NCDs negatively impact on macroeconomic productivity, national incomes, health care budgets, household income and impoverishment. Extensive simulations predict that over the period 2011–2025, the cumulative global economic losses due to the four main NCDs will surpass US$ 51 trillion. While the cost of inaction associated with the four major NCDs in LMICs alone is projected to be more than US$ 7 trillion between 2011 and 2025, the cost of action in these countries is estimated at US$ 170 billion in the same period (WHO Global Coordination Mechanism on the Prevention and Control of Non communicable Diseases, Final report and recommendations).
A growing funding gap
Although dominating the global burden of death and disability, with around 70% of deaths, NCDs attract less than 2% of all global health funding (Luke Allen, “Why Is There No Funding For Non-Communicable Diseases?"). They are no longer diseases of rich and developed countries only. The funding gap is indeed a major concern in LMICs facing an increasing burden of NCDs.
There are many reasons for this “growing disconnect” (Luke Allen) between funding and burden of disease. An “unengaging name and narrative” is one of them and public health specialists call for renaming NCDs, considering it as a “non-definition that only tells what this group of diseases is not” (Luke Allen). NCDs have also less emotional charge than communicable diseases affecting children, which “naturally arouse charitable sentiment” (Luke Allen). Funders may be more concerned by infectious diseases because these conditions expose others to risk. As regards NCD risk factors, too much focus is still put on individual behavior rather than societal and external drivers (i.e. consumer environment as regards dietary risk factors, air pollution or working conditions) which largely influence individual lifestyle choices. The common perception is that it is the responsibility of everyone to reduce risk factors for NCDs and nobody should pay for something which is avoidable. Difficulties in making the economic and business case for investing in NCD prevention and control persist and donors tend to prefer vertical programs focusing on diseases which show quick results and wins.
NCDs are the most prominent cause of mortality and morbidity in Eastern Europe and Central Asia, reaching 80% in total. Cardiovascular and respiratory diseases, cancer, diabetes, as well as their corresponding risk factors, could be dramatically reduced through efficient prevention and promotion of healthy lifestyles. Locally adapted community-based approaches, multi-sectoral collaboration for specific health policies and the creation of supportive environments are crucial in ensuring more sustainable results. However, post-soviet curative and hospital-centric health systems are not sufficiently prepared to address these challenges.
Shaping the NCDs national, regional and global agenda
In the last five years, new priorities have been set by the Swiss Agency for Development and Cooperation (SDC) in the country Cooperation Strategies for Ukraine, Moldova, Albania, Bosnia and Herzegovina, Kosovo, Kyrgyzstan and Tajikistan. Most of bilateral programs, including in new EU member States, have now a strong focus on NCD prevention and control at primary healthcare level and in community settings.
Together with the Federation of Russia and Kazakhstan, Switzerland is one of the major bilateral donors significantly contributing to addressing NCDs in the region. The current SDC portfolio amounts to around CHF 80 million, with a commitment over 10 years.
As regards the global NCD agenda, taking a whole-of-government approach through close collaboration with the Federal Office of Public Health, the Sectoral Foreign Policies Division, and the Permanent Mission of Switzerland to the UN Office, SDC promotes policy coherence, multisectoral cooperation and the integration of NCDs goals in development and sectoral planning processes. Switzerland contribution in global policy-making processes in relation to NCDs is significant. Recent examples include the update of the Appendix 3 of the Global Action Plan for the Prevention and Control of NCDs 2013-2020, and the elaboration of the WHO global action plan on physical activity 2018-2030.
SDC is a member of various WHO NCDs working groups addressing health promotion (follow up on the Shanghai Conference 2016 Commitments), health literacy (NCDs/GCM) and the monitoring and evaluation of NCD National Strategies and Action Plans in the WHO European region.
Tackling determinants of health is a central pillar of the SDC Global Program Health. Two initiatives addressing the regulatory and legal framework on child obesity dietary risk factors and the climate change and health nexus are currently being developed. This engagement at global level will considerably leverage efforts made at country level.
Bilateral projects implemented in the region provide strong evidence which is continuously fed into national, regional and global policies and strategies. This sound evidence highly contributes to the positioning of SDC as a reliable and innovative stakeholder in the fight against NCDs.
Strong and resilient health systems for preventing and managing NCDs
SDC advocates for increased health expenditure for the prevention and control of NCDs, with a view to attaining national NCD targets for 2025 and 2030, based on the nine global, voluntary targets for NCDs and the NCD-related targets included in the SDGs.
The use of different aid modalities, ranging from budget support to mandated projects, and high flexibility allow leverage efforts and foster commitment of key stakeholders. In Kyrgyzstan, the conditionalities set up within the sector wide approach arrangements significantly contribute to sustain the results achieved within bilateral programs.
SDC doesn’t address NCDs vertically. Aiming to strengthen health systems to better respond to this growing burden, interventions take a comprehensive and systemic approach in tackling issues related to NCD policy framework, promotion of healthy lifestyles, primary and secondary prevention, reshaping of primary health care services, health literacy and consumer environment, and determinants of health.
At the national level, SDC advocates for NCD prevention and control as a part of universal health coverage packages that should be given priority in overall health budget according to the burden of NCDs. Strong policy dialogue and capacity building components aim at supporting governments to strengthen their stewardship, mainstream NCDs in all policies and effectively and efficiently use domestic resources to implement national NCD responses. In Kosovo, SDC supports the introduction of a financial protection mechanism covering NCDs and thus reducing related private or informal expenditures. In Moldova, the capacities of the healthcare insurance fund for strategic purchasing of services for NDCs are also strengthened.
Active and healthy ageing in Moldova. Photo: © SDC, 2017
SDC’s approach aims at developing a comprehensive investment framework for NCDs. Interventions support the introduction of “best buys” part of the WHO Global Action Plan on NCDs 2013–2020. It consists in the implementation of a number of multisectoral and multistakeholder evidence-based policy options and cost-effective public health interventions, such as banning trans-fats in the foodchain or raising taxes on sugarsweetened beverages to reduce sugar consumption.
In order to ensure a strong multisectoral collaboration, in Moldova and Ukraine, governments are supported in establishing effective and transparent intersectoral governance structures in charge of NCDs, with a dedicated budget to implement concrete actions and clear responsibility and accountability lines.
NCD interventions aim at strengthening people-centered primary health care and moving from a “level-of-care approach” to a life-course approach. Programs work with different partners at local, regional and national level on three major pillars: individual-based interventions, population-based interventions, and creating the necessary enabling environment.
Chronic care implies the diversification of services and the integration of medical and social care. SDC interventions highly contribute to the deinstitutionalization of primary health care services by using and transposing Swiss models and expertise: home-based care inspired by the Swiss Spitex model has been introduced in Bulgaria, community-based mental health in Bosnia and Herzegovina, general practitioners clusters in Hungary, and palliative care in the Czech Republic.
In addressing NCD risk- and health-seeking behaviors, specific interventions targeting men have been designed. They are focused on improving health literacy and changing stereotypes and social and cultural norms about masculinity which can lead to unhealthy lifestyle choices.
Mobilizing civil society around NCD prevention and healthy lifestyles promotion is also a key component of all NCD interventions. It mainly consists in fostering grass-roots and civil society movements and consumer-led advocacy calling for more investments in NCDs and improved environments.
An unfinished agenda
Weak political commitment and inadequate institutional set up to address NCDs seriously hamper programs’ efforts. In most of the Eastern European countries, there is no dedicated unit for NCDs within the Ministry of Health or no inter-ministerial unit.
NCD policy and regulatory frameworks remain weak: national NCD targets and indicators not set, operational national multi-sectoral policy and action plan on NCDs not developed, and measures to reduce risk factors not introduced. Countries are unable to generate reliable cause-specific mortality data on a routine basis or to develop evidence-based guidelines for the management of major NCDs.
At service delivery level, the main difficulty lies in strengthening NCD prevention and promotion of healthy lifestyles at primary level, mainly due to high resistance to change from health care staff. Referral systems remain weak and rehabilitation systems dysfunctional. Generic, affordable NCD drugs and technologies are still not available in most of the countries.
Changing population’s unhealthy behavior patterns remains also a major challenge, as well as going beyond individual behavior and tackling underlying drivers (food, urban development, trade). The influence of the food, beverage and tobacco industry is high and building partnerships with the private sector in order to promote healthy lifestyle choices remains difficult.
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