41. Ministers reaffirmed the Pacific Islands Forum Leaders’ declaration that the Pacific is now in an NCD crisis and commit to implementing the decisions of Forum Leaders by taking relevant actions within the jurisdiction of Ministries of Finance and Economic Development, agreed to allocate and mobilise resources for initiatives that have been proven to reduce the incidence and prevalence of NCDs. 42. Ministers supported implementation of taxation interventions targeting NCD risk factors, secondary intervention (including preventative measures) and nutrition policy dialogue as part of the NCD roadmap for the Pacific Island region that would provide the basis for an effective ‘whole of government’ and ‘whole of community’ approach to addressing the NCD crisis in the region, in collaboration with national health and other relevant ministries/departments and development partners. 43. Given the high priority accorded to addressing NCDs in the region by Leaders, Ministers agreed to include NCDs as a standing agenda for future FEMMs and requested the Secretariat of the Pacific Community, on behalf of the Quintilateral Partners in Health, to provide updates on the development of the NCD roadmap and ensure close engagement of Forum Members. 44. Ministers requested Secretariat of the Pacific Community, on behalf of the Quintilateral Partners in Health, to present the finalised NCD roadmap to Economic Ministers in 2014 outlining the specific role and contribution of Economic Ministers in strengthening NCD prevention and control in the Pacific region. 45. Ministers directed that the Forum Secretariat and Secretariat of the Pacific Community explore options for a joint meeting of Economic and Health Ministers to promote greater collaboration to tackle the epidemic rate of NCDs in the region. 46. Ministers noted the importance of political will in leading the fight against NCDs which may have positive implications for selected Forum Island Countries’ national budgets, as well as reducing NCDs’ burden as a result of implementation of the NCD roadmap which shall be developed.
Annex 6 Summary of recommendations Ministry or stakeholder responsible. Proposed action Expected benefit in reducing NCD Specific indicator to verify progress Likely cost / revenue implications Feasibility and obstacles to implementation Political implications (including winners and losers) Government Ministries Prime Minister’s Office Prime Minister to establish, and then actively chair, a regular meeting of a multi-sectoral task force to supervise progress in addressing NCDs Hold Government departments and other stakeholders accountable for progress through active monitoring and evaluation. Use the authority and convening power of the PM to create a sense of urgency and develop a genuinely approach to responding to NCDs. Weak implementation is the Achilles heel of many good policies. Lack of accountability and weak implementation wastes scarce Frequency of meetings of task force, and the level and breadth of representation. Evidence that the multi task force is taking decisions and that they are being implemented and actively monitored. Low direct financial cost. Some involvement of time by all stakeholders. Potential for cost savings if duplication of Government and other stakeholder effort is reduced, and revenue increased if new taxes agreed to. There are large – but hidden – costs when accountability is Easily feasible. Few obstacles to implementation initially, although maintaining commitment and momentum over the longer term may be a challenge. Difficult, but essential. Difficulties can be expected if tobacco, alcohol, or food processing industries use surrogates to weaken task force Some short term political pain when agencies realise they are being actively held accountable for implementation. Medium to long
financial and human resources. weak and implementation stalls. term gain in the authority, credibility and prestige of the Prime Minister’s office when agencies become – and are seen to become – more accountable for results. Attorney General The will need to be involved in any multi-sectoral task force to ensure that taxation and other measures are legally sound. Reduces the chance that taxes and other policies can be overturned by self-interested legal challenges, including from industry. Extent and quality of active participation by Attorney General or representative in multi-sectoral task forces. Avoidance of large court fees and compensation payments if legislation is sound and valid at the outset. Easily feasible to involve Attorney General or representative. Credibility of Government efforts is increased (decreased) if laws are found to be valid (invalid) Ministries of Agriculture Promote the production and marketing of fresh fruit, vegetables and fish. Restrict the use of land for smallholder Increases the availability of healthy foods, decreases production of domestic tobacco. Increases in the quantity, quality and availability of fruit, vegetables and fish in local markets. Decreased Increased cost for identifying and promoting healthy food products, especially if refrigerated warehouses for Need for consistent quality and reliable supply by producers. Assumes consumers will Potential for increased income from smallholder farmers and fishers. Resistance from small holder
production of tobacco leaf production of tobacco leaf from smallholders and others. fish have to be constructed. Some potential for reduced import bill on foodstuffs if local markets are attractive and competitive. Some potential for increased tax revenue to the extent that horticulture farmers, fishers, and retailers become more involved in the formal sector of the economy, rather than the informal sector actually switch back to local fresh products rather than processed products. tobacco farmers Ministries of Communication Ban or severely restrict advertising of unhealthy Counters aggressive marketing of unhealthy Cessation of advertising of unhealthy products at critical Some net cost to monitor compliance. Will need to monitor other alternatives eg advertising of Reduced revenue for TV and radio stations and print media over the
products especially when children are involved. Promote informed views and images about healthy lifestyles, including through social media products. Promotes knowledge and improved image of healthy living times, especially when children involved. Role models on popular TV shows exhibiting healthy lifestyles and eating habits Some possible gain to revenue if fines are imposed for repeated breaches. unhealthy products via social media short to medium term. Opposition from those whose products are banned from advertising. Ministries of Customs and Excise Strengthen the collection of excise duties on tobacco, alcohol and unhealthy food products (eg strengthen compliance of existing laws to reduce the sale of single stick cigarettes at markets). Collect – and publish – statistics on excise revenue collection of Reduces disregard of government regulations Improves the statistical and evidence base for policy making and Rise in the total value of revenue collected from unhealthy products. Map showing ‘hot spots’ where unhealthy products are Will increase government revenue collection Administratively feasible. But needs to be well supervised to ensure compliance officers are not subject to threats or bribes. Resistance from small trade store owners and others currently not paying the correct amount of excise revenue. Criticism from general public unless the reasons for the tighter compliance are explained well in advance. Support from National Statistics Office, PMs office
unhealthy products in collaboration with National Statistics Office, MOH and Ministry of Finance future revenue collection widely known to be sold, but where excise duties are inexplicably low etc for generating a better statistical evidence base for policy. Ministries of Education Screen school canteen menus to replace unhealthy food and drinks with healthy alternatives. Work with town councils to minimise fast food outlets and street vendors near schools. Promote exercise programs. Provide education about NCD risks and responses. Prohibit use of educational or sports scholarships from Reduce exposure to risk factors amongst a large population entering adulthood. In short term, change in the availability of healthy versus unhealthy food and drinks in the school environment, and changes in the level of physical activity. In the medium term, increase in knowledge of students about the risk factors for NCDs. In the medium to longer term, some Medium to high set up and transition costs to ensure there is sufficient, reliable, quality, local food supply chains in place to meet school canteen needs. Low overall running and operational costs and possibly some savings to school budgets if local food prices are cheaper than alternative manufactured foods and drinks. Switching school Technically feasible. However changes will require good communication and sensitising students to the reasons for changes if they are to be accepted in practice. Need to trial different menus to test acceptability. Need to ensure local supply chain can produce sufficient quantities of local healthy foods at Local farmers and fishers would benefit from expanded sales to school canteens. Fast food outlets and nearby trade stores selling sugar sweetened drinks and tobacco will lose business. Nearby horticultural producers and fishers will have an expanded market.
Increase excise duty on tobacco to reach 70% of the retail price of domestic and imported tobacco. Apply the excise duty on all tobacco products, and not just imported products, to increase revenue, reduce consumption, and be compatible with WTO rules and obligations. Reduces existing consumption new uptake of a major source of NCDs. Compliance ensures the intended health and revenue benefits are achieved. Reduces the attractiveness and affordability of cigarettes to the young and the poor. Government excise duties increased progressively over coming 3 years to reach 70% of retail price. Increased revenue Administratively easy to increase the excise duty. Strong resistance can be expected from tobacco industry. Need to ensure local smallholders do not increase growing of local tobacco leaf. Need to ensure compliance of new excise rates at customs borders and in small local trade stores. Significant and measurable reduction in NCDs over the medium to longer term. Reduction in wasted expenditure on cigarettes by the poor and the young as price increases take effect. Increased revenue for Ministry of Finance (depending upon price elasticities and compliance). Tobacco companies lose production and sales over the medium term. Government revenue a winner. Local traders breaking the law a
current disputes between Australia and tobacco companies are resolved. Avoid preferential rates for until their safety and effectiveness as tobacco cessation tool has been assessed. Increase taxes on other products linked to NCD risk factors including alcohol. Await further research and advice from WHO. Reduced consumption of alcohol, especially at harmful levels. Reduction in domestic violence and traffic accidents Increases in additional revenue and reduction over time in alcohol related NCDs (especially liver cancer etc) and alcohol related violence Will depend upon price elasticities of individual products and income elasticities of individual consumers. Increasing excise duties on alcohol is relatively straightforward from an administrative point of view. promote their products. Resistance from industry, support from women’s groups and churches. Ministries of Review and Strategic action to Increases in the Increased Requires good Government
Analyse reasons for different prices charged for imported essential NCD drugs such as simvastatin. Avoid high cost / low impact interventions (including possibly dialysis) and ‘futile care’. Improves the cost-effectiveness of essential drugs, and reduces costs. Reallocates scarce resources to areas of greater impact and financial sustainability. incidence and complications. Per unit price of key NCD drugs are competitive when compared to others in the Pacific and globally. Correctly measure the full economic cost per patient of dialysis, and health outcomes, as well as the cost and outcomes of ‘end of life futile care’. 900,000 to $NZ 4 million over five years). Over the medium to longer term there should be a net reduction in hospitalisation costs. Potential for major cost savings. Potential for major savings with little change in overall health results. Variable according to needs of the population group. improvement in the referral system etc. Initial analysis for price differences is easily feasible. Feasibility of reducing costs would depend upon circumstances. Technically feasible but difficult politically. reduction in access to traditional healers. Potentially major savings to MOH drug budget. Possible resistance from drug suppliers. Opposition from those who believe Government must ‘do everything’ for a patient (even if it is unaffordable or the resources could be used to save many more people in alternative uses).
monitoring and evaluation as the foundation for making best use of scarce resources evidence base to ensure scarce resources devoted to NCDs are not wasted. according to the key drivers of NCD risk and prevalence in the country. costs in monitoring and evaluating. Net savings where good monitoring and evaluation identifies scope for improvements. expertise, and willingness of management to make use of the findings. identify both winners and losers. Likely to attract strong support, at least in principle, from development partners. Ministries of Labour and Industry (and the Public Service Commission) Work constructively – but firmly - with food and drink manufacturers, and retailers, and Ministries of Health, to reduce the production and sale of unhealthy products. Work in an even – handed way to promote the production and marketing of alternative Unhealthy food products are important driver of NCDs especially in high risk groups. Expand public access to healthy foods. Improved labelling; reduced salt and sugar; etc Increased production – and consumption – of healthy food products in public markets etc, Small additional costs for Government; additional costs for manufacturers as they transition across to improved labelling, reduced salt etc. Some capital investment costs required (eg refrigerated warehousing at local public Technically feasible. Requires skilled negotiating and alliance building by Government. Feasibility is difficult and complex. Will require a combination of several factors: Initial resistance by food manufacturers. Need to ensure negotiations with industry are transparent: avoiding behind the scenes lobbying and ‘deals’
healthy local foods: eg regulations on food safety, quality, and labelling of locally produced and marketed vegetables, meat, fish, fruit. Where price controls are already in place, use these to encourage consumption of healthy products / discourage consumption of unhealthy products. Actively make workplaces “heart healthy” eg organising health checks amongst Workplaces are major catchment pools for large numbers of adults. including especially in poorer neighbourhoods. Initially, the number of ‘heart healthy’ work environments. Over the medium markets) May require subsidising by Government (companies may be reluctant to invest if they think workers then move to another job). ability of local producers to scale up - and then sustain reach improved food safety standards etc. Also assumes that consumers will respond by purchasing local products. Potentially difficult. On the demand side, it requires management to Initial support from local food producers. But enthusiasm and momentum may erode as it becomes clear that food quality standards and product consistency needs to improve. Some resistance from industry if it thinks Government is shifting the
and drink manufacturers of sporting teams and venues venues who lose sponsorship in the short term (although other more healthy industries may offer sponsorships). Opposition from unhealthy industries. Ministries of Trade Pacific Islands take a ‘whole of government’ approach, preferably led by the Prime Minister’s Office, and specifically involve Ministries of Health, in the development of a country’s position on trade and taxation issues Promote policy coherence in the response to a nationwide and regional NCD crisis. Avoid key health issues (eg import of unhealthy products) being overlooked in policy discussions. Initially, evidence that Ministry of Health is involved in the formulation of trade policy positions. Over the medium to longer term, evidence that a country’s trade policy position reflects a balancing of health priorities with trade objectives. Mixed. Excise duties on some unhealthy imports will increase (eg tobacco, alcohol, sugar-sweetened drinks and unhealthy foods) while excise duties on some other products (fresh fruit and vegetables) decrease. Administratively simple to involve MOH officials in policy formulation of trade. But some initial resistance likely from Ministry of Trade personnel. (Having Prime Minister’s Office emphasing the NCD crisis rationale for MOH involvement would help reduce institutional More coherent ‘whole of government’ approach to trade and economic policy. May be some resistance from Ministry of Trade officials, and opposition from manufacturers and importers of unhealthy products.
and fresh food markets – compared to unhealthy facilities – including fast food outlets and plan future developments in better ways. Consider including in planning codes that new developments have recreational areas; sidewalks; dog control (to prevent attacks on those walking); and parks etc are maintained As above active lifestyles. In the medium term, evidence that the mapping exercise has led to more ‘heart healthy’ built environments As above Reduced revenue if parks, bicycle paths and sidewalks are created (but this can be covered by increased rates). Potential for increased revenue by charging higher rates to fast food outlets May be hidden costs unless planned well: eg a fall in land tax from commercial users of increased recreational space. As above Possible objections from property developers. Likely strong support from broader community National Statistics Office Collect new relevant data in Provides the evidence base for The addition, within one year, Minimal cost to add questions to Technically and administratively Government policy makers win
household expenditure eg household expenditure data on tobacco, alcohol, sugar sweetened drinks, and / or out of pocket expenditure on health. Where possible, make the questions consistent between countries so that comparisons can policy makers to make more informed decisions: eg scale and trends of tobacco consumption, and prevalence amongst lowest two wealth quintiles. Pacific Islands share some common challenges when addressing NCDs. of key questions in household income surveys that are relevant to policy makers addressing NCDs (the actual questions will be very Within two years, evidence that the expanded survey questionnaire has then been analysed and used by policy makers to formulate NCD and broader health policy. Consistency, where possible, in the survey questionnaire between countries. the survey instrument. Should help policy makers target revenue policies more accurately, and estimate the welfare implications for the poorest two quintiles of any policy measures. Minor cost. easy to include additional questions. Some capacity constraints in some countries to actively interpret and use the data. Technically feasible. because they have a stronger and more objective evidence base to defend policies. Allows comparisons.
be made. Remove unhealthy products (tobacco, sugar sweetened drinks, turkey tails, mutton flaps etc) from the basket of goods used for tracking inflation. Sends a signal that unhealthy products are not a normal or desired part of consumption. Removal of the items from the statistical basket of goods. Minor cost to remove the items from the collection survey. Medium to longer term implication may be that wages increases are moderated if they were based on consumer price index movements. Technically feasible. Requires some adjustments to allow comparisons with previous periods. Likely to result in a reduction in the inflation rate of the consumer price index. Ministry of Transport Identify key bottlenecks that prevent fresh farm produce and fresh fish reaching consumers, and include that when prioritising future investments Can reduce a key bottleneck in some countries of the Pacific where fresh food spoils due to transport delays. Initially, that bottlenecks in fresh food transport are identified. Over time, that such information is included in priority setting criterai of investments Requires good surveys and assessments to be useful. Over time, could help plug the gaps due to food spoilage in the value added chain of rural production and fishing Feasible but requires good survey techniques and expertise in traffic flows and transport planning Rural food producers and those engaged in fishing likely to support. Development partners Provide financial and technical support to MOH Additional financial resources and Sustained additional financial and Revenue enhancing for Pacific Island Feasible over the medium term, but should not be Governments and development partners have
and other department efforts to reduce NCDs. Ensure design and implementation of aid projects in sectors outside the health sector expertise are needed to address NCDs. Confirms that all NCD responses need to be technical assistance support aligned to MOH priorities, and well monitored. Evidence that development partners are including NCD risk mitigation factors governments provided there is no substitution of aid money for Government’s own expenditure efforts (‘fungibility’). Increased cost (eg to design sidewalks etc into road projects) but costs are less than assumed. Development partners need confidence that public financial management of existing resources is improving, and that Pacific Island Governments are taking all available steps to increase their own revenues (eg through taxing tobacco) and reducing waste. Feasible over the medium to longer term. Government needs to provide mutual interests in seeing a reduction in NCDs. Community support for more ‘heart healthy’ environments.
(eg roads, education etc) help to reduce NCDs. Adopt a more coherent ‘whole of government’ approach to NCDs and other health issues when engaging with the Pacific (eg trade policy aligns with aid and other policies). Reduce disconnect and conflict between aid, development, and trade objectives when engaging with Pacific Island countries. into the designs and implementation of projects in all sectors, not just health sector. Improved coherence and whole of government approach to trade negotiations. trying to retrofit such features for NCD health reasons after a project is completed. Will vary according to the situation. leadership and set consistent design standards at the outset. Requires strong political leadership to overcome institutional ‘silo’ perspectives. Private sector Work with Government to establish a formal, transparent, regular, high level, task force for communication about NCD policies, including taxation and Opens a dialogue with the private sector, sensitising them to the NCD crisis and their role in responding. Encourages dialogue to be formal and Initially, the establishment of a task force for liaison and communication. Over the medium term, evidence that the task force is identifying areas for Minor. Requires ‘in kind’ contribution from private sector. Requires sustained commitment from leaders in Government and the private sector. Provides a safety valve to air concerns and avoid misunderstanding.
regulation of harmful products / promotion of healthy products. Work with Ministry of Health, and employees, to conduct workplace health surveys in the private and public sectors Work with Ministry of Health, Trade and Industry, Statistics Office and transparent, rather than behind the scenes lobbying and private deals. Alerts private sector to the scale of NCD related disability and risk factors in the workforce Provides an evidence base for industry and government to make future collaboration with the private sector, and avoiding communication breakdowns. Initially, the number of workplace health surveys; number of workers screened and the results. In the medium term, the indicator should shift to measuring the reduction in risk factors for NCDs and other health problems Initially, the number of well conducted and published assessments of Minor cost to conduct (voluntary) health surveys of workers. Potential to avert premature death and disability. Well conducted surveys could be expensive. However good evidence could Needs to be voluntary screening, conducted by technically competent health professionals, with regard to privacy and with pathways to follow up remedial action available: eg referrals to private clinics etc Feasible. May need technical assistance from Universities in development Likely to generate good will amongst workers if managed well. Workforce are likely to appreciate the exercise provided it is framed as an
academic institutions to accurately measure the level and trends of lost productivity in individual firms and industries as a result of NCDs. targeted interventions and the costs, and benefits, of additional actions. the direct financial costs and indirect productivity losses to industry of NCDs in the Pacific. In the medium term, evidence that firms are using that data to support workplace interventions to reduce NCDs. then generate cost-saving interventions over the longer term partner countries. investment in their own worker productivity, and not a cost-cutting exercise by the firm. Civil society Alliances formed between Government and churches, media and universities to leverage responses to NCDs. Provides a national response, not just a government response, to the NCD crisis. Will vary according to country circumstances. Examples might include church organised ‘biggest loser’ competitions, and reduced incidence of actors smoking or being Minor direct cost. Requires good community organising and public liaison skills. Likely to be positive to government and other stakeholders.
Churches to work with Ministry of Health to conduct health surveys and assessment of risk factors amongst the overweight in local soap opera films. Regional Support regional initiatives addressing NCDs. Evidence based regional initiatives (eg tobacco free Pacific) will reduce risk factors for NCDs. Level of engagement over time in WHO and SPC brokered regional initiatives. Low. Some travel, liaison and implementation costs. Feasible. Requires sustained leadership to maintain enthusiasm and momentum. Pacific Leaders can demonstrate they have translated commitments made in various communiques into tangible responses and actions.
to reduce amount of duty free sales Adequately fund the implementation and enforcement of tobacco control measures contained in existing commitments such as WHO Framework Convention on Tobacco Control (FCTC) and Tobacco Free Pacific 2025. Reduce sales of single sticks of cigarettes and sales to children. Public awareness campaign launched and tested. Baseline study conducted by NGOs Reduction of 25% such sales Reduction of 70% such sales Reduction of 95% such sales Ministry of Finance and Police to ensure adequate finance. Police (and perhaps NGOs) to provide enforcement 2. Reduce consumption of unhealthy food and drink known to cause NCDs Reduction in salt intake Baseline study and discussion with industry Trial of options Evaluation of trials Implement ‘best buys’ Ministry of Health Tax on sugary drinks Baseline study on current consumption levels, especially by groups at high risk of developing diabetes National trial of 30% increased tax Trial evaluated end 2016, with focus on consumption patterns of groups at high risk of acquiring type 2 diabetes Possible future increases Ministry of Finance 3.Improve efficiency of existing health dollar expenditure
Allocate scarce resources to preventing and treating NCDs in high risk groups Reallocate resources to favour primary and secondary prevention. Continue scale up of PEN as a basis for achieving wide coverage of essential but affordable diagnostic and treatment services in all health centres. Identify high risk groups at risk of premature death / disability from NCDs and develop protocols that allow affordable treatment for such groups Reallocate resources to favour primary and secondary prevention Continue scale up of PEN as a basis for achieving wide coverage of essential but affordable diagnostic and treatment services in all health centres. Trial of primary and secondary prevention amongst high risk groups. Trial to include data on costs and compliance by patients. Reallocate resources to favour primary and secondary prevention Evaluate scale up of PEN in terms of inputs, outputs, and costs. Continued trial of primary and secondary prevention of high risk groups Reallocate resources to favour primary and secondary prevention Identify options for improving PEN in the light of evaluation findings. Evaluate trial of primary and secondary prevention of high risk groups Ministry of Finance oversight of Ministry of Health Ministry of Health
Ministry of Health, with support from Ministry of Finance and perhaps development partners for the evaluation of trials and business case for scaling up expanded activities. Achieving competitive prices for pharmaceuticals Compare price of key generic drugs with those obtained by other PICs Work with WHO to identify options for drug price reductions Negotiate more competitive prices Monitor prices and quality Ministry of Finance together with Ministry of Health
4. Strengthen evidence base to ensure resources are used well Assess of different approaches to health promotion eg is a stand-alone Health Promotion Foundation more cost-effective than integrated services within the existing primary health care system Baseline study on the costs, and consequences, of alternative health promotions Data collection and analysis Identification of ‘best buys’ in that country situation Implement and monitor best buys Ministry of Finance to manage studies perhaps with national Universities, but in collaboration with Ministry of Health Identify cost differences primary and tertiary level Baseline study of treatment cost of cardio vascular disease, and diabetes, at a primary health care clinic and at the outpatients department of the main hospital Analysis of reasons for the cost differences Analysis and trialling of alternative approaches Assessment of trials as basis for scale up Ministry of Finance to manage studies perhaps with national Universities, but in collaboration with Ministry of Health Other priorities selected from the menu of options suited to that country’s specific circumstances effectiveness
Ministry of Agriculture Improved availability of fresh food and fish Baseline study on obstacles to improved production and sales Design and construction of refrigerated warehouse at main market Assessment of change in consumer purchases Assessment of change in consumer health Ministry of Agriculture Ministry of Education Improve diet of school children. Education campaign amongst all school children about diet and health. Liaison with trade stores and vendors near schools Remove sugary drinks from school canteens and for sale within 2 km of a school as a first step. Evaluate impact on weight and fitness of children Respond to evaluation findings. Ministry of Education Engagement with development partners NCD risk factors included in designs of roads etc Discussions and awareness raising with development partners Designs for roads include footpaths; buildings have stairs. Assessment of additional costs and outcomes Policy for future programs designed Ministry of Finance and / or Planning.