14–15 February 2020Manila, Philippines

Meeting Report

INFORMAL TECHNICAL CONSULTATION ON THE FUTURE POLIO VACCINATION SCHEDULE

IN THE WESTERN PACIFIC REGION

30 June 2020Virtual Meeting

Meeting Report

PRELIMINARY MEETING FOR THE TECHNICAL ADVISORY GROUP FOR NONCOMMUNICABLE DISEASE PREVENTION

AND CONTROL IN THE WESTERN PACIFIC REGION

30 June 2020Virtual Meeting

Meeting Report

PRELIMINARY MEETING FOR THE TECHNICAL ADVISORY GROUP FOR NONCOMMUNICABLE DISEASE PREVENTION

AND CONTROL IN THE WESTERN PACIFIC REGION

Preliminary Meeting for the Technical Advisory Group for Noncommunicable Disease Prevention and Control in the Western Pacific Region

30 June 2020

WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC

RS/2020/GE/17(PHL) English only

MEETING REPORT

PRELIMINARY MEETING FOR THE TECHNICAL ADVISORY GROUP FOR NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL IN THE

WESTERN PACIFIC REGION

Convened by:

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

1–30 June 2020

Not for sale

Printed and distributed by:

World Health Organization Regional Office for the Western Pacific

Manila, Philippines

September 2020

NOTE

The views expressed in this report are those of the participants of the Preliminary Meeting for the Technical Advisory Group for Noncommunicable Disease Prevention and Control in the Western Pacific Region and do not necessarily reflect the policies of the conveners.

This report has been prepared by the World Health Organization Regional Office for the Western Pacific for Member States in the Region and for those who virtually participated in the Preliminary Meeting for the Technical Advisory Group for Noncommunicable Disease Prevention and Control in the Western Pacific Region between 1 and 30 June 2020.

CONTENTS

SUMMARY ............................................................................................................................................. i

1. INTRODUCTION .............................................................................................................................. 1

1.1 Meeting organization .................................................................................................................... 1 

1.2 Meeting objectives ........................................................................................................................ 1 

2. PROCEEDINGS ................................................................................................................................. 1

2.1 Opening session ............................................................................................................................ 1 

2.1.1 Opening remarks .................................................................................................................... 1 

2.1.2. Keynote speech ..................................................................................................................... 1 

2.2 COVID-19 and noncommunicable diseases ................................................................................. 2 

2.3 NCD pre-TAG overview and governance of TAG in the WHO Regional Office ........................ 3 

2.4. Technical working group presentations ....................................................................................... 3 

2.4.1. Summary of working group sessions: Knowledge, data & surveillance and social determinants of health .......................................................................................... 3 

2.4.2. Summary of working group sessions: Risk factor reduction focused on upstream measures ................................................................................................................ 4 

2.4.3. Summary of working group sessions: NCD individual services and management .............. 5 

2.4.4. Summary of working group sessions: PIC perspective ......................................................... 6 

3. CONCLUSION ................................................................................................................................... 7

3.1. Conclusion and future directions ................................................................................................. 7 

3.2. Move forward and next steps ....................................................................................................... 8 

3.3 Closing remarks ............................................................................................................................ 8 

ANNEXES .............................................................................................................................................. 9

Annex 1. List of participants

Annex 2. Meeting programme

Annex 3. Summary of working group sessions (Group 1) on knowledge, data & surveillance and social determinants of health 

Annex 4. Summary of working group sessions (Group 2) on risk factor reduction focused on upstream measures 

Annex 5. Summary of working group sessions (Group 3) on NCD individual services and management 

Annex 6. Summary of working group sessions (Group 4) on PIC perspective

Keywords

Noncommunicable disease – prevention and control / Health promotion / Regional health planning

SUMMARY

For the Future: Towards the Healthiest and Safest Region, a vision for the work of the World Health Organization (WHO) in the Western Pacific for the coming years, was endorsed at the seventieth session of the Regional Committee for the Western Pacific in October 2019. The document highlights a critical need to conceptualize and operationalize new ways of working to tackle noncommunicable diseases (NCDs) in the Region. There is significant demand from countries to address the root causes of persistent gaps and inequities through strategic and systems-oriented approaches, moving beyond business as usual. The WHO vision for the Western Pacific Region encompasses four technical priorities, one of which is NCDs and ageing, to be implemented through operational shifts that address the structural and fundamental gaps in NCDs across the Region.

To support Member States in operationalizing the NCD agenda, virtual sessions of the Preliminary Meeting for the Technical Advisory Group (TAG) for Noncommunicable Disease Prevention and Control in the Western Pacific Region were held between 1 and 30 June 2020, with the objectives: to develop recommendations on the themes, mechanism, composition, terms of reference and expected outcomes of the NCD TAG meeting to be held in 2021; and to identify and elaborate on technical recommendations for strengthening multisectoral and multi-stakeholder action to address the above-mentioned priority areas in each group.

The preliminary meeting sought input from 10 temporary advisers on future directions for the three priority action areas for NCDs outlined in For the Future: knowledge, data and surveillance; risk factor reduction focused on upstream determinants; and individual services. Three working groups were set up by priority area, as well as a fourth group specifically addressing the perspective of the Pacific island countries and areas (PICs). Working groups for each priority area convened separately in two sessions throughout the month prior to the plenary session on 30 June 2020, to discuss key gaps and challenges, as well as identify directions moving forward. These discussions were then presented at the plenary session.

For the Future has set an ambitious goal for the Western Pacific to be the “healthiest and safest region”. Working towards this necessitates conceptual groundwork to approach NCD prevention and control in systematic, strategic and systems-oriented ways. However, this relies on commitment at the highest levels, as well as strong coordination of different sectors and stakeholders. Policy-enabling environments must be fostered, ensuring that solutions address existing inequities – instead of widening them.

Most low- and middle-income countries and PICs are far behind in meeting the 2025 global NCD impact and outcome targets, as well as the 2030 Sustainable Development Goal target to reduce premature deaths due to NCDs by one third. Immediate action must be taken to establish strong cross-sectoral teams responsible for NCD surveillance, risk factors and social determinants. Likewise, countries must be supported in developing and implementing national plans by identifying priorities and establishing strong multisectoral engagement. To reduce risks of premature mortality due to NCDs, people-centred NCD services that are promotive, preventive and curative must be integrated. These are meant to guide actions towards the 2021 NCD TAG meeting, with For the Future culminating in 2024 and the United Nations General Assembly Fourth High-level Meeting on NCDs convening in 2025.

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1. INTRODUCTION

1.1 Meeting organization

The Preliminary Meeting for the Technical Advisory Group for Noncommunicable Disease Prevention and Control in the Western Pacific Region (NCD pre-TAG) was held virtually between 1 and 30 June 2020. The meeting was attended by 10 temporary advisers, seven observers, and WHO staff from headquarters, the Regional Office for the Western Pacific and representative country offices. This meeting report covers the proceedings of the plenary session held on 30 June 2020. The list of participants can be found in Annex 1 and the meeting programme in Annex 2. Annexes 3–6 contain the summary reports of the four working groups.

1.2 Meeting objectives

The objectives of the meeting were:

1) to develop recommendations on the themes, mechanism, composition, terms of references and expected outcomes of the NCD TAG meeting to be held in 2021; and

2) to identify and elaborate on technical recommendations for strengthening multisectoral and multi-stakeholder action to address the above-mentioned priority areas in each group.

2. PROCEEDINGS

2.1 Opening session

2.1.1 Opening remarks

In his opening remarks, Dr Takeshi Kasai, WHO Regional Director for the Western Pacific, expressed his appreciation to all participants for their support and participation, giving special thanks to Professor Sir Michael Marmot, the keynote speaker. He highlighted that a TAG meeting is a simple yet powerful mechanism for listening to and implementing the technical advice of TAG members towards eventually achieving a specific global or regional goal. Following a year’s consultation with Member States, the NCD pre-TAG was restructured into three groups covering data/surveillance, upstream interventions and NCD services, with all WHO TAGs falling under the umbrella TAG for universal health coverage (UHC).

Recognizing the rapid changes occurring in the Region and variation among Member States, Dr Kasai reminded participants of areas of shared concern: health security, including antimicrobial resistance; NCDs and ageing; climate change, the environment and health; and reaching the unreached – people and communities still affected by infectious disease and high rates of maternal and infant mortality. The current coronavirus disease 2019 (COVID-19) pandemic is yet another challenge faced by all Member States in the Region.

2.1.2. Keynote speech

Professor Sir Michael Marmot delivered the keynote speech focusing mainly on the upstream social determinants of health. The WHO Commission on Social Determinants of Health developed a conceptual framework describing the intersectionality of social and economic inequities, gender, sexuality, ethnicity, disability and migration. Structural drivers of inequities in money, power and

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resources include political, social, cultural and economic structure; natural environment, climate change and relationships to land; and health equity impacts of history and legacy, ongoing colonialism and structural racism.

Professor Marmot pointed out that while a dramatic reduction in the poverty rate in East Asia and the Pacific between 1990 and 2015 is part of the explanation for improved health in the Western Pacific Region, there is no relation between national income and life expectancy once a certain gross domestic product (GDP) has been reached. Having a comprehensive social protection system reduces the Gini coefficient, a measure of income inequality, but is more challenging to fund when taxes are reduced for the wealthy. He gave several examples of successes in alleviating poverty, such as conditional cash transfers to poor women in Brazil, which improves the health of their children and reduces under-5 mortality.

He also discussed other global concerns, such as the informality of work, which impacts occupational health; ageing and the importance of ensuring a dignified life for older people; prevalence of domestic and intimate partner violence; and poor environment and housing conditions, among others. For health system matters, governance arrangements and respect for human rights are key.

Reflecting on what society should look like after the COVID-19 pandemic, he concluded with a quote from the Treasury of New Zealand: “a wellbeing approach can be described as enabling people to have the capabilities they need to live lives of purpose, balance, and meaning for them.”

2.2 COVID-19 and noncommunicable diseases

Dr Bente Mikkelson from WHO headquarters presented on the deadly interplay between the COVID-19 pandemic and NCDs. While chronic underinvestment in the prevention, early diagnosis, screening, treatment and rehabilitation for NCDs has long been a problem, the disruption of services for prevention and treatment of NCDs has led to a long-term upsurge in deaths. Based on a rapid assessment survey of NCD service delivery conducted by WHO in May 2020 with data from 122 countries, the more severe the transmission phase of the COVID-19 pandemic, the more NCD services have been disrupted, with rehabilitation the most commonly disrupted service.

Countries requested WHO guidance and support in terms of four different categories: how to provide continuity of NCD programmes (e.g. how to include NCDs in public health emergency protocols); communication materials (e.g. risk factor campaigns); better data (e.g. how to develop projection models, how to use digital tools); and country support (e.g. training for policy-makers, technical assistance to adapt the HEARTS and WHO Package for Essential NCD interventions technical packages to the COVID-19 context).

Dr Mikkelson outlined the immediate actions to be taken, such as strengthening national governance to include NCDs in national COVID-19 plans. Taking a “build back better” perspective requires executing a forward-looking strategy inclusive of NCDs. To ensure the continuity of essential health and community services, we can learn from the digital health solutions already in place and make them available. There is a need to answer for new international funding patterns, while continuing to strengthen domestic funding.

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2.3 NCD pre-TAG overview and governance of TAG in the WHO Regional Office

Dr Hai-Rim Shin presented an overview of the NCD pre-TAG and overall governance of the TAGs in the Western Pacific Region. The Western Pacific Regional Action Plan for the Prevention and Control of NCDs (2014–2020) provides a framework for the regional context, aligning its six objectives with the goal to reduce premature mortality due to NCDs by one third, as well as promote mental health, by 2030. Despite considerable gains and achievements, current progress has fallen short, due in part to persisting gaps, especially in reaching the unreached. NCDs also disproportionately affect PICs, which take the brunt of the burden.

The agenda put forth in For the Future: Towards the Healthiest and Safest Region, WHO’s vision for its work with Member States and partners in the Western Pacific, sees NCDs and ageing as important priorities, for which there are three pillars to build on: data and surveillance, upstream drivers of health, and individual services. The NCD pre-TAG has therefore been organized accordingly and is benefiting from a wealth of input from temporary advisers and observers, as well as colleagues from all three levels of WHO. Health systems need to be reoriented to better answer existing and emerging needs, necessitating operational shifts in our approach.

With UHC a “joint enterprise” to which all WHO programmes and systems contribute, a renewed UHC TAG will serve as an overarching TAG. Moving forward, there are discussions on having representatives from each focused TAG become part of the UHC TAG, to contribute to broader health systems transformation, as well as to find other ways to link up and collaborate with other TAGs. This transformation requires creative and strategic leadership to ensure that our “new normal” is a “better normal” and not just a return to business as usual.

2.4. Technical working group presentations

2.4.1. Summary of working group sessions: Knowledge, data and surveillance and social determinants of health

The COVID-19 pandemic has exposed and exacerbated the wide gaps and challenges in data, knowledge and surveillance of NCDs, which leave vulnerable population groups invisible and without access to effective coverage of health. For example, limited support for intersectoral surveillance results in loss of many opportunities for effective interventions. Although policy- and decision-making should be an evidence-based process, there is insufficient capacity to use and present information for this purpose.

In his summary of the working group discussions, Dr Chang-yup Kim identified the following directions for the future:

• Enable NCD political commitment and leadership for intersectoral collaboration, by facilitating space for dialogue and building capacity among persons in NCD leadership positions on how to adapt during emergency situations.

• Establish information system infrastructures that allow for, and encourage, intersectoral data collection and disaggregated analysis (e.g. establishment of national intersectoral public health outcomes frameworks that include NCD outcomes and risk factors, as well as social determinants of health).

• Strengthen NCD research and data analysis by building capacity on alternative research methods and approaches (multi-country approaches, community-based methods, small-scale

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case studies), facilitating collaboration between institutions, and supporting the development/update of relevant tools to standardize research methods.

• Support environments that enable countries to implement NCD surveillance among vulnerable groups, by building capacity on how to involve communities in data collection/analysis and implement qualitative research methods, and on how to analyse data to identify opportunities for action and assess needs.

• Facilitate NCD evidence-based policy- and decision-making by creating capacity on the use of data for decision-making, as well as by creating space for dialogue between data gatekeepers and decision-makers.

Dr Kim also highlighted the significance of environmental key stakeholders, such as governmental stakeholders beyond health, diverse representative communities, champions, institutions and networks working with affected communities, social media stakeholders and WHO country offices.

A question was raised about the establishment of a regional NCD data hub. In the Western Pacific Region, health information initiatives are being undertaken by the WHO Data, Strategy and Innovation programme, which is compiling all data. Collaboration was proposed with the Institute for Health Metrics and Evaluation (IHME) in Viet Nam.

Another question was about what capacity or support would be required to implement these recommendations, especially for small countries with very limited technical expertise (e.g. PICs with limited workforce), given the strain on existing resources to cover the COVID-19 outbreak. The main concerns were how to facilitate and maintain existing data collection systems in addition to this new initiative, and how to utilize the opportunity posed by COVID-19 to strengthen the data collection system. WHO is emphasizing inclusion of NCDs as an essential element in national COVID-19 response plans, presenting an opportunity to strengthen infrastructures by utilizing national COVID-19 response systems in combination with data collection and information systems for NCD management.

See Annex 3 for a summary of the discussion notes for this working group.

2.4.2. Summary of working group sessions: Risk factor reduction focused on upstream measures

This working group identified the many gaps and challenges to addressing the NCD risk factors of tobacco use, harmful alcohol use, unhealthy diet and physical inactivity. Examples of effective multisectoral, multi-stakeholder collaboration to address these include: working simultaneously with top leaders while mobilizing grassroots support; engaging with traditional leaders and across different government sectors beyond health; starting with a small dedicated team for NCD coalition; conducting stakeholder analysis; and framing issues as opportunities corresponding to the priorities of stakeholders. Other challenges during the COVID-19 era include industry interference and potential conflicts of interest when collaborating with the private sector, while recognizing that opportunities may exist for the private sector to contribute to health in a way that they may not at other times.

In his summary of the working group discussions, Dr Jonathan Liberman proposed a number of potential innovations and approaches, including the need for capacity-building and coordination in mapping health issues against the mandates of relevant government agencies to address policy incoherence, and having a clear mandate or policy that sets out the terms of engagement with industry or private sectors and with accountability mechanisms in place, among others.

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Dr Liberman concluded with the following future directions and next steps:

• Create a space and invite community or civil society for dialogue as partners for driving changes in NCD risk factor policies and interventions.

• Delineate and frame NCD risk factor issues to corresponding mandates and responsibilities of different government agencies and stakeholders to achieve sustainable multisectoral cooperation and collaboration for prevention and health promotion.

• Strengthen NCD risk factor prevention and health promotion leadership and capacity for efficient upstream interventions.

• Improve regulatory capacity for NCD risk factor prevention through education and training, professional development, and focused advocacy for policy-makers.

• Equip upstream interventions for NCD risk factor prevention and health promotion with mandatory notions for community engagement and participatory approaches for implementation.

• Ensure that equity is a fundamental consideration in the development, implementation and enforcement of all interventions, with particular attention paid to impacts on vulnerable groups.

• Strengthen “think tanks” for policy and regulatory professionals to bridge the gap between NCD risk factor prevention and health promotion, and prevention and management of communicable diseases.

See Annex 4 for a summary of the discussion notes for this working group.

2.4.3. Summary of working group sessions: NCD individual services and management

The working group on NCD services and management took stock of the current access to and utilization of NCD services and explored ways to improve service delivery through an integrated approach across the levels of care and to ensure continuity of essential NCD services for people living with NCDs during the pandemic, the emerging “new normal” situation and in future crises.

In his summary of the working group discussions, Dr Gabriel Leung outlined the following directions to “build back better” through the seven operational shifts in For the Future:

• Support countries to apply a health systems approach for more sustained health improvements – especially in low-resource settings – using UHC as the foundation for expanding NCD service delivery and financial coverage.

• Clearly define the long-term NCD goals of the Western Pacific Region and Member States and “backcast” milestones from there to the present time. Existing global NCD targets from the Sustainable Development Goals and targets in the NCD Global Monitoring Framework should be used as reference.

• Support countries to build health information systems that can routinely measure NCD service capacity, quality, effectiveness and impact to enable policy-makers and programme managers to design and implement more locally appropriate evidence-based policies.

• Encourage countries to build “grounds-up” solutions by listening to people living with NCDs and those who are at risk and empower them in self-management. The COVID-19 pandemic has exposed the weaknesses of most health systems and the importance of strong primary health care institutions, which includes community health.

• Support countries to explore innovative solutions, like digital health technology for disseminating health education messages, health monitoring and tracking of individuals for

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screening, diagnosis and treatment. Potential problems with patient data privacy and service access inequities are anticipated and need to be well addressed.

• Support countries to build back better and raise the urgency for strengthening health systems for NCD services through strategic communications highlighting the continued relevance of NCD prevention and control during the COVID-19 pandemic. This is particularly important in engaging other partners outside the health sector.

• WHO should play a very important role in convening or promoting strategic multisectoral partnerships within countries to propel political, non-health sector, private sector, community and patient buy-in and engagement for initiatives on health systems strengthening and integrated people-centred NCD services.

These seven operational shifts shall be collectively used in the design, implementation and evaluation of a five-year country-specific programme to strengthen health systems for integrated people-centred NCD services through a One WHO approach. Backcasting from the 2025 health targets to 2020, country milestones include increased availability and access to integrated people-centred NCD services and improved self-management capacities through country-specific interventions that are informed by a health systems assessment in 2020.

See Annex 5 for a summary of the discussion notes for this working group.

2.4.4. Summary of working group sessions: PIC perspective

Many of the issues discussed by this working group align with and are reflected in the discussions of the other working groups, though the PICs do face some unique challenges. For example, lack of economies of scale due to having small, dispersed populations results in high costs for implementation of interventions and scaling up of activities across urban, rural and maritime areas. PICs are also challenged by climate change and exposure to natural disasters, economic precariousness and limited natural resources. However, a strong collectivist culture cultivates community-led innovations and initiatives, while also nurturing a Pacific “regionalism” approach.

In her summary of the working group discussions, Dr Gade Waqa identified the following directions for the future:

• Empower primary health care staff to deliver more NCD services and enhance accessibility.

• Consider less resource-demanding options (e.g. standardized tools, sentinel site surveys, use of social media platforms).

• Link implementation with broader approaches (e.g. NCD data collection as part of health promoting schools).

• Support research to enhance understanding of NCDs in Pacific contexts, such as the way culture impacts people’s behaviour (e.g. compliance, risk factors).

• Support data interpretation and utilization for policy and planning, including by community and health staff.

• Modify processes to ensure engagement/leadership of civil society, faith-based organizations and community groups, including applying tactical engagement in policy prioritization, development, enforcement and advocacy, and empowering/upskilling to encourage engagement.

• Utilize regional mechanisms more proactively to ensure action for NCDs.

• Identify strategic opportunities to leverage the Healthy Islands vision for NCDs.

• Cultivate a shared commitment and investment to support NCDs.

See Annex 6 for a summary of the discussion notes for this working group.

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3. CONCLUSION

3.1. Conclusion and future directions

Dr Annette David summarized and synthesized the points made by the four working groups. By tapping into their collective knowledge, areas of expertise and regional experience, the groups were able to assess the current situation and provide guidance on how to counter the NCD epidemic, especially during the COVID-19 pandemic. NCD prevention and control must be a fundamental priority for all Member States, but it should not be perceived as a stand-alone set of interventions, but instead embedded in each of the regional priorities and across the regional health programmes.

Dr David pointed out that although NCDs are a cross-cutting issue, they are hampered by a vertical perspective – reinforced by organizational structures organized along vertical programme lines – which fails to capture the opportunities for cross-programme and cross-sectoral leveraging and integration of NCD interventions. A stronger case must be made to other government sectors that NCD prevention and control is integral to healthy development and that investments in NCD prevention and control contribute positively to a healthy economy. The current pandemic has highlighted this issue by demonstrating the fallacy of “health versus economy”, when in fact these are not mutually exclusive but mutually reinforcing. Thus, a whole-of-society approach is necessary and vital. Most importantly, an equity lens needs to be applied to ensure that strategies and interventions capture those who are invisible and narrow the inequities.

While the COVID-19 pandemic has highlighted vulnerabilities caused by NCDs, it has also uncovered the potential opportunity to make a stronger case for NCD prevention and control to be embedded in disaster and pandemic preparedness, linking NCDs to the communicable disease agenda. Strategic and creative framing and communications play a vital role in this regard.

The working groups identified many gaps in capacity, investment, community engagement and accountability. The temporary advisers proposed the following future directions, which align with the operational shifts – the “how” – that are delineated in For the Future:

• Innovation and backcasting are fundamental leadership skills that can address the gaps in capacity and investment in NCD prevention and control.

• The systems approach with UHC as the foundation addresses the gap in care. • The bottom–up approach directly links to community engagement and empowerment.

• Measurement and impact assessment address how to close the accountability gap, with special focus on reaching the unreached through an equity lens.

• Health beyond the health sector is accounted for by strengthening cross-sectoral leadership, advocating for investment in NCDs and community engagement.

• Strategic communications ties the other operational approaches together and is another fundamental skill of leadership.

The outputs from this NCD pre-TAG consultation will inform and provide the basis for the 2021 TAG meeting. Dr David raised a fundamental question: Are we in NCDs future ready? She encouraged participants to think about transforming from managers to leaders, where managers value efficiency but leaders value innovation. By developing a mindset that welcomes change, the future becomes an opportunity, not a challenge, and change a catalyst for transformation, not an obstacle.

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3.2. Move forward and next steps

In her remarks on next steps, Dr Huong Tran reminded participants that the majority of NCD risk factors are driven by other sectors, including industry, agriculture, trade, education, employment and transport. Though NCDs as a political priority is relatively new, many global and regional action plans, political declarations and guidance documents on the prevention and control of NCDs have been produced. This has led to considerable progress, especially in the Western Pacific Region. However, progress has been disproportionate across income groups, with high-income and upper-middle-income countries showing better improvements compared to low- and middle-income countries and PICs. Most Western Pacific Member States will not hit global NCD impact and outcome targets due to persisting health systems challenges, further exacerbated by the COVID-19 pandemic.

In October 2019, all Member States endorsed For the Future as a shared vision for health in the Western Pacific. The development of the vision was based on extensive consultations with governments and a wide range of partners, including civil society and the youth sector across the Region. Thus, this vision is by and for countries. It also reflects a commitment to build on former Regional Director Shin Young-soo’s legacy of reform that put countries at the centre, leveraging this to address the challenges of tomorrow and to make the Western Pacific the healthiest and safest region in the world. To ensure that we achieve this vision, we should empower countries to face NCDs head on, build capacity for people on the ground by strengthening health systems, and build up champions and advocates at every level of society.

Progress made in the Western Pacific will put the Region in a strategic position for the United Nations General Assembly Fourth High-level Meeting on NCDs in 2025. Dr Tran remarked that whatever progress is made stands on the expertise graciously offered by the participants of this consultation.

3.3 Closing remarks

In his concluding remarks, Dr Liu Yunguo proposed that the valuable inputs from this meeting be adopted as a guide moving forward on what WHO will prioritize in order to support Member States for the prevention and control of NCDs. He also encouraged each participant to do more – to be a stronger advocate of NCD and health promotion in each other’s work, because that will help turn the future directions we take here into actions on the ground.

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ANNEXES

Annex 1. List of participants

1. TEMPORARY ADVISERS

Dr Philippe Biarez, Head, Hospital Moorea, Ministry of Health, Rue des Poilus Tahitiens, BP 611 - 98713 Papeete, French Polynesia. Tel. No.: (689) 79 1959. Email: Philippe.BIAREZ@sante.gov.pf

Dr Annette David, Director, Health Partners, L.L.C., 125 Tun Josen Toves Way, Tamuning, Guam. Tel. No.: (671) 646 5227. Email: amdavid@guam.net

Dr Chang-yup Kim, Professor, School of Public Health, Seoul National University, San 56-1 Sillim-dong, Gwanak-gu, Seoul, Republic of Korea. Tel. No.: (82) 2 880 6973. Email: cykim@snu.ac.kr

Dr Gabriel Leung, Dean, Li Ka Shing Faculty of Medicine and Public Health Medicine and School of Public Health, The University of Hong Kong, William M.W. Mong Block, 2 Sassoon Rd., Pokfulam, Hong Kong SAR. Tel. No.: (852) 3917 5886. Email: deanmed@hku.hk

Mr Jonathan Liberman, Associate Professor, Melbourne Law School and the Melbourne School of Population and Global Health, University of Melbourne, 185 Pelham St, Carlton, VIC 3053, Australia. Tel. No.: (61) 3 9035 5511. Email: jonathan.liberman@unimelb.edu.au

Professor Sir Michael Marmot, Director, The Institute of Health Equity, University College London, Gower St, Bloomsbury, London WC1E 6BT, United Kingdom. Tel. No.: (440) 20 7679 2000. Email: m.marmot@ucl.ac.uk

Dr Kunhee Park, Director General, Sangnoksu District Health Office, 5 Chadolbaegi-ro 1-gil, Sa-dong, Sangnok-gu, Ansan-si, Gyeonggi-do, Republic of Korea. Email: kpark.ghealth@gmail.com

Dr Tomofumi Sone, Vice President, National Institute of Public Health, 2-3-6 Minami, Wako City, Saitama 351-0197, Japan. Tel. No.: (679) 3307530/3312008. Email: sone.t.aa@niph.go.jp

Dr Thi Mai Oanh Tran, Director, Health Strategy and Policy Institute, A36 Lane, Ho Tung Mau St., Cau Giay District, Hanoi, Viet Nam. Tel. No.: (844) 3823 4167. Email: tranmaioanh@hspi.org.vn

Dr Gade Waqa, Director, Centre for the Prevention of Obesity and Non-Communicable Disease, School of Public Health and Primary Care, Fiji National University, Tamavua Campus, Princess Road, Tamavua, Fiji. Tel. No.: (679) 338 1044. Email: Gade.waqa@fnu.ac.fj

2. OBSERVERS

Dr Veisinia Matoto, Director, Community Health, Ministry of Health, P.O Box 59, Naku’alofa, Tonga. Tel. No.: (676) 23200. Email: matotov@gmail.com/vmat986@aucklanduni.ac.nz

Dr Thanh Huong Nguyen, Associate Professor, Hanoi University of Public Health, 1A Duc Thang Road, Duc Thang Ward, North Tu Liem district, Hanoi, Viet Nam. Tel. No.: (84) 24 6266 2299. Email: nth@huph.edu.vn

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Dr Bradley Christian, Lecturer, La Trobe Rural Health School, La Trobe University Bendigo Campus, Edwards Rd, Flora Hill, VIC 3550, Australia. Tel. No.: (613) 5444 7908. Email: B.Christian@latrobe.edu.au

Dr Fabrizio D’Esposito, The Fred Hollows Foundation Limited, Level 2, 61 Dunning Ave., Rosebery, New South Wales, Australia. Tel. No.: (612) 8741 1999. Email: fdesposito@hollows.org

Ms Hayley Jones, Acting Director, WHO Collaborating Centre for Law and Non-communicable Diseases, The McCabe Centre for Law and Cancer, 615 St Kilda Rd, Melbourne, VIC 3004, Australia. Tel. No.: (613) 9514 6100. Email: nth@huph.edu.vn

Dr Si Thu Win Tin, Team Leader, Noncommunicable Diseases, The Pacific Community, SPC Suva Regional Office, Lotus Building, Nabua, Fiji. Tel. No.: (679) 337 9450. Email: sithuw@spc.int

Professor Brian Oldenburg, Chair, Non-Communicable Disease Control Melbourne School of Population and Global Health, University of Melbourne, 207 Bouverie Street, Carlton, VIC 3053, Australia. Tel. No.: (61) 3 8344 0149. Email: Brian.oldenburg@unimelb.edu.au

3. SECRETARIAT

Dr Hai-Rim Shin, Director, Division of Healthy Environments and Populations, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No.: (632) 8528 9860. Email: shinh@who.int

Dr Huong Tran, Director, Division of Programmes for Disease Control WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No.: (632) 8528 9701. Email: tranh@who.int

Dr Martin Taylor, Director, Division of Health Systems and Services, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No.: (632) 8528 9951. Email: taylorm@who.int

Dr Liu Yue, Coordinator, Universal Health Coverage, and acting Director, Data, Strategy and Innovation Group, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No.: (632) 8528 9933. Email: weilerg@who.int

Dr Kira Fortune, Coordinator, Social Determinants of Health, Division of Healthy Environments and Populations, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No.: (632) 8528 9806. Email: fortunek@who.int

Mr Jun Gao, Coordinator, Data, Strategy and Innovation Group, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No.: (632) 8528 9835. Email: gaoj@who.int

Dr Juliawati Untoro, Technical Lead, Nutrition, Division of Healthy Environments and Populations, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No.: (632) 8528 9093. Email: untoroj@who.int

Dr Warrick Junsuk Kim, Medical Officer, Management of Noncommunicable Diseases, Division of Programmes for Disease Control, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No.: (632) 8528 9888. Email: kimw@who.int

Dr Po-lin Chan, Medical Officer, Health, Statistics and Information Systems, Division of Programmes for Disease Control, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No.: (632) 8528 9750. Email: chanpo@who.int

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Dr Josaia Tiko, Medical Officer, Prevention of Noncommunicable Diseases, Division of Healthy Environments and Populations, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Email: tikoj@who.int

Mr Ogochukwu Chukwujekwu, Technical Officer, Health Policy and Service Design, Division of Health Systems and Services, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No.: (632) 8528 9898. Email: chukwujekwuo@who.int

Ms Isabel Constance Espinosa, Technical Officer, Gender, Equity and Human Rights, Social Determinants of Health, Division of Healthy Environments and Populations, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No.: (632) 8528 9825. Email: espinosai@who.int

Ms Mina Kashiwabara, Technical Officer, Tobacco Free Initiative, Division of Healthy Environments and Populations, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No.: (632) 8528 9894. Email: kashiwabaram@who.int

Ms Caroline Lukaszyk, Technical Officer, Violence and Injury Prevention, Social Determinants of Health, Division of Healthy Environments and Populations, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No.: (632) 8528 9856. Email: lukaszykc@who.int

Mr Phoubandith Soulivong, Programme Management Officer, Division of Healthy Environments and Populations, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No.: (632) 8528 9897. Email: soulivongp@who.int

Ms Charlotte Kuo-Benitez, Consultant, Division of Healthy Environments and Populations, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Email: kuobenitez@gmail.com

Ms Amy Elisabeth Bestman, Consultant, Social Determinants of Health, Division of Healthy Environments and Populations, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Email: bestmana@who.int

Mr Gato Borrero, Consultant, Division of Healthy Environments and Populations, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No.: (632) 8528 9874. Email: borrerog@gmail.com

Ms Ruth Anna Julia Castro, Consultant, Management of Noncommunicable Diseases, Division of Programmes for Disease Control, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No.: (632) 8528 9851. Email: castroru@who.int

Dr Heeyoun Cho, Consultant, Prevention of Noncommunicable Diseases, Division of Healthy Environments and Populations, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Email: hcho@who.int

Ms Joy Dawkins, Consultant, Social Determinants of Health, Division of Healthy Environments and Populations, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Email: dawkinsj@who.int

Ms Nina Ashley Dela Cruz, Consultant, Division of Healthy Environments and Populations, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Email: delan@who.int

Mr Sangjun Lee, Consultant, Management of Noncommunicable Diseases, Division of Programmes for Disease Control, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Email: salee@who.int

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Ms Joung-eun Lee, Consultant, Tobacco Free Initiative, Division of Healthy Environments and Populations, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Email: joulee@who.int

Mr Boyang Li, Consultant, UHC Tools and Techniques, Universal Health Coverage, Data Strategy and Innovation Group, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Email: libo@who.int; jimmylee1900@foxmail.com

Atty Ben Lilley, Consultant, Health, Law and Ethics, Division of Health Systems and Services, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Email: lilleyb@who.int

Dr Ma Carmela Mijares-Majini, Consultant, Management of Noncommunicable Diseases, Division of Programmes for Disease Control, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Email: mijaresmajinim@who.int

Mr Brian Raymond Riley, Consultant, Knowledge Management Data, Strategy and Innovation Group, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Email: rileyb@who.int

Dr Ying Cui, Technical Officer, WHO Office of the WHO Representative in China, 401, Dongwai Diplomatic Office Building, 23, Dongzhimenwai Dajie, Chaoyang District, 100600 Beijing, China. Email: ycui@who.int

Dr Nargiza Khodjaeva, Technical Lead, Noncommunicable Diseases and Health through the Life-Course, WHO Office of the WHO Representative in Cambodia, No 61-64 Norodom Blvd corner Street 306, Sangkat, Boeung Keng Kang 1 Khan Chamkamorn, Phnom Penh, Cambodia. Tel. No.: (855) 2321 6610. Email: khodjaevan@who.int

Mr Sam Ath Khim, Technical Officer, Noncommunicable Diseases and Health through the Life-Course, WHO Office of the WHO Representative in Cambodia, No 61-64 Norodom Blvd corner Street 306, Sangkat, Boeung Keng Kang 1 Khan Chamkamorn, Phnom Penh, Cambodia. Tel. No.: (855) 2321 6610. Email: khims@who.int

Dr Wendy Dawn Snowdon, Coordinator, Noncommunicable Diseases and Health Through the Life-course, Division of Pacific Technical Support, Office of the WHO Representative in the South Pacific, Level 4 Provident Plaza One, Downtown Boulevard, 33 Ellery Street, Suva, Fiji. Tel. No.: (679) 323 4152. Email: snowdonw@who.int

Dr Ada Moadsiri, Technical Officer, Division of Pacific Technical Support, Office of the WHO Representative in the South Pacific, Level 4 Provident Plaza One, Downtown Boulevard, 33 Ellery Street, Suva, Fiji. Email: moadsiria@who.int

Ms Shelley Wallace, Technical Officer, Division of Pacific Technical Support, Office of the WHO Representative in the South Pacific, Level 4 Provident Plaza One, Downtown Boulevard, 33 Ellery Street, Suva, Fiji. Email: wallaces@who.int

Ms Nola Vanualailai, National Professional Officer, Surveillance, Division of Pacific Technical Support, Office of the WHO Representative in the South Pacific, Level 4 Provident Plaza One, Downtown Boulevard, 33 Ellery Street, Suva, Fiji. Email: vanualailain@who.int

Dr Francisca Cuevas, Consultant, Division of Pacific Technical Support, Office of the WHO Representative in the South Pacific, Level 4 Provident Plaza One, Downtown Boulevard, 33 Ellery Street, Suva, Fiji. Email: cuevasf@who.int

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Dr Mareta Jacob, Consultant, Division of Pacific Technical Support, Office of the WHO Representative in the South Pacific, Level 4 Provident Plaza One, Downtown Boulevard, 33 Ellery Street, Suva, Fiji. Email: jacobm@who.int

Mr Douangkeo Thochongliachi, National Professional Officer, Tobacco Free Initiative, WHO Office of the WHO Representative in Lao PDR, 125 Saphanthong Rd Unit 5, Ban Saphangthongtai Sisattanak District, Vientiane, Lao People’s Democratic Republic. Tel. No.: (856) 2135 3902. Email: thochongliachid@who.int

Dr Bolormaa Sukhbaatar, Technical Officer, Noncommunicable Diseases, WHO Office of the WHO Representative in Mongolia, N11-Khairkhan Street, 25th Khoroo, Songinokhairkhan, Ulaanbaatar, Mongolia. Tel. No.: (976) 8886 6349. Email: sukhbaatarb@who.int

Ms Anna Alexandra Maalsen, Coordinator, Universal Health Coverage/Health Systems, Life-course and Healthier Populations, WHO Office of the WHO Representative in Papua New Guinea, AOPI Center Waigani, Port Moresby, Papua New Guinea. Tel. No.: 675 325 7827. Email: maalsena@who.int

Dr Tsogzolmaa Bayandorj, Medical Officer (NCD), WHO Country Liaison Office in Vanuatu IATIKA Complex, Ministry of Health, Rue Cornwall Street, PO Box 177, Port Vila, Vanuatu. Tel. No.: (976) 1132 2914. Email: bayandorjt@who.int

Dr Duc Truong Lai, Technical Officer, WHO Office of the WHO Representative in Viet Nam, 304 Kim Ma Street, Ba Dinh District, Hanoi, Viet Nam. Tel No.: (844) 3850 0312. Email: laid@who.int

Dr Bente Mikkelsen, Director, Department of Noncommunicable Diseases, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland. Tel. No.: (41) 22 791 7998. Email: mikkelsenb@who.int

Dr Temo Waqanivalu, Programme Officer, Integrated Service Delivery, Department of Noncommunicable Disease, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland. Tel. No.: (41) 22 791 2617. Email: waqanivalut@who.int

Dr Benn David McGrady, Technical Officer (Legal), Public Health Law and Policies, Health Promotion Department, Healthier Populations Division, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland. Tel. No.: (41) 22 791 7998. Email: mcgradyb@who.int

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15

Annex 2. Meeting programme

WORLD HEALTH ORGANIZATION

ORGANISATION MONDIALE DE LA SANTE

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL

PRELIMINARY MEETING FOR THE TECHNICAL ADVISORY 26 June 2020 GROUP FOR NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL IN THE WESTERN PACIFIC REGION 30 June 2020 (virtual Plenary meeting) ENGLISH ONLY

PROGRAMME OF ACTIVITIES

Time (in Manila)

Activities Speaker

1400 – 1405 Opening remarks Dr Takeshi Kasai

WHO Regional Director for the Western Pacific Manila

1405 – 1410 Group Photo 1410 – 1430 Keynote speech Sir Michael Marmot

Director The Institute of Health Equity University College London United Kingdom

1430 – 1440 Presentation on COVID-19 and

noncommunicable diseases

Dr Bente Mikkelsen Director Department of NCDs WHO Headquarters Geneva

1440 – 1455

Pre-NCD TAG overview and governance of TAG in WPRO

Dr Hai-Rim Shin Director Division of Healthy Environments and Populations WHO WPRO Manila

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1455 – 1525 Summary of working group sessions (Group 4)- Pacific Island Countries Q&A

Dr Gade Waqa Director Centre for the Prevention of Obesity and Non-Communicable Disease School of Public Health and Primary Care Fiji National University Suva

1525 – 1555 Summary of working group sessions

(Group 1): Knowledge, data and surveillance and social determinants of health Q&A

Dr Chang-yup Kim Professor School of Public Health Seoul National University Republic of Korea

1555 – 1605 Mobility break 1605 – 1635 Summary of working group sessions

(Group 2) Risk factor reduction focused on upstream measures Q&A

Professor Jonathan Liberman Associate Professor Melbourne Law School and the Melbourne School of Population and Global Health University of Melbourne Australia

1635 – 1705 Summary of working group sessions

(Group 3) NCD individual services and management Q&A

Professor Gabriel Leung Dean Faculty of Medicine and Public Health Medicine and School of Public Health University of Hong Kong Hong Kong SAR

1705 – 1715 Mobility break 1715 – 1735 Conclusion and future direction

Q&A

Dr Annette David Director Health Partners LLC Guam

1735 – 1745 Move forward and next step Dr Huong Tran

Director Division of Programme for Disease Control WHO WPRO Manila

1745 – 1800 Closing remarks Dr Liu Yunguo Director Programme Management WHO WPRO Manila

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Annex 3. Summary of working group sessions (Group 1) on knowledge, data and surveillance and social determinants of health

Session 1 (4 June 2020)

Key messages by speakers and temporary advisers:

• The Western Pacific Region is changing rapidly. Unprecedented economic growth, migration and urbanization in the Region have created opportunities for better lives that many people could not have imagined a generation ago.

• Despite dramatic improvements, including those in NCD data, knowledge and surveillance, these achievements have not benefited all population groups in an equitable manner, and as a consequence, large groups are left invisible and without access to effective coverage of health.

o For example, data on premature mortality demonstrate significant gender differences both between and within countries, with an increased risk of 50% or higher among men than women in the Region.

o And in most countries, undernutrition prevalence in children aged under 5 years is at least two-fold higher among children whose mothers had no education than children whose mothers had attended higher education.

• To ensure that everyone benefits equally from progress towards better health in the Region, we must be aware of who is being left behind, understand why they are being left behind and we must be prepared to adapt so as to reach them in all that we do.

• As outlined in the strategic For the Future paper, we will move forward as a Region, addressing key thematic priorities, two of which pertinently focus on ageing and NCDs, and reaching the unreached.

• Addressing health beyond the health sector is one of our greatest assets and strengths for achieving the Sustainable Development Goals and UHC, and in becoming the healthiest and safest Region.

o For example, by applying an intersectional gender and equity-based analysis to available data and information, countries will be able to understand more easily the key differences between men and women, as well as between different social groups in term of susceptibility to NCDs and its risk factors, population needs, as well as the barriers hindering effective coverage of NCD prevention and control services in the Region.

Current data, evidence and surveillance gaps and challenges to identifying and reaching vulnerable groups most affected by NCDs and their risk factors in the Western Pacific:

• Political commitment, support and leadership: o For different reasons, including lack of awareness, there is a lack of political support

towards intersectoral data collection, analysis and research.

• Information system infrastructure: o Information system infrastructures do not lend themselves to intersectoral

collaboration. o There is no integration of information systems across sectors. o Within health, there are often multiple systems that are not integrated or coordinated. o There is no mechanism that facilitates integration and coordination of data. o Many data information systems belong to areas beyond health, limiting the health

sector’s reach and leadership potential. o Data gatekeepers do not coordinate or communicate amongst themselves.

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o Because of the ways our surveillance systems are set up, including the way data are collected, we miss key vulnerable groups (such as persons living in non-formal settings).

• NCD research and data analysis: o Due to scarce resources in the PICs, there is insufficient research being conducted or

published on the interlinkages between NCDs, their risk factors and social determinants of health.

o Research on the interlinkages between NCDs, their risk factors and social determinants of health is not prioritized.

o There is limited capacity on how to conduct research looking at the impact of social determinants on NCDs and their risk factors.

• NCD surveillance that captures the vulnerable groups most affected by NCDs and their risk factors, including the context in which these groups live:

o There is a culture of valuing quantitative over qualitative data collection and analysis, allowing for conclusions about the how, rather than the why and how come.

o Data collection and analysis is not involving affected communities. o Data on NCDs are lacking in many countries. o Data are not being disaggregated by key social stratifiers. o There is a lack of data in PICs on children in younger ages.

• Evidence-based policy- and decision-making: o Limited country capacity on how to use and present data and knowledge to drive

evidence-based policy- and decision-making. o Low knowledge base in terms of good practices to manage NCDs among vulnerable

groups.

Future direction and next steps:

• Ensuring political commitment, support and leadership: o Advocate for political commitment and leadership and endorsement for intersectoral

dialogue and collaboration. o Advocate for information systems to serve NCDs, rather than other way around. o Advocate for NCD information needs to be in high-level agenda – for example, trade

ministers, finance ministers – to drive the recognition of importance of this work. • Strengthening information system infrastructures to enable intersectoral NCD data collection

and analysis: o Support the development of strategic intersectoral data infrastructure plans to ensure

the systematic enhancement of data collection and continuous data quality improvements across sectors.

o Establish structures that will allow for intersectoral data collection and analysis. o Facilitate dialogue between data gatekeepers from across sectors, to identify potential

synergies, avoid duplication of efforts, identify possible data gaps, and to explore possibilities for coordination.

o Support a coordinated data gap analysis exercise. o Support the development and implementation of an intersectoral public health

outcomes framework that includes NCD outcomes, risk factors, as well as social determinants of health:

Once developed, support the implementation of a gap analysis and a needs assessment to identify what the needs would be to implement such a framework.

Advocate for the implementation of such a framework.

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One could start with a few countries, and if promising, scale up to cover other countries.

• Ensuring a favourable environment for NCD research and data analysis: o Support multi-country approaches (research and publication). o Support the update/development of practical tools, instruments and methodologies

that could help standardize research methods. o Support collaboration and coordination between research institutes. o Invest in community-based participatory methods to promote research in areas where

there is little to begin with. o Build capacity at national and local levels on research, data analysis, and getting

published (skills to develop scientific papers, for example). • Ensure that NCD surveillance captures the vulnerable groups most affected by NCDs and

their risk factors, including the context in which these groups live. o Involve communities in collecting, analysing and interpreting the data. o Figure out alternative ways of capturing hard-to-reach populations in data collection

efforts. o Explore possibilities for extracting data from data systems that go beyond health

(housing information systems, for example). o Advocate for, and build capacity on, the implementation of qualitative methods in

NCD surveillance – moving from focusing only on quantitative methods towards a mixed-methods approach.

o Build capacity on how to analyse data to understand who the vulnerable groups are in terms of NCDs and their risk factors; examine the specific challenges and barriers to health that these groups experience; understand the social determinants creating these barriers; as well as identify possible context-based solutions to reaching them.

• Using evidence to drive policy- and decision-making: o Build capacity at national and local levels on how to use and present data for

decision-making. o Facilitate forums to present national decision-makers with new and relevant data and

knowledge.

Critical stakeholders to involve:

• Governmental stakeholders that go beyond health (ministries of women, agriculture, education, etc.). This can include, but not be limited to:

o Political leaders and decision-makers o Data gatekeepers o Programme managers and health personnel.

• Individuals from diverse and representative communities, especially those that we seek to reach.

• Regional, national and local-level “champions”. • Institutions/agencies/networks that serve as gatekeepers to the communities that we seek to

reach. • Social media stakeholders (influencers, etc.). • WHO country offices. • Other partners that go beyond the technical (for example, our relational partners).

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Session 2 (15 June 2020)

Key messages by speakers and temporary advisers

• In terms of COVID-19, the pandemic has exposed and amplified inequalities in society that must be addressed using a whole-of-society approach.

• Since the outbreak began, there has been a worry within the NCD community that focus and already-limited resources are shifting away from NCDs to that of COVID-19 response.

• Recent data, however, show important links between the two – links that may provide great opportunities for developing and mobilizing new and innovative approaches that integrate NCD-related efforts with COVID-19 response efforts, using a whole-of-society approach. These new approaches would not only help control and manage NCD prevalence, but also help address the COVID-19 pandemic, as well as reduce inequalities in both NCD- and COVID-19-related mortality.

o First, data indicate that NCDs are major risk factors for persons affected by COVID-19, with those living with NCDs being at higher risk of developing severe illness due to the disease.

o Second, recent data show that mortality from COVID-19 follows a social gradient, with the more deprived the area, the higher the mortality rates.

o The results parallel the social gradient in all-cause mortality, with the more deprived the area, the higher the all-cause mortality.

o Indeed, when you look at each of the NCDs, the inequalities in NCDs and the inequalities in COVID-19 mortality are quite similar by levels of deprivation.

o In other words, the same set of causes of inequalities in health more generally, are also leading to inequality in COVID-19 mortality.

Current data, evidence and surveillance gaps and challenges to identifying and reaching vulnerable groups most affected by NCDs and their risk factors in the Western Pacific:

• Political commitment, support, and leadership: o During the current COVID-19 pandemic, there has been a loss of attention and

concern for whole-of-system perspectives. o In many settings, due to a lack of capacity, persons in positions of leadership have

been unable to adapt to the new normal, missing key opportunities to integrate NCD management and control with COVID-19 efforts.

• Information system infrastructure: o Information system infrastructure does not lend itself to intersectoral collaboration –

a situation that has been specifically exposed during the current COVID-19 outbreak. o There is no integration of information systems across sectors – a situation that is of

particular concern during emergency situations, including the COVID-19 outbreak. • NCD research and data analysis:

o During the current COVID-19 pandemic, the diversion of resources for surveys and research has been amplified.

• NCD surveillance that captures the vulnerable groups most affected by NCDs and their risk factors, including the context in which these groups live:

o Data on NCDs are lacking in many countries – a situation that has been amplified during the COVID-19 outbreak.

o Due to the protective measures put in place to curb the COVID-19 pandemic, a lot of the face-to-face data collection has been replaced by electronic data collection. This has left key vulnerable groups invisible, thus contributing to a widening equity gap.

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• Evidence-based policy- and decision-making: o Limited country capacity on how to use and present data and knowledge to drive

evidence-based policy- and decision-making.

Future direction and next steps:

• Ensuring political commitment, support and leadership: o Build capacity among persons in leadership positions on how to adapt during

emergency situations and in the new normal. • Strengthening information system infrastructures to enable intersectoral NCD data collection

and analysis: o Support a decentralization of health information system to minimize consequences of

national-level responses to COVID-19. o Advocate for the acquiring of NCD surveillance positions, as well as the inclusion of

these staff in health information system planning. • Ensuring a favourable environment for NCD research and data analysis:

o Support small-scale case studies. • Ensure that NCD surveillance captures the vulnerable groups most affected by NCDs and

their risk factors, including the context in which these groups live: o Work with actors, such as social media, that go beyond health to disseminate key

(and correct) information and evidence to vulnerable groups. o Support documentation of the socioeconomic and health effects of measures taken by

countries to control the spread of COVID-19, including lockdowns. • Using evidence to drive policy- and decision-making:

o Build capacity at national and local levels on how to use and present data for decision-making

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Annex 4. Summary of working group sessions (Group 2) on risk factor reduction focused on upstream measures

Session 1 (5 June 2020)

Session 1 was composed of one presentation and three discussion sessions. The presentation was a brief overview of different upstream measures that address the four key NCD risk factors such as tobacco use, harmful alcohol use, unhealthy diet and physical inactivity. The three discussion sessions focused on the gaps and challenges to addressing the NCD risk factors through various upstream measures, examples of effective multisectoral and multi-stakeholder collaborations, and the opportunities and challenges for multisectoral collaboration for NCD policy interventions. Gaps and challenges to addressing NCD risk factors through upstream measures

• Different interests and mandates among policy-makers or different government sectors, leadership shifts and competing priorities.

• Looking at the environment where interventions can happen to address commercial, sociocultural and physical determinants.

• Regulatory and enforcement capacity within countries to address the risk factors. • Delayed, limited, or weak civil society engagement and community engagement in policy

development and implementation. • Issues on awareness among non-health sectors about role in addressing NCD risk factors

through policy and environmental change; industry interference; different frameworks for other risk factors.

• Need more work on how principles and approaches in policies can be applied to other settings, particularly in countries with low resources.

• Ensuring equity in impacts of various NCD policies and interventions to identify which groups are being overlooked or missed; point out and address unintended consequences on equity in terms of various population groups in society.

• Preference given to non-prioritized NCD risk factor strategies/plans/commitments; loopholes in adopted laws; false evidence from industry.

Examples of effective multisectoral and multi-stakeholder collaboration for NCD policy interventions

• Working simultaneously from the top leadership but also mobilizing grassroots support – existing success stories in PICs.

• Guam NCD consortium –involves not just health-related groups, but also groups that work on environment, education, faith communities, revenue and taxation, etc.

• Legislation on tobacco packaging, health warnings; tobacco packaging in Republic of Korea – tobacco pictorial health warnings through advisory board composed of different stakeholders; defence of tobacco plain packaging against constitutional/trade/investment challenges in Australia.

• Traditional forms of leadership that can have strong cultural influence, engage the real influential people – experience in Palau: traditional female leader who helped move NCD policies.

• Engaging across different government sectors to address NCDs, not just ministry of health, i.e. education, agriculture, trade.

• Enhancing political buy-in through: start with a small dedicated team for NCD coalition, conduct stakeholder analysis, frame issue well – priorities and opportunities for the stakeholders.

• Mongolia – physical activity services such as attending gyms and sports clubs – engagements with education and social sectors and funded/subsidized from health insurance.

• Cambodia – National Committee for Tobacco Control (CFTC); also similar body in Solomon Islands – multisectoral collaboration among ministries of health, education, youth and sport to develop school health curriculum and textbooks on NCDs, risk factors, nutrition and mental health.

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Challenges and opportunities for multisectoral collaboration for NCD policy interventions

Challenges:

• Monitoring and evaluation of different upstream measures or policies. • Mapping of which part of government has responsibility/mandate for what; different health

elements to the health problem or issue; different mandates and responsibilities for each agency; and points in time when the different agencies need to be engaged. Important to not only focus on bringing stakeholders together but also how to use such forums as vehicles for change.

• Lack of capacities and knowledge of non-health sectors on the issues. There may be challenges to understanding with speaking technical language/terminology. Advocacy can be enhanced by identifying policy arguments that will resonate with different sectors and gathering evidence to present a convincing case for action (e.g. PICs); tapping into subregional experts and endorsing multisectoral leadership.

• Conflicts of interest may arise when involving various stakeholders. It is recognized that there is a need to bring together civil society and the private sector to mobilize all available resources, as appropriate, for the implementation of national responses for the prevention and control of NCDs, while giving due regard to managing conflicts of interest.

Opportunities:

• Entry point in different platforms such as through roadmaps and action plans (such as in PICs and Cambodia), working together with leaders and other sectors.

• Using the existing multisectoral platform or settings as an entry point (such as school setting). • Need to know the player – finding a champion can be an important opportunity to drive and

mobilize policy dialogue (e.g. China and Mongolia). • Revamp NCD risk factor prevention policies/plans/commitment; fact finding for

misinformation.

Session 2 (15 June 2020) Session 2 was mainly composed of three discussions focusing on the proposed strategies, priority actions and potential innovations for each NCD risk factor during crises such as COVID-19, recommendations/cohesive approaches for multisectoral and multi-stakeholder collaboration on NCD policy interventions, and how to combine economic, social and environmental priorities with health priorities and risk factors. The discussion on strategies, priority actions and potential innovations for each NCD risk factor during crises such as COVID-19 started with identifying the challenges and opportunities that the pandemic has created and then proposing different potential strategies, actions and innovations that can be done during and even after the pandemic. Challenges/opportunities that arise because of COVID-19

• Stop the business as usual mindset in terms of NCD prevention and control work. • Importance of health and one health system:

o importance of NCD prevention o delayed or not happening – cancer and other NCD services.

• Collaborations with private sector. • Issues around health literacy, impact of built environment and working from home on health

policies. Proposed strategies/priority actions

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• Preventing NCDs can have an impact on preventing communicable diseases (CDs) and reducing their impacts during a pandemic (less inequality, fewer people with increased risk).

• Proactive messaging to situate NCD prevention as fundamental to pandemic to decrease number of hospitalizations and deaths and counter misinformation promoted by industry:

o Experience with tobacco industry has emphasized the need for proactive messaging from health sector to situate and frame NCD control as essential to pandemic efforts.

o Series of infographics to highlight continued importance of NCD prevention when focused on combating infectious diseases (tobacco, alcohol and mental health).

• Build or improve on regulatory capacity that applies across both NCDs and CDs. • Increase policy windows and regulatory measures for taxation and other types of restrictions –

availability of tobacco and alcohol products. • Increase government revenue through taxation on sugar-sweetened beverages or other risk

factor products. • Increase use of walking and green spaces or options such as use of bicycles. • Create a “Think Tank” of policy and regulatory professionals to bridge the gap between CDs

and NCDs (both during pandemics/crises and at other times). • Enhance collaboration opportunities for promotion of NCD prevention and control. • Consider potential conflicts/vested interests and mitigate as necessary. • Integrate roles and responsibilities for healthy and safe workplaces. • Consider revision of current strategies and health promotion in response to changes associated

with the pandemic. Consider developing new best practice models moving forward.

Potential innovations • Social media’s role that brings unique opportunities to communicate and engage with

stakeholders towards improvement in advocacy and health promotion work. • Social media is led by media houses, journalists, media influencers and general public in

addition to national institutes and other governmental agencies – take best out of all actors in social media with communication and distribution of messages, including tackling misinformation. The pandemic is a real learning point in all this.

o Case in Guam where farmers lost markets due to isolation – one mayor developed a programme through WhatsApp to collect and deliver goods to the public every week.

o Exercise-at-home videos. o E-commerce and online selling and delivery option or grocery shopping for fruits and

vegetables (same case in the Philippines). The discussion on recommendations/cohesive approaches for multisectoral and multi-stakeholder collaboration on NCD policy interventions lifted the opportunities and challenges for multisectoral collaborations from Session 1 and proposed recommendations and approaches corresponding to each challenge or opportunity, as summarized below:

• Need for capacity-building and coordination in mapping health issues and corresponding mandates of relevant government agencies.

• Create space for dialogue and require a convener for national multisectoral committees. • Have a clear mandate or policy that spells out the terms of engagement and consider

accountability mechanisms. • Shift the thinking on civil society from targets of interventions to partners driving changes in

policy and prevention. • Recruit people to different causes. • Promote NCD leadership capacity-building – important for WHO to revisit this role. • Reconsider how we teach in universities, training of medical and public health workforce

(including broadening how we conceive of the public health workforce); health issues need to be in other areas (i.e. environmental studies, sports, etc.).

• Need to integrate emergency management plans and activities and advocate for integration into the plans.

26

• Strengthen the value of multisectoral action within the United Nations system. • Collaborate with range of other institutions such as the academe to build knowledge and

evidence for advocacy and awareness. • Look into sustainable community-based enforcement.

The last discussion on how to combine economic, social and environmental priorities with health priorities and risk factors sought to know the difference that can be made with multisectoral and multi-stakeholder cooperation in upstream regulations and interventions for NCD risk factor prevention and a healthier and greener environment. Key messages identified were:

• Identify commonalities of NCD prevention and control with environmental and economic priorities.

• Need for very creative type of framing for investment cases for NCD risk factor prevention and control.

• Opportunities for more local sustainable food supply chains through working with agricultural sectors and promoting and building up capacities for community farming.

• Many businesses have been innovative and creative – linking the positive initiatives from work of the international trade systems, logistics chains and collaboration across sectors.

• Best practices on new public transport and mobility are very circumstantial and context specific.

• Urban planning is going to change significantly after COVID-19 – promote urban planning for the future that builds communities where people live close to where they work and green open spaces.

• Consider population-level or local-level mechanisms to address multisectoral priorities within economic, social and environmental priorities in relation to health.

• There are different ways in which lockdowns affect the behavioural NCD risk factors such as consumption of alcohol/tobacco, access to healthy foods and challenges in doing physical activity.

• Important to harness the power of social media for health but also to limit the dissemination of false/harmful messages or information.

• Taxation and other fiscal policies are great opportunities to combine economic and social priorities with health priorities and reduction of risk factors.

Future directions and next step As gaps, challenges and opportunities have been identified in various upstream actions for NCD risk factor reduction, key future directions and next steps have emerged:

• Create a space and invite community or civil society for dialogue as partners for driving changes in NCD risk factor policies and interventions.

• Delineate and frame NCD risk factor issues with corresponding mandates and responsibilities of different government agencies and stakeholders to achieve sustainable multisectoral cooperation and collaboration for prevention and health promotion.

• Strengthen NCD risk factor prevention and health promotion leadership and capacity for efficient upstream interventions.

• Improve regulatory capacity for NCD risk factor prevention through education and training, professional development, and focused advocacy for policy-makers.

• Equip upstream interventions for NCD risk factor prevention and health promotion with mandatory notions for community engagement and participatory approaches for implementation.

• Ensure that equity is a fundamental consideration in the development, implementation and enforcement of all interventions, with particular attention paid to impacts on vulnerable groups.

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• Strengthen “Think Tank” for policy and regulatory professionals to bridge the gap between NCD risk factor prevention and health promotion, and prevention and management of CDs.

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Annex 5. Summary of working group sessions (Group 3) on NCD individual services and management

Session 1 (10 June 2020)

Key messages by presenters, temporary advisers and observers: NCDs pose a significant burden, not just in the Western Pacific Region, but globally. This has spurred political action, guided by global strategies on the prevention and control of NCDs, as well as their major risk factors. In 2010, the first WHO Global Status Report on NCDs was published, paving the way for stronger political declarations and the setting of targets for NCDs aligned with the broader Sustainable Development Goals.

Despite political commitment and the progress seen across countries, significant gaps still remain:

• While most countries in the Western Pacific Region have seen a decline in the age-standardized NCD mortality rate, as well as the probability of premature mortality from NCDs, from 2010 to 2016, data show that most countries will not hit the 2030 targets of reducing premature mortality due to NCDs (Sustainable Development Goal target 3.4: By 2030, reduce by one-third premature mortality from NCDs through prevention and treatment, and promote mental health and wellbeing).

• This likewise applies to other time-based targets on reducing the prevalence of hypertension, and halting the rise of blood sugar.

These gaps are rooted, in part, in health systems challenges that acknowledge how siloed programmes across all levels of the health system decelerate the overall impact that NCD management ought to achieve. These challenges include:

• Lack of access to quality, affordable, essential NCD medicines in primary health care (PHC). • Inadequate human resources capacity to deliver NCD services designed around acute care. • High out-of-pocket costs. • Weak systems for NCD surveillance and monitoring. • Lack of confidence in public health services. • Devolution of responsibility to regions without required funding and capacity. • Lack of regulation of private sector.

In terms of COVID-19, the pandemic has likewise surfaced challenges that countries have faced in providing NCD services; 120 countries have reported disruptions in NCD services. A decrease in inpatient volume due to cancellation of elective care, closure of population-level screening programmes, government lockdowns hindering access, NCD staff being deployed to do COVID-related work, and the closure of outpatient clinics, among other things, form part of what has caused these disruptions.

Countries are asking for urgent guidance and support on four main domains:

• Guidance on how to provide continuity for NCD programmes: Countries have so far struggled with how to provide essential NCD services in light of lockdowns, against a broader goal of protecting people living with NCDs.

• Communication materials: These unprecedented times have brought to fore the importance of risk communication, especially towards people living with NCDs. Campaigns for health-care workers on how to provide NCD care in emergencies have also proven essential.

• Better data: While it has been clear that people living with NCDs are at risk of developing severe or fatal disease from the virus, there is a need at country level to develop projection models to make the impact of the COVID-19 pandemic on NCDs visible. This presents opportunities to use digital tools to record patient management regime and enable remote management in emergencies through telemedicine.

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• Country support: Continuous support is needed to build capacity on how to integrate NCDs into national COVID-19 plans, as well as in adapting the PEN and HEARTS technical packages into the COVID-19 context.

What the pandemic makes clear is that there has been a shift in the way that NCDs figure into the bigger picture of ensuring health. From a health systems perspective, these are succinctly presented in three Ps: political, given the shift of focus and priority from NCDs to CDs; physical, in light of services now having to necessarily contend with the imposition of physical distance; and, in terms of protection: how do we ensure the protection of both patients and the health workforce?

The political challenge is exacerbated by hesitation at the community level to access care in hospitals and health centres for fear of the virus.

Human resource development for NCD management has also suffered as modes of training and capacity-building adapt to the limitations set by physical distancing. This both provides opportunities but also brings up challenges:

• There is greater opportunity to advocate for self-management, but this discussion has to move forward in line with addressing its own challenges.

o Country context: In Tonga, population control has been an issue given the scarce availability of needed supplies. This is further exacerbated by border issues that have halted the supply of necessary medicines and equipment. Self-management in under-resourced contexts provides gaps that have to be addressed with a health systems perspective.

o A strength at this level is the communal ownership of programmes, allowing opportunities to educate and mobilize even non-health personnel. This communality creates environments in which NCD management, as well as the promotion of healthy behaviours, thrives.

• A gap that must be closed to advocate for self-management is two-fold: mentoring and capacity-building harkens back to challenges of the limitations of face-to-face interaction, as well as the availability of tools.

• The COVID-19 response, as well as NCD management in general, necessitates that the solutions we propose do not widen inequalities. While the current context provides an opportunity to leverage existing mobile platforms such as telemedicine and mHealth, or even self-management, we must be careful to adapt a perspective that lends itself well to issues of equity, permitting a more holistic approach.

• To this end, we must create environments where these solutions – telemedicine, digital tools, self-management, for example – are possible and sustainable.

• Another challenge looks at how siloed programmes – especially for services that have been rendered inaccessible given the current situation, such as oral health – emphasize a big disconnect in how NCD services have been provided. We need to look at how receiving, extending and funding services for particular issues can be leveraged to pivot to a more effective, scalable delivery system for NCD management.

o One way to address this is by shifting to an integrative perspective on health care, in essence, breaking down barriers in terms of expanding the scope for health-care providers to an extent that allows them to provide advice on particular issues.

o It is likewise important to look at NCD care on a spectrum. When talking of self-care, there is opportunity to promote healthy behaviours hand-in-hand with the management and control aspect. The community also provides an opportunity to extend health-care provision beyond health.

A more global perspective on the integration of NCD management into the health system builds the case for integration by looking at the NCD burden from a social and economic perspective. NCDs worsen poverty, with an estimated 97 million people impoverished by out-of-pocket health-care

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spending in 2010 (World Health Stats). Integration is aligned with Global Good 566 that looks to integrate NCDs into national HIV/AIDS, tuberculosis, and sexual and reproductive health programmes and the health system. It improves equity by maximizing the level and distribution of health and well-being, bolsters effectiveness of multiple health outcomes through practical approaches to service delivery, and enables cost-effectiveness by minimizing the duplication of finite resources:

• For NCDs, CDs, and sexual and reproductive health, integration means addressing comorbidities and multi-morbidity, paying mind to shared socio-environmental and behavioural risk factors.

• The continuum of integrating these disease programmes is maximizing the impact and outcomes of these various responses.

• This necessitates a strong health system oriented towards NCDs.

UHC should serve as the foundation moving forward for NCDs, especially in light of the new normal, ensuring financial protection even as service coverage expands. This is underlaid by the need to “reach the unreached” and for new technology in NCD management:

• The new normal necessarily informs a systems-based approach to NCD management. The health and fiscal crisis presents an opportunity for health; as there are risks of lower ministry allocations due to lower government revenue, there are opportunities to increase allocations for health, which can precede a shift to health systems-based approaches that will benefit NCDs in the long run.

• This also presents an opportunity to start looking at how to better integrate digital platforms in service delivery.

• Health information systems likewise play into the integration of NCD management, given the need to generate information and provide evidence about NCD service integration across whole systems.

o There is a need to strengthen the implementation of health information systems across the health system, which in turn surfaces the need to assess these systems, and the health facilities in which they are implemented.

• Looking at specific populations textures these discussions in a way that better looks at the linkages between NCDs and other areas. For maternal and child health, for example, this has been seen in how health outcomes and practices during the antenatal, postnatal, newborn and childhood periods predispose individuals to NCDs, while NCDs and their risk factors have adverse effects on maternal and child health and pregnancy outcomes.

o This presents opportunities for NCD prevention and control in maternal and child health services, in part using local data to improve the quality of maternal and child health care.

o A challenge lies in ensuring quality care (increasing the percentage of women who receive services, increasing the availability of medicines), as well as referrals for specialized care, and screening and counselling for risk factors.

o While there has been significant progress through what is known as “survive” interventions, there is a need to broaden the focus to “thrive” interventions for overall well-being. Several existing entry points during antenatal, postnatal, newborn and child health care which can serve as a platform to address NCD prevention and control, and for which collaborations beyond the health sector, are vital.

Several considerations were surfaced in these discussions:

• Fundamental changes in how we think about care and service delivery fundamentally comes down to leadership.

• Technical guidelines for NCDs are clear, as are the approaches; but putting these into action is as important, as well as advocating these guidelines to policy-makers.

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• The pandemic has presented a paradigm shift, but it is a mistake to believe that the evidence base has changed just in the past three months; instead, what we have seen is a rapid pivoting. The challenge now is how countries will approach this, and how leadership will change.

• It brings to fore the importance of an enabling policy environment, in order to make these interventions and policies sustainable.

• Integration beyond the health sector – cross-sectoral collaborations – are vital. • While necessary focus is given to vulnerable sectors, there has been a perceived tendency to

ignore the working age group that sets the scene for the aged population. Because NCDs develop over the life course, we have to be more proactive in keeping these populations healthy.

Session 2 (18 June 2020)

With NCDs a significant burden across countries in the Western Pacific Region, it is vital to strengthen health systems for integrated people-centred NCD services. To this end, several country examples were provided:

• In Japan, the integration of NCD management has included the prevention of diabetes aggravation. A multisectoral approach was applied, with the prefectural government taking point. The project initially started with several prefectures and municipalities in 2014, but has since expanded nationwide beginning in 2016. The programme was a response to an increase in diabetes patients by 2.2 times, with many dropping out of treatment, while new dialysis cases by diabetic nephropathy have increased by 2.8 times. Medical costs have likewise been on the rise.

o What this has required is an underlying universal health insurance scheme, human resource support, financial and technical support, as well as a six-month motivational health guidance provided through collaboration with a private institution.

o Several challenges were encountered: people’s awareness was generally low, and human resources were needed, with capacity-building a necessary consideration. Visible outcomes were likewise a challenge.

o What the programme makes clear is that quality health and cost statistics are what drive policies forward. On the ground, prefectural and local partners are key players.

o Moving forward, the programme is looking at further expansion, especially in light of the COVID-19 outbreak.

• In the Republic of Korea, NCD management services that have been integrated include early detection, registration, treatment, case management and health education, among others. Four projects have been ongoing: hypertension and diabetes registration and management since 2007; a clinic-level NCD management project since 2012; a community primary health care pilot in 2014; and an NCD payment pilot since 2016. The two latest projects have since been consolidated from 2019. These were implemented towards strengthening PHC competency in managing NCDs, with the National Health Insurance Service, primary health clinics and doctors’ associations, and District Health Offices implementing.

o PHC clinics have needed refresher trainings and capacity-building, especially for physicians, as well as additional human resources. At this level, reimbursement is through the National Health Insurance Service, including some out-of-pocket payments. The District Health Offices have taken point in supporting registration and recall reminder, and health education. Funding is through the national or district public health budget. An evaluation is ongoing.

o A challenge has been in the consolidation of the three different pilot projects, given concerns about funding sources, incentives, and how to approach health education (individual at the clinic versus group at the district health centre). Coordination and assessment fall either to the clinicians themselves, or care coordinators at PHC or district level.

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o Further coordination with the welfare department for integration with housing, long-term care and other social services is underway.

Another point of discussion is whether the adaptation of integrated people-centred services for NCD management is feasible given the constraints of the new normal – in particular, whether these interventions are sustainable in low- and middle-income countries (LMICs). The health service delivery network is organized across the different levels of care, so integration would be between health facilities along those levels. This is especially relevant, given that LMICs have health systems reliant on primary care. Joint action between multi-stakeholders inform this integration.

• From a ministry of health perspective, what would be necessary is a policy framework to guide this, as well as key performance indicators for monitoring and evaluation. A mechanism for countries to exchange knowledge and share experiences would be helpful.

• Minor concerns were surfaced as to whether country experiences that differ contextually would be applicable. Key differences – such as in resources, for example – potentially alters applicability. However, there was a general consensus that knowledge-sharing is vital regardless.

• While sustainable, this would still grapple against challenges on two levels: from a consumer perspective as well as from a health systems perspective:

o Health literacy and a people-centred perspective remain key. o From a systems point of view, there is a need for comprehensive policy frameworks,

as well as health system continuity. A common challenge is workforce shortage of those with competencies in NCD prevention and control.

To move forward, several considerations for WHO were presented through a SWOT analysis:

• Western Pacific Regional Office: The strength of the Regional Office is its easy access to focusing political action, with a robust network and credibility to governments. However, at an organizational level, components of NCD prevention and control are scattered across divisions, owing to vertical programme structures. There is opportunity to leverage COVID-19 to heighten awareness of cross-sectoral relevance of NCDs, even during infectious pandemics. A prevailing threat is rooted in a more global landscape, with the United States pull-out potentially reducing financial and technical contributions, leaving U.S. territories in less-than-ideal positions.

• Country offices: In-country presence has always fostered good working relationships with ministries of health and other stakeholders, but the pre-existing structures for NCDs are likely to be exacerbated by NCD staff pull-out for repurposing for the COVID-19 response. The same opportunities for the Regional Office apply, but a threat is Member State bandwidth, during and post pandemic, across health and broader economic sectors.

• Ministries of health: There is a fundamental commitment to NCDs, especially in the Western Pacific. However, resources and personnel may be limited, further spread thin by the ongoing COVID-19 responses, especially in smaller PICs as well as LMICs. The same opportunities for the Regional Office and country offices apply, but a threat lies in political support at the national level being overshadowed, even in the aftermath of the pandemic.

Strategic and immediate actions were recommended for both the Regional Office and country offices:

• Western Pacific Regional Office: A strategic action point is to promote cross-division teams to delineate roadmaps for integrated NCD management, as well as highlight high-yield interventions (tobacco control, sin taxes, etc.). More immediate is the need to heighten awareness and provide data products highlighting the continued relevance of NCDs in light of COVID-19. It is likewise vital to keep NCDs on the political radar for countries.

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• Country offices: As a strategy, convening, facilitating and promoting strategic multisectoral partnerships within countries remains vital for engagement and buy-in. For immediate action, country offices must be capacitated to provide technical and risk communication assistance to emphasize the importance of NCD prevention and control for pandemic preparedness, and COVID-19 control efforts.

For consideration, WHO would benefit from looking at how to improve capacity across levels of WHO for integrated people-centred NCD services. This may manifest in the way it organizes its work, partnerships, COVID-19 response, and recognition of high-yield, low-hanging targets both regionally and nationally. Two technical products from the Regional Office were presented in response to discussed and prevailing concerns:

• A regional framework provides an overview of the approach for integration of NCD management in countries.

• A Country-centred Programme Guide for integrated NCD management outlines how to integrate the management of NCDs, eye, ear and oral health into existing programmes and health systems.

o The Programme looks to strengthen health systems for integrated NCD management services. The initial approach starts with six demonstration countries and areas (equally distributed across Asia and the Pacific) to serve as models. Country roadmaps are context specific, with targets to reduce risk of premature mortality, halt diabetes, and reduce hypertension prevalence through the increased availability and utilization of NCD services.

o A tentative timeline starts implementation in 2021, with 2023 midterm evaluation simultaneous with cross-country learning and scale-up. An end-line evaluation is tentatively slated for 2025.

o Questions and concerns were raised on several fronts:

▪ On how the Country-centred Programme would differ from existing collaborations between international agencies (such as JICA, KOICA) and countries for project expansions: The Programme highlights WHO’s coordinating role, especially for programmes linked with ministries and other programmes. Likewise, it seeks to lessen duplications and better utilize resources.

▪ On scope and scale: The basic concept is to move away from individual programmes or packages; strengthen collaboration with health systems and UHC colleagues; and ensure that objectives are embedded in existing systems.

▪ On what it means to be a demonstration country, and other concerns on language, phrasing: The capacity to develop good examples of people-centred services may not be strong. There must be caution moving forward to move away from focusing too much on country-level criteria without simultaneous focus on on-the-ground capacity.

o With the country focus of these programmes, there is opportunity for countries to drive what the parameters of the framework would be. The development would benefit from a scan of existing food examples in different communities, and (sub)national levels before any assessments are made.

o Likewise, this also presents the opportunity to deviate from usual approaches that have so far focused on higher levels: instead of the national picture, we must look at assessments from a community/patient perspective.

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Future directions and next step:

• To use UHC as the foundation for health systems strengthening and integrated NCD services • To consider the following health system actions for the integration of NCD services:

o Governance – leadership building across all levels; political advocacy; and strategic partnerships and participatory planning.

o Finance – sin taxes for government revenue; essential NCD benefit packages; and private provider incentives.

o Service delivery – NCD services at primary care level with community engagement; self-management (with protocols, access to basic needs); and provider networks.

o Digital health platforms – for the scope of NCD services; as a tool for self-management and capacity-building; and for NCD service integration through integrated medical records systems. A key point is to ensure equitable access.

o Health workforce – new cadres of health workers for NCD services and home-based care; and NCD management competencies in education curricula for health providers.

o Health information – information on service capacity, individual health behaviour and community involvement; information use and exchange at health facility level; vulnerable populations; and capacity-building at national and local levels on how to leverage data for policy.

At the close of the session, comments in closing brought to fore the need to emphasize leadership as key, for which there should be sustained investment (as in WHO projects like leadership workshops), further enunciating the need to collaborate with WHO collaborating centres and countries.

Another sustained point during both sessions was strengthening human resource development that – while implied in the models discussed – must be more explicit: it is vital to push change in this domain as well, lest it remain constrained in terms of numbers but also capability. There is opportunity to think about competencies, as well as assess whether staff are already available.

Lastly, while the importance of digital health was emphasized, it must likewise remain important to leverage traditional means, especially for areas where digital health is not easily accessed.

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Annex 6. Summary of working group sessions (Group 4) on PIC perspective

Session 1 (1 June 2020)

Session 1 was composed of one presentation followed by a discussion on how to best ensure that the needs, challenges and context of the PICs are reflected in Groups 1–3. The presentation described the objectives of Groups 1–3 and noted that while several evidence-based approaches, actions and recommendations for NCD prevention and management have been identified, the means by which (i.e. the “how”) to support their effective implementation remains elusive. Further discussions highlighted while some challenges and gaps are not unique to the Pacific, its context often impacts the way challenges and gaps manifest, while also providing unique opportunities.

Group 4 made plans to embed representatives in groups 1–3 to ensure inclusion of Pacific viewpoints and to hold “mini-group” sessions prior to Group’s 1–3 sessions. Group 4 then planned to meet again on 26 June 2020 to compile key issues for the Pacific and suggestions for moving forward.

Session 2 (26 June 2020)

Each “mini group” presented gaps, challenges, and barriers followed by suggestions for moving forward. Each presentation was followed by discussion which provided an opportunity for additional input. The session also included a presentation and discussion of needed priority actions in the context of COVID-19.

Mini group 1: Knowledge, data and surveillance

Gaps, challenges, and barriers:

• Health information systems fragmented, which don’t lend themselves to collaboration; multiple vertical systems; front line over-burdened with reporting

• Surveys can only be periodic as they are costly, time consuming • Limited data on younger children • Limited research in the PICs; lack of priority and time for research • Limited action research and evaluation of interventions • Data utilization • Limited cross-sectoral commitment, particularly related to commercial influences • Gaps in knowledge of factors driving risk factors, access issues, compliance • Lack of funding for research, monitoring and evaluation, surveys; lack of dedicated personnel • Perceived impact of climate change on NCDs and knowledge translation.

Future directions and next steps:

• Build capacity to undertake and publish research through collaborative approach with Pacific academic and other institutions

• Establish NCD surveillance positions and include clinical staff in health information system and NCD strategy planning

• Consider sentinel site surveys as interim and monitoring, which is lower cost • Ensure inclusion of vulnerable and hard-to-reach populations when utilizing electronic

surveillance • Explore community-based participatory research and surveillance, including qualitative

approaches • Link data collection with broader approaches (e.g. Health Promoting Schools) • Develop/standardize tools for collecting data on younger children • Provide tools and guidelines for local adaptation (e.g. on health-seeking behaviour,

adherence) • Establish collaborative approaches and build capacity to evaluation of interventions • Ensure NCD in high-level agenda (e.g. trade ministers, finance ministers) • Consider desktop reviews/studies to understand more about commercial influences.

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Mini group 2: Risk factor reduction focused on upstream determinants

Gaps, challenges, and barriers:

• Delayed or limited involvement of community in policy prioritization, development, implementation

• Limited enforcement of policies and laws • Unimplemented NCD strategies/plans/commitments • Limited awareness among non-health sectors about their role in addressing NCDs • Industry interference • Competing priorities (internal and external to health sector) • Conflicts of interest among different government sectors.

Future directions and next steps:

• Modify processes to ensure engagement/leadership of civil society in policy prioritization, development, implementation

• Identify a spectrum of options for engaging communities in enforcement, including tactical engagement of various leaders to advocate

• Identify and leverage entry points to prompt and sustain engagement; consider legal mandate options

• Implement mechanisms to ensure continuity of efforts to address shifts in leadership • Establish mechanisms to ensure transparency and that require deliberation of health impacts

in policies of all sectors. • Make commitments based on feasibility (e.g. socio-political climate, resources, etc.) and

strategic prioritization.

Mini-group 3: Individual services and management

Gaps, challenges, barriers:

• Large NCD population • Huge disparity between budget for public health and for hospital services

o Limited investment in PHC

• Limited integration between clinical NCD management level and health promotion • Numerous forms of data (hard copy/electronic), but information is not necessarily linked • Limited capacity, confidence and/or authority to provide certain NCD services • Mental health and support for families/caretakers of persons with NCDs • NCD-related disability and NCD-related rehabilitation requirements (both primary health

care-based and specialized services) • Data interpretation and utilization.

Future directions and next steps:

• A role-delineation policy to guide the delivery of a comprehensive package of NCD clinical services and to improve referral systems so PHC health-care workers are well-supported

• Investing finance in PHC centres to improve the quality of care for NCD patients seen at PHC centres – e.g. telemedicine (remote referral) would connect the primary care provider to physician/specialist

• Health promotion integrated at PHC; strengthened community involvement in supporting NCD patients:

o Motivational interviewing for behaviour change is an approach that should be explored in the Pacific context

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• Train PHC health professionals in modern behaviour change techniques • Integration with current health information system, clinical audits to monitor compliance and

quality • Nurses to cover additional aspects of service delivery; allowing specialists to focus on more

complicated cases (review licensing regulations, etc.) • Develop strong clinical networks across the Pacific to assist each other through visiting

consultants, having regional guidelines with Pacific context • Establish “one-stop shops” for comprehensive NCD service delivery; promote self-

management among patients and consider NCD “passports” to empower patients • Strengthen participation of clinical services representatives, faith-based organizations, and

community representatives on national multisectoral NCD committees.

Needed priority actions in the context of COVID-19:

• Communicate that the investment in NCD prevention would reduce the negative impact of health threats such as COVID-19.

• Frame NCD prevention and management as fundamental to pandemic mitigation efforts. • Decentralize resources to support NCD services. • Review and revise job descriptions to reflect the changes made on the workflow and on how

services (including NCD management) are being delivered. • Support analysis of intersection between NCD prevention and CD pandemic response to

minimize conflicts, maximize synergies and avoid unintended incoherence. • Support studies addressing health/social/economic determinants of mental health. • Unpack and explore impact of de-urbanization to rural areas to engage in subsistence farming

in the PICs as a result of COVID-19 restrictions. • Incorporate core NCD risk factor prevention services such as tobacco cessation, physical

activity strategies during home quarantine, mental health resiliency building in “wraparound” services for the pandemic preparedness response.

• Ensure consistent funding for NCD prevention and management.

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