacco control
Tobacco control involves not only addressing tobacco use at the individual level but it also includes having multisectoral approaches to target production, taxation, trade, and implementation of tobacco control laws. In 2003, the WHO FCTC was the first evidence-based treaty negotiated under the auspices of the WHO. It came into being because of the rise of the tobacco epidemic globally and consisted of articles that mainly addressed the demand and supply chain of within country and cross country tobacco chain.
In Philippines, The Tobacco Regulation Act (RA 9211) was established in 2003 as a result of which the Interagency Committee for Tobacco was instituted by the Philippine Government to govern tobacco control. In the current scenario, private commercial gains overpower health concerns and governments strive for a “balance” between the two. It is important for policy-makers to focus on health objectives while designing a policy for NCD prevention and control.
The ultimate strategy for tobacco control is the reduction of demand and supply of tobacco. The solution for tobacco control is to strengthen existing networks and partnerships among researchers and tobacco control advocates. Key measures for such a comprehensive tobacco control strategy include measures involving various sectors such as law, justice, finance, treasury, customs and excise, trade and commerce, consumer affairs, agriculture, external affairs and international trade, labor, transport, and public service, health, education, environment, defense, culture and sports, and religion. Tobacco control agencies have faced the wrath of the tobacco industry. Despite that, there have been success stories in enforcing tobacco legislation. The Indian Government has been successfully able to demonstrate the reduction of tobacco users through multisectoral action through COTPA evidenced by a reduction of tobacco users from 18.4% in GATS 1 to 12.4% in GATS 2 among young users which is a welcoming evidence to the world.
Multisectoral action plans have been drafted by many countries like India, Sri Lanka, and Nepal in the SEA region following the Global Action Plan 2013. However, the implementation mechanisms for MSAPs need more focus and investment in population-wide prevention approaches must be done. Clear, scalable actions that are appealing to the mandate of each sector need to be incorporated into policy such that every sector is accountable for its role. Strong leadership from heads of the state is required for implementation of these programs along with mechanisms developed for facilitating, supporting, and monitoring multisectoral collaboration and action.
The resource persons for the session were Arun Kumar Jha, Chief Economic Advisor and Joint Secretary, Tobacco Control, Ministry of Health and Family Welfare (MoHFW), India, Dr. Davison Munodawafa, Former Regional Advisor, WHO Africa Region, Dr. Rajeev Kumar, Director NCD, MoHFW, India, Vineet Gill Munish, National Professional Officer, WHO, India, Dr. Bundit Sornpaisarn, Director, Thai Health Promotion Foundation, Dr. Sadhna Bhagwat, NPO (NCD), WHO, India, Dr. Fikru Tullu, Team Leader NCD, WHO, India, Prof. J. S. Thakur, Professor, School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh.
Financial support and sponsorship
The project was funded by the World NCD Federation as a requisite for the World NCD Congress, Chandigarh 2017. The funds were provided by the WHO, Country Office, India, to the World NCD Federation for this session.
Conflicts of interest
There are no conflicts of interest.
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