Learning from progress: global NCD policy implementation at national level
Authors: Sandeep P Kishore, Usnish B Majumdar
Journal: The Lancet Global Health (2019)

Non-communicable diseases (NCDs) have begun to receive promising political and social attention from heads of state and ministries of health. Starting in 2011, several high-level UN meetings have generated political declarations, assessments of global progress, and key NCD-related goals for the 2030 Agenda for Sustainable Development.1NCD Countdown 2030 collaboratorsNCD Countdown 2030: worldwide trends in non-communicable disease mortality and progress towards Sustainable Development Goal target 3.4.Lancet. 2018; 392: 1072-1088Google Scholar In concert, WHO has presented 18 best-buy national policies that are deemed cost-effective in systematically and equitably reducing NCD mortality and morbidity—including the provision of relevant metrics (ie, survey infrastructure and targets regarding relevant health outcomes), market-oriented interventions (ie, tobacco and alcohol advertising bans), and policies governing access to key medications and counselling (ie, cardiovascular therapies). In light of this remarkable consensus, it has remained difficult to assess, track, and understand slow and uneven country-level progress in implementing these best-buy policies. To what extent do our intuitions about the social and political conditions for policy progress hold true? What can be learned from countries that have encountered barriers to implementation, or from those that have achieved success? Previous research in this area has centred around closely read case studies and commentary in Scandinavia, sub-Saharan Africa, and the USA.2Juma PA Mohamed SF Matanje Mwagomba BL et al.Non-communicable disease prevention policy process in five African countries.BMC Public Health. 2018; 18: 961Google Scholar, 3NCD AllianceDraft political declaration for UN High-Level Meeting on NCDs lacks strength and ambition required to avoid a preventable global health crisis.https://ncdalliance.org/news-events/news/draft-political-declaration-for-un-high-level-meeting-on-ncds-lacks-strength-and-ambition-required-to-avoid-a-preventable-global-health-crisisDate: Aug 8, 2018Date accessed: November 17, 2019Google Scholar The generalisability of these learnings to other settings where NCD-related reform is in progress is uncertain without more systematic analysis. In The Lancet Global Health, Luke N Allen and colleagues4Allen LN Nicholson BD Yeung BYT Goiana-da-Silva F Implementation of non-communicable disease policies: a geopolitical analysis of 151 countries.Lancet Glob Health. 2019; (published online Dec 5)https://doi.org/10.1016/S2214-109X(19)30446-2Google Scholar provide an empirical, systematic approach to analysing variation in NCD policy responses due to several geopolitical and economic factors. Using 2015 and 2017 WHO NCD progress monitors, the authors developed implementation scores for 151 countries across 18 WHO-identified best-buy NCD policies. They examined the association of seven social, political, and economic factors with policy implementation. Many of these factors are intuitive barriers and promoters of progress: region, NCD burden, human and financial resources (ie, personal wealth, tax burden), political ideology, and social solidarity. The Article builds on the framing of accountability highlighted in the NCD Countdown 2030 paper in The Lancet1NCD Countdown 2030 collaboratorsNCD Countdown 2030: worldwide trends in non-communicable disease mortality and progress towards Sustainable Development Goal target 3.4.Lancet. 2018; 392: 1072-1088Google Scholar to animate progress and variations in NCD policy implementation using WHO data. Overall, the authors find the mean NCD policy implementation score to be 49·3% (SD 18·4%), with just under half of the 18 policies implemented. Costa Rica and Iran had the joint-highest implementation scores (86·1% of all WHO-recommended policies) and Haiti and South Sudan had the lowest (5·5%). The authors find the most frequently implemented policies are clinical guidelines, graphic warnings on tobacco packages, and NCD risk factor surveys. In examining which factors are most associated with progress, in their multivariate model the strongest predictor was the human capital index, a World Bank metric. This analysis brings forth three major contributions. First, a crucial contribution of the manuscript is to provide fresh quantitative data to test key geopolitical assumptions on NCD policy implementation—to move beyond intuition and provide a scorable profile to explore variance in implementation progress at national level. Second, the authors show that NCD implementation need not be expensive. The authors highlight the example of Moldova, which ranks 130th out of 151 countries in terms of gross national income, but joint fifth overall for NCD policy implementation. The highest implementation scores were by middle-income countries. The authors affirm that NCD policies are cost-effective and often even generate revenue—a message that deserves amplification in a time of global austerity and retrenchment on public health investment. Third, the authors provide one of the first investigations of national political characteristics and their relationship to NCD policy implementation. Previous work by Bollyky and colleagues5Bollyky TJ Templin T Cohen M Schoder D Dieleman JL Wigley S The relationships between democratic experience, adult health, and cause-specific mortality in 170 countries between 1980 and 2016: an observational analysis.Lancet. 2019; 393: 1628-1640Google Scholar found that democracy is positively associated with health outcomes and service provision; the present study observes that although democratic countries might be more responsive to vulnerable groups, they might also be less likely to impose measures that address commercial determinants of health. The USA, for example, performed poorly on market-related policies ranking 50th out of 151 countries; Denmark, Sweden and Iceland and the Netherlands did not make the top 20 countries per NCD policy implementation. The UK, on the other hand, came joint second. Interestingly, the social and political factors chosen by the authors only explained 61·1% of the variance in NCD implementation scores. What types of social and political factors could have been included to capture the remaining variance? Furthermore, the associations that were found between democracy, tax burden, and human capital indices raise new questions about the relationship between democracy and public health. Nonetheless, this work represents an important step in bringing empiricism to global NCD strategy. SPK was an author for NCD Countdown 2030. He has also served as a consultant for Resolve to Save Lives for hypertension control and has led a partnership on multiple chronic conditions supported by the Arnhold Institute for Global Health at the Icahn School of Medicine at Mount Sinai and Teva Pharmaceuticals. UBM declares no competing interests. Implementation of non-communicable disease policies: a geopolitical analysis of 151 countriesImplementation of WHO-recommended NCD policies is increasing over time. On average, countries implemented just under half of the NCD policies recommended by WHO in 2017. Nutrition-related policies saw gains, while those related to alcohol and physical activity were the most likely to have been dropped. Aggregate implementation scores tended to be highest in high-income countries that invest in health care and education. Full-Text PDF Open Access