Feature Non-Communicable Diseases

Targets for non-communicable disease: what has happened since the UN summit?

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f3300 (Published 21 May 2013) Cite this as: BMJ 2013;346:f3300
  1. Joyce K Ho, Stanford-NBC news media and global health fellow,
  2. Rajaie Batniji, Stanford Center for Innovation in Global Health fellow
  1. 1Grant Building, 300 Pasteur Drive, Stanford, CA 94305, USA
  1. Correspondence to: J K Ho joyceho613{at}gmail.com

This week’s World Health Assembly will again discuss targets for non-communicable diseases. Joyce K Ho and Rajaie Batniji examine the difficulties of getting an agreement

Back in September 2011, health ministers from 194 countries around the world met in New York under the auspices of the United Nations. Their aim was to put non-communicable diseases (NCDs), such as diabetes, cancer, lung and heart disease, on the international health agenda. NCDs are currently the biggest killers in the world, causing 63% of all global deaths in 2008.1 After a series of negotiations, an outcomes document was produced that called upon the World Health Organization to spearhead the development of global targets for controlling NCDs by the end of 2012.2

This week, a year and a half after the UN meeting, the WHO’s annual meeting, the World Health Assembly, should agree on a final set of nine targets and 25 indicators. Only one target has been adopted so far: a 25% reduction in NCD related mortality by 2025.3 But getting to this point has not been straightforward.

Lack of consensus

The process started back in December 2011, when WHO published its original list of ten targets ranging from diabetes prevention to smoking and alcohol reduction (table 1).4 But not everyone agreed. Discussions with all of the countries involved meant the 10 targets were whittled down to five by March 2012.5

Table 1

Evolution of targets since the NCD summit in September 2011

View this table:

Gone were the goals to reduce the prevalence of diabetes and obesity and consumption of alcohol and trans-fats, as well as targets to increase coverage of treatments for cardiovascular disease and cervical cancer screening. A major concern was that the targets could not be met. Western Pacific and European countries were worried about how to monitor progress, and the Americas questioned whether there are effective interventions for targeting diabetes and obesity. Without interventions, countries argued, these targets are not feasible. The ones that remained on the list targeted overall NCD related mortality, salt intake, high blood pressure, and tobacco use.

The disappearance of the five targets from the list created concern. Countries that were initially silent began to speak up once targets were removed. Obesity and diabetes targets, which did not meet WHO criteria for inclusion on the list, were particularly contentious. Countries in the eastern Mediterranean strongly pushed for adding them, reflecting the high burden of disease in this region. WHO was charged with doing further research around the four main risk factors for NCDs (tobacco, harmful use of alcohol, diet, and physical activity)—and its research was published last October.6 After reviewing the data, member states began an extensive negotiation in November, and a compromise was reached to produce the final list of targets and indicators to be voted on this week.7

Compromise

Although all 10 original WHO targets are in the final list, there have been some changes. Halting of diabetes and obesity became one shared target because they have similar risk factors. Cholesterol and fat intake, initially criticised for lacking baseline measurements, were encompassed in other targets such as diabetes and obesity and redefined as indicators. Cervical cancer screening also became an indicator. These changes reflected the desire of member states to have fewer targets while including all relevant issues.

But who wanted what? WHO published a report breaking down country support for targets by region (table 2).8 The targets with least support all pertain to reduction of alcohol consumption and limiting of diet such as fat, salt, and cholesterol. Countries were uncomfortable with monitoring these targets, partly because of a lack of baseline data. The Americas had reservations about how indicators were developed for alcohol and diet related targets. And the food and alcohol industries were especially active in penetrating the discussions at UN civil society hearings.9

Table 2

WHO regional breakdown of target evaluation in November 2012

View this table:

The South East Asia region was concerned about achievability of a salt intake target, and the Western Pacific region thought that there were too many targets altogether, questioning “all targets for all indicators for all countries.” If a decision is reached about the targets and indicators this week, member states will then face the next round of negotiations: how to monitor and evaluate progress.

Despite countries each having their own agendas, WHO is hopeful that they will adopt the new list. Judith Mackay, senior adviser to the World Lung Foundation, sums up sentiment from charities representing the disease conditions. When asked about the evolution of targets and the vote this week, she simply responds, “It’s about time.”

Notes

Cite this as: BMJ 2013;346:f3300

Footnotes

  • We thank the Stanford-NBC News Media and Global Health Fellowship, Dr Timothy Armstrong, and Dr Matthew Park for contributions and support for this piece.

  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References