NCDs Global Action Plan 2013-2020

The final draft of Global Action Plan 2013-2020 (GAP) for prevention and control of non-communicable diseases (NCDs) is expected to be ready ahead of the forthcoming 66th World Health Assembly in April/May 2013 for its approval and adoption. With the GAP approved, and available as a guide, then, the world will be truly armed with an instrument to change the global NCDs scenario.

The GAP zero draft of October 2012 came up as the first draft before the 11 January 2013 meeting of the WHO. The first draft has important structural changes over the zero draft calling for "a world in which all countries and parties sustain their political and financial commitments". The overarching principle being" NCDs are a challenge to social and economic development". 

The GAP first draft also has added the elements of NCDs Global Monitoring Framework (including twenty-five indicators) and Voluntary Global Targets (nine targets) finalised in the WHO meeting of member states late last year (5-7 November 2012). However the stakeholders want the 25 indicators of Global Monitoring Framework (GMF) and 9 voluntary global targets should be integrated in GAP alongwith evidence based interventions. Let us examine the GMF and GAP in some detail:

The Global Monitoring Framework: 

The WHO meeting of member states held late last year (5-7 November, 2012) had concluded work on GMF including indicators and set of voluntary global targets for prevention and control of NCDs. The meeting agreed with consensus for their consideration and adoption by the WHO Executive Board in January 2013 meeting and recommending them to the 66th WHA without "reopening discussion on them".

The framework comprise three components namely, (1) Mortality & Morbidity, (2) Risk Factors, (3) National Systems Response. In all there are 25 indicators for these three components:

1. Mortality and morbidity (Two indicators) 

•  Unconditional probability of dying between ages 30 and 70 years from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases.

• Cancer incidence, by type of cancer, per 100 000 population.

2. Risk factors (Twenty-three indicators)

• Behavioural risk factors (Ten indicators):

1. Harmful use of alcohol: Total (recorded and unrecorded) alcohol per capita (15+ years old) consumption within a calendar year in litres of pure alcohol, as appropriate, within the national context.
2. Harmful use of alcohol: Age-standardized prevalence of heavy episodic drinking among adolescents and adults, as appropriate, within the national context. 
3.  Harmful use of alcohol: Alcohol-related morbidity and mortality among adolescents and adults, as appropriate, within the national context.
4. Age-standardized prevalence of persons (aged 18+ years) consuming less than five total servings (400 grams) of fruit and vegetables per day.
5.  Prevalence of insufficiently physically active adolescents (defined as less than 60 minutes of moderate to vigorous intensity activity daily). 
6. Age-standardized prevalence of insufficiently physically active persons aged 18+ years (defined as less than 150 minutes of moderate-intensity activity per week, or equivalent). 
7. Age-standardized mean population intake of salt (sodium chloride) per day in grams in persons aged 18+ years. 
8. Age-standardized mean proportion of total energy intake from saturated fatty acids in persons aged 18+ years.
9. Prevalence of current tobacco use among adolescents. 
10. Age-standardized prevalence of current tobacco use among persons aged 18+ years.

• Biological risk factors (Five indicators):

1.  Age-standardized prevalence of raised blood glucose/diabetes among persons aged 18+ years (defined as fasting plasma glucose value _7.0 mmol/L (126 mg/dl) or on medication for raised blood glucose). 
2. Age-standardized prevalence of raised blood pressure among persons aged 18+ years (defined as systolic blood pressure _140 mmHg and/or diastolic blood pressure _90 mmHg); and mean systolic blood pressure.
3. Prevalence of overweight and obesity in adolescents (defined according to the WHO growth reference for school-aged children and adolescents, overweight – one standard deviation body mass index for age and sex, and obese – two standard deviations body mass index for age and sex).
4. Age-standardized prevalence of overweight and obesity in persons aged 18+ years (defined as body mass index _25 kg/m² for overweight and body mass index _30 kg/m² for obesity). 
5. Age-standardized prevalence of raised total cholesterol among persons aged 18+ years (defined as total cholesterol _5.0 mmol/L or 190 mg/dl); and mean total cholesterol.

3. National systems response (Eight indicators):

1. Proportion of women between the ages of 30–49 screened for cervical cancer at least once, or more often, and for lower or higher age groups according to national programmes or policies.
2. Proportion of eligible persons (defined as aged 40 years and over with a 10-year cardiovascular risk _30%, including those with existing cardiovascular disease) receiving drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes. 
3. Availability and affordability of quality, safe and efficacious essential noncommunicable disease medicines, including generics, and basic technologies in both public and private facilities.
4. Vaccination coverage against hepatitis B virus monitored by number of third doses of Hep-B vaccine (HepB3) administered to infants. 
5.  Availability, as appropriate, if cost-effective and affordable, of vaccines against human papillomavirus, according to national programmes and policies. 
6. 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.  
7. Access to palliative care assessed by morphine-equivalent consumption of strong opioid analgesics (excluding methadone) per death from cancer. 
8.  Adoption of national policies that limit saturated fatty acids and virtually eliminate partially hydrogenated vegetable oils in the food supply, as appropriate, within the national context and national programmes. 

Voluntary Global Targets:

The WHO member states are required to achieve a set of nine voluntary global targets by using fifteen indicators by 2025 in order to achieve meaningful prevention and control of NCDs. Achievement of these sixteen targets by 2025 would be an indication of major progress in the prevention and control of NCDs. 

1. Indicator for premature mortality and morbidity from NCDs  

Target: A 25% relative reduction in overall mortality from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases. 

• Indicator: Unconditional probability of dying between ages 30 and 70 from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases.

2. Indicators for risk factors 

2.1 Behavioural risk factors 

2.1.1 Harmful use of alcohol 

Target: At least a 10 % relative reduction in the harmful use of alcohol, as appropriate, within the national context.

• Indicator: Total (recorded and unrecorded) alcohol per capita (15+ years old) consumption within a calendar year in litres of pure alcohol, as appropriate, within the national context.

•  Indicator: Age-standardized prevalence of heavy episodic drinking among adolescents and adults, as appropriate, within the national context. 

• Indicator:  Alcohol-related morbidity and mortality among adolescents and adults, as appropriate, within the national context. 

 (Note: Countries to select their indicator (s) of harmful use, appropriate to national context, in line with WHO’s global strategy to reduce the harmful use of alcohol; harmful use may include heavy episodic drinking, total alcohol per capita consumption, and alcohol-related morbidity and mortality).

 

2.1.2 Physical inactivity 

Target: A 10% relative reduction in prevalence of insufficient physical activity.

• Indicator: Prevalence of insufficiently physically active adolescents defined as less than 60 minutes of moderate to vigorous intensity activity daily.

• Indicator: Age-standardized prevalence of insufficiently physically active persons aged 18+ years (defined as less than 150 minutes of moderate-intensity activity per week, or equivalent). 

2.1.3 Salt/sodium intake 

Target: A 30% relative reduction in mean population intake of salt/sodium intake.3

•  Indicator: Age-standardized mean population intake of salt (sodium chloride) per day in grams in persons aged 18+ years.

(Note:  As per WHO’s recommendation, the consumption should be 5 grams of salt or 2 grams of sodium per person per day).

2.1.4 Tobacco use 

Target: A 30% relative reduction in prevalence of current tobacco use in persons aged 15+ years.

•  Indicator: Prevalence of current tobacco use among adolescents. 
•  Indicator: Age-standardized prevalence of current tobacco use among persons aged     18+ years.

2.2 Biological risk factors:

2.2.1 Raised blood pressure   

Target: A 25% relative reduction in the prevalence of raised blood pressure or contain the prevalence of raised blood pressure according to national circumstances.

• Indicator:  Age-standardized prevalence of raised blood pressure among persons aged 18+ years (defined as systolic blood pressure _140 mmHg and/or diastolic blood pressure _90 mmHg).

2.2.2 Diabetes and obesity 

Target: Halt the rise in diabetes and obesity.

• Indicator: Age-standardized prevalence of raised blood glucose/diabetes among persons aged 18+ years (defined as fasting plasma glucose value _7.0 mmol/L (126 mg/dl) or on medication for raised blood glucose.

• Indicator:  Prevalence of overweight and obesity in adolescents (defined according to the WHO growth reference for school-aged children and adolescents, overweight – one standard deviation body mass index for age and sex and obese – two standard deviations body mass index for age and sex).

•  Indicator:  Age-standardized prevalence of overweight and obesity in persons aged 18+ years (defined as body mass index _25 kg/m² for overweight and body mass index _30 kg/m² for obesity).

3. National systems response Indicators

3.1 Drug therapy to prevent heart attacks and strokes 

Target: At least 50% of eligible people receive drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes.

• Indicator:  Proportion of eligible persons (defined as aged 40 years and over with a 10-year cardiovascular risk _30%, including those with existing cardiovascular disease) receiving drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes.

3.2 Essential noncommunicable disease medicines and basic technologies to treat major noncommunicable diseases  

Target: An 80% availability of the affordable basic technologies and essential medicines, including generics, required to treat major noncommunicable diseases in both public and private facilities.

• Indicator:  Availability and affordability of quality, safe and efficacious essential noncommunicable disease medicines, including generics, and basic technologies in both public and private facilities.

 …………..to be concluded in the next Post.