65132 H N P D i s c u s s i o N P a P e R EFFECTIVE RESPONSES TO NON-COMMUNICABLE DISEASES Embracing Action Beyond the Health Sector Montserrat Meiro-Lorenzo, Tonya L. Villafana, Margaret N. Harrit September 2011 EFFECTIVE RESPONSES TO NON-COMMUNICABLE DISEASES: Embracing action beyond the health sector Montserrat Meiro-Lorenzo, Tonya L. Villafana, Margaret N. Harrit September 2011 Health, Nutrition and Population (HNP) Discussion Paper This series is produced by the Health, Nutrition, and Population Family (HNP) of the World Bank’s Human Development Network (HDN). The papers in this series aim to provide a vehicle for publishing preliminary and unpolished results on HNP topics to encourage discussion and debate. 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For information regarding the HNP Discussion Paper Series, please contact Homira Nassery at hnp@worldbank.org or 202-522-3234 (fax). © 2011 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved. ii Health, Nutrition and Population (HNP) Discussion Paper Effective responses to non-communicable disease: Embracing action beyond the health sector Paper prepared in support of The World Bank’s work on non-communicable diseases in preparation for the United Nations General Assembly High Level Meeting on Non Communicable Diseases Abstract: ―Effective responses to non-communicable disease: Embracing action beyond the health sector‖ focuses on solutions, indicating opportunities for the prevention and control of non-communicable diseases and the kinds of actions that will achieve it. NCDs exact a heavy toll on individuals and society. They cause disease, disability, and death, and reduce productivity which is vital for development. They also impose hefty costs on health services, particularly since NCDs frequently lead to ongoing disability and need for long-term care. Prevention that results in healthy aging and the reduction of morbidity is far more cost-effective and financially sustainable than treatment alone. A small number of proven prevention measures could stem the rise of the NCD epidemic. Data indicate the potential of affordable, potent, prevention tools focused on five key areas: tobacco, alcohol, diet, exercise and nutrition. Together, programs targeting these areas could reduce the burden of NCDs by more than half, while costing only a tiny fraction of current health spending. NCDs arise from a complex combination of genetics, behavioral, and environmental factors, thus effective prevention efforts typically require the involvement of actors beyond the health sector, including from sectors such as education, agriculture, energy, and urban design among others. Successful prevention efforts – of which this paper profiles a cross-section – adopt a variety of ―multi-sectoral‖ approaches, underpinned by a range of policy instruments. While the health sector has a critical stewardship role to play in bringing all key stakeholders together in addressing NCDs, it will also need to undergo adaptation to cope with the growing NCD challenge in both MICs and LICs. Since successful prevention involves multiple sectors and actors, countries will need to adopt a framework that clearly sets out the different levels of accountability of each role player. Such a framework will require strong national buy-in, but there are tools, examples, and support agencies available to facilitate this. Middle- and low-income countries can seize the opportunity and act now to tackle NCDs and the underlying risk factors of these diseases. If they do so, these countries will greatly increase their prospects of reaping the full benefits of their demographic dividend, and of ensuring sustained economic development, greater equality, and a better quality of life for their people in the years ahead. Key words: non-communicable diseases, noncommunicable diseases, chronic diseases, NCDs, prevention, multi-sectoral, Correspondence Details: Montserrat Meiro-Lorenzo, World Bank, 1818 H Street, N.W. Washington DC, 20433. Email: Mmeirolorenzo@worldbank.org iii Table of Contents Introduction ..................................................................................................................................... 1 1. Halting the NCD epidemic: the prevention imperative .............................................................. 1 2. A multisectoral approach: key to effective prevention ............................................................... 6 Range of targeted risks factors ............................................................................................ 6 Leadership by a range of different sectors .......................................................................... 7 Initiatives at national and sub-national levels ..................................................................... 8 Action by both public and private actors ............................................................................ 9 Different degrees of coordination ..................................................................................... 10 3. Success factors and policy levers .............................................................................................. 10 Key success factors for interventions to combat NCDs.................................................... 11 Policy instruments to promote effective multisectoral interventions ............................... 12 4. Repositioning health systems .................................................................................................... 13 Conclusion .................................................................................................................................... 15 Appendix: Table of case examples in order of appearance in the text ......................................... 16 References ..................................................................................................................................... 21 iv v ACKNOWLEDGEMENTS This paper was authored by Montserrat Meiro-Lorenzo, Tonya L. Villafana and Margareta N. Harrit. The team is grateful to our peer reviewers and colleagues for their insights and contributions. The peer reviewers included Abeyah A. Al-Omair, Enis Baris, Patricio V. Marquez, Andre Medici, and Luis Orlando Perez. In addition, the team received a variety of valuable inputs from Maria Eugenia Bonilla-Chacin, Daniel Cotlear, Shiyan Chao, Ramesh Govindaraj, Fernando Lavadenz, Anthony Measham, Irina A. Nikolic, Anne M. Pierre-Louis, Sameh-El Saharty, and Abdo Yazbeck. The team also received helpful inputs from colleagues in other sectors including, Sameer Akbar, Julie Babinard, Daniel Hoornweg and Andreas Dietrich Kopp. This work also drew on insights from recent reports and regional and country studies, produced by Bank colleagues. We would like to thank Colin Douglas for his invaluable editorial support and Mary Liu for her help with the manuscript. Finally the team thanks management, Cristian Baeza and Nicole Klingen, for their guidance and support in developing the concept of this paper, and advising us throughout the process. vi vii INTRODUCTION This paper is the second in a series of World Bank knowledge products on the global epidemic of non- Key messages: communicable diseases (NCDs). The first, ―Chronic  Preventing premature disease and mortality from NCDs will accelerate the development Emergency: Why NCDs Matter‖, underlines the of middle- and low-income countries. massive health and socio-economic impact that  Proven, cost-effective, fiscally sustainable NCDs will bring if the epidemic is left unchecked, interventions to prevent NCDs exist. particularly for less developed economies and  Preventing NCDs requires action beyond the poorer populations. The impact of the mounting health sector. NCD challenge cannot be fully understood without  The health sector has a central role in considering the broad range of direct and indirect preventing NCDs, but it may require a effects on economies and health systems, as well as paradigm shift. on the affected individual and his or her household. These effects drive economic and human development outcomes, including: decreased country productivity and competitiveness, greater fiscal pressures, diminished health outcomes, and increased poverty, inequity, and opportunity loss. This paper focuses on solutions, indicating opportunities for prevention and the kind of actions that can achieve it. NCDs exact a heavy toll on individuals and society. They cause disease, disability, and death, and reduce productivity which is vital for development. They also impose hefty costs on health services, particularly since NCDs frequently lead to ongoing disability and need for long-term care. Prevention that results in healthy aging and the reduction of morbidity is far more cost- effective and financially sustainable than treatment alone. Because NCDs arise from a complex combination of genetics, behavioral, and environmental factors, effective prevention efforts typically require the involvement of actors beyond the health sector, including from sectors such as education, agriculture, energy, and urban design. Successful prevention efforts – of which this paper profiles a cross-section – adopt a variety of ―multisectoral‖ approaches, underpinned by a range of policy instruments. Yet, the health sector has a critical stewardship role to play in bringing all key stakeholders together in addressing NCDs. It will also need to adapt to cope with the growing NCD challenge in both middle- and lower-income countries. 1. HALTING THE NCD EPIDEMIC: THE PREVENTION IMPERATIVE A small number of proven prevention1 measures could stem the rise of the NCD epidemic. Data indicate the potential of affordable, potent, prevention tools focused on five key areas: tobacco, alcohol, diet, exercise, and nutrition. Together, these programs could reduce the burden of NCDs by more than half, yet cost only a tiny fraction of current health spending. 1 In this paper the term prevention includes two different but complementary concepts: “disease prevention� and “health promotion�. Disease prevention is considered to be action, usually emanating from the health sector, dealing with individuals and populations identified as exhibiting identifiable risk factors, often associated with different risk behaviors. Health promotion strives to boost the resources that help people avoid getting sick and thus seeks to support the autonomy of individuals. These terms are frequently used interchangeably, but some countries do make a clear distinction between the concepts. 1 If nothing is done to reduce the risks of chronic diseases, considerable loss of human life and economic costs will follow. Studies (Abegunde et al 2007) suggest that in 23 low- and middle- income countries with the highest burden of NCDs, 250 million lives and US$ 84 billion of national output could be lost between 2006 and 2015. Most countries will not be able to afford the fiscal burden of treating NCDs. Preventing NCDs will help promote development in middle- and low-income countries, which can take advantage of the “demographic dividend�. Middle-and low-income countries are entering a limited period in which the size of the working-age population is growing substantially relative to the non-working or dependent population, i.e. their dependency ratios are falling (see example in Figure 1). This phenomenon gives rise to a ―demographic dividend", which is very favorable for development because a larger share of resources is available for saving, investment, and production (Cotlear, ed. 2001). After a generation or so, however, dependency ratios begin to rise again. Aside from appropriate economic policies, countries need a healthy population of working-age adults to fully realize the benefits of the demographic dividend. In Egypt, for example, NCDs reduce hours worked by as much as 50%, leading to an estimated overall production loss of about 12% of its GDP (Rocco 2001). Figure 1: Demographic Dividend in Chile 1990 2011 54.8% = Working Age 59.7% = Working Age Working Age Population 2 Source: International data base. US Census Bureau Many developing countries are confronting NCDs at lower levels of income and among younger populations than high-income countries experienced (World Bank 2011). In developing countries, a large percentage of deaths from NCDs and about 80% of all disability occur before the age of 60, most of which could be prevented. By reducing exposure to a few risk factors, preventing NCDs can be feasible, fiscally sustainable, and often equitable. Treating NCDs involves high cost and often lifelong expenses. For most middle- and low- income countries, prevention is the only financially sustainable way to bring NCD-related morbidity and mortality down to OECD levels (WHO 2008). Globally, only about 50% of the burden of NCDs can be attributed to aging populations; this proportion is likely to be significantly smaller in middle- and low-income countries. The rest of the burden is driven by two sets of socio-economic factors. The first is economic transition, which includes urbanization and the globalization of risk factors such as tobacco use. The second centers around poverty (figure 4), which increases exposure to NCD risk factors such as poor 2 http://www.census.gov/population/international/data/idb/informationGateway.php 2 diet and poor access to healthy foods. A study conducted in two similar Finnish provinces between 1972 and 1992 found that decreases in NCD risk factors contributed greatly to a steep decline in mortality from ischemic heart disease (Figure 2). Figure 2: Trends in risk factors and ischemic heart disease (North Karelia & Kuopio) The study demonstrated that major Trends in ischemic health disease, associated risk factors (1972-1992) reductions in mortality from NCDs can be 100% Tobacco usage achieved through dietary changes, increased (10% decline) physical activity, reduced smoking, and Average blood 80% pressure (11% decline) close control of serum cholesterol and blood Cholesterol levels pressure. In one province, the annual (15% decline) 60% mortality rate of chronic heart disease fell by some 85% in 20 years, driven by innovative Ischemic heart 40% disease mortality co-communication strategies and changes in (60% decline) primary health care, environment, nutrition, 20% and tobacco control. 1970 1975 1980 1985 1990 1995 Source: “Changes in risk factors explain changes in mortality from ischemic heart disease in Finland�. Vartiainen, Puska, Pekkanen, Tuomilehto, Jousilahti. Source: Adapted from Vartiainen, et all, 1994. A substantial percentage of the burden of NCDs can be prevented through a few, key health promotion and disease prevention interventions, at very low costs per capita. These costs are likely to be fiscally sustainable for middle-income and most low-income countries. Figure 3 compares the estimated costs per capita of various key preventive interventions in relation to total health spending for several middle-income countries. Estimates on the cost of prevention vary from around US$ 1.5 to 4.5 per capita per year for a comprehensive package that includes the most efficient regulatory- and health-care measures for NCD prevention. In comparison, the median annual cost of treatment for diabetes patients in India has been found to be US$ 142 per patient in rural areas and US$ 227 in urban areas (Ramachandran et al 2007). Figure 3: Estimated yearly cost per capita of key preventive interventions (in US$) Per capita cost for each risk factor by country in US$ Proposed interventions for each risk factor Brazil China India Mexico Russia South Africa Tobacco: excise tax increase, information and labeling, 0.25 0.14 0.16 0.54 0.49 0.60 smoking restrictions, and advertising bans Alcohol: excise tax increase, advertising bans, and 0.15 0.07 0.05 0.24 0.52 0.29 restricted access Diet and exercise: mass media campaigns, food taxes and 0.48 0.43 0.35 0.79 1.18 0.99 subsidies, nutritional information/labeling, and marketing restrictions High blood pressure and cholesterol: – Reduced dietary salt (mass media campaigns, 0.12 0.05 0.06 0.22 0.16 0.15 regulation of food industry) – Combination drug therapy for high-risk individuals 1.89 1.02 0.90 2.74 1.73 1.85 Total cost per capita of a comprehensive package of interventions 2.89 1.72 1.52 4.53 4.08 3.88 Cost of comprehensive package as share of current per capita total health spending 0.39% 0.97% 3.38% 0.88% 0.86% 0.80% Source: Adapted from: M. Ceccini, et al. 2010. Per capita health expenditure World Bank data (2009) 3 There is a global consensus on the cost-effectiveness of the above interventions in comparison to treatment. However, the importance of treatment to reduce mortality and disability cannot be underestimated. The relative importance and feasibility of these preventive interventions may vary country by country. Each country will need to find a balance between a selected number of preventive and treatment interventions to respond to the specific risk factors to which its population is exposed, its demographic and epidemiological profile, the level of a country’s resources, its institutional capacity, the impact of some measures on resources distribution (for example, taxes and subsidies can be regressive), and the equity of the distribution of resources and health outcomes (for example, smoking or cancer may be more prevalent among the poor or middle class). Poverty is an indirect risk factor for NCDs. NCDs are not only ―diseases of wealth‖. Poverty restricts the ability of individuals, households, and whole segments of the population to reduce their exposure to risk factors for NCDs. For instance, the prevalence of low birth-weight and malnutrition in the first 1,000 days of life is higher among the poor. Low-nutrient, high-caloric foods are becoming easily available in poor areas and are generally cheaper than healthier foods. In many cities, ―convenience stores‖ selling tobacco and unhealthy snacks are open 24 hours, while grocery stores are not. Similarly, the poor can seldom choose to work in smoke-free and healthy environments, they tend to use less-clean fuels for cooking and heating, and live in areas with few recreational spaces where there are many alcohol outlets. Studies in Canada and the UK (Wilson et al 2010) show that factors related to socio-economic status (SES) account for differences in the level of NCDs between poor and rich, even when controlling for the quality of health services (Figure 4). Figure 4: Risk behaviors in neighborhoods of low versus high socio-economic status Hamilton, Canada Glasgow, Scotland -23% Low SES Neighborhoods Studied High SES Neighborhoods Studied 79% -40% 61% -41% -23% -44% 39% 29% 24% 24% 24% 24% 18% 17% 14% 8% Obese Smokers Not physically active Obese Smokers Not physically active Source: Wilson et al. 2010. In most developing countries, both the NCD and the MDG agendas need to be part of the health policy dialogue. Low birth weight and malnutrition in the first 1,000 days of life contribute significantly to diabetes and cardiovascular problems later in life. Hypertension and diabetes during pregnancy also increase the risk of diabetes and cardiovascular disease later in 4 life3. Smoking and alcohol abuse increase the probability of developing active tuberculosis by 50% and reduce the effectiveness of treatment. The links between sexually transmitted diseases and several cancers are well documented. These facts indicate the need for comprehensive health policies that utilize existing resources better. In low-income, low-capacity settings, national health strategies would primarily focus on the most cost-effective prevention measures, complementing the MDG agenda. In middle-income countries, the concern is most likely the economic and fiscal pressures NCDs will place on health systems and government budgets. The most recent International Monetary Fund Fiscal Monitor (IMF 2011) identifies health care costs as the main source of fiscal pressure for middle- and high-income countries, and projects that unless action is taken, the impact of increasing health expenditures in these countries could dwarf the impact of the current economic crisis. Today’s policy decisions in middle- and low-income countries will determine the disease profile of their populations in the coming years. The outcome of adequate NCD prevention is healthy aging and the reduction of morbidity. OECD countries that have achieved similar stages of development do not necessarily have the same health outcomes. A broad spectrum of possible health outcomes in relation to obesity, as an example, is illustrated in Figure 5. The challenge for low- and middle-income countries, then, is to address NCD risk factors to stay ahead of similar indicators in high-income countries (Adeyi et al 2007). Figure 5: Obesity levels and HALE in the top 20 OECD countries 76 Correlation: Top 20 OECD Obesity Levels and HALE 40% Healthy Years Life Expectancy ( HALE) 74 30% % of Obese Adults 72 20% 70 10% 68 0 Netherlands Luxembourg Belgium Iceland Sweden Germany Denmark Kingdom Ireland Switzerland Australia Finland Austria France Italy Norway Spain Canada Japan United States United HALE Obesity Rate 4 Source: Authors calculations from WHO Statistical Information system data . HALE: Healthy Life Expectancy at Birth While treatment of NCDs lies naturally in the domain of health, effective prevention requires active leadership, involvement, and cooperation from a range of sectors and actors beyond the health sector. This presents an opportunity for governments to develop and implement an accountability framework with key indicators, identifying the responsibility of different sectors for achieving key government priorities. The next section presents evidence that effective NCD control is feasible, with examples of multisectoral approaches across the world. 3 http://www.globalhealthmagazine.com/cover/stories/ncd_prevention 4 http://www.who.int/whosis/indicators/2007HALE0/en/ 5 2. A MULTISECTORAL APPROACH: KEY TO EFFECTIVE PREVENTION No single sector can reduce all the important risk factors or influence all relevant dimensions of the NCD problem. The health sector typically plays a central coordinating role in prevention efforts but other sectors have important leadership roles in areas such as education, agriculture, energy, social norms, and the natural and built environments. Case examples show that successful prevention takes many different forms and varies by scope, the risk factors addressed, sectoral roles, and the degree of coordination required. The previous section of the paper demonstrated the importance and urgency of action to prevent NCDs. How can such action be best configured and implemented for maximum impact? There is a universe of multisectoral interventions that can tackle NCDs. Which sector is best positioned to participate in such interventions depends in part on the choice of intervention and the risk factor being addressed. Figure 6 illustrates how sectors beyond health have a potential role to play in reducing the major NCD risk factors. Figure 6: Sectors in which actions can be taken to reduce key risk factors for NCDs Poor Diet & Physical Unhealthy Injuries & Tobacco Nutrition inactivity Alcohol environment Pathogens violence Health √ √ √ √ √ Education √ √ √ √ √ √ Finance √ √ √ √ Urban Planning √ √ √ √ Agriculture √ √ √ Industry √ √ √ √ Transport √ √ √ Source: Authors Prevention efforts by governments and other actors in high-, middle-, and low-income countries take many different forms – there is certainly no ―one size fits all‖ approach. In this section we examine several successful examples of multisectoral action, classified along the following five dimensions: the risk factors covered by the intervention, the sector leading the effort, the scope of the intervention (national or sub-national), the type of actor participating (public or private), and the degree of coordination required. RANGE OF TARGETED RISKS FACTORS Some interventions are comprehensive and target several risk factors concurrently, such as in the case in Karelia and Kuopio previously discussed (figure 2). These often have the highest impact but their implementation is generally more complex. More often, successful interventions focus only on one risk factor and tend to be easier to execute. The choice of approach depends on country circumstances. 6 Consider Uruguay’s campaign to reduce tobacco use and the effects of secondhand smoke through a 100% smoke-free policy in all public places and workplaces. Led by the President, the campaign had support from the Ministry of Health, public and private sectors, civil society, the Pan American Health Organization, and the media. In March 2006, Uruguay became the first country in the Americas and the first middle-income country to enact comprehensive smoke-free legislation. Studies in Montevideo showed a reduction in air nicotine concentrations of 91% between 2002 and 2007 (Blanco-Marquizo et al 2010). In Argentina’s effort to control salt, programs by the Federal Ministry of Health in collaboration with universities, research institutions, and associations representing the baking and food industries have led to: (a) the development and dissemination of nutritional guidelines for healthy salt consumption; (b) legislation to create a coordinated national plan for salt reduction and to regulate the use of salt by the food industry; (c) the development of food products containing less sodium (PHAC 2009); and (d) a law reducing access to salt shakers in restaurants. A 15% reduction in dietary salt intake in Argentina could save about 60,000 lives over the period 2006-2015 at a cost of US$ 0.14 per capita (Asaria et al 2007). Samoa’s ban on imports of turkey tail meat (which has high fat content) was a response to concern over both the impact of fat on health and the ―dumping‖ of ―low quality‖ food on the market (Thow et al 2010). The Prime Minister proposed the ban and the Ministry of Health prepared a paper detailing the links between fat intake and NCDs (Thow et al 2010). The ban, introduced in 2007, was designed and implemented by the Ministry of Revenue and enforced by the Customs Department. It reduced the supply of turkey tail meat by 98%, raising the awareness of fat as a contributor to poor health. LEADERSHIP BY A RANGE OF DIFFERENT SECTORS While some NCD prevention programs are led by the health sector, others are initiated by other actors. An example of this is the National Biomass Cookstove Initiative in India (Box 1). Sustrans National Cycle Network in the UK is an NGO that encourages cycling, through partnerships with local transport authorities and public health teams, other NGOs, and volunteers (Cooper 2011). In 2009, 407 million cycling and walking journeys were made on the National Cycle Network: an increase of 6% from 2008, with an estimated health benefit from cycling and walking of approximately US$ 625 million, as well as reduced greenhouse gas emissions5. In Russia, a Government Commission for Road Safety is being led by the Ministry of Internal Affairs to coordinate efforts to implement the Federal Targeted Program for Ensuring Road Traffic Safety 2006-2012 (Marquez and Bliss 2010). The program aims to reduce road fatalities by 33% from 2004 levels through a comprehensive legislative framework and tighter enforcement of blood- and breath-alcohol-content limits. From 2004 to 2008, road traffic deaths and non-fatal road traffic injuries were reduced by 13%. 5 http://www.ecf.com/4053_1 7 Box 1: The Indian National Initiative for Advanced Biomass Cookstoves: the Benefits of Clean Combustion (Venkataraman et al 2010). Program goals:  To replace traditional cookstoves in Indian households using highly pollutant biomass and coal with energy-efficient ones  To reduce the harm caused by traditional cookstoves to the environment and health Program rationale: More than 770 million Indians across 160 million poor households rely primarily on biomass as their cooking fuel with very negative impacts on health and the environment. Key actors participating:  Led and coordinated by the Ministry of New and Renewable Energy, with support from Prime Minister and other officials  Implementing partners include state agency nodes, private sector actors, NGOs, self-help groups, and several technical research institutions such as X PRIZE Foundation and the Indian Institute of Technology Delhi Policy instruments used: Subsidies for innovation and use; provision of information Activities carried-out: Setting up of testing, certification, and Indian Premature Deaths Due to Lack of monitoring facilities, and R&D training across Indian technical Clean Burning Cookstoves (2005) institutions. Launch of a global competition to develop and 31 570 41 deploy clean cookstoves. Assessment of existing improved 119 biomass cookstoves through a series of pilot-scale projects in several locations. Deployment and development of new 154 225 cookstoves and partial subsidy of cookstove costs for consumers. Impact: While it is too early to assess its impact, modeling suggests that the program has the potential to:  Wood Agr. Res. Dung Coal Other Total Annual Reduce the national disease burden by almost 3% (avoiding Source: “The Indian National Initiative for Advanced Deaths 570,000 premature deaths per year in women and children) Biomass Cookstoves: The benefits of clean combustion�.  Eliminate one third of India’s black carbon emissions along with a range of other air pollutants.  Reduce 4% of India’s greenhouse gas emissions, worth up to US$ 1 billion on the international carbon market. INITIATIVES AT NATIONAL AND SUB-NATIONAL LEVELS Often actions are undertaken at local level. The Mayor of New York City brought the health sector and hospitality industries together in a way that influenced similar actions across the US. In 1995, New York City forbade smoking in all restaurants with over 35 seats. In 2002, this was expanded to virtually all bars and restaurants. In 2002, 21.5% of New York adults were current smokers but there were only 15.8% by 2009 (a decrease of approximately 350,000 smokers). During the same period, the number of adults who had never smoked increased by approximately 4%6. In another measure, two years after its ban on trans-fats, the proportion of the city’s restaurants using trans-fats fell from 50% to less than 2%. Sub-national leadership is important in a diverse and decentralized country. In Jakarta, for example, partners are working with the city administration on an anti-smoking policy. Violators of the ban on smoking in public buildings face administrative sanctions and shaming in local media. In addition, an alliance of 12 Indonesian Mayors coordinates implementation of anti- smoking policies7, with the support of the Ministry of Health and the International Union Against Tuberculosis and Lung Disease8. 6 New York City Department of Health and Mental Hygiene Database. New York, NY. http://www.nyc.gov/html/doh/html/browse/browse-data.shtml 7 http://www.searo.who.int/LinkFiles/TFI_policies-Indo.pdf 8 http://www.theunion.org/index.php/en/newsroom/news/item/1-mayors-alliance-to-accelerate-sub-national-smokefree- efforts-in-indonesia 8 The government of Colombia’s capital city of Bogotá aimed to develop a more sustainable transport system, by upgrading the rapid bus transit system and creating 300 km of cycle paths across the city. Every Sunday a 70 mile route across the city, the Ciclovia, closes to cars, attracting more than a million pedestrians and cyclists every week (almost 15% of Bogotá’s population). Results of a recent evaluation led by the health sector suggest that the initiative increases the population’s weekly physical activity (Sarmiento et al 2010). Particulate matter from vehicles is 13 times lower during Ciclovia9. The program which began in 1974 has been replicated in at least 12 other cities in Colombia and throughout North and South America10. ACTION BY BOTH PUBLIC AND PRIVATE ACTORS At times the private sector may be best positioned to initiate action. Consider for example, the Gum Marom Kids League in Northern Uganda. In this region, many children were abducted and forced to serve as child soldiers during 20 years of civil war (Cooper 2011). Launched in 2010, this initiative focuses on physical activity (soccer) to improve the mental health of children aged 10-14 years and includes peace-building activities and conflict management. Community-based NGOs are driving the initiative, in partnership with schools and local government, primarily the local Sports Office and Education Officer. The Ministry of Health of the United Arab Emirates and Bin Sina Pharmacy formed a public- private partnership in 200811 by which Bin Sina offers a consolidated health examination, and assistance and advice on cholesterol, blood pressure, diabetes, and obesity to everyone who visits their 30 outlets at a subsidized price12. In the first year of the program, some 28,000 people participated and high cholesterol was discovered in 27% of participants – almost half of whom were unaware of it. In Trinidad and Tobago, Jamaica, Barbados, and the Bahamas, thousands suffer from high blood pressure, high cholesterol, diabetes, Alzheimer’s disease, and depression. The Pfizer Together Program was created in October 2010 to enhance knowledge of these conditions, promote treatment adherence, and ultimately make a positive impact on patients’ quality of life. The program targets low-income patients and brings together key external stakeholders such as physicians and pharmacies around the common agenda of improving patient health outcomes. The program has provided tools and information to a network of some 1,900 doctors to help them educate patients about chronic diseases. Eligible patients receive discounted prices for certain Pfizer medicines addressing cardiovascular diseases, depression, Alzheimer’s, and glaucoma, as well as access to a free telephone hotline that provides real-time answers about their diseases and medications. Although this program is in early stages the initial results are encouraging, with 300 patients have already been enrolled. 9 http://www.8-80cities.org/articles-car-free/Ciclovias%20Recreativas%20of%20the%20Americas.pdf 10 http://cicloviarecreativa.uniandes.edu.co/english/index.html 11 http://www1.albawaba.com/news/moh-binsina-pharmacys-second-campaign-against-high-risk-ailments-launched 12 Bin Sina Pharmacy is the oldest pharmacy in the UAE, and has about five million customers per year, serving up to 14,000 customers per day 9 DIFFERENT DEGREES OF COORDINATION In the Cooper Union for the Advancement of Science and Art, a single independent actor has had impact on a wide scale, influencing other actors in New York City. An urban architect designed a building to emphasize interaction and activity while keeping people moving – slow elevators stop on only three of the eight floors, and a wide staircase encourages students to walk the campus that has become the ―social heart‖ of the building13. Other programs have many actors, like Agita São Paulo (Box 2). These examples illustrate some of the many combinations of actors and drivers that can have an effective impact on NCDs. The next section considers what helped these initiatives to be successful and the policy tools that governments could use to lever them. Box 2: Agita São Paulo, launched in 1996 (Matsudo et al 2003, 2010) PROGRAM GOALS:  To increase the population’s knowledge on the importance of physical activity and up activity levels by 20% over 10 years PROGRAM RATIONALE: In the early 1990s nearly 70% of the adults in São Paulo were not sufficiently active leading to poor health outcomes that placed a heavy burden on the health system. ACTORS PARTICIPATING:  Launched by the State Secretariat of Health of Sao Paulo  Coordinated by the Studies Centre of the Physical Fitness Research Laboratory of Sao Caetano do Sul (CELAFISCS)  Implementing partners: more than 300 governmental, non-governmental, and private partners from several industries  Funded through direct and indirect partner contributions, private business, and the State Health Secretariat, with State funds equivalent to less than $0.01 per state inhabitant per year POLICY INSTRUMENTS USED: Cues to channel behavior; education and information; and partnerships with voluntary controls ACTIVITIES: Mass media; promotional giveaways; mega-events (Active Community Day, Annual São Paulo Mega-Walk); access to sporting facilities; improving physical environments; and “prescription� of physical activity by health professionals IMPACT OF PROGRAM: Sao Paulo Resident Physical Activity Survey 2002-2008  Physical activity: the proportion of residents with no physical -73% activity fell from nearly 10% to less than 3% between 2002 and 43.7% 2008; and the proportion of individuals with less than 150 2002 2008 minutes of weekly activity fell from 43.7% to 11.6%  Awareness: between 2002 and 2008 the proportion of residents aware of the program rose from 37% to 60% -72% SUCCESS FACTORS: 9.6% 11.6%  A respected coordinating body able to attract partners 2.7%  Simple and straightforward messages and activities No Physical Less than 150  Cross-sector partnerships leveraging program reach and capacity Activity Whatsoever minutes of physical  activity a week Technical cooperation and support among partners allowing Source: “Time Trends in Physical Activity in the State of Sao Paulo, Brazil: program to remain dynamic and innovative 2002-2008� V. Matsudo, S. Matsudo, T. Araujo, D. Andrade, L. Oliveira, P. Hallal. 3. SUCCESS FACTORS AND POLICY LEVERS Successful efforts at multisectoral prevention share a few common factors, including the use of well-tailored policy instruments. Typically, such efforts focus on a well-defined target, give high-profile leaders a central role, identify wins for non-health stakeholders, generate indirect health impacts from programs outside the health sector, ensure that different actors are 13 http://www.nytimes.com/2009/06/05/arts/design/05coop.html 10 assigned roles that play to their strengths, and apply policy instruments appropriate to the problem ranging from command-and-control regulation to education and information. KEY SUCCESS FACTORS FOR INTERVENTIONS TO COMBAT NCDS An analysis of the success factors common to high-impact multisectoral prevention efforts, such as those profiled in this paper, suggests five core actions for country leaders:  Focus on a well-defined target while addressing risk factors from several angles. Successful programs have clear and consistent messaging on their targets, such as ―Promote 30 minutes of daily exercise‖ or ―Ban smoking in restaurants‖, which lead to a diversity of actions. If the objective is to reduce morbidity and mortality from traffic accidents, for example, redesigning roads will go only part of way; impact is likely to be higher with additional measures, such as legislation, enforcement of speed limits and seat belt use, education of youth drivers on road safety, and well-planned trauma hospitals. Coordinated interventions commonly have more impact than those driven by a single sector; action should therefore be designed in collaboration with other stakeholders and involve multiple policy interventions.  Give high-profile leaders a central role in driving initiatives. Strong personalities with influence on policy makers and the general public are well placed for bringing different actors together to collaborate towards a well-defined NCD prevention goal. Mayors, Presidents, Prime Ministers, and First Ladies have frequently been at the forefront of national and other efforts. They can help provide a balance between and within different sectors and reinforce the accountability of partner institutions. In the example from New York City for instance, Mayor Bloomberg’s leadership brought the health sector and hospitality industries together to address smoking and trans-fat risk factors.  Be opportunistic, identify indirect impacts on health, and optimize impact. The initiatives profiled in this paper show that there are major opportunities for policies and programs outside the health sector to have direct or indirect impact on health. In the example of Samoa’s ban on turkey tail meat, the negative health effects of cheap, fatty meat, especially on the poor, were included in trade discussions that were already underway on meat ―dumping‖. Significant health gains have also been achieved from initiatives aimed at reducing air pollutants that contribute to climate change (Box 1).  Identify wins for non-health stakeholders. All sectors are accountable for improving lives but constructive measures may nevertheless meet resistance from a range of stakeholders where economic interests conflict. It is important, therefore, to identify incentives beyond health that will encourage sectors and leaders to support NCD prevention measures. The fight against NCDs, food prices, and climate change, for instance, may intersect with each other in positive or negative ways. Certain agricultural subsidies, for example, may be contributing to the obesity epidemic and rising food prices. Grain and soya subsidies have helped to change eating habits across the planet, resulting in lower prices of certain food additives (such as sweeteners), meat and farmed fish, and processed foods. Meanwhile, these same subsidies contribute to climate change through the increase of CO2 and methane from intensive animal farming. These subsidies have also lowered prices for biofuels, which are now driving food price increases. This illustrates the complexity of the issues involved. Sometimes direct financial gains can be made, such as the potential saving of US$ 1 billion on the international carbon market in the National Biomass Cookstove Initiative in India (Box 1). 11  Ensure that different actors focus on what they do best. Coordinated efforts by different sectors add value in identifying opportunities, crystallizing incentives, and monitoring impact, but this need not mean that different actors must follow the same structure. Rather, they can participate by leveraging the networks of different actors and building on each others’ strengths. Working through different channels generally provides access both to the broader population as well as defined target groups. By allowing the flexible adaptation of interventions, different actors can tailor their messaging to the local, socio-cultural realities of the population groups they serve. Many of the programs discussed in this paper are in emerging markets without advanced resource allocations to treat NCDs; perhaps this is because leaders in middle- and low-income countries have learnt to innovate. This is not to say that more resources will not be needed to address NCDs in those countries. However, these programs illustrate real opportunity for governments in the developing world to tackle NCD risk factors early and forge a path of development where governments, the private sector, civil society, and populations hold joint accountability to shape healthier and more productive lifestyles. POLICY INSTRUMENTS TO PROMOTE EFFECTIVE MULTISECTORAL INTERVENTIONS To underpin action to prevent NCDs, policy makers may make use of one or more of the policy instruments set out below to enforce or encourage behavior shifts by individuals or organizations. Different instruments are more or less effective in different situations and contexts. Figure 7 sets out the impact of the different instruments for the initiatives discussed in the previous section. It is important to note that combinations of policy levers can tackle a particular risk factor more comprehensively. For example, bans on smoking in public areas together with taxes on cigarettes can lead to effective control of tobacco use. The cases considered in Section 3 are highlighted in the Appendix with regard to their policy levers, aim, actors and impacts. Figure 7: Illustrative policy instruments to reduce key risk factors for NCDs Source: Authors 12  Price-based regulations including taxes and subsidies do not prohibit or mandate a behavior but use financial incentives and disincentives. Where there is insufficient consensus and it is not feasible to eliminate or enforce behavior, policy makers may use these mechanisms to coax changes for health, political, or social reasons. It is not feasible to ban smoking in people’s homes, but sufficiently high and comprehensive taxes are the single most cost- effective measure to discourage new smokers and reduce use. Also, increasing fuel taxes and subsidizing public transport will encourage people to walk more. In this example, synergy results from involving more than one sector.  Channel or nudge factors may or may not involve regulation. This policy instrument uses non-financial incentives and disincentives. For example, consumers may be nudged into making healthier choices by the specific placement of certain products in groceries and cafeterias14. Employing similar measures across a variety of outlets, sectors, and industries will create maximum impact. Changing the layout of a building so that people use the stairs instead of an elevator, as in the case of The Cooper Union for the Advancement of Science and Art in New York City, makes the default choice the most likely option. Coordinating the actions of industry, retail, revenue, and consumer groups gives best results.  Voluntary controls, agreements and non-regulatory partnerships are useful to ensure that there is buy-in from key stakeholders. A good example is voluntary self-regulation within an industry. So far, the efficacy of this approach is doubtful due to the possibility of default by one party, even where there is a genuine interest in healthier practices. Such initiatives more frequently arise where an industry is either homogeneous (e.g. bread makers in Buenos Aires), or dominated by one or two big companies (e.g. soda manufacturers). Even in such cases, the industry may eventually request government regulation to ensure cooperation. Lawmakers can support and encourage such initiatives.  Education and the provision of information are often supported by the public sector to promote public health. While increased awareness and information has been shown to modify attitudes about the health consequences of behavior, there remain serious limitations on their effectiveness to modify actual behavior in all but children of school going age. For this reason, these instruments are more useful when applied in tandem with other policy measures, both as a way to foster acceptance of them and to facilitate coordinated vision and implementation among different players and sectors. 4. REPOSITIONING HEALTH SYSTEMS As discussed above, many of the drivers of NCDs are outside the remit of the health sector. What, then, can be the role of the health sector in NCDs prevention? As the only sector with a mandate to approach health issues from a holistic point of view, the health sector must play a central role in NCD prevention and mitigation efforts. This role includes: assessing the size of the NCD problem and the nature of its drivers; initiating dialogue with relevant actors and helping them develop priority interventions; and monitoring and evaluating outcomes. 14 Studies show that by placing healthy foods at the entrance or at eye level with unhealthy products in more obscure areas will result in people choosing healthier options. Regulation of product placement in school cafeterias and fast food outlets outside the perimeter of schools is being piloted in the US. 13 The health sector is uniquely positioned to collect and provide the information that is needed to stimulate the development and support the implementation of all kinds of initiatives – from action by the private sector to shifts in government policy. It has, firstly, the ―know how‖ and scientific resources to identify the direct NCD risk factors and the immediate drivers of the epidemic. At the same time, it can assess the size of the problem and present this evidence to society at large. In this way, it can initiate dialogue with relevant actors and help them identify priority interventions. Finally, the health sector has the fundamental role of monitoring and evaluating the outcomes and results of interventions, prompting any shifts that may be necessary to correct a course of action. In identifying and monitoring the rise and persistence of risk factors, the health sector can act as a catalyst through identifying policy ―windows‖ across various sectors including international trade, climate change, education, and many others. Similarly, the health sector can facilitate other sectors in having an appreciation for the health impact of their actions and initiatives. With these attributes, the heath sector has the potential to help coordinate certain types of action by multiple sectors. It is imperative that the health sector offer tools for monitoring intermediate goals (such as increased physical activity), as well as the long-term impact on health outcomes. It is equally critical that results are tracked and widely publicized. A key priority must be to provide better data on the economic and fiscal impact of health gains resulting from specific NCD prevention initiatives. These actions will help other actors and sectors to optimize their initiatives, potentially beyond country borders. In facing up to the challenge of NCDs, the health sector requires a paradigm shift on many levels. The chronic nature of NCDs poses the most challenging demand for developing country health systems, which are largely designed to respond to acute diseases of limited duration. Several differences between acute and chronic care are given in Figure 8. Figure 8: Differences between acute and chronic conditions relevant for health systems Acute conditions Chronic conditions Treat to heal Treat to prolong life and avoid complications Discontinuous episodes with resolution Continuous illness with complications Treatment compliance good because duration short Treatment compliance very low Prevention often does not require behavior change Prevention requires adjustments in behaviors and lifestyles Mostly resolve without sequelae or end in death Often accompanied by long term disability before death Individual feels sick and seeks care Disease silent for years. Often diagnosis of complications One-off direct medical expenditure Ongoing medical expenditure for family and health system One-off indirect costs (transport) Substantial indirect costs(repeated visits to health services) Information systems count episodes Patients need to be tracked not just counted Measuring NCDs requires that information systems evolve from counting acute cases to the long-term and regular tracking of exposure to risk factors and eventually complex illness and disability. The depth of the changes and the level of investment required in adapting the health service to deal with NCDs are different in low and middle-income countries but even in low- income countries effective changes can be introduced with modest additional resources. 14 The health sector needs to adjust how it and its services are organized and financed to become much more effective in addressing NCDs. Its organization and the financial incentives involved must be aligned to encourage screening and identification of people at high risk of developing an NCD and for initiating the interventions needed. This applies at the level of primary prevention to stop disease from developing and at secondary prevention to reduce its impact where already present. In low-income countries most screening and ongoing treatment can and should be done at the level of primary care. In the presence of disease, finally, the health sector will need to make the necessary adjustments to coordinate the appropriate continuum of care whenever this is feasible, within the context of available resources CONCLUSION Prevention is key to limiting the growing burden of NCDs; is cost-effective and necessary to address the socio- economic costs and suffering associated with NCDs; and is necessary to support development goals and improve levels of equity, especially in middle- and low-income countries. The appropriate strategic mix between prevention and treatment must be dealt with in the local context. The paper has shown how a few key interventions can help to avoid the risk factors that lead to NCDs, including tobacco and alcohol use, poor diet and exercise, indoor air pollution, and poverty and reduced agency. And the paper has shown that the best way to design and deliver such interventions is through policy measures and actions by multiple sectors and actors. Many of the underlying risk factors of NCDs both direct15 and indirect16, extend beyond the reach of the health sector, and there is a growing and diverse set of examples of success in tackling these factors, several of which this paper has mentioned. Taking action to prevent the epidemic of NCDs is everyone’s business—and the whole of society’s responsibility. Nonetheless, as this paper has emphasized, the health sector has a central role to play in collecting and publicizing data to galvanize and catalyze prevention efforts by multiple sectors. Because successful prevention involves multiple sectors and actors, countries need to adopt a framework that clearly sets out the different levels of accountability of each role player. Such a framework will require strong national buy-in, but there are tools, examples, and support agencies available to facilitate this. The World Bank already works with all the sectors that can impact NCDs and is particularly well placed to support policy measures through its lending policy, including policy loans and specific investment loans, and through its analytical and advisory services. Countries may, for instance, need support in launching prevention policies and in implementing them. The Bank already supports NCD control through more traditional instruments including knowledge products, technical assistance, policy dialogue, and the leveraging of resources. Middle- and low-income countries can seize the opportunity and act now to tackle NCDs and the underlying risk factors of these diseases. If they do so, these countries will greatly increase their prospects of reaping the full benefits of their demographic dividend, and of ensuring sustained economic development, greater equality, and a better quality of life for their people in the years ahead. 15 Such as tobacco and alcohol use, poor diet and exercise, indoor air pollution, etc. 16 Such as poverty and reduced agency 15 Appendix: Table of case examples in order of appearance in the text Policy Lever Scope Actors Incentives Impact • Command • Campaign to reduce tobacco use and • Decree led and signed by the • Government incentive to • Exposure to secondhand and control effects of secondhand tobacco President of the Republic and reduce tobacco as a risk smoke decreased significantly regulation smoke (rates for which were the supported by the Ministry of factor in indoor public places and highest in Latin America prior to Health • Civil society desire to reduce workplaces. One study campaign) through a 100% smoke- • Popular social support: exposure to second hand focusing on Montevideo free policy in all public places and government launched two widely smoke showed a reduction in air Tobacco workplaces. In 2006, Uruguay successful media campaigns to nicotine concentrations of Control became the first country in the garner public support 91% between 2002 and 2007, (Uruguay) Americas and the first middle- • Ministry of Health inspectors and confirming comprehensive income country in the world to enact citizens who collaborated with smoke-free legislation as a a comprehensive smoking ban inspectors as observers best practice to protect • National Alliance for Tobacco public health with wide Control, public, private, and civil applicability for other society countries. • Education and • National and regional studies on salt • National Ministry of Health • National Ministry of Health • A recent study estimated a information use and impacts (initiated in 2006) • National University of La Plata sought to encourage healthy 15% reduction in dietary salt • Initial non- • Dissemination of nutritional • National Institute of Industrial lifestyles with an emphasis on consumption across regulatory guidelines for healthy salt Technology lowering blood pressure Argentina would save 60,000 National partnerships/v consumption • Argentine Federation of Bread and • CIPPA incentive to be seen as lives over approximately 10 Sodium oluntary • Bills before parliament to regulate Flour Industries collaborative and part of years Intervention controls use of salt by food industry • Chamber of Industrial Bakers, solution agreeing to (Argentina) • Command and • Efforts to develop alternative food Pastry Cooks, and Related technology transfer for the control products containing less sodium Professionals (CIPPA) production of reduced-salt regulation breads and other baked goods 16 Policy Lever Scope Actors Incentives Impact • Command and • Ban on US turkey tail meat imports in • Government of Independent • Ministry of Trade: Concern • Almost half of consumers control 2007 in an effort to limit NCDs. Samoa over the “dumping� of switched to cheap meats Restricting regulation Turkey tail meat is a highly fatty meat • Designed by the Ministry of perceived “low-quality“ food such as chicken and mutton, Unhealthy and widely consumed in Samoa by Revenue and implemented by the on the market – history of and about one quarter Food middle- and low-income families due Customs Department using import bans in Samoa replaced turkey tails with Imports – to its low price • National media to affect food supply lower-fat meat or seafood Turkey Tail • The Government was also concerned • Ministry of Health: Fatty • Samoa is under pressure to Meat Import about the lowering of trade barriers foods have become a rising abandon its turkey-tail import Ban resulting in an influx of inferior food epidemic in the Pacific as the restriction as it negotiates to (Samoa) imports region battles the highest join the WTO obesity rates in the world • Subsidies and • Launched in 2009, the aim is to develop • Ministry of Energy, universities, NGOs, • Ministry of Energy: to reduce air • Estimated that initiative could the promotion of next-generation cleaner biomass and private corporations pollutants and greenhouse gas result in avoiding 570,000 markets cookstoves and deploy them in all Indian • Ministry of New & Renewable Energy emissions that contribute to premature deaths of poor households currently using traditional (India) climate change, reduction in crop women and children and a cookstoves • X-Prize Foundation, a non-profit that yields and poor health outcomes reduction of 4% of India’s designs research prizes • Ministry of Health: to reduce estimated greenhouse gases as of National • As part of the initiative, the Indian • National and international private premature deaths resulting from 2010; avoided emissions Biomass government formed a partnership to sector biomass cookstove producers indoor air pollution currently would be worth US $1 Cookstove create a global competition to develop • In addition, initiative looks to billion on the international and deploy affordable, clean and efficient reduce deforestation carbon market Initiative • Further data needed cookstoves • Private corporations: opportunity (India) to tap into a market of over 750 million people • NGO (X-Prize) to spur development of a key technology that could save millions of lives • Education and • Sustrans is an NGO that partners with • Sustrans National Cycle Network • Advocating active transport • Significant increases in bicycling information communities, local authorities, and other • Local and central governments across modes across the UK increases across the United Kingdom, with • Non-regulatory organizations to build projects across the the UK physical activity to improve positive health impacts due to partnerships/ UK enabling active transportation while • Multiple charitable trusts, schools, and health and attracts public funding physical activity increases and Sustrans voluntary additionally advocating for sustainable private partners • Decreases traffic congestion and impact on the environment National controls and healthy transport-friendly policies • Non-departmental public bodies improves air quality while through reduced carbon Cycle • The European Union lowering CO2 emissions emissions. In 2009, 407 million journeys were made on the Networks National Cycle Network, a 6% (UK) increase from 2008, with estimated health benefit of £384million 17 Policy Lever Scope Actors Incentives Impact • Education and • In 2006 the Russian Government launched • Russian Ministry of Internal Affairs • Ministry of Internal Affairs: • Russia experienced a 20% drop in information a national initiative to improve road • Russian Ministry of Health and Social Improves safety of citizens and road traffic deaths per 10,000 • Non-regulatory safety and decrease the incidence of Development overall well-being vehicles between 2006 and 2008 partnerships/ traffic accidents and deaths • Djandelidze Research Institute of • Ministry of Health and Social • Russia experienced a 17% drop Russian voluntary • The Ministry of Internal Affairs Emergency Medicine Development: Campaign to in traffic accidents per 10,000 Government controls coordinates the multi-pronged initiative • Regional government partners reduce drinking improves health vehicles between 2006 and 2008 Commission • Command and which has included: stricter drunk-driving of citizens and encourages for Road control laws; anti-alcohol and safe driving healthier lifestyles regulation campaigns; new road signs and speed Safety • Channel / Nudge bumps; legislation proposals to reduce (Russia) regulation speed limits; the organization of emergency services; and improved vehicle design and safety equipment • Command and • Incremental legislation to push smoking • 2002-11 Legislation has been led and • Positive publicity for Mayor as • By 2009 the number of adults control and tobacco use out of public places aggressively touted by Mayor of NYC, legislation viewed as protecting classified as current smokers regulation through fines and social pressure. Michael Bloomberg bar and restaurant employees; decreased to 15.8% from 21.5% New York 1995: Smoking forbidden in all • NYC Board of Health decreasing societal healthcare in 2002 City restaurants with at least 35 seats; 2002: costs Smoking Expanded to virtually all bars & • NYC Board of Health: Reduce Ban (USA) restaurants; 2011: Ban extended to tobacco use and exposure to public parks and beaches second hand smoke • Command and • In 2006, with the support of Mayor • NYC Board of Health • NYC Board of Health: to reduce • Percentage of restaurants using New York control Bloomberg, NYC Board of Health risk factors contributing to artificial trans fats decreased regulation introduced a mandatory ban on all cardiovascular disease from 50 percent to less than 2 City Ban on artificial trans fats in New York City percent in 2 years Trans Fat in restaurants • Initiative has prompted at least all 13 jurisdictions in the US to adopt Restaurant similar laws including state of (USA) California • Command and • An alliance of 12 Indonesian mayors was • Mayors of 12 Indonesian cities • Indonesia has the 3rd highest • The alliance was launched early control launched in early 2011 to enact tobacco • Indonesia Ministry of Health smoking rate in the world and an in 2011, the goal is to expand it Mayor’s regulation control legislation at the sub-national • International Union Against estimated 200,000 Indonesians to 22 cities and increasingly • Education and level. The alliance will share best practice Tuberculosis and Lung Disease die annually as a result of influence the 95 members of the Anti- models from cities already implementing tobacco-related illnesses. The Mayors Association of Indonesia information Tobacco such legislation as they attempt to build Indonesian government spends as their mandate grows to a Alliance the alliance to spread anti-tobacco approximately $1.2 billion national scale (Indonesia) legislation across the country annually to treat tobacco-related illnesses. 18 Policy Lever Scope Actors Incentives Impact • Command and • Bogotá has aimed to create a more • Bogotá Department of Transport • Promoting physical activity over • Ciclovia attracts more than 1 control sustainable transport system by creating a • Bogotá Department of Recreation sedate travel modes reduces million cyclists and pedestrians regulation 300 km network of bike paths across the • Bogotá Police Department traffic congestion and air every week; which is almost 15% • Channel/ nudge city , upgrading the rapid bus transit • Bogotá Mayor’s Office pollution across Bogotá and of Bogotá’s population Sustainable regulation system and restricting private cars in the decreases travel times while • Since the construction of over Transport & city through several measures improving the health and 300 km worth of bike lanes, Ciclovia • “Ciclovia� an over 30-year-old, much- mobility of the city bicycle usage has increased 5 (Bogota replicated tradition, which shuts down a times throughout the city and it 70 mile route across the city for bicycling is estimated between 300,000 Colombia) and pedestrian use only every Sunday and 400,000 trips are made daily via bicycles across the city • Education and • Launched in 2010, this initiative was set • Local community based organization, • Peace building activities, conflict • Mental health was measured information up to engage the local community, build a the Youth Coalition for Peace, management, and health using a locally-developed tool, • Non-regulatory more robust peace, and improve the Canadian-based NGO OA Projects, and awareness was an incentive for and physical health using a ‘beep’ Gum Marom partnerships/ physical and mental health of children Kids League Uganda all actors test, standing jump and BMI for Kids League voluntary aged 10-14 years in this region that has • Schools and local government age. Preliminary analysis of data controls recently emerged from 20 years of civil (primarily the local Sports Office and collected at the start of the (Northern war Education Officer) project suggests normal growth Uganda) patterns, but identified a population-wide deficit in physical fitness and persistent mental-health challenges. • Education and • With obesity, diabetes and other • United Arab Emirates Health Ministry • The rise of NCDs in the UAE will • In the first year 28,000 citizens information conditions rising at an alarming rate in the • Bin Sina Pharmacy pose a growing health crisis in the participated (across UAE Health United Arab Emirates, the Health Ministry future if not addressed; approximately 30 outlets) Ministry partnered with Bin Sina Pharmacy in an population needs to be educated • The checkups revealed 27% of Awareness effort to raise the public consciousness about their own health participants had high cholesterol, around healthy lifestyles and the danger almost half of whom were Campaign of risk factors. unaware of their condition (United • In the partnership, Bin Sina offers health Arab examinations, assistance, and advice on Emirates) cholesterol, blood pressure, diabetes, and obesity in a consolidated checkup to all who visit their outlets at 19 Policy Lever Scope Actors Incentives Impact • Education and • Program to combat physical inactivity • Led by the Sao Paulo State Secretariat • Public institutions sought to • Proportion of inactive individuals information amongst residents of the Brazilian state of of Health and the Studies Center for improve public health declined from 9.6% in 2002 to • Non-regulatory São Paulo though major public Physical Fitness Research Laboratory • Partners received positive 2.7% in 2008 partnerships/ information campaigns and the (CELAFISCS) publicity and goodwill by • Proportion of individuals with voluntary sponsorship of programs for physical • More than 300 partner organizations, partnering with CELAFISCS – an less than 150 minutes of activity controls activity including initiatives to develop governmental, NGOs, and private internationally renowned per week decreased from 43.7% Agita Sao facilities for physical activity. Launched in sector, ranging from health, education, research institution – and may to 11.6% Paolo 1996. Core message: 30 minutes of sports, industry, workers, and also have been motivated to see • Significant impact documented in moderate physical activity/day on most environment improvements in the health of small groups including elderly (Brazil) days of the week their specific workers or patients women, private school students, patients with hypertension and diabetes in a small insurance company, amongst others • Initiative spread continent-wide • Education and • Program was created in 2010 to enhance • Pfizer, • Incentives: Improving patient • Program has provided tools and information, knowledge of, promote treatment • physicians, health outcomes by improving information to a network of 1900 non-regulatory adherence, and make a positive impact on • pharmacies knowledge and treatment doctors to help educate patients partnerships quality of life for patients with conditions • adherence about chronic diseases. Eligible Pfizer such as high blood pressure, high patients have received Together cholesterol, diabetes, Alzheimer's disease discounted prices for medicines Program and depression. The program targets low- addressing cardiovascular (Trinidad income patients. disease, depression, Alzheimer's and Tobago, • and glaucoma and access to a free telephone hotline that Jamaica, provides real-time answers about Barbados, their disease and medications. To Bahamas) date more than 300 patients have been enrolled in the program. • Channel/ • Urban architect Thom Mayne designed • The Cooper Union for the • The design features of the • The central staircase has been nudge regulation the college’s NYC building to have a wide, Advancement of Science and Art building were planned to called the “social heart� of the Urban centrally-located staircase while building emphasize socialization and to building and is helping influence College elevators are purposefully slow and only keep people moving in the a new movement of “slow Campus, stop on 3 of the building’s 8 floors so building architecture� in NYC and students naturally walk the “vertical elsewhere that emphasizes New York campus� movement and attempt to City (USA) minimize elevator use 20 REFERENCES Abegunde, Dele O., Colin D. Mathers, Taghreed Adam, et al. 2007. ―The Burden and Costs of Chronic Diseases in Low-income and Middle-income Countries.‖ The Lancet 370: 1929-38. 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