The world can do more to fight chronic disease

The first analysis of WHO-recommended policies to prevent and control non-communicable diseases (NCDs) finds that implementation is slowly improving, but on average just over half get no further than being endorsed.

The study uses figures from 151 countries and was published in The Lancet Global Health journal. The study is the first to analyse what progress was made in putting 18 policies into practice worldwide between 2015 and 2017.

In 2015, 193 countries committed to reduce premature NCD deaths by a third by 2030 as part of the UN’s sustainable development goals. WHO member states have endorsed a set of interventions to help reduce the four main risk factors for NCDs: tobacco use, the harmful use of alcohol, unhealthy diets and physical inactivity.

In 2018, the WHO’s independent high-level commission on NCDs, of which The Lancet is a partner, called for bold actions from heads of state to prevent and treat NCDs and to promote mental health and wellbeing.

“The WHO has provided a road map to help governments respond to the challenge of reducing preventable premature deaths from non-communicable diseases, and we set out to see whether it’s being followed in practice and, if not, why that might be,” says Dr Luke Allen from the University of Oxford, UK. [1]

For their analysis, the authors used progress reports released by the WHO in 2015 and 2017, which monitored the extent to which 18 NCD policies were implemented in 151 countries.

To score countries on how well they had implemented the policies, they awarded a point for every policy fully implemented, half a point for partial implementation, and zero for no implementation, or when there was no data (this was then converted into a percentage). The authors ranked countries according to the percentage of policies they had applied.

The new study found that overall, implementation improved from an average of 42% in 2015 to 49% in 2017, so the percentage of policies implemented remained just under half. 109 countries increased the number of NCD policies implemented, but in 32 countries progress reversed. In South Sudan and Haiti, only 5% of policies were implemented in 2017, while Costa Rica and Iran had the joint highest implementation scores, at nearly 87%.

On average, implementation improved for 14 out of 18 policies. The most commonly implemented were the introduction of clinical guidelines, graphic warnings on tobacco packaging and surveys on national NCD risk factors.

The least widely implemented were market-related policies, including tobacco taxation, tobacco mass-media campaigns and alcohol advertising bans, as well as providing cardiovascular drug therapy.

Many countries took a step backwards on promoting physical activity through mass-media campaigns (on average, implementation fell from 61% to 54%) and on imposing restrictions on the sale and promotion of alcohol (implementation of alcohol advertising bans fell by 10% between 2015 and 2017; from 43% to 33%).

The researchers analysed associations between the extent of implementation and seven political, geographic, economic and mortality indicators such as each nation’s democracy index, World Bank income group and risk of premature death from NCDs.

The results suggest that more policies were implemented in democratic centre-left countries. The authors say that, in theory, democracies are more responsive to their populations, although they point out that they might also be less likely to impose measures that constrain industry profits.

For example, the USA performed poorly on market-related policies and came 50th out of 151 countries overall for the percentage of all policies it had implemented.

Many high-income countries were in the top 20 for implementation, while scores were lowest in low-income countries. For example, 17 of the bottom 20 countries were in sub-Saharan Africa. However, some countries defied this trend.

For example, the highest implementation scores were achieved by two middle-income countries, Iran and Costa Rica, while Moldova ranked joint fifth overall for NCD policy implementation despite coming 130th out of the 151 countries in terms of gross national income.

“Although financial resources are helpful, putting NCD policies into effect is not necessarily expensive, and some – like taxes – can actually generate revenue, adding to a country’s balance sheet rather than being a drain,” says Beatrice Yeung from the University of Oxford, UK.

The authors highlight several limitations to their study. For example, some policies are more effective than others at combating NCDs but the implementation scores treat them as equivalent. Meanwhile, the analysis of possible explanations for the wide variability in implementation was able to identify associations, but these cannot be seen as causes.