National Strategic Plan for the Prevention and Control of Major Non-Communicable Diseases 2013-2017 EFY (2020/21-2024/25)

7. Dr. Kunuz Abdela Finally, I would also like to recognize the several experts who have read and forwarded valuable comments in the realization of this strategic plan. Hiwot Solomon (MPH) Director, Diseases Prevention and Control Directorate Ministry of Health 6 ACRONYMS AND ABBREVIATIONS AAU Addis Ababa University ARF Acute Rheumatic Fever CRD Chronic Respiratory Diseases CKD Chronic Kidney Disease COPD Chronic Obstructive Pulmonary Diseases CMNN Communicable, Maternal, Neonatal and Nutritional CVDs Cardio-vascular Diseases DALYs Disability-adjusted Life Years DM Diabetes Mellitus Echo Echocardiography ECG Electrocardiography EDA Ethiopian Diabetes Association EDHS Ethiopia Demographic and Health Survey EPHI Ethiopian Public Health Institute EPHA Ethiopian Public Health Association FCTC Framework Convention on Tobacco Control MOH-E Ministry of Health-Ethiopia EFDA Ethiopia, Food and Drug Control Authority GABHS Group A Beta Hemolytic Streptococci GBD Global Burden of Disease GNI Per capita Gross National Income per capita HIV Human Immuno-Deficiency Virus HBV Hepatitis B-Virus HCV Hepatitis C-Virus HEP Health Extension Program HEWs Health Extension Workers HPV Human Papilloma Virus HSDP Health Sector Development Program HSTP Health Sector Transformation Plan IHD Ischemic Heart Disease IHME Institute of Health Metrics and Evaluation, University of Washington IPD In-patient Department LMICs Low-and Middle-Income Countries MDG Millennium Development Goals MNS Mental, Neurological and Substance Use NCDs Noncommunicable Diseases 7 NCDIs Non-communicable Diseases and Injuries NGOs Non-governmental Organizations NSC National Steering Committee (Multisectoral) NHA National Health Accounts NHL Non-Hodgkin’s Lymphoma NSAP National Strategic Action Plan OOP Out-of-Pocket OPD Out Patient Department EPSA Ethiopian Pharmaceutical Supply Agency PHC Primary Health Care PSI Population Service International RHB Regional Health Bureau RHD Rheumatic Heart Disease RTA Road Traffic Accident SARA Service Availability and Readiness Assessment SDGs Sustainable Development Goals SSA Sub-Saharan Africa STEPS STEPwise approach to Surveillance SWOT Strengths, Weakness, Opportunity, Threats TB Tuberculosis UHC Universal Health Coverage USD US Dollars UN United Nations VIA Visual Inspection with Acetic Acid (cervical cancer) WB World Bank Group WHF World Heart Federation WHO World Health Organization YLD Years Lived with Disability 8 Executive Summary Non-communicable diseases, such as cardiovascular diseases, cancer, chronic respiratory diseases and diabetes, are the leading causes of morbidity and mortality globally. Evidences are emerging that Ethiopia is in a state of “epidemiologic transition”, and it is now facing a triple burden of diseases; with the mix of still pervasive CMNN conditions, increasing non-communicable diseases and injuries. Despite the high burden of NCDs and its complex economic and social impact, NCDs have been neglected for too long both from the global and national health agenda. The SDGs have for the first time increased global attention to NCDIs. To this end, SDG 3 outlines the importance of ensuring healthy lives and promoting wellbeing for everyone at all ages and includes specific sub target on NCDs (target 3.4). Understanding the disease burden and the global direction Ethiopia recognized the potential health and economic impact posed by NCDs. The country was implementing its first NCD Strategic plan 2014-2016. The Ministry of Health-Ethiopia developed this second national strategic plan for the prevention and control of NCDs with the overall goal envisioned to reduce the burden of NCDs by promoting healthy lifestyles, reducing the prevalence of common risk factors and providing integrated evidenced based treatment and care to those diagnosed with NCDs in the most cost-effective manner. This action plan is thus the road map for the prevention and control of NCDs in Ethiopia. It comprises fundamental public health and clinical “best-buy” interventions and describes resource needs. It calls for a collective multi-sectoral response, strategic policy changes, resource mobilization and collaboration among all stakeholders. Strong national and sub-national political commitment and government leadership is fundamental for the success of this action plan. Scope of the national NCD Strategic Plan:- Major NCDs (CVDs, DM, CRDs, CKD) and Risk Factors (tobacco use, harmful use of alcohol, khat use, unhealthy diet, physical inactivity, air pollution, infectious causes). Vision of the national NCD Strategic Plan:- To see healthy, productive and prosperous Ethiopians free from preventable and avoidable non-communicable diseases. Mission of the national NCD Strategic Plan: • To promote health and wellbeing of Ethiopians through providing a comprehensive package of promotive, preventive, curative and rehabilitative NCD services of the highest possible quality in an equitable manner. Goal of the national NCD Strategic Plan: • To reduce the burden of NCDs by promoting healthy lifestyles, reducing common risk factors and providing integrated, evidenced based, innovative and cost effective clinical interven- tions. Objectives of the national NCD Strategic Plan:

1 — Strengthen national capacity, public policies through health in all policies, leadership, governance,

1. Strengthen national capacity, public policies through health in all policies, leadership, governance, multi-sectoral action and partnership to accelerate country response for prevention and control of non-communicable diseases. 9

2 — Reduce exposure to modifiable risk factors for non-communicable diseases and promotion of

2. Reduce exposure to modifiable risk factors for non-communicable diseases and promotion of health throughout the lifecycle through the creation of health-promoting environments.

3 — Strengthen and reorient health systems to address prevention and control of non-communicable

3. Strengthen and reorient health systems to address prevention and control of non-communicable diseases through people-centered primary health care and universal health coverage.

4 — Strengthen national capacity for NCD surveillance and high-quality research for prevention and

4. Strengthen national capacity for NCD surveillance and high-quality research for prevention and control of non- communicable diseases

5 — Strengthen international cooperation and advocacy to raise the priority accorded to prevention

5. Strengthen international cooperation and advocacy to raise the priority accorded to prevention and control of non-communicable diseases in the development agenda and in internationally agreed development goals. Targets to Monitor the National NCD Strategic Plan: • Reduction in premature mortality • Reduction on behavioral, environmental and infectious risk factors • Increase coverage and quality of services Priority Areas for of the national NCD Strategic Plan:

1 — Priority Area One: Strengthen the national response through policy, governance, leadership

1. Priority Area One: Strengthen the national response through policy, governance, leadership and coordination.

2 — Priority Area Two: Health promotion and disease prevention targeting behavioral, infectious

2. Priority Area Two: Health promotion and disease prevention targeting behavioral, infectious and environmental risk factors.

3 — Priority Area Three: Comprehensive and Integrated Screening, Diagnosis, Treatment, Care

3. Priority Area Three: Comprehensive and Integrated Screening, Diagnosis, Treatment, Care and Support for NCDs and their risk factors.

4 — Priority Area Four: Monitoring, evaluation and research

4. Priority Area Four: Monitoring, evaluation and research. Implementation of the National NCD Strategic plan • Prong One: The Multisectoral Response For Ncds • Prong Two: The Health Sector Response For Ncds • Roles And Responsibilities And Coordination Costing and financing of the National NCD strategic Plan • A total of USD 258,539,000 will be required for the coming 5 years to implement these highest priority interventions. 10 CHAPTER ONE: BACKGROUND 1.1 COUNTRY PROFILE Ethiopia is a federal republic made up of 10 Regional States and two city administrations found in the horn of Africa. The country shares borders with Sudan and South Sudan on the west; Kenya on the south; Eritrea in the North, Djibouti in the East and Somalia in the East and South East. It has an estimated population of about 114 million in 2019. The male to female ratio is 0.96 to 1. Ethiopia has a very young population with 47 % of its population between 0-14 years and 48% between 15-64 years of age. The proportion of the population 65 years and above is nearly 5%. The population of Ethiopia is estimated to reach 140 million by 2037. Figure 1: The Population Pyramid of Ethiopia, 2020 (Source: Population Pyramid.net ) Ethiopia is one of the fastest growing economies in Africa, and the nation is undergoing a rapid economic transformation. If the current trend is maintained, the country is expected to become a lower-middle-income country by 2025. The major driver of the economy is agriculture, which employs more than 80% of the population. There was an expansion of schools and Universities in the past two decades. Despite that the literacy rate stands at a national average of 50%. The country is still a very low-income country with GNI per capita of $740 USD in 2017, and the poverty headcount ratio at $1.90 USD a day (2011 PPP) was 26.7%. Using the multi-dimensional poverty index (MPI), which includes education, health and living standards in addition to income, 79.2% of the population is classified as impoverished. In urban areas, 4.4 million people (27% of urban population) were among the global poorest billion, however in rural areas, 66.4 million people (90% of rural population) were among the poorest billion. Currently, the urban population is about 20.9% and is growing at 3.8 % rate annually and according to CSA projections the urban population will triple and reach 30% by 2037. 1.2 THE HEALTH POLICY AND THE HEALTH CARE SYSTEM The Health Policy of the Transitional government of Ethiopia which was developed in early 1993 placed promotive and preventive health care as the main priority through democratization and decentralization of health care delivery as its pillars. Mental health and prevention of chronic 11 conditions were mentioned in the policy as secondary priorities to communicable, maternal, neonatal, and nutritional (CMNN) disorders. The Health policy is under revision and its focus areas will include NCDs and their risk factors. Health services are mainly delivered by the government, particularly in the rural part of the country, where an estimated 82% of the total population resides. In the past couple of decades, major health care reforms were introduced, resulting in exponential expansion of infrastructure and human resources that led to a significant improvement of the health status of the people. In 2015 the country finalized a 20-year National Health Sector Development Program (HSDP) and started the Health Sector Transformation Plan (HSTP) which is running from 2016 to 2020. The HSDP was launched in 1997 and has been implemented in four phases focusing on prioritized disease prevention and control, decentralization of the delivery of health services, strengthening partnerships between the government and non-governmental organizations to implement basic health care packages and achieve universal primary health care coverage, and with increasing national health spending. The Health Service is organized into three levels. Level one is a Woreda/District health system com- prised of primary hospital (to cover 60,000- 100,000 population), health centers (1 to 15,000- 25,000 population) and their satellite health Posts (1 to 3,000-5,000 population) connected to each other by a referral system. The primary hospital, 5 health center and 25 health posts form a Primary Health Care Unit (PHCU). Level two is a General Hospital covering a population of 1-1.5 million peo- ple; and level three is a Specialized Hospital covering a population of 3.5-5 million people. Primary health coverage has now reached more than 95%. By the end of 2015, the country had achieved most of the health related MDGs. Life expectancy at birth increased from 45 years in 1990 to 51 years in 2000 to 65 years in 2015, and over the same period, the under-five, infant and neonatal mortality rate decreased from 166, 97 and 49 to 67,48 and 29 per 1000 live births respectively. Total fertility dropped from 5.5 to 4.6 and the maternal mor- tality ratio to 412 per 100,000 live births. The immunization coverage and skilled delivery improved markedly. Morbidity and mortality from TB, HIV and malaria dropped dramatically. Since 2015/16 the country is implementing the health sector transformation plan 2015/16-2019/20. The sector envisioned transformation in four areas – access and equity; information revolution; Compassionate respectful and caring professionals, woreda transformation. Multiple initiatives have been initiated across these four transformation areas, which are unique to the HSTP – they were not present in the sector previously. There was positive movement of sector financing moving towards domestic financing. Although the share of health in domestic financing remains at 7.7%, the government was able to fund more than what is projected in the HSTP framework. Domestic financing was increasing in absolute amounts and as share of total sector financing (share of domestic funding increasing from 50% to 64% and share of external financing declining from 50 to 36%). There is good progress in expanding prepayment mechanisms for non-formal sector (CBHI) to more than 39% of woredas although enrolment rates in these woredas remain only 44% and nationally 15%. Ethiopia developed its essential health service package in 2005 and was implementing until now. The package lacks clear comprehensive interventions at different levels of the health sector on NCD and their risk factors. The country has launched its second Essential Health Service Package with expanding set of interventions for NCDs. In HSTP 2 which will be running from EFY 2013-2017, NCDs and their risk factors are expected to be accorded their proper attention as they are recognized to be not only a health but a development agenda. 12 CHAPTER TWO: NON-COMMUNICABLE DISEASES AND THEIR RISK FACTORS 2.1 INRODUCTION TO NON-COMMUNICABLE DISEASES A noncommunicable disease (NCD) is a medical condition or disease that is by definition noninfectious and non-transmissible among people. It has a prolonged course, that does not often resolve sponta- neously, and for which a complete cure is rarely achieved. They are the result of a combination of genetic, physiological, environmental and behavioral factors. These diseases are driven by forces that include aging, rapid unplanned urbanization, and the global- ization of unhealthy lifestyles. Unhealthy lifestyles may cause raised blood pressure, increased blood glucose, elevated blood lipids, and obesity which again predispose to NCDs. All age groups and all regions of the world are affected by NCDs. The most common NCDs include cardiovascular diseases (such as heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructive pulmonary disease and asthma), and diabe- tes. NCDs share several common, modifiable risk factors – tobacco use, harmful alcohol use, physical inactivity, and unhealthy diet (high consumption of sugar, salt, saturated fats, and Trans fatty acids). Mitigating the effects of these common risk factors is critical to combatting NCDs worldwide. Other NCDs of public health importance in Ethiopia include mental, neurological and substance use (MNS) disorders, chronic kidney disease, injuries, eye diseases, oral-dental diseases, thyroid disorders, musculoskeletal disorders, plus chronic diseases of an infective origin like rheumatic heart diseases and chronic liver disease. The chronic nature of NCDs means patients are sick, suffer longer and require more medical care. Consequently, family members often have to care for loved ones who are unable to work due to illness or disability, resulting in additional lost productivity and wages. In 2011, the World Economic Forum estimated that the combined global economic impact of cardiovascular disease, chronic respiratory disease, cancer, diabetes, and mental health will be more than $47 trillion dollars over the next 20 years. 2.2 NON-COMMUNICABLE DISEASES – GLOBAL PERSPECTIVE NCDs are by far the leading cause of death worldwide. In 2016, they were responsible for 71% (41 million) of the 57 million deaths which occurred globally. The NCDs responsible for these deaths includ- ed cardiovascular diseases (17.9 million deaths, accounting for 44% of all NCD deaths and 31% of all global deaths); cancers (9 million deaths, 9% of all NCD deaths and 16% of all global deaths); chronic respiratory diseases (3.8 million deaths, 9% of all NCD deaths and 7% of all global deaths); and diabetes (1.6 million deaths, 4% of all NCD deaths and 3% of all global deaths) (Figure 2). An even higher proportion (75%) of premature adult deaths (occurring in those aged 30–69 years) were caused by NCDs, demonstrating that NCDs are not solely a problem for older populations. The global probability of dying from one of the four main NCDs in 2016 was 18%, with a slightly higher risk for males (22%) than for females (15%). 13 Figure 2: GLOBAL MORTALITY (% OF TOTAL DEATHS), ALL AGES, BOTH SEXES, 2016 (Source: Global NCD Report 2018) A clear relationship is evident between premature NCD mortality and country income levels. In 2016, 78% of all NCD deaths, and 85% of premature adult NCD deaths, occurred in low- and middle-in- come countries (LMICs). Adults in low and lower-middle-income countries faced the highest risk of dying from an NCD (21% and 23% respectively) – almost double the rate for adults in high-income countries (12%). Likewise, in high-income countries, the proportion of all NCD deaths that were premature was almost half (25%) that of low-income (43%) and lower-middle-income (47%) countries. Globally, raised blood pressure is responsible for 13% of deaths; while, tobacco use causes 9%, raised blood glucose 6%, physical inactivity 6%, overweight and obesity 5% and alcohol 3.8% deaths. The global tobacco epidemic kills more than 7 million people each year, of which close to 900 000 are non-smokers dying from breathing second-hand smoke. Nearly 80% of the more than 1 billion smokers worldwide live in low- and middle-income countries, where the burden of tobacco-related illness and death is heaviest. Globally nearly 2.3 million people die each year from the harmful use of alcohol (3.8% of all deaths in the world). More than half of these deaths occur from NCDs caused by alcohol, including cancers, cardiovascular disease and liver cirrhosis. Encouragingly, the risk of dying from any one of the four main NCDs for those aged 30–69 years, de- creased from 22% in 2000 to 18% in 2016. To address the growing burden of NCDs, WHO identified a package of 16 “best buy” interventions that are cost-effective, affordable, feasible and scalable in all settings. Implementing all 16 “best buys” in all countries between 2018 and 2025 would avoid 9.6 million pre- mature deaths, thus moving countries appreciably towards the NCD mortality reduction targets. 2.2.1 Global Commitments on Non-communicable Diseases Non-communicable diseases have been neglected for too long. The UN High level meeting in 2011 acknowledged that the global burden and threat of non-communicable diseases constitutes one of the major challenges for development in the twenty-first century and passed a Political Declaration on the Prevention and Control of Non-communicable Diseases through its General Assembly and WHO was 14 tasked to lead this global commitment. The WHO developed NCD Global Action plan 2013-2020 and the comprehensive global monitoring framework for the prevention and control of non-communicable diseases. The Global NCD Monitoring framework has 9 targets and 25 indicators. The Sustainable Development Goals (SDGs) have increased global attention on the neglected non- communicable disease (NCD) pandemic. SDG 3, to ensure healthy lives and promote wellbeing for everyone at all ages, includes a specific sub target on NCDs (target 3.4), to reduce premature mortality from NCDs by a third. The United Nations General Assembly in its Third High-Level Meeting on Noncommunicable Diseases on September 27,2018 has adopted an ambitious political declaration, entitled, “Time to Deliver: Accelerating our response to address NCDs for the health and well-being of present and future generations.” The political declaration includes commitments to reduce NCD mortality by one-third by 2030, and to scale-up funding and multi-stakeholder responses to treat and prevent NCDs. 2.3 BURDEN OF NONCOMMUNICABLE DISEASES IN ETHIOPIA Available evidences show Ethiopia is in epidemiologic transition. In the context of this epidemiological transition, a triple burden of disease is already emerging with the mix of persistent infectious diseases, increasing non-communicable diseases and injuries. Non-communicable Diseases Country Profiles 2018 Report by the World Health Organization indicated there were a total of 700,000 deaths in Ethiopia in 2016 (Figure 3). Among these deaths 39 % was attributed to non-communicable diseases (NCDs), 12% to Injuries and 49% to Communicable, maternal, perinatal and nutritional (CMNN) conditions Overall cardiovascular diseases accounted for 16%, cancers for 7% and respiratory disease for 2% of all causes of death. Furthermore, diabetes accounted for 2%, injuries for 12% and other NCDs for 12% of causes of deaths in the same year. Figure 3: Proportional Mortality in Ethiopia, 2016 (n=700,000) (Source: WHO Global NCD Report 2018) The Ethiopia NCDI Commission report launched in November 2018 has interestingly shown very similar results to the WHO report shown above. According to the Commission’s report, NCDs and injuries cause 43.5% and 8.5% of the deaths in Ethiopia in 2016 respectively. Cardiovascular diseases (35%) and cancer (19%) contribute to an estimated 54% of the overall NCDIs mortality. More than half (51%) of the NCDI mortality occurs before age 40, and 63% occurs before age 50. Deaths alone are not good measures of diseases burden. Disability Adjusted Life Years (DALYs) measure both death and life years lived with disability. In this regard, NCDIs were found to contribute to the substantial loss of total 15 DALYs in Ethiopia in 2016 (46.1%). Among the NCDIs, injuries (19%), cardiovascular diseases (17%); mental, neurological and substance use disorders (16%) and cancer (11%) contribute to the highest loss of DALYs. Over 60% of DALYs lost due to NCDIs in Ethiopia occurred before age 40 showing a very high burden in the productive age group. 2.4 MAGNITUDE OF SELECTED NCDs AND INJURIES IN ETHIOPIA

1 — CARDIOVASCULAR DISEASES

1. CARDIOVASCULAR DISEASES Cardiovascular diseases (CVDs) are a group of disorders of the heart and blood vessels and they include: • Coronary heart disease– disease of the blood vessels supplying the heart muscle; • Cerebrovascular disease (Stroke) – disease of the blood vessels supplying the brain; • Peripheral arterial disease – disease of blood vessels supplying the arms and legs; • Rheumatic heart disease – damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria; • Congenital heart disease – malformations of heart structure existing at birth; • Deep vein thrombosis and pulmonary embolism – blood clots in the leg veins, which can dislodge and move to the heart and lungs. CVDs are the number one cause of death globally: more people die annually from CVDs than from any other cause. An estimated 17.9 million people died from CVDs in 2016, representing 31% of all global deaths. Of these deaths, 85% are due to heart attack and stroke. Over three quarters of CVD deaths take place in low- and middle-income countries. Out of the 17 million premature deaths (under the age of 70) due to non-communicable diseases 37% are caused by CVDs. The most important behavioral risk factors for heart disease and stroke are unhealthy diet, physical inactivity, tobacco use and harmful use of alcohol. The effects of behavioral risk factors may show up in individuals as raised blood pressure, raised blood glucose, raised blood lipids, and overweight and obesity. These “intermediate risks factors” can be measured in primary care facilities and indicate an increased risk of developing a heart attack, stroke, heart failure and other complications. Most cardiovascular diseases can be prevented by addressing behavioral risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity and harmful use of alcohol using population-wide strategies. People with cardiovascular disease or who are at high cardiovascular risk (due to the presence of one or more risk factors such as hypertension, diabetes, hyperlipidemia or already established disease) need early detection and management using counselling and medicines, as appropriate. 1.1 HYPERTENSION Hypertension is when blood pressure in the arteries is persistently elevated. It is defined as systolic blood pressure 140mmHg and above or diastolic blood pressure 90mmHg and above in 2 or more occasions. Hypertension is an important risk factor for CVD and remains the single biggest risk factor for stroke. Based on the National NCD STEPS Survey conducted in Ethiopia in 2015, the prevalence of hypertension is reported as 16%, with higher prevalence among urban dwellers (22% urban versus 13% rural) and older adults. There was no marked difference between the sexes or between income quintiles. 16 A Meta-analysis of several studies showed the mean prevalence of hypertension in Ethiopia to be 19.6 % (23.5 % in urban population and 14.7 % in rural/urban population). The study also showed that the prevalence of hypertension in males and females was 20.6 % and 19.2 % respectively. Hospital based studies have shown that hypertension was the cause of 70% of the strokes in Ethiopia. Additionally, the studies indicated hypertension and hypertensive heart disease are second commonest causes of cardiac follow ups in Hospitals in Ethiopia. Approximately 60% of patients with high blood pressure in Ethiopia were never diagnosed and among those identified cases, only 28% were taking medications. Of those on treatment 74% had poorly controlled hypertension. 1.2 CORONARY HEART DISEASE Among the STEPS Survey participants 3.4% of participants reported ever having had a heart attack or chest pain from heart disease (angina) or a stroke. The highest prevalence was found to be 5.6% in the age group of 60–69 years. The prevalence of a 10-year CVD risk of ≥30% for the age group 40–69 years was 4.7% showing that coronary heart disease is an emerging but under recognized health problem in Ethiopia especially in urban settings. Hospital based studies also showed the increasing trend in coronary heart disease. 1.3 STROKE The prevalence of stroke in Ethiopia is unknown. Global burden of diseases study estimates that stroke is the second highest cause of Cardiovascular death next to Coronary Heart disease in Ethiopia. Forty- four percent of the strokes in Ethiopia were hemorrhagic stroke in contrast to that seen in western countries (<15%) due to the fact that the prevalence of undetected or uncontrolled hypertension is very high. More males than females were affected in Ethiopia with a male-to-female ratio of 1.28 to 1. 1.4 RHEUMATIC HEART DISEASE Rheumatic heart disease is caused by damage to the heart valves and heart muscle from the inflammation and scarring caused by rheumatic fever. Rheumatic fever is caused by an abnormal response of the body to throat infection with streptococcal bacteria (GABHS Tonsillopharyngitis). Rheumatic fever mostly affects children in developing countries, especially where poverty is widespread. Globally, about 2% of deaths from cardiovascular diseases is related to rheumatic heart disease. The Ethiopia NCDI Commission report indicated the prevalence of RHD to be 17/1000 children and young adults aged 4-24 years based on school-based studies. Community Based estimates for age groups 6-25 years are higher at 37.5/1000. More than 500,000 Ethiopians are estimated to be living with RHD. It is the commonest cause of heart failure and is the second commonest cause of stroke in Ethiopia. In the country 46.6 % all cardiovascular follow ups are for RHD. RHD is fatal disease in Ethiopia with annual mortality rate reaching 12.5% (compared with 1.5% elsewhere). More than 10,000 patients are on surgical waiting list. 17

2 — DIABETES MELLITUS

2. DIABETES MELLITUS Diabetes is a chronic, metabolic disease characterized by elevated levels of blood glucose, which leads over time to serious damage to the heart, blood vessels, eyes, kidneys, and nerves. The most common is type 2 diabetes (>90%), usually in adults, which occurs when the body becomes resistant to insulin or doesn’t make enough insulin. In the past three decades the prevalence of type 2 diabetes has risen dramatically in countries of all income levels. Type 1 diabetes is a chronic condition in which the pancreas produces little or no insulin by itself. The National NCD STEPS survey demonstrated a prevalence of diabetes in adults to be 3.2% (3.5% males and 3.0% females) in Ethiopia. International Diabetes Federation Estimates for 2017 however showed a much higher prevalence of 5.2% (with 2.6 million with DM now. Ethiopia is now 1st in SSA). A systematic review of other studies reported prevalence of diabetes ranging from 0.3% to 7.0% in the general population, and up to 8.5% in patients with HIV or TB. The review also showed up to 84% of individuals (particularly in rural areas) with diabetes remained undiagnosed. Among identified cases as having DM and received treatment, only 24% achieved blood sugar control. Patients were found to have high rates of complications.

3 — CHRONIC RESPIRATORY DISEASES

3. CHRONIC RESPIRATORY DISEASES Asthma is a fairly common health problem in Ethiopia, affecting 1.5-3% of the population. The prevalence of COPD is unknown in Ethiopia even though hospital-based studies showed the problem to be fairly common. The majority of households use biomass fuel which exposes women and children to excessive amounts of particulate matter. Indoor air pollution in Ethiopia is a known cause of COPD and other respiratory and cardiovascular diseases.

4 — CANCER

4. CANCER Cancer, especially breast and cervical cancers, is a staggering public health problem in Ethiopia. An estimated 65,000 people develop cancer annually in Ethiopia. Two-third of the incident cases occurred in females (43 thousand) while the rest were in males (22 thousand) with female-to-male ratio of 2:1. The most common cancers in women were breast (takes 23% of all cancers) and cervix followed by ovary, colorectal, leukemia, thyroid, Non-Hodgkin’s lymphoma (NHL), skin, uterus and liver while the top ten cancers in men were colorectal, NHL, prostate, leukemia, lung and bronchus, urinary bladder, stomach, liver, skin and connective & soft tissue. Nearly four thousand cancer cases were expected in the age group below 15 years in 2015 in Ethiopia. Leukemia was the most common cancer in children 0-14 years of age (representing nearly 30% of all cancers in children) followed by NHL, Wilm’s tumor and Retinoblastoma. Most patients with cancer in Ethiopia present at a very late stage, treatment facilities are limited and are often poorly staffed and equipped which results in very poor outcomes. Scale-up of cost-effective preventive, screening, and treatment approaches targeting the most common cancers in Ethiopia could ameliorate morbidity and improve cancer survival.

5 — CHRONIC KIDNEY DISEASES

5. CHRONIC KIDNEY DISEASES Chronic Kidney Diseases (CKD) are characterized by irreversible damage to the nephrons of the kidney with resultant diminishing of the kidney functions. Chronic kidney disease is an important and common public health problem. It has a prevalence rate of 5 to 10% of the population. Chronic kidney disease is increasing in prevalence in Ethiopia. In 2016 there were an estimated 6701 deaths due to CKD. The majority of CKDs in Ethiopia occur due to hypertension, diabetes and glomerulonephritis. 18

6 — INJURIES

6. INJURIES Based on the National NCD STEPS Survey about 3% of respondents were involved in a road traffic crash as a passenger, driver, or pedestrian during the past 12 months preceding the survey. Nearly 3% of the respondents had sustained injury other than road traffic accident in the past 12 months preceding the survey. From all injuries other than road traffic accident, fall is the leading cause, 40.2%, followed by cut, which was 31.5%.

7 — MENTAL, NEUROLOGICAL AND SUBSTANCE USE DISORDERS

7. MENTAL, NEUROLOGICAL AND SUBSTANCE USE DISORDERS The burden of mental health disorders in Ethiopia is high accounting for 19% of all years lived with a disability (YLD) in 2015. It afflicts close to 30% of the Ethiopian population at any one point in time. Common mental disorders are the commonest mental health problems (21.56%), followed by major depression (6.8%). Even though schizophrenia (0.5%), bipolar disorder (0.5%) and epilepsy (0.52%) are less common mental health problems their severity puts them top in the agenda of mental health problems. Substance use disorders are emerging mental, social, security and economic problems in Ethiopia. Mental health services in Ethiopia are poorly resourced and generally accessible to only the most severely ill. Most of the facilities, especially inpatient settings are located in urban areas. Mental health care provided at primary health care (PHC) facilities and social workers based in the community are scarcely available in Ethiopia.

8 — EYE HEALTH

8. EYE HEALTH Eye health problems are also major causes of disability in Ethiopia. According to the 2005/6 National Survey on Blindness, Low Vision and Trachoma, the prevalence of blindness was 1.6% and low vision 3.7%, which represents one of the highest prevalence rates in the world. It is estimated that 87% - 91% of blindness and low vision in Ethiopia is avoidable (either preventable or treatable). The main causes of blindness were: cataract (49.9%), trachoma (11.5%), other corneal opacities (7.8%), refractive errors (7.8%) and glaucoma (5.2%). Similarly, the major causes of low vision were: cataract (42.3%), refractive errors (33.4%) and trachoma (7.7%). Estimates show that, nearly 640 thousand blind people and an additional 1.25 million people with low vision are due to cataract; nearly 150 thousand are blind due to trachoma, more than 50 thousand are blind due to glaucoma and nearly 1 million people have low vision due to refractive errors.

9 — SURGICAL CONDITIONS

9. SURGICAL CONDITIONS According to global estimates, East Africa has one of the highest needs for surgical procedures with a reported 6,145 procedures per 100,000 population. Surgical conditions are among the most common causes of admissions to secondary and tertiary hospitals in Ethiopia. Most surgeries were related to injuries, malignancies and acute abdominal emergencies for adults, and congenital abnormalities and acute abdominal emergencies in children. 19 2.5 MAGNITUDE OF NCDI RISK FACTORS IN ETHIOPIA 2.5.1 Risk Factors for NCDIs Risk factor is an aspect of personal behavior or lifestyle, an environmental exposure, an infection or a hereditary characteristic that is associated with an increase in the occurrence of a particular disease, injury, or other health condition. The underlying causes of the main NCDs are complex. They include genetic predispositions, as well as modifiable risk behaviors (such as tobacco use, harmful use of alcohol, physical inactivity and unhealthy diets), environmental risks (such as air pollution), and infections (like hepatitis B and C, HIV, HPV, EBV, Group A beta hemolytic streptococci). Figure 4: Determinants of NCDs and responsibilities for response (Source: The Case for Investment on NCDs in Ethiopia 2018, WHO) As shown in the framework (figure 4) underlying determinants predispose to behavioral and environmental risk factors and these in turn result in intermediate or metabolic risk factors. The final result in the cascade are the Major NCDs. NCD Risk factors can be classified as modifiable and nonmodifiable risk factors. Non-modifiable risk factor is a risk factor that cannot be reduced or controlled by intervention; Among these factors are age, gender, race/ethnicity and genetics. A modifiable risk factor is a behavioral risk factor that can be reduced or controlled by intervention, thereby reducing the probability of disease. • Physical inactivity, • Tobacco use, • Harmful use of Alcohol, and • Unhealthy diets (trans fat consumption, high saturated fat, high sodium, high sugar foods and sugary drinks, and low fruit and vegetable intake). 20 Other risk factors include: • Air pollution (indoor and outdoor) • Khat use • infections and infestations • Stress Behavioral risk factors can lead to metabolic/physiologic changes or intermediate risk factors. WHO has prioritized the following four metabolic risk factors: • Raised blood pressure • Elevated plasma glucose • Raised total cholesterol • Overweight and obesity. The World Health Organization (WHO) identified four main NCDs as leading causes of mortality: cardiovascular disease (CVD), diabetes mellitus, chronic respiratory diseases, and cancers. These four diseases share four modifiable risk factors: physical inactivity, unhealthy diet, harmful alcohol use, and tobacco use. Studies showed that the modifiable risk factors are usually established during adolescence and are then carried to adulthood (hence life course approach to NCDs). Based on this model up to 80% of CVD and type 2 diabetes mellitus; and over one-third of cancers can be prevented by reducing or eliminating the four modifiable shared risk factors globally. However, based on the GBD study 2017 estimates for Ethiopia only 47% of the NCDs mortality is attributable to metabolic, behavioral and environmental/occupational risk factors. The top five risk factors for NCDs related death and disability in Ethiopia are dietary risks, high systolic blood pressure, high fasting plasma glucose, air pollution and impaired kidney function which constitute two-thirds of the attributable risk. Additionally, infection-related NCDs are ubiquitous and significant causes of suffering and death in Ethiopia. The prevalence of both Hepatitis B and Hepatitis C viruses are very high and is so for the associated chronic liver diseases and liver cancer. Helicobacter pylori is a bacterial infection that causes peptic ulcer disease and several gastrointestinal cancers. Its prevalence is very high in Ethiopia, explaining the high prevalence of these conditions in Ethiopia. Rheumatic heart disease, which is a chronic sequelae of a Beta hemolytic group A streptococcal bacterial sore throat, affects more than 500,000 children and young adults in Ethiopia. RHD is rare in the western world, but in Ethiopia and other Sub-Saharan African countries, it continues to be a significant cause of premature death and suffering. HIV itself is associated with a myriad of noncommunicable diseases and cancers. Several other viral infections like human papillomavirus, Epstein-Barr virus, human herpes viruses are also associated with many cancers. Table 1 below shows the list of risk factors and associated NCDIs. 21 Table 1: Shared risk factors for common NCDIs Cancer Oral-Dental Diseases Musculo skeletal Mental Disorder Cardiovascular Chronic Kidney Chronic Respiratory Diabetes Eye Diseases Diseases Injuries NCDI >>>> Risk factor disease Disease Disease Unhealthy Diet X X X X X X X X Tobacco Use X X X X X X X X X Harmful use of Alcohol X X X X X X X X X Physical Inactivity X X X X X X X Khat X X X X X Indoor Air Pollution X X X X Overweight Obesity X X X X X X X Raised Blood Pressure X X X X Raised Blood Glucose X X X X X X X Raised Blood Cholesterol X X X X Infections (Viruses, bacte- ria, protozoa) X X X X X X X X NB: Adapted from multiple sources 2.5.2 Prevalence of NCD Risk Factors in Ethiopia Based on data from nationally representative population-based surveys (National NCD STEPS Survey 2015 and Ethiopian Demographic and Health Survey 2016) and from global databases the prevalence of NCD risk factors is summarized in the table below. 22 Table 2: Prevalence of NCD risk factors in Ethiopia NCD Risk factors Description Male Female Total Data Year Total alcohol per capita con- sumption, adults aged 15+ (li- Harmful use of alcohol ters of pure alcohol) 5 1 3 2016 Current Alcohol Use, Adults Harmful use of alcohol aged 15+ (%) 46.6 33.5 40.7 2015 Physically inactive based on WHO Criteria, Adults aged Physical Inactivity 15+ (%) 4 7.9 5.8 2015 Mean population salt intake, Salt Intake adults aged 15+ (g/day) 9 7.4 8.3 2015 Salt intake Daily consumption >5g/day 96.2 2015 Current tobacco use, Adults aged 15+ (%) (GATS Survey Tobacco Use 2016) 8.1 1.8 5 2016 Current Khat Chewing, Adults Khat Use aged 15+(%) 21.1 9.4 15.8 2015 Vegetable and fruit consump- Low Vegetable and tion less than recommended by Fruit consumption WHO, Adults aged 15+ (%) 98 97.1 97.6 2015 Exceedance of WHO guide- lines level for annual PM2.5 Ambient Air Pollution concentration (by a multiple of) - - 3 2016 Population with primary re- liance on polluting fuels and Household air pollution technologies (%) - - 93 2016 Overweight or Obe- Overweight or Obesity, adults sity aged 15+ (%) 4.4 8.8 6.3 2015 Serum total cholesterol Raised Total Serum >200mg/dl, adults aged 15+ Cholesterol (%) 3.9 6.8 5.2 2015 Serum Triglyceride level >150mg/dl, Adults aged 15+ Raised TG (%) 21.7 20.2 21 2015 Serum LDL level >130mg/dl, Raised LDL Adults aged 15+ (%) 10.3 18.8 14.1 2015 Serum HDL level <40mg/ dl men; Women <50mg/dl, Low HDL Cholesterol Adults aged 15+ (%) 64.8 73.5 68.7 2015 HBV Prevalence Adults 15+ (%) 9.4 2015 Raised blood pressure, adults Raised Blood pressure aged 15+ (%) 15.7 16.5 16 2015 Raised blood glucose, adults Diabetes aged 15+ (%) 3.5 3.0 3.2 2015 Sources: National NCD STEPS Survey, GATS Survey, Ethiopia NCDI Commission Report 2018, EDHS 2016 Report, Global NCD Report 2018. 23 Based on the National NCD STEPS Survey ~ 98% of adults have at least one NCD risk factor and about 4.5% of adults have 3 or more risk factors indicating the potential for rising of NCDs in the near future. 2.6 SERVICE AVAILABILITY AND READINESS Provision of quality care and treatment services depends on the availability of basic infrastructure, diagnostics and medical supplies. The number of health facilities in Ethiopia is expanding and it is expected to increase more in the coming 5 years, especially with the number of hospitals to increase dramatically. Currently the number of facilities is as shown in table 6 below. Table 6: Number, types and functional status of health facilities and health posts in Ethiopia, Health and Health Related Indicators 2019 Health facility Fully Functional Under Construction Total type Health Posts 17,162 425 17,587 Health Centers 3,678 86 3,764 Hospitals 425 108 533 However, the readiness of health facilities to deliver health services are severely limited by a complex list of challenges. Top on the list based on the National SARA Survey 2018 are unavailability of basic amenities (mean availability was 39%), basic equipment (mean availability was 60%), standard precautions (mean availability was 42%), diagnostics (mean availability was 40%) and essential medicines (mean availability was 28%). The situation is even worse for NCDs service delivery. Even though 49%, 48%, 53% and 9% of health facilities claimed to provide diagnosis and management of CVD, DM, CRD and Cervical Cancer respectively, the mean availability of tracer items for the above services was only 42%,48%,27% and 52% respectively indicating that almost half of the facilities which reported delivering an NCD service are not well prepared to do so. 2.7 IMPACT OF NCDIs IN ETHIOPIA NCDs pose a significant threat to Ethiopia’s health and economic development. NCDs are not only major causes of premature death, disease and illness but also threaten to slow Ethiopia’s rapid economic growth. Ethiopian citizens face the financial burden through out-of-pocket health spending and lost income from breadwinners who leave the labor force. This burden undermines efforts to improve nutrition and education and the initiative to reduce poverty and narrow inequalities to leave no one behind. According to a report by WHO in 2018, the risk of premature mortality from noncommunicable diseases (NCDs) in Ethiopia was 20% in 2016. The report indicated the economic costs of NCDs were significant and were due principally to their impact on the non-health sector (reduced workforce and productivity). It was estimated that NCDs cost Ethiopia at least 31.3 billion Ethiopian Birr (US$ 1.1 billion) per year, equivalent to 1.8% of the gross domestic product (GDP) as shown figure 5 below. Less than 15% of the costs is for health care (See figure below). 24 Figure 5: Structure of the economic burden of NCDs in Ethiopia, 2017 (Source: WHO 2018. The case for Investment for NCDs in Ethiopia) Thus, the impact of NCDs goes beyond increasing the cost of health services. Significant costs to individuals, families, businesses, the health systems and the government and adds up to major macroeconomic impacts. Poverty is closely linked with NCDs. NCDs and poverty create a vicious cycle whereby poverty exposes people to behavioral risk factors for NCDs and, in turn, the resulting NCDs become an important driver of families towards poverty. According to National Health Accounts 6th report, 68% of NCDI services in Ethiopia were financed by Out of Pocket (OOP) expenditures from households. Government was responsible for nearly 30% of NCDIs expenditure, while the contribution of donors for such services was negligible at only 1%. Overall, 23% of total OOP expenditures in Ethiopian households are due to NCDs. Renal failure accounted for 10% of all OOP expenditures, the second highest proportion of all conditions, and significant household spending goes to other NCDs, such as mental disorders (6%), cancers (5%), diabetes (2%), and injuries (2%). Among patients with cardiovascular diseases in Addis Ababa who sought care in health facilities, 27% had experienced catastrophic health expenditures, and was even higher in low-income households of patients residing outside of Addis Ababa. Additionally, evidence is mounting that an individual’s NCDs may put the person at higher risk for key infectious diseases. For example, the risk of developing TB in diabetes very high. Patients with NCD who acquire COVID-19 are at increased risk of severe illness and death. Patients with NCDs are also at higher risk of depression and anxiety which worsens the death and disability associated with NCDs. 2.8 THE NATIONAL RESPONSE TO THE NCDs EPIDEMIC Despite the remarkable successes in the prevention and control of communicable, maternal and child health diseases and conditions the prevention and control of Non-Communicable Diseases appears to be neglected for too long. It first appeared in the Health Sector Development Program (HSDP) III which spanned from 2005-2010, though there was no meaningful implementation of the NCD Program at that time. The NCD Program evolved in in the subsequent HSDP IV which was from 2010-2015. During this time the NCD Strategic framework was developed in 2010 and the NCD Case Team was established in 2013 under the Diseases Prevention and Control Directorate for the first time. 25 NCDs were considered as one of the major disease control priorities in the Health Sector Transformation Plan 2015/16-2019/20, with elaborate strategies and costed interventions. It attempts to address the four NCDs (namely cardiovascular disease [CVD], chronic respiratory disease [CRD], diabetes mellitus [DM)] and cancer) and the four main risk factors for NCDs (namely physical inactivity, unhealthy diet, harmful use of alcohol, and tobacco use) as the main strategy. Twelve out of 176 indicators were included to monitor the epidemiology and service coverage for NCDs. Some of the Initiatives and successes of the HSTP on NCDs were: • Establishing NCDs Units/positions with required man power under DPCD in Ministry of Health and NCD Focal persons in RHBs, • Developed and launched first National Strategic Action Plan for the prevention and control of non-communicable diseases (NCDs) 2014-2016. • It also developed National Eye Health Strategic Plan 2016-2020, National Cancer Control Plan 2016-2020, National Hepatitis Prevention and Control plan 2016-2020 and National Mental Health Strategic Plan 2012/13-2016. • National Childhood and Adolescent Cancer Control Plan Of Ethiopia 2019-2023. • Successfully conducted the National NCD STEPS survey in 2015/16 to generate evidences to guide the national responses and report launched September 2017. • National NCDI Commission was established to study the NCDI burden and recommend cost effective interventions and released its report on Nov 27,2018. • Developed different guidelines and manuals on diseases management and trainings on NCDs (NCDs, Cervical cancer, RHD, Hepatitis, Breast cancer) • Integrated NCDs indicators into the revised national HMIS indicators list, • Developed different screening and treatment registers, M & E tools and job aids, • Working to Integrate supply issues management through assigning Pharmacy professional for NCDs logistics also started to work with pharmaceutical partners to address affordable drugs with low price and consistently to our citizen. • Establishing national working and advisory groups (DM, HTN, Cancer, CVD, Eye health, CRD, Hepatitis, Mental Health). • Capacity building for hospital and health center staff and program staff. • Tobacco control initiative started by endorsing FCTC. • Stringent Alcohol and FCTC compliant Tobacco control proclamation 1112/2019 issued by Ethiopian Parliament in Feb 2019. • Cervical Cancer Screening with Visual Inspection with Acetic Acid (VIA) and cryotherapy for VIA Positive lesions being implemented country wide. • Radiotherapy Center expansion to six additional sites underway and will be finalized soon. • Viral Hepatitis treatment program initiated and being scaled up. • Decentralization of care for Diabetes, Hypertension, Rheumatic heart disease and CRD underway in collaboration with Addis Ababa University, RHBs and implementing partners like PSI-Ethiopia Healthy Heart Africa Initiative, Friends of Children’s Heart fund of Ethiopia and others. • The Ministry of health was implementing the National Strategic Action Plan on Prevention and control of NCDs 2014-2016. A detailed analysis of the NCD response at national and regional level has been done and the results are summarized in the SWOT Analysis table below. 26 Table 3: SWOT ANALYSIS OF NCD PROGRAM IN ETHIOPIA STRENGTH OPPORTUNITIES • Dedicated and functional National and • Strong primary healthcare structure especially Regional NCDs Units, designed for disease prevention and health • Evolving interest and commitment of the MOH-E promotion through the Health Extension Program and RHBs on prevention and control of NCDs • The four NCDs are preventable by addressing • Expanded NCDs agenda incorporated within their shared risk factors (“best buy” intervention HSTP2 through population-wide approach) • Strategic plans, annual plans being regularly • Recent initiative for high level political developed commitment at the global and regional levels • Guidelines, training materials and client and • NCDI Commission report with cost effective provider education materials developed interventions recommended. • Awareness raising campaigns being conducted • The health policy and Essential health service though not in a structured manner packages are under revision. • NCDs issues integrated into the Health Extension • Growing role of the private health sector in the program clinical care of non-communicable diseases, • NCD program integrated into the Ethiopian • Growing number of health professional Primary Health care guideline training institutions (colleges of health sciences, • National NCD STEPS Survey and GATS Survey universities), Conducted and result launched. • Cumulative experience in HIV/AIDS, MCH • National NCDIs Commission established and and other communicable diseases- conducting assessed NCDIs Situation and developed training, developing training material, recommendations and cost-effective mentoring, supportive supervision, task shifting interventions and task sharing. • UN Agencies including WHO, as well as growing international interest on NCDs 27 WEAKNESS THREATS • Poor prioritization of NCD prevention and • Lower awareness and misconceptions about control at all levels of the health system the burden and consequences of NCDs, among especially in Regions and Woredas. the policy makers, health professionals and the • Inadequate high-level advocacy for political general public leaders on NCDs and risk factors • Weak multi-sectoral coordination mechanism • Lack of financial and technical resources for for prevention and control of NCDs program implementation • Lack of resources for NCDs (competing priorities • Poor capture and reporting of NCD related from triple burden of diseases) indicators in the HMIS with resultant paucity of • Limited number of national and international planning data. partners for technical and financial support of • Low Awareness of the community, health care the NCD program providers and the political leaders on NCDs • Unregulated transnational (global) trade • Poor availability and affordability of high leading to imported products and behaviors, quality, safe and effective basic technologies • Proliferation of industrial/commercial food and medicines for screening, diagnosis, processing and brewery- promoting unhealthy treatment and monitoring of NCDs. • Globalization with resultant lifestyle changes • Inadequate mix and capacity of the health (smoking, alcohol, physical inactivity, foods with workforce added salt, sugar and saturated or trans-fat) • Poorly staffed RHBs • Low health seeking behavior among the public • Limited number of HFs providing integrated often due to asymptomatic nature of NCDs. management of NCDs at primary health care • Economic gain by the government from the level and poor referral networks booming industry which predisposes to NCD • Poor partnership between the public and risk factors (alcohol, Khat, soft drinks). private health systems. • Rapidly expanding urban centers and industries. • Poor or No regulation on Khat, Oils and fats, Sugar, salt and environmental pollution 28 CHAPTER THREE: NATIONAL STRATEGIC PLAN FOR THE PREVENTION AND CONTROL OF NONCOMMUNICABLE DISEASES 3.1 SCOPE, VISION AND MISSION 3.1.1 SCOPE Cardiovascular diseases (CVD), chronic respiratory diseases (CRD), Chronic Kidney Diseases and Diabetes Mellitus (DM) are included in this National Strategic Action Plan. These four categories of NCDs make the largest contribution to morbidity and mortality among the non-communicable diseases especially in low and Low-middle income countries (LMIC). Even though cancer is the other major contributor to NCDs morbidity and mortality it is not included in this strategy as it has been addressed separately in the National Cancer Control Plan 2016-2020. The other major contributors to NCDs morbidity, namely mental, neurological and substance use (MNS) disorders, Hepatitis and eye health problems, are covered in their respective National Mental Health Strategy, National Hepatitis Prevention and control and National eye health strategic plans. This NSP will focus on the aforementioned four NCDs and their shared risk factors. As per the national health policy and health sector transformation plan 2 of Ethiopia, this NSP for the prevention and control of NCDs will focus on prevention and control activities for the population at large as well as provision of quality NCDs services in an equitable manner for individuals with NCDs or at high risk of developing NCDs. 3.1.2 VISION To see healthy, productive and prosperous Ethiopians free from preventable and avoidable non- communicable diseases. 3.1.3 MISSION To promote health and wellbeing of Ethiopians through providing a comprehensive package of promotive, preventive, curative and rehabilitative NCD services of the highest possible quality in an equitable manner.” 3.2 GOAL, OBJECTIVES AND TARGETS 3.2.1 GOAL To reduce the burden of NCDs by promoting healthy lifestyles, reducing common risk factors and providing integrated evidenced based, innovative and cost-effective public health and clinical interventions. 3.2.2 OBJECTIVES:

1 — To strengthen national capacity, public policies through health in all policies, leadership,

1. To strengthen national capacity, public policies through health in all policies, leadership, governance, multi-sectoral action and partnership to accelerate country response for prevention and control of non-communicable diseases.

2 — To reduce exposure to modifiable risk factors for non-communicable diseases and promotion of

2. To reduce exposure to modifiable risk factors for non-communicable diseases and promotion of health throughout the lifecycle through the creation of health-promoting environments.

3 — To strengthen and reorient health systems to address prevention and control of non-communicable

3. To strengthen and reorient health systems to address prevention and control of non-communicable diseases through people-centered care with financial risk protection and universal health coverage. 29

4 — To enhance national capacity for NCDs and risk factors surveillance and research for prevention

4. To enhance national capacity for NCDs and risk factors surveillance and research for prevention and control of non- communicable diseases

5 — To foster international cooperation and advocacy to raise the priority accorded to prevention

5. To foster international cooperation and advocacy to raise the priority accorded to prevention and control of non-communicable diseases in the development agenda and in internationally agreed development goals. 3.2.3 TARGETS OF THE NATIONAL STRATEGIC PLAN The WHO global action plan on NCDs 2013 - 2020, outlines nine voluntary targets (see Annex 4) for the prevention and control of non-communicable diseases by the year 2025.The current national strategic plan clearly defines targets for prevention and control of NCDs and their risk factors in the Ethiopian context as has been included in the Health Sector Transformation Plan 2 (2020-25). The 2015 National NCD risk factors STEPS survey, Global NCD Report 2018, GATS Survey 2016, EDHS Survey 2016 and SARA Survey 2016 have been used as a baseline for the target setting. The targets are listed in the table below. Table 4: Selected NCDs Targets for 2020 - 2025 Ser. Indicators Baseline Target by 2025 No. 1 Reduce overall premature mortality 20% (WHO 2016 for 25% relative from Non-communicable Diseases Ethiopia) reduction 2 Reduce prevalence of current tobacco 5 % GATS Survey 2016 30% relative use in persons aged 15+ years reduction 3 Reduce harmful use of alcohol in per- 12.5% NCD STEPS by 2015 10% relative sons aged 15+ years reduction 4 Reduce prevalence of current khat use 16% NCD STEPS by 2015 20% relative in persons aged 15+ years reduction 5 Reduce prevalence of insufficient phys- 5.8% NCD STEPS by 2015 10% relative ical activity in persons aged 15+ years reduction 6 Reduce mean population salt intake 96.2% STEPS Survey in 30% relative to <5 grams per day in persons aged 2015 reduction 15+ years 7 Reduce insufficient fruit and vegeta- 97.6% STEPS by 2015 25 % relative ble consumption in persons aged 15+ reduction years 8 Reduce the percentage of people who 6.3% STEPS in 2015 15% relative are obese or overweight reduction 9 Reduce the age-standardized preva- 5.6% STEPS in 2015 10% relative lence of raised total cholesterol among reduction persons aged 18+ years 10 Reduce prevalence of raised blood 16% STEPS in 2015 25% relative pressure in persons aged 15+ years reduction 11 Reduction in the prevalence of ARF/ 17/1000 school children 25% relative RHD in age group 4-24 years old and young adults (NCDI reduction Commission Report 2018) 30 12 Increase treatment (pharmacologic and 3% STEPS Survey 2015 50% nonpharmacologic) coverage for pa- tients with hypertension 13 Increase the proportion of people with 30% based on pilot Study 60 % hypertension with controlled blood by MOH-E 2016 pressure 14 Halt raise in prevalence of raised blood 3.2 % STEPS in 2015 zero percent increase sugar in persons aged 15+ years 15 Increase the proportion of people with 30% based on pilot Study 60% diabetes with controlled blood glucose by MOH-E 2016 level 16 Increase treatment coverage for pa- 3% STEPS Survey 2015 50% tients with diabetes (pharmacologic and nonpharmacologic). 17 Increase availability of basic technol- 28% availability based on 80% ogies and essential medicines includ- SARA 2018 Report ing generics, required to treat NCDs in both public and private facilities; 18 All health centers and hospitals provide Baseline 27% readiness for 100% routine and emergency asthma care asthma care 19 Decrease household air pollution from Baseline > 95% households < 60% biomass fuel use use biomass fuel (based on EDHS 2016) 3.3 GUIDING PRINCIPLES FOR THE NSAP ON NCDS AND RISK FACTORS The development and recommended implementation of this strategic plan was based on the following guiding principles and approaches:

1 — Multi-sectoral approach:- NCDs are both a health and a development agenda. Social, economic,

1. Multi-sectoral approach:- NCDs are both a health and a development agenda. Social, economic, behavioral and environmental determinants expose people to high risk factors such as tobacco smoking, unhealthy diet, physical inactivity, harmful use of alcohol, khat, and environmental pollu- tion. The nature of NCDs and their risk factors calls for the involvement of both health and non-health sectors in prevention and control measures. Mechanisms will be put in place to ensure that there is a coordinated multi-stakeholder engagement and multisectoral action for health both within gov- ernment and by nongovernment actors. Health should be incorporated in all policies and a whole of government approach where appropriate should be considered.

2 — Life-course approach:- the risk of non-communicable diseases may occur at critical periods of hu

2. Life-course approach:- the risk of non-communicable diseases may occur at critical periods of hu- man growth and development or risk may accumulate with age and be influenced by factors acting at all stages of the life span. With the trajectory of NCD risk starting early in the life-course, early intervention will have the greatest impact. (figure 4) 31 Figure 6: A life course approach for NCD prevention (Source: NCD Strategic plan 2014-16) Opportunities to prevent and control non-communicable diseases occur at multiple stages of life; interventions in early life often offer the best chance for primary prevention. Policies, plans and services for the prevention and control of non-communicable diseases need to consider the health and social needs at all stages of life.

3 — Universal health coverage:- achieving universal health coverage (UHC) without attaining NCDs

3. Universal health coverage:- achieving universal health coverage (UHC) without attaining NCDs prevention and control is impossible, hence NCDs have to be prioritized in UHC design and im- plementation. When achieved, UHC can provide a powerful vehicle to accelerate progress in NCDs outcomes, inequalities, and socio-economic impact. Quality health services and innovative approaches are key requisites for effective prevention and control of non-communicable diseases. The vicious link between non-communicable diseases and impoverishment cannot be severed in the absence of universal health coverage in national health systems. Ensure universal access to primary health care through expanded health insurance coverage.

4 — Decentralization and Integration:- Intervention and approaches towards the prevention and con

4. Decentralization and Integration:- Intervention and approaches towards the prevention and con- trol of NCDs should be integrated from policy development to service delivery with a focus on primary health care. NCDs prevention and curative services will be delivered integrated within the three-tiered health care system of the country (primary, secondary and tertiary). Services will be given at all levels ranging from the community, the health posts up to the tertiary referral hospitals.

5 — Human rights approach:- The constitution of Ethiopia states that every citizen has the right to life,

5. Human rights approach:- The constitution of Ethiopia states that every citizen has the right to life, the right to the highest attainable standard of health and the right to access information. The Na- tional NCD Strategic Plan is firmly rooted in these rights.

6 — Equity-based approach:- The disparity in occurrence of NCDs is due to unequal distribution of

6. Equity-based approach:- The disparity in occurrence of NCDs is due to unequal distribution of social determinants of health. Action on the determinants of health, both for vulnerable groups and the entire population, is essential to create inclusive, equitable, economically productive and healthy communities.

7 — Empowerment of Individuals and communities:- Individuals and communities’ participation

7. Empowerment of Individuals and communities:- Individuals and communities’ participation should be anchored in information geared toward helping them make informed decisions. In ad- dition, they should also participate in the prevention and control of non-communicable diseases through advocacy, policy development, planning, legislation, service provision, research, monitor- ing and evaluation.

8 — Evidence-based:- Interventions should be based upon evidence and implementation should focus

8. Evidence-based:- Interventions should be based upon evidence and implementation should focus on the achievement of well-formulated objectives and targets.

9 — Management of real, perceived or potential conflicts of interest:- Real, perceived or potential

9. Management of real, perceived or potential conflicts of interest:- Real, perceived or potential conflicts of interest in policy must be acknowledged and managed. 32 CHAPTER FOUR: PRIORITY AREAS AND STRATEGIES FOR THE NSAP The underlying risk factors of NCDs are largely preventable. Interventions are needed at population level (primordial prevention), at community level (primordial and primary prevention), through early diagnosis (primary prevention) and through comprehensive and cost-effective management (secondary prevention), palliative care and rehabilitation (tertiary prevention). To address the growing burden of NCDs, WHO identified a package of 16 “best buy” interventions that are cost-effective (costing as little as $1 per person per year), affordable, feasible and scalable in all settings. See Annex 3 for details of the WHO Best Buys. According to WHO, implementing all 16 “best buys” in all countries between 2018 and 2025 would avoid 9.6 million premature deaths, thus moving countries appreciably towards the NCD mortality reduction targets. The cost of inaction is unbearable to the individual, households, the health system and the nation at large. The case for investment on NCDs and their risk factors in Ethiopia developed by the joint WHO and UNDP mission in consultation with sectoral ministries in Ethiopia in 2018 has shown that 242.2 Billion Birr is the Investment required for selected best buys intervention packages over a 15-year period. The return on the investment for the same time period will be 62.1 billion Birr. The report estimates that full implementation of preventive and treatment interventions would prevent more than 1 million premature deaths over 15 years. The Ethiopia NCDI Commission expanded on the WHO Best Buy interventions and has reviewed evidence for implementation of highest priority NCDI Interventions. Based on the WHO Best Buy Interventions and the recommendations stipulated by the Ethiopia NCDI Commission Report the National NCD Prevention and Control Strategic Plan is organized by priority area, consisting of four targeted areas of intervention that will guide the implementation of NCD activities and interventions. These priority areas are:

1 — Priority Area One:- Strengthen the national NCD response through policy, governance, leadership

1. Priority Area One:- Strengthen the national NCD response through policy, governance, leadership and coordination.

2 — Priority Area Two:- Health promotion and disease prevention targeting behavioral, infectious

2. Priority Area Two:- Health promotion and disease prevention targeting behavioral, infectious and environmental risk factors.

3 — Priority Area Three:- Comprehensive and Integrated Screening, Diagnosis, Treatment, Care and

3. Priority Area Three:- Comprehensive and Integrated Screening, Diagnosis, Treatment, Care and Support for NCDs and their risk factors.

4 — Priority Area Four:- Monitoring, evaluation and research

4. Priority Area Four:- Monitoring, evaluation and research. The objectives, initiatives and strategies of each priority areas are described in the subsequent sections of this document Refer also to Annex 1 to see the detailed implementation log frame. PRIORITY AREA 1: STRENGTHEN THE NATIONAL NCD RESPONSE THROUGH POLICY, GOVERNANCE, LEADERSHIP AND COORDINATION. OBJECTIVE:- To strengthen the national capacity and country-wide ownership of NCD interventions through influencing policy formulation, leadership, governance, multi-sectoral action and partnerships. Strategic initiatives for Priority Area One are detailed below: 33 Strategic Initiative 1: Strengthen National health policy on NCDs and their risk factors. The objective of this strategic initiative is to address the challenges posed by NCD risk factors and the diseases themselves through policy and regulation. Much of the NCD risk factors will be addressed through appropriate national policies and regulatory measures. In Ethiopia, risk factors that will be given most attention includes: tobacco, unhealthy diet, physical inactivity, indoor and outdoor air pollution, harmful alcohol use and khat consumption. Strategic interventions: • Ensure Specific policies and legislation are developed to address the rising burden of NCD risk factors. • Designed policies and legislation to prioritize medical intervention for people affected by NCDs • Foster public participation in designing and implementation of NCD interventions (prevention and care) policies. Strategic Initiative 2: Establish/Strengthen NCD governance at all levels . The objective of this strategic initiative is to create a response to the high burden and multifaceted challenge of NCDs. An effective, proactive and evidence informed NCD governance should be established at all levels to address the burgeoning challenges the country faces regarding NCDs and their risk factors. Mainstreaming NCD agenda into all health and health-related policies, strategies and services is of paramount importance. Since NCDs accumulate through the life course interventions should begin before conception, continued during conceptions, childhood, adolescence and early adulthood. Strategic interventions: • Strengthen NCD Coordination and Governance at Federal and RHB levels by expanding structures and budgets. • Mainstreaming of Noncommunicable diseases prevention and control in all health sector strategies and activities, and enhanced coordination of services • Strengthening and/or establishing NCD coordinating structures at zonal, woreda and health facilities levels. • Set up a national and sub national NCDs Advisory group and technical taskforce. • Mobilize adequate resources for NCD programs at all levels. Strategic Initiative 3: Establish Multisectoral Coordination Mechanism for prevention and control of NCDs and Risk factors at all levels of the government. The objective of this strategic initiative is to strengthen multisectoral response at all levels involving all relevant sectors and stakeholders with clear roles and responsibilities on NCDS and their risk factors. This initiative will be implemented through the Woreda Transformation Platform (WTP) which is composed of the WTP Steering Committee and the WTP Technical Working group at all levels. Strategic Interventions: • Establish a functioning multi-sectoral coordinating body at all levels with a multi-sectoral accountability framework. • Coordinate the development of the Multisectoral Action Plan (MSAP). • Ensure Integration of prevention and control of NCDs and their risk factors in the multisectoral Woreda Transformation Platform. • Monitor implementation of the Multisectoral Strategic Action Plan and • Mobilize financial and technical resources for prevention and control of NCDs. 34 PRIORITY AREA 2: INTENSIFY HEALTH PROMOTION AND DISEASE PREVENTION TARGETING BEHAVIORAL, INFECTIOUS AND ENVIRONMENTAL RISK FACTORS Objective:- Promote healthy lifestyles and reduce exposure to modifiable risk factors for non- communicable diseases. Strategic Initiative 1: Increase public awareness on NCDs and their risk factors The objective of this strategic initiative is to enhance knowledge to bring about behavioral changes on NCDs and their risk factors. Over 80% of CVDs and diabetes and nearly 40% of cancers are preventable through addressing their shared behavioral risk factors. Strategic Interventions • Develop NCD communication strategy and health education modules on NCDs and their risk factors (behavioral, infectious and environmental) • Conduct Advocacy on NCDs and their risk factors to increase the awareness and commitment of policy makers, health managers and health care workers. • Integrate Communication Packages on NCDs and their risk factors in School Health and Nutrition and the Health extension programs. • Integrate NCD and risk factors messages into the routine health education program of health facilities • Conduct Awareness raising programs on NCDs and risk factors in work places. Strategic Initiative 2: Promoting Healthy Diet The objective of this strategic initiative is to increase public awareness on healthy diet which includes adequate intake of vegetables, fruits and whole grains; limited intake of sugar, salt and saturated fat and avoidance of trans-fats. Healthy diet promotive services shall encompass all stages of life. The MOH-E should engage the non- health sectors that can contribute to the promotion of healthy diet. Strategic Interventions • Implementing public awareness activities on healthy diets during the life course • Develop national dietary guidelines to promote healthy dietary habits. • Collaborate with the national/regional nutrition council and task forces to address the dietary risk factors for NCDs. • Liaise with the Ministry of Education to introduce healthy diet promotion in school curriculums and awareness creation activities. • Develop and implement policies and legislations to promote healthy diet (reduction of salt, sugar, saturated fat, trans-fat; and promote regular fruit and vegetable consumption). Strategic Initiative 3: Promoting Physical Activity The objective of this strategic initiative is to create awareness on the benefits of physical activity and to create conducive environment for physical exercise. 35 Strategic Interventions • Creating public awareness on the health benefits of physical activity in prevention and control of NCDs • Liaise with the Ministry of Youth and Sports to develop/adopt a strategic implementation plan to enforce the national sport policy. • Liaise with the Ministry of Education for the promotion of all-inclusive physical activity in schools. • Engage the Ministry of Housing and Construction and the Ministry of Transport to create an enabling environment for physical activity including playgrounds, walkways, and cycling lanes. • Promote mass sport including competitive sport events in collaboration with stakeholders. • Promoting physical activity in the community, private and public institutions, workplaces and health facilities. • Strengthen the Car free roads days initiative implementation in all urban areas in collaboration with other stakeholders. Strategic Initiative 4: Reduce Harmful Use of Alcohol The objective of this strategic initiative is to create awareness on harms of alcohol use and foster the full implementation of legislations and polices on production, sale and use of alcohol. Strategic Interventions • Creating public awareness on the health, security and economic harms of alcohol use. • Implement and monitor enforcement of the EFDA proclamation 1112/2019 on prohibition of advertising, promotion and sponsorship of alcoholic beverages, and mandatory labelling of alcoholic beverages at the National and Regional levels. • Liaise with Ministry of Finance, Ministry of trade and industry and other relevant sectors to regulate alcohol production, sale, use and taxation. Strategic Initiative 5: Tobacco Use Reduction The objective of this strategic initiative is to increase public awareness on the health hazards of use of tobacco and tobacco products and strengthen the implementation of legislations and directives on tobacco and tobacco products. Strategic Interventions • Creating public awareness on the health, societal and economic harms related to tobacco use. • Monitor enforcement of the proclamation of articles on tobacco control in the EFDA proclamation 1112/2019 in accordance with the WHO framework convention for the control of tobacco (FCTC). • Promote gradual substitution of tobacco farms with other income generating agricultural products. Strategic Initiative 6: Reduction of Khat Use The objective of this strategic initiative is to increase awareness on the health risks of Khat use. Considering the vicious cycle between khat use and other NCD risk factors (like concurrent alcohol use, sugar intake, physical inactivity and impaired judgment) the following strategic interventions are to be implemented. 36 Strategic Interventions • Implement public awareness on the dangers of khat consumption and its related risks. • Liaise with national Multisectoral Committee to develop legislations and regulation on domestic production, sale and use of khat. • Liaise with the Ministry of Education and other sectors for developing access restrictive measures aimed at children and young people including in schools and higher education institutions. • Evidence gathering • Promote gradual substitution of khat farms with other income generating agricultural products. Strategic Initiative 7: Promote interventions on the reduction of exposure to environmental and occupational risk factors. This strategic objective aims to promote interventions to reduce exposure to contaminants arising from the environment (outdoor air pollution due to vehicle and factory exhaust fumes), home (Biomass fuel) and workplaces (e.g. Cobble stone, Mines, Cotton Mills, Cement) and strengthen the surveillance of these contaminants in order to mitigate the effects of exposure. Strategic Interventions • Create public awareness on prevention of exposure to environmental and occupational risk factors on NCDs • Strengthening the implementation of the legal frameworks, policies, standards and guidelines to reduce exposure to environmental and occupational risk factors in collaboration with Ministry of Labor and Social Affairs, Ministry of Trade and Industry, Ministry of Transport, Ministry of Mines and Energy, Environmental Protection Agency and other relevant sectors. • Initiate and promote programs aimed at protecting and reducing exposure to risk factors for NCDs at the workplace, public and home environment. Strategic Initiative 8: Prevention of Rheumatic Heart Disease Acute Rheumatic Fever (ARF) is an inflammatory disorder of the connective tissue of the heart and other body parts, triggered by a Group A Beta hemolytic streptococcal (GABHS) throat infection. This condition causes temporary, painful arthritis and other symptoms. Acute rheumatic fever primarily affects the heart, joints and central nervous system. But, the major importance of acute rheumatic fever is its ability to cause fibrosis of heart valves, leading to crippling valvular heart disease, heart failure and death. There are cost-effective, affordable and feasible interventions for the prevention and control of RHD. Strategic Interventions • Primordial Prevention activities such as personal hygiene and policy measures on avoidance of overcrowding. • Primary prevention of RHD: is treatment of bacterial pharyngitis for prevention of acute sequalae of group A streptococcal throat infections. • Secondary prevention of RHD: the continuous administration of specific antibiotics to patients with a previous attack of rheumatic fever, or well-documented rheumatic heart disease (RHD registry based). 37 PRIORITY AREAS 3: COMPREHENSIVE AND INTEGRATED CLINICAL INTERVENTIONS FOR NCDs AND THEIR RISK FACTORS Objective:- To expand access to comprehensive, high quality and integrated services for the community on NCDs and their risk factors. Strategic Initiative 1: Strengthening Health Service Delivery The objective of this strategic initiative is to strengthen the health system for effective and integrated NCDs and risk factors service provision. Services will be provided at all levels starting from the community, in health centers, primary hospitals, general hospitals and referral hospitals. Recommended Interventions that will be delivered at the different levels of the health care system are shown in Annex 2. Strategic Interventions: • Define essential package of care on NCDs and risk factors for each level of the health care system. • Reorient and reorganize the health services in accordance with the NCDs and risk factors care package. • Decentralize and Integrate NCDs services and prevention of NCDs risk factors into the primary health care through task shifting, task sharing and improved referral networks. • Empower patients and families in the care of patients with NCDs. Strategic Initiative 2: Develop the Human Resource for NCDs Service Delivery The objective of this strategic intervention is to capacitate the health work force at the different levels of the heath service to provide quality NCD screening, diagnosis, care and treatment services. Strategic Interventions: • Ensure NCDs and their risk factors are given due attention in all health-related preservice training curricula. • Ensure the assignment of appropriate mix of healthcare workers as per the minimum standard. • Develop NCDs and risk factor guidelines, training materials, care and treatment protocols for health care providers and train health care workers. • Develop NCDs Program Management training materials and train NCD Program Managers. • Strengthen health facility level Mentorship Programs on NCDs and risk factors • Ensure health facility level quality improvement system incorporates NCDs services. Strategic Initiative 3: Improve Infrastructure, Diagnostics, Medical Supplies and Technologies. The objective of this strategic initiative is to improve the quality of screening, diagnosis, treatment and care for NCDs and their risk factors through improved infrastructure and technologies. Strategic Interventions: • Define the components of the service standards (Infrastructure, screening tools, diagnostics, essential medicines, medical equipment, essential medicines, laboratory supplies and reagents) for delivery of NCDs services in the Ethiopian setup. • Ensure health facilities fulfill minimum standards to deliver NCDs and risk factors screening, diagnosis, treatment and care services. 38 • Ensure uninterrupted supply of essential medicines and laboratory reagents for diagnosis and management of NCDs and risk factors • Ensure continuous and sustainable availability of essential medical and lab equipment for diagnosis and management of NCDs and risk factors • Strengthen laboratory networks and Lab Quality Assurance system. • Strengthen the health insurance system to increase population service utilization. PRIORITY AREA 4: RESEARCH, SURVEILLANCE, MONITORING AND EVALUATION OBJECTIVE:- to increase the use data on NCDs and risk factors for evidence-based decision making. A comprehensive monitoring framework should include relevant outcomes (mortality and morbidity), exposures (risk factors), and health system capacity and response – with emphasis on priorities in congruent with the UN political declaration of NCDs customized according to local context. It follows the Monitoring framework depicted in the figure below (figure 7). FIGURE 7: M&E FRAMEWORK FOR PREVENTION AND CONTROL NCDS AND RISK FACTORS Strategic Initiative 1: Incorporate key indicators of NCDs into the national health information Management System (HMIS) The objective of this strategic intervention is to strengthen the national health information Management System (HMIS) to capture NCD indicator Strategic Interventions • Develop and Integrate Relevant NCD indicators in the National HMIS including DHIS2 and Other electronic platforms • Develop monitoring and evaluation tools for NCD services • Integrate NCDs service indicators in the National Joint Supportive Supervision program • Capacity building on NCD services M&E for program mangers health care workers and Health information technicians on data capturing, analysis and use • Include NCD Indicators in the Health Center and Hospital KPI 39 Strategic Initiative 2: Establish/Strengthen Disease Registries, Research and Surveillance The objective of this strategic intervention is to improve the availability and quality of information/ data on NCDs and risk factors. Strategic Interventions: • Assess the level of adult mortality through the national vital registration system • Establish Disease specific registries for understanding of national and regional burden and trends. • Support verbal autopsy activities in sentinel sites • Conduct WHO Stepwise Survey on NCD risk factors (2020 and 2025) • Strengthen SARA survey to incorporate adequate NCDs and risk factors health facility service and readiness indicators. • Set research agendas on NCDs, risk factors and interventions and support researches conducted 40 CHAPTER FIVE: IMPLEMENTATION OF THE NATIONAL STRATEGIC PLAN FOR NCDS AND RISK FACTORS Factors controlling NCDs and determinants of NCDs are very diverse and multifactorial and at large beyond the reach of the health sector alone. Besides, NCDs evolve throughout the life cycle, as such; interventions shall encompass all stages of life. Cognizant of this; the response requires involvement of both governmental and nongovernmental stakeholders. Thus, the prevention and control of NCDs requires a multi-sectoral response and collaborations. Besides, the response requires prompt and isolated actions of the health sector too, where the health sector is primarily responsible to ensure availability and delivery of quality health services through the primary health care to ensure universal health coverage. Therefore, the implementation of the NCD NSP will be two pronged. 5.1 PRONG ONE: THE MULTISECTORAL RESPONSE FOR NCDS As has been mentioned elsewhere in this document, the prevention and control of NCDs requires a multi-sectoral response and collaborations. As such an appropriate organizational structure to support coordination and implementation will ensure the delivery of efficient NCDs prevention and control programs in the country. Primarily the multisectoral response focuses on interventions that require policy level actions. Actors include both governmental and nongovernmental agencies. Governmental actors included but are not limited to the Ministry of Health (MOH), Ministry of Trade and Industry, Ministry of Education (MOE), Ministry of Agriculture (MOA), Ministry of Finance, the Federal Attorney General’s Office (FAGO), Ministry of Women, Children and Youth Affairs (MWCYA), Ministry of Culture and Tourism, Ministry of Housing and Urban Development (MHUD), Ministry of Transport, Ministry of Labor and Social Affairs (MOLSA), Sport’s Commission, Ministry of Mines and Energy, Environmental Protection Agency, Ethiopian Broadcasting Authority(EBA), and Federal and Regional Government Medias. Nongovernmental actors include International and Local NGOs, UN Agencies, Faith Based Organizations, Civic Society Organizations (CSOs), Professional Associations, Patients’ Associations, Community Based Organizations and the Private Media. 41 Table 8: Multi-sectoral and policy interventions for the prevention and control of Non-communicable Diseases Risk factors/ Interventions Policy category Responsible sec- disease tors in Ethiopia Raise taxes on tobacco Tax and subsidies Finance Enforce Bans on tobacco ad- Regulation and enforcement EFDA, EBA vertisement, promotion and sponsorship Smoke free indoor work Regulation and enforcement EFDA, Law enforcement places and public spaces Tobacco use Implement plain packaging Health education and infor- MoH, Media, Education, and large graphic health mation (HEI) EFDA warnings on all tobacco packages Restrict sell of single stick Regulation and enforcement Legislators, Federal At- Cigarette. torney General, EFDA, Law Enforcement Ban sell of Cigarette for mi- Regulation and enforcement Legislators, Federal At- nors and also ban sale by torney General, EFDA, minors Law Enforcement Raise taxes on alcoholic bev- Tax and subsidies Finance, Revenue and erages Custom Authority Enforce restrictions on avail- Regulation and enforcement Law Enforcement Entities ability and sell of retailed Alcohol use alcohol Bans on alcohol advertising Regulation and enforcement EFDA, EBA Ban on sell of alcohols to Regulation and enforcement Legislators and Law en- minors and by minors (<21 forcement Years Old) Implement a popula- Health Education and Infor- Culture and Tourism, tion-based public health pro- mation and built environment MoH, Education, Media, gram to increase physical Sport Commission, Min- Physical inactivity activity istry of Housing and Ur- ban Development Create supportive environ- Regulation and enforcement Ministry of Housing and ments (build environment) for Urban Development behavioral change of physi- cal activity levels 42 Replace trans-fat and sat- Regulation and enforcement Trade and Industry, EFDA urated fats with mono and polyunsaturated fats Impose regulations to reduce Regulation and enforcement Trade, Industry, EFDA salt in manufactured food Unhealthy diet products Increase taxation of sugar Tax and subsidies Finance, EFDA sweetened beverage Front of pack labeling of salt Regulation and enforcement EFDA, EPHI, Ethiopian and sugar content of packed Standardization Agency and processed foods and (ESA) drinks. Reduce salt and sugar intake Health education and infor- MoH, Education, Media through behavior change mation (HEI) communication and mass me- dia campaign Increase consumption of fruits Increase production, distri- Ministry of agriculture, and Vegetables bution and use Ministry of Revenues, Ministry of transport Raise taxes on Khat Tax and subsidies Finance Khat Use Bans on commercial Khat Regulation and enforcement EFDA, EBA chewing places Crop Substitution Incentivize Agriculture Indoor air pollution: expand Built environment Mines and energy access to electricity Indoor air pollution: Reduce Regulation and enforcement Education, Media, MoH, the use of biomass fuels and Mines and Energy kerosene for cooking and heating in households. Air pollution Indoor air pollution: pro- Health education and infor- Mines and energy mote the use of low-emission mation (HEI) household devices Emission: regulate transport, Regulation and enforcement Transport, Environmental industrial and power genera- Protection Agency tion emission and take action on pollutant entities Indoor air pollution: promote Regulation and enforcement, EPA, MOH-E, Mines and the construction of well-venti- Energy lated households with sepa- rated kitchen. Public transportation: build Built environment Transport and strengthen affordable public transportation system in urban areas EFDA (Ethiopian Food, and Drugs Control Authority), EBA (Ethiopia Broadcast Authority), MoLSA (Ministry of Labor and Social Affairs), EPA (Ethiopian Environmental Protection Authority), MoH (Min- istry of Health), MoCT (Ministry of Culture and Tourism). Source: Table adapted from The Ethiopia NCDI Commission report 2018 The key steps to mitigate the impacts of NCDs is to have a proper policy framework, strategy, develop capacity and committed leadership at all levels. 43 The following key priority interventions are recommended:

1 — Raise the priority status of NCD within the Health Sector and non-health Sector

1. Raise the priority status of NCD within the Health Sector and non-health Sector

2 — To ensure enforcement of the EFDA Proclamation on Tobacco and alcohol

2. To ensure enforcement of the EFDA Proclamation on Tobacco and alcohol.

3 — Develop and enforce other regulations and directives on NCD risk factors like khat, Trans-fat,

3. Develop and enforce other regulations and directives on NCD risk factors like khat, Trans-fat, Saturated fats, Sugar, Salt.

4 — To review all relevant government policies to ensure consistency with NCD prevention and con

4. To review all relevant government policies to ensure consistency with NCD prevention and con- trol measures in keeping with the concept of ‘Health in All Policies’

5 — Develop and lead a multi-sectoral national strategy to guide the multi-faced national responses

5. Develop and lead a multi-sectoral national strategy to guide the multi-faced national responses to NCDs burden The UN political declaration on NCDs underscores a national multisectoral response lead by the Head of State/Head of Government. In Ethiopia, multisectoral responses led by National Steering Committee (NSC). The NSC will have a chairperson and secretary elected from the NSC member ministries where mainly they will be in charge of leading and oversee the general functions of the NCDs prevention and control response in the country. To facilitate its work the NSC can organize technical team comprised of technical expertise from each member sector. The NSC will be in charge of coordination, monitoring and evaluation of the different agreed upon action points of the multi-sectoral response. Structure and objective of the national multisectoral response are proposed below, while ultimately will be decided in a consensus by the NSC. The national steering committee for NCDs: a. shall comprise of all relevant sectoral ministries, the private sector and development partners, preferably led by the office of the prime minister or an elected chair b. will be responsible in developing one national multisectoral NCD prevention and control strate- gy, with clearly stated objectives, goals, targets and monitoring framework. c. will monitor and evaluate the implementation of the agreed upon interventions and deliverables d. All members of the committee shall sign a memorandum of understanding which binds all to the stated actions and obligations e. As per the guidance of the committee the following duties will be discharged to subcommittees shall be established with specific duties and responsibilities. The following four subcommittees will be stablished:

1 — Promotive/Incentivize subcommittee

1. Promotive/Incentivize subcommittee: i. This subcommittee will work on NCD risk factors that have promotive health behaviors, such as promoting physical activity and consumption of healthy food. The subcommittee shall comprise appropriate sectoral ministries, agencies, private sector and development partners. ii. As per the guidance of national strategic plan the subcommittee will develop detail action plans, implementation strategies, and monitoring framework such that contributes and delivers to the overall goals and targets set above.

2 — Inhibitive/Restrictive subcommittee

2. Inhibitive/Restrictive subcommittee: i. This subcommittee will work on NCD risk factors such as tobacco, alcohol and khat use. ii. The subcommittee shall comprise appropriate sectoral ministries, agencies, private sector and development partners. iii. As per the guidance of national strategic plan the subcommittee will develop detail action plans, implementation strategies, and monitoring framework such that it contributes and delivers to the overall goals and targets set above. 44

3 — Resource Mobilization Subcommittee

3. Resource Mobilization Subcommittee This subcommittee will help mobilize resources for the implementation of the multisectoral action plan.

4 — Monitoring and Evaluation Subcommittee

4. Monitoring and Evaluation Subcommittee This subcommittee with the other subcommittees will develop an M&E framework, targets and indicators for monitoring the progress of the Multisectoral strategic plan. 5.2 PRONG TWO: THE HEALTH SECTOR RESPONSE FOR NCDS The prevention and control of NCDs demands a pragmatic and aggressive response from the health sector. The health sector responses for NCDs are diverse whereas, services are supposed to be integrated for all major NCDs and risk factors. Required Actions for Health Systems Strengthening as the key to the NCDs Response

1 — Improve governance and structure of health administration for NCDs at all levels

1. Improve governance and structure of health administration for NCDs at all levels

2 — Reorient the health system in keeping with the burden of NCDs and risk factors

2. Reorient the health system in keeping with the burden of NCDs and risk factors.

3 — Deploy adequate staff at the ministry of health, regional health authorities and public health

3. Deploy adequate staff at the ministry of health, regional health authorities and public health facilities to support the NCD program

4 — Secure adequate funding to support the NCD programme through the regular government

4. Secure adequate funding to support the NCD programme through the regular government budget and development partners

5 — Strengthen the capacity of health work force to manage and deliver high quality care for

5. Strengthen the capacity of health work force to manage and deliver high quality care for NCDs in both public and private sectors

6 — Improve laboratory and diagnostic services at national, regional and institutional level

6. Improve laboratory and diagnostic services at national, regional and institutional level in order to provide adequate capacity for diagnosis and management of NCDs

7 — Improve pharmacy services and ensure the provision of essential medicines and technologies

7. Improve pharmacy services and ensure the provision of essential medicines and technologies for the diagnosis, treatment and prevention of NCDs at the primary, secondary and tertiary care levels. Whereas, the health sector response for NCDs and risk factors shall be managed and coordinated at different levels of the health system: The Federal Ministry of Health (MOH-E), regional health bureaus, zonal health offices/departments and district health offices will play various roles and responsibilities in the prevention and control of NCDs and their risk factors. All of them have the responsibility to ensure integration of services for NCDs and risk factors into the existing health programs and services. 5.3 ROLES AND RESPONSIBILITIES AND COORDINATION NATIONAL LEVEL The MOH-Ethiopia is responsible for setting standards, developing and revising national guidelines, preparing national action plans including target setting, mobilizing resources necessary for capacity- building, monitoring and evaluation, advocacy and operational research, and for overseeing overall national coordination of health services and programs for NCDs and risk factors. Within the MOH-Ethiopia, different specialized agencies and directorates play key roles in ensuring implementation of the health services for NCDs and risk factors. Coordination of these bodies is crucial for effective and efficient program implementation and improvement of quality of services. Mainstreaming NCD agenda in all health and health related strategies and documents is critical. 45 At the federal level team of experts and key implementers on NCDs and risk factors will be organized into various technical working groups (TWGs) so as to advise the ministry on key policy formulations, provide technical guidance on evidence-based recommendations, and propose possible solutions for implementation challenges. REGIONAL LEVEL RHBs take the technical guidance from the MOH and adopt it per their regional context to implement interventions on the prevention and control NCDs and risk factors. The RHBs therefore, are in charge of planning, coordinating, implementing, monitoring and evaluation of the health sector response for NCDs and risk factors in the respective regions. At the regional level team of experts and key implementers on NCDs and risk factors will be organized into various technical working groups (TWGs) so as to advise the regional health bureau on key evidence-based recommendations and propose solution for implementation challenges. ETHIOPIAN PHARMACEUTICALS SUPPLY AGENCY (EPSA) For a responsive health services to NCDs and risk factor pragmatic supply chain procurement and delivery system is of paramount importance. The MOH-Ethiopia in close collaboration with EPSA will do regular quantifications of necessary commodities for NCDs Program service delivery. EPSA will also coordinate the quantification, procurement and distribution of the necessary commodities by integrating into existing supply chain management system. Reporting and requisition formats will be updated to incorporate commodities needed for NCDs and risk factors. ETHIOPIAN PUBLIC HEALTH INSTITUTE (EPHI) Ensuring, quality laboratory and diagnostic services will play a significant role in the provision of health services for NCDs and risk factors. EPHI in collaboration with the MOH-Ethiopia will be in charge of laboratory services, moreover, EPHI will lead the development and revision of training manual as well as provision of training for laboratory professionals. EPHI with its regional reference laboratories will work to build the diagnostic capacities at facility level. In addition, EPHI will put a mechanism for EQA by integrating into existing quality assurance mechanisms. EPHI in collaboration with MOH-Ethiopia will conduct operational research as needed. ETHIOPIAN FOOD AND DRUG CONTROL AUTHORITY (EFDA) Essential medicines, medical technologies and supplies for NCDs and risk factors are too broad, and are evolving global phenomenon. Accordingly, most drugs, technologies and supplies are new or are not contextualized to Ethiopia. The MOH-Ethiopia in collaboration with EFDA will take the necessary steps so as to enlist and make available these essential drugs, technologies and supplies as per the recommendation of the national guideline and will regulate the safe importation, production, use and disposal of these products in Ethiopia. HEALTH FACILITIES All health facilities will be in charge of delivering screening, diagnostic, treatment and care services for NCDs and risk factors based on the national Essential Health Services Package. In collaboration with Woreda, Zone and Regional health managers the health facilities will determine the type and depth of health services for their catchment populations. 46 HEALTH POSTS/COMMUNITY • Health Extension Workers in collaboration with the Health Development Army will help cre- ate an awareness in the community on prevention and control NCDs and risk factors • Strengthen screening services for NCDs and their risk factors • Help strengthen adherence to care and treatment for NCDs and their risk factors DEVELOPMENT PARTNERS • Provide the necessary technical and financial assistance to MOH-Ethiopia and the RHBs in the national response to NCDs. And participate in strengthening the capacity of government at all level of the health system to effectively implement programs on NCDs and risk factors. • Enhance local and international resource mobilization and build technical and institutional capacities to sustain effective and efficient national response. • Ensure their contributions are aligned with the national and regional responses. PRIVATE HEALTH SECTOR The role of private sector in the prevention and treatment of NCDs and risk factors will be of paramount importance. Private sectors should be proactively involved in the development and implementation of national NCDs and risk factors guidelines and strategic documents. Private health institutions should adhere to the diagnostic and treatment standard as mentioned in the national guidelines while providing their services. In addition, the sector will also play key role in the production, procurement and distribution of essential medicine and technologies for diagnosis and management of NCDs. 47 CHAPTER SIX: COSTING AND FINANCING OF THE NSAP The Ethiopia NCDI Commission in 2018 identified an initial list of highest priority interventions that have been listed in the following table. Treatment of pharyngitis in children to prevent rheumatic heart disease is an example of very cost-effective intervention with cost effectiveness ratios below $100 USD (2012) per DALY averted. Targets were set to 30% effective coverage over the first 2-year period (2020/21-2021/22), with further scale up to 50 % by 2025. Cost by intervention was estimated using One Health Tool Version 4.5 using the software’s default data on cost of drugs and supplies and the default population model for Ethiopia. The One Health Tool also provides default assumptions on the number of interventions needed, personnel time needed, number of drugs needed, etc. Program costs (such as training, supervision, and construction of new facilities) were not included in the first cost estimates. Therefore, the Commission added 10% to the total cost estimated to account for programme costs, mostly for training and supervision. Multi-sectoral interventions that are designed to reduce population level behavioral and environmental risk factors (e.g. tobacco and alcohol use, air pollution, excessive sugar consumption, and others) are presented in Table 5. Many of these were policy interventions, which fall into four broad categories: taxes and subsidies; regulations and related enforcement mechanisms; built environment and informational. Some of these inter-sectoral interventions could be cost saving, and others could potentially generate more resources for health. These interventions will be costed during the development of Multi-sectoral plan. Table 9: Costing of High Priority interventions for diabetes, cardiovascular and chronic respiratory diseases and their cost effectiveness listed by delivery platform, EFY 2013-2017. Investment across implementation years (in C E A Delivery Interventions $1,000 USD) ( U S D platform 2013EFY 2 0 1 4 E F Y 2015EFY 2 0 1 6 E F Y 2017EFY p e r ( 2 0 2 0 - (2021-22) ( 2 0 2 2 - (2023-24) ( 2 0 2 4 - DALY) 21) 23) 2025) Encourage adher- $152 Community 15 17 20 22 25 ence to medications Community based Community opportunistic screen- 644 690 738 788 842 ing for CVD Primary prevention $ 6 7 - Health for those with ab- 177 center 4591 4849 5115 5423 5741 solute risk of CVD >10% Treatment of cas- Health es with established center ischemic heart dis- 320 342 365 389 415 ease (secondary prevention) 48 Treatment of cas- Health es with established center 194 208 222 240 254 CVD (secondary prevention) Treatment of cas- $12 Health es with acute phar- center 35 39 41 45 47 yngitis to prevent rheumatic fever Treatment of cases Health with rheumatic heart center 18 19 22 26 29 disease (with ben- zathine penicillin) Management of Health 21,137 22666 24226 25823 27436 Type 2 DM center Insulin management District of diabetes mellitus 2,301 2362 2434 2513 2603 hospital type 1 Asthma: Low-dose District inhaled beclometh- 16,104 16664 17214 17756 18304 hospital asone + SABA COPD: Exacerba- District tion treatment with 104 116 127 139 153 hospital antibiotics Cardiac surgery for Referral rheumatic heart dis- 1,008 1058 1111 1166 1224 Hospital ease Total cost of all in- 258,539 terventions for CVD, USD 46,471 49,030 51,635 54,330 57,073 (Grand CRD and diabetes Total) USD per capita $0.44 $0.87 $1.31 $1.75 $2.19 CEA: Cost Effectiveness Analysis A total of USD 258,539,000 will be required for the coming 5 years to implement these highest priority interventions (see table 10). Table 10. Summary of Costing by Priority Areas (USD in thousands) Summary Year 1 Year 2 Year 3 Year 4 Year 5 Total Amount in USD National Systems Re- 3,020.620004 3,186.955279 3,356.28056 3,531.45585 3,709.751145 16,805.06 sponse Health Pro- motion 7,481.834002 7,893.833168 8,313.238336 8,747.13351 9,188.756687 41,624.80 49 Medical 24,257.86 25,593.66 26,953.47 28,360.26 29,792.10 134,957.34 Treatment M&E 11,710.688 12,355.55578 13,012.02 13,691.15532 14,382.39108 65,151.81 Total Cost in USD 46,471 49,030 51,635 54,330 57,073 258,539 NB: medical treatment includes capital expenditures for technologies and equipment, running costs of laboratory diagnostics, clinician salary and medicines and treatment enablers. Following the cost of medical treatment (52.3%), the largest priority area is the cost of monitoring and evaluation. This priority area is estimated to be 25.2% of the total program cost. This area is followed by the estimated cost of health promotion, at 16.1% of the total program cost. National level NCD response is estimated to consume 6.1% of the estimated budget. Funding for the NSAP will be mobilized from national and international sources. Ethiopia is implementing a community-based health insurance (CBHI) system for the informal sector that covers the health expenditures required for diagnosis and treatment of major NCDs. Social Health Insurance is expected to implemented soon for the formal sector. The MOH-Ethiopia and RHBs will adopt innovative funding and resource mobilization mechanisms in order to ensure adequate availability of the required finance. 50 ANNEXES

ANNEX 1: IMPLEMENTATION LOG FRAME OF THE NSAP FOR NCDS — IMPLEMENTATION LOG FRAME OF THE NSAP FOR NCDS

ANNEX 1: IMPLEMENTATION LOG FRAME OF THE NSAP FOR NCDS PRIORITY AREA 1: STRENGTHEN THE NATIONAL RESPONSE THROUGH POLICY, GOVERNANCE, LEADERSHIP AND COORDINATION. Activities (Indicator) Time frame Responsible Means of Verifica- body tion (Data Source) Objective: To strengthen the national capacity and country-wide ownership of NCD interventions through influencing policy formulation, leadership, governance, multi-sectoral action and partner- ships. Strategic Initiative 1: Strengthen National health policy on NCDs and their risk factors. Ensure Specific policies NCD and Risk fac- 2019-2020 MOH-E, PM Revised Policy and legislations are de- tors are included in Office veloped to address the the Health Policy rising burden of NCDs and risk factors. Design policies and leg- Policies on NCDs 2019-2020 MOH-E, PM Policies, directives, islations to prioritize Office, HOPR proclamations medical intervention for people affected by NCDs Foster public participa- Number of indi- 2020-2025 MOH-E, RHBs Policies, directives, tion in designing and viduals engaged proclamations implementation of NCD in policy, strategy prevention and care and guideline de- policies. velopment Strategic Initiative 2: Establish/Strengthen NCD governance at all levels Strengthen NCD Coordi- NCD Case team 2022 MOH-E and Establishing document nation and Governance promoted to NCD RHBs at Federal and RHB lev- Directorate in els by expanding struc- MOH-Ethiopia and tures and budgets RHBs Mainstreaming of Non- All Health sec- 2020-2025 MOH-E and Strategic Documents communicable diseases tor strategies and its agencies and activities review prevention and control documents and (DPCD, MCH, in all health sector strat- services give due PH and HEP egies and activities, and attention to NCDs D i r e c t o r a t e, enhanced coordination and their risk fac- Medical Ser- of services tors vices General Directorate, PR and Communi- cation etc) 51 Strengthening and/or Number of Staff at 2020-2025 MOH-E, RHB, Activity report establishing NCD co- all levels working ZHDS, WoHO ordinating structures on NCDs at zonal, woreda and health facilities levels. Set up national, Region- Federal, Regional, 2020-2025 MOH-E, RHBs, Activity reports al and Zonal/Woreda Zonal and Woreda ZHDs and NCDs Technical Working Level TWGs estab- WoHO Groups and Task forces lished and function- al. Mobilize adequate re- Adequate Budget 2020-2025 MOH-E, RHB, Activity report sources for NCD pro- allocated on NCDs ZHDs, WoHO grams at all levels. and Risk factors Strategic Initiative 3: Establish Multisectoral Coordination Mechanism for prevention and control of NCDs and Risk factors at all levels of the government. Ensure Integration of Steering committee 2019-2020 PM Office, Steering committee prevention and control established MOH-E, Sec- minutes of NCDs and their risk toral Ministries factors in the multisec- toral Woreda Transfor- mation Platform. Coordinate develop- Multisectoral Ac- 2020/21 MOH-E, Sec- Multisectoral re- ment of the NCD Multi- tion plan devel- tors sponse action plan sectoral Strategic Action oped Plan (MSAP) Monitor implementation Policies and regu- 2020-2025 MOH-Ethiopia Reports of actions of the Joint Multisectoral lations enforced and Other sec- Strategic Action Plan toral Ministries (MSAP) Mobilize financial and Resource mobilized 2020-2025 MOH-E, NCD Activity reports technical resources for case team, prevention and control NTWG, devel- of NCDs opment part- ners 52 PRIORITY AREA 2: INTENSIFY HEALTH PROMOTION AND DISEASE PREVENTION TARGETING BEHAVIORAL, INFECTIOUS AND ENVIRONMENTAL NCD RISK FACTORS. Activities (Indicator) Time frame R e s p o n s i b l e MOV (Data body Source) Objective: Promote healthy lifestyles and reduce exposure to modifiable risk factors for non- communicable diseases. Strategic Initiative 1: Increase public awareness on NCDs and their risk factors Develop NCD communica- Communication strat- 2020 MOH-E, inter- Activity reports, tion strategy and health egy developed; sectoral task d e v e l o p e d education modules on health education force strategic docu- NCDs and their risk fac- module developed ment/s tors Conduct Advocacy on Number of health 2020-2025 MOH-E, RHBs, Activity report NCDs and their risk factors education, awareness ZHDs, WoHO to increase the awareness raising and advocacy and commitment of policy campaigns for policy makers, health managers makers and donors and health care workers. Integrate NCD and risk Number of health 2020 - 2025 MOH-E, RH- Activity reports, factors messages into the education at HFs B,ZHD, WoHO, number and routine health education HFs type of health program of health facili- education ses- ties sions Conduct Awareness rais- Number of health 2020 - 2025 MOH-E, RHB, Activity reports, ing programs on NCDs education, awareness ZHDs, WoHO number and and risk factors in work raising campaigns in type of health places. Work places education ses- sions Integrate Communication Type and number of 2020 - 2025 MOH-E, inter- Activity reports, Packages on NCDs and health promotion ac- sectoral task number and their risk factors in School tivities force type of health Health and Nutrition Pro- education ses- gram and the Health ex- sions tension programs. Strategic Initiative 2: Promoting Healthy Diet Develop national dietary National dietary 2020 MOH-E Guideline, Ac- guidelines to promote guideline developed tivity report healthy dietary habits. Implementing public Number of pub- 2020-2025 MOH-E, RH- Number of peo- awareness activities on lic awareness cam- B,ZHD, WoHO ple reached healthy diets during the paigns conducted on through the life course healthy diet campaigns 53 Collaborate with the na- Number of TWG 2020-2025 M O H - E , R H - Activity Report tional/regional nutrition meetings attended B,ZHD, WOHO council and task forces to address the dietary risk factors for NCDs. Liaise with the Ministry Implementation of 2020-2025 MOH-E, MOE Activity Reports of Education to introduce promotion of Healthy healthy diet promotion diet in school health in school curriculums and and nutrition pro- awareness creation activ- gram ities. Develop and implement Directives, procla- 2020-2025 MOH-E, EFDA Directives and policies and legislations mations on saturated PMO, HOPR, proclamations to promote healthy diet fat, trans fat, salt and (Reduction of Salt, Sugar, sugar Trans-fat; encourage Fruit and Vegetable consump- tion) Strategic Initiative 3: Promoting Physical Activity Promote mass sport in- Sporting events per 2020 - 2025 MOH-E, In- Activity reports cluding competitive sport annum ter-ministerial events in collaboration taskforce with stakeholders. Creating public aware- Number of pub- 2020-2025 MOH-E, MOCT, Activity reports ness on the health bene- lic awareness cam- MOWCYA, fits of physical activity in paigns on physical Sports Commis- prevention and control of activity sion NCDs Liaise with the Ministry of Sports policy en- 2022 MOH-E, MOW- Sports policy Youth and Sports to de- dorsed by HOPR CYA, Sports velop/adopt a strategic Commission implementation plan to enforce the national sport policy. Liaise with the Ministry of School Health and 2020-2025 MOH-E,MOE Activity Report Education for the promo- Nutrition Program tion of all-inclusive physi- cal activity in schools. Engage the Ministry of Physical activity 2020-2025 MOH-E,MOHU- Activity report Housing and Urban Devel- friendly environment D,MOT opment and the Ministry created of Transport to create an enabling environment for physical activity including playgrounds, walkways, and cycling lanes. 54 Promoting physical ac- People engaged 2020 - 2025 MOH-E, In- Activity report tivity in the community, in physical activity, ter-ministerial private and public insti- work place physical taskforce tutions, workplaces and activity facilities health facilities. Strengthen the Car free number of monthly 2020-2025 MOH-E, Sports Activity report roads days initiative im- car free roads days Commission, plementation in all urban events conducted in MOT, Police areas. all cities and towns Strategic Initiative 4: Reduce Harmful Use of Alcohol Implement and enforce Policy/directive de- 2020-2025 MOH-E, In- Activity report EFDA Proclamation veloped, implement- ter-ministerial 1112/2019 on prohibi- ed taskforce tion of advertising, pro- motion and sponsorship of alcoholic beverages, and mandatory labelling of alcoholic beverages at the National and Region- al levels. Creating public aware- Type and number of 2020 - 2025 MOH-E, inter- Activity reports ness on the health, securi- awareness sessions sectoral task ty and economic harms of force alcohol use. Liaise with Ministry of Fi- Alcohol regulation 2020-2025 MOFEC, MOTI, Activity report nance, Ministry of trade activities conducted. MOH-E and industry and other relevant sectors to regu- late alcohol production, sale, use and taxation. Strategic Initiative 5: Tobacco Use Reduction Enforce the implementa- FCTC implemented, 2020-2025 MOH-E, EFDA Activity reports tion of articles on tobacco Tobacco proclama- control in the EFDA proc- tion endorsed lamation 1112/2019 in accordance with the WHO framework conven- tion for the control of to- bacco (FCTC). Promote gradual substitu- Number of tobacco 2020-2025 Ministry of Agri- Activity report tion of tobacco farms with farms replaced with culture, Ministry other income generating alternative crops of Trade and In- agricultural products. dustry Raising public awareness Type and number of 2020-2025 MOH-E, inter- Activity reports, on the health, societal and awareness sessions sectoral task number and economic harms related force type of health to tobacco use. education ses- sions Strategic Initiative 6: Reduction of Khat Use 55 Liaise with national Mul- Legislation/directive 2020 I n t e r s e c t o r a l Activity reports tisectoral Committee to developed and im- taskforce/EFDA develop legislations and plemented regulation on domestic production, sale and use of khat. Promote gradual substi- Legislation/directive 2020-2025 I n t e r s e c t o r a l I n t e r s e c t o r a l tution of khat farms with developed and im- taskforce/EFDA NCD Risks As- other income generating plemented sessment Survey agricultural products. report Raise public awareness on Type and number of 2020 - 2025 NCD case team, Activity reports, the dangers of khat con- awareness sessions i n t e r s e c t o r a l number and sumption and its related task force type of health risks. education ses- sions Liaise with the Ministry of Legislation/directive 2020-25 I n t e r s e c t o r a l School Assess- Education and other sec- developed and im- taskforce/EFDA ment Survey re- tors for developing ac- plemented ports cess restrictive measures aimed at children and young people including in schools and higher educa- tion institutions. Strategic Initiative 7: Promote interventions on the reduction of exposure to environmental and occupational risk factors. Strengthening the im- ü Number of legis- 2020-2025 MOH-E, MoL- Activity Report plementation of the le- lations and policy SA, Ministry gal frameworks, policies, areas developed of Trade and standards and guidelines Industry, Min- to reduce exposure to en- ü Number of istry of Trans- vironmental and occupa- guidelines docu- port, Ministry of tional risk factors in col- ments developed Mines and Ener- laboration with relevant gy, Environmen- sectors tal Protection Agency Initiate and promote pro- • Number of work 2020-2025 MOH-E, MOL- Activity Reports grams aimed at protect- place programs SA, EPA, Inter- ing and reducing expo- • Number of Public sectoral task sure to environmental and programs force occupational risk factors • Number of home for NCDs at the work- programs place, public and home environment. 56 Create public awareness • Number of 2020-2025 MOH-E, Inter- Activity reports on prevention of expo- awareness cam- sectoral task sure to environmental and paigns carried force occupational risk factors out on NCDs • Number of IEC materials devel- oped and dis- seminated • Number of sensi- tization meetings held Strategic Initiative 8: Prevention of Rheumatic Heart Disease Primordial Prevention Advocacy sessions 2020-2025 MOH-E, RHB, School health activities: Reduce over- conducted on over- MOE, EPHI survey report crowding in congregated crowding reduction settings, in schools and at and personal hy- homes and improve per- giene sonal hygiene. Primary prevention of Number of children 2020-2025 MOH-E, RHB, Activity report RHD: is treatment of bac- and young adults ZHDs, WoHO, terial pharyngitis for pre- treated for bacteri- HFs, Ministry of vention of acute sequalae al tonsillopharyngitis education of group A streptococcal with appropriate an- throat infections tibiotics for the right duration Secondary prevention of Number and type 2020 - 2025 M O H - E , R H - Activity report RHD: the continuous ad- of guidelines/pro- B,ZHDS, WOHO ministration of specific tocols and training/ antibiotics to patients with teaching materials a previous attack of rheu- developed, number matic fever, or well-doc- of facilities providing umented rheumatic heart services disease (RHD registry based). 57 PRIORITY AREAS 3: COMPREHENSIVE AND INTEGRATED CLINICAL INTERVENTIONS FOR NCDs AND THEIR RISK FACTORS Activities (Indicator) Time frame Re s p o n s i b l e MOV (Data body Source) Objective: To expand access to comprehensive, high quality and integrated services for the commu- nity on NCDs and their risk factors. Strategic Initiative 1: Strengthening Health Service Delivery Define essential package Essential NCD Ser- 2020-2020 MOH-E, EFDA Essential pack- of care on NCDs and risk vices packages de- age document factors for each level of veloped the health care system. Reorient and reorganize Number and pro- 2020-2025 MOH-E, RHB, SARA Survey the health services in ac- portion of health ZHDs, WoHO cordance with the NCDs facilities ready to and risk factors care deliver minimum package. package of NCD services Decentralize and Inte- Number and pro- 2020-2025 MOH-E, RHB, SARA Survey grate NCDs and risk fac- portion of primary ZHDs, WoHO tors services into the pri- health facilities mary health care through task shifting, task sharing and improved referral networks. Empower patients and Number of patients 2020-2025 MOH-E, RHB, Activity Report families in the care of and families trained ZHDs, WoHO patients with NCDs. to deliver home and self-care for NCDs Strategic Initiative 2: Develop the Human Resource for NCDs Service Delivery Ensure the assignment Multidisciplinary 2020 – 2025 M O H - E , Activity report of appropriate mix of NCD Care teams RHBs,ZHDs, healthcare workers as established Woredas per the minimum stan- dard. Ensure NCDs and their Curricula on NCDs 2020-2025 MOH-E, MOSHE Curricula docu- risk factors are given due incorporated ment attention in all health-re- lated preservice training curricula. Develop NCDs and risk Number and type 2020 – 2025 MOH-E, RHBs, Activity report factor guidelines, train- of guidelines train- development ing materials, care and ing materials and partners, NTWG treatment protocols for protocols devel- health care providers oped and train health care Number of HCWs workers. trained 58 Strengthen health facili- Number of HCWs 2020 – 2025 MOH-E, RHBs, Activity report ty level Mentorship Pro- supported through ZHDs, Woredas grams on NCDs and risk mentoring factors. Develop NCDs Program Number of NCD 2020-2025 MOH-E, RHBs, Activity report Management training Program manag- ZHDs, Woredas materials and train NCD ers trained on NCD Program Managers at Program manage- all levels. ment Ensure health facility Number of QI ini- 2020-2025 MOH-E, RHBs, Activity report level quality improve- tiatives on NCD ser- ZHDs, Woredas ment system incorporates vices NCDs services. Strategic Initiative 3: Improve Infrastructure, Diagnostics, Medical Supplies and Technologies. Define the components I n f r a s t r u c t u r e , 2020-2020 MOH-E, RHBs, Activity report of the service standards screening tools, di- EFDA, EPSA, EPHI for delivery of NCDs agnostics, essential services in the Ethiopian medicines, medical setup. equipment, essen- tial medicines, labo- ratory supplies and reagents Ensure health facilities Proportion of HFs 2020 – 2025 MOH-E, RHBs, Activity report fulfill minimum standards fulfilling optimal ZHDs, Woredas to deliver NCDs and standards for care risk factors prevention, screening, diagnosis, treatment and care ser- vices. Ensure uninterrupted Number of HFs with 2020 – 2025 MOH-E, RHBs, Activity report, supply of essential medi- essential medicines ZHDs, Woredas Surveys cines and laboratory re- and laboratory re- agents for diagnosis and agents management of NCDs and risk factors Ensure continuous and Number of HFs with 2020 – 2025 MOH-E, RHBs, Activity report, sustainable availability essential medical ZHDs,Woredas Surveys of essential medical and instruments and lab lab equipment for diag- equipment nosis and management of NCDs and risk factors Strengthen laboratory Number and type 2020 – 2025 MOH-E, RHBs, Activity report networks and Lab Quali- of lab quality as- ZHDs,Woredas ty Assurance system. surance reports Strengthen the health Health insurance 2020-2025 MOH-E, MOLSA Activity Report, insurance system to in- coverage crease population ser- vice utilization 59 PRIORITY AREA 4: RESEARCH, SURVEILLANCE, MONITORING AND EVALUATION Activities (Indicator) Time Responsible MOV (Data frame body Source) OBJECTIVE: to improve the use data on NCDs and risk factors for evidence-based decision making. Strategic Initiative 1: Integration of NCDs surveillance and monitoring system into the Nation- al Health Management Information system Develop and Integrate Key Indicators 2020-2025 MOH-Ethiopia NCD NCD Indicators Relevant NCD indicators included in HMIS Team, PPM&ED in the National HMIS in- cluding DHIS2 and Oth- er electronic platforms Develop monitoring and Number of 2020-2025 MOH-E/PPD NCD registry evaluation tools for NCD modified NCD services registers Integrate NCDs service Integrated sup- 2019-2025 MOH-E/PPD Activities report indicators in the Nation- portive supervi- al Joint Supportive Su- sion pervision program Capacity building on Number trained 2020-2025 MOH-E/PPD Activities report NCD services M&E on NCD M&E for program mangers health care workers and Health information tech- nicians in data captur- ing, analysis and use Include NCD Indicators Number Key 2020-2025 MOH-E/PPD Activities report in the Health Center and p e r f o r m a n c e Hospital KPIs Indicators on NCDs included Strategic Initiative 2: Establish/Strengthen Disease Registries, Research and Surveillance Assess the level of adult Vital registra- 2020-2025 VERA/CSA Annual Report and child mortality tion in all Kebe- through the national vi- les/Districts in tal registration system Ethiopia Support verbal autopsy verbal autopsy 2020-2025 MOH-E/MOSHE/ Activities report activities in sentinel sites conducted Sentinel sites Establish Disease spe- Developed reg- 2020-2025 MOH-E/RHB HMIS cific registries for un- ister for CVD, derstanding of national DM, RHD, CRD, and regional burden CKD. and trends. Conduct WHO Stepwise NCD Risk factors 2020, 2025 M O H - E / E P H I / Activities report Survey on NCD risk fac- STEPS survey WHO tors (2020 and 2025) 60 Set priority research Priority research 2020-2025 MOH-E, EPHI, AHRI Number of research agendas on NCDs, risk agendas identi- publications factors and interventions fied; researches and support conduct of conducted research Strengthen SARA sur- SARA Ade- 2020,2024 MOH-E, EPHI, SARA Survey vey to incorporate ad- quately ad- WHO equate NCDs and risk dresses major factors health facility NCD indictors service and readiness indicators. 61

ANNEX 2:

ANNEX 2: PRIORITIZED NCD SERVICE ACTIVITIES AT DIFFERENT LEVELS OF THE HEALTH SYSTEM Core Services Main Communities and Health Centers/ General Hospi- Tertiary Hospi- NCDs HEP Primary Hospi- tals tals/ Specialized tals Centers - Awareness about - Health promo- - Diagnosis and - C o m p l i c a t i o n s streptococcal infec- tion and aware- M a n a g e m e n t screening for RHD tion ness of streptococcal - Intensified RHD - Promotion of person- - Diagnosis and sore throat treatment al and environmental M a n a g e m e n t - Second prophy- - Clinical review hygiene and crowd- of streptococcal laxis with BPG Rheumatic ing sore throat of RF and RHD heart dis- - Information on the im- - Secondary pro- - Patient assess- ease portance of antibiotic phylaxis with ment for RHD treatment and pro- BPG of RF and and manage- phylaxis RHD ment - Screening for - ECG, ECHO RHD and refer- ral - Health promotion on - Health promo- - Patient assess- - Clinical review salt reduction, ex- tion on salt re- ment and man- - Assessment of ercise and fruit and duction, exercise agement includ- complex cases, in- vegetable consump- and fruit and ing inpatient tensified treatment tion vegetable con- managements - Complication - Awareness on screen- sumption - Screening of screening, treat- ing and early detec- - Screening and c o m p l i c a t i o n s ment and monitor- tion diagnosis and manage- ing - Population screen- - Patient assess- ment - Down referral of ing for raised blood ment and man- - Personal plan stabilized cases Hyperten- pressure agement targets for BP, sion - Non-medical inter- - Personal plan weight, exercise, ventions- lifestyle targets for BP, smoking cessa- (tobacco cessation, weight, exercise, tion physical activity, smoking cessa- - Specialist refer- healthy diet, alcohol, tion ral of complex khat) - Screening for cases complications - Pediatric ser- - Referral of com- vices plex cases - Pregnancy ser- vices 62 - Awareness raising on - Life style modi- - Patient informa- - Clinical review risk factors of Heart fication (tobac- tion - Assessment of attack, CKD and co cessation, - Assessment of complex cases stroke physical activity, cases including - Intensified treat- Prevention - Prevention measures- healthy diet, salt those referred ment of heart non-medical interven- reduction, khat, from health cen- - C o m p l i c a t i o n attack, and tions alcohol) ters & risk strati- screening, treat- stroke - Treatment support - Cardiovascular fication ment and monitor- risk assessment & - Drug therapy, ing risk stratification follow up, moni- - S u p p o r t toring s e l f - m a n a g e - - ECG, ECHO ment, education - Specialist refer- - Drug therapy ral of complex, and follow up difficult cases of – BP, glucose, lipids - Regular & pe- riodic screening of complications, referral Prevention - Awareness raising on - Life style modi- - Patient informa- - Clinical review of chronic risk factors of CKD fication (tobac- tion - Assessment for kidney dis- - Prevention measures- co cessation, - Assessment of complications ease (CKD) non-medical interven- physical activity, cases including - Intensified treat- tions healthy diet, salt those referred ment - Treatment support reduction, khat, from health cen- - C o m p l i c a t i o n alcohol) ters & risk strati- screening, treat- - S u p p o r t fication ment and monitor- s e l f - m a n a g e - - Drug therapy, ing ment, education follow up, mon- - Dialysis, Renal - Drug therapy itoring of renal transplantation re- and follow up of function and ferral – BP, glucose, lip- complications ids, urine protein - ECG, ECHO - Regular & pe- - Dialysis and oth- riodic screening er supportive of complications, therapy referral 63 Diabetes - Information on risk - Health promo- - Patient assess- - Clinical review factors tion as the pre- ment and man- - Assessment of - Awareness on screen- ceding agement includ- complex cases, in- ing and early detec- - Screening and ing inpatient tensified treatment tion diagnosis managements - Insulin stabilization - Population screening - Insulin or drug - Targeted com- - C o m p l i c a t i o n for raised blood glu- therapy & in- p l i c a t i o n s screening, treat- cose tensive glucose screening & ment and monitor- - Non-medical inter- management management ing ventions- lifestyle - Personal plan - Personal plan - Down referral of (tobacco cessation, targets for targets for BP, stabilized cases physical activity, weight, BP, ex- weight, exercise, healthy diet, alcohol, ercise, smoking smoking cessa- khat) cessation tion - Importance of weight - Targeted com- - Specialist refer- management plications (eye, ral of complex, foot, nerve etc) difficult cases screening man- - Pediatric ser- agement and/or vices referral - Pregnancy ser- - Referral of com- vices plex, difficult cases - Information on risk - Health promo- - Patient informa- - Clinical review factors (biofuels, tion as the pre- tion, assessment - Spirometry smoking) ceding - Patient manage- - Assessment of - Life skill develop- - Screening and ment including complex cases, in- Asthma & ment to build and diagnosis of inpatient man- tensified treatment COPD use smokeless house- asthma and agements - Down referral of hold cooking facilities COPD - Specialist refer- stabilized cases Awareness on screen- - Use of Peak flow ral of complex, ing and early detec- meter difficult cases tion - Inhaler and drug - Pediatric ser- - Non-medical inter- therapy vices ventions- lifestyle (to- - Referral of com- - Pregnancy ser- bacco cessation) plex, difficult vices cases 64

ANNEX 3:

ANNEX 3: WHO NON-COMMUNICABLE DISEASE “BEST BUYS” 2 Total risk is defined as the probability of an individual experiencing a cardiovascular disease event (for example, myocardial infarction or stroke) over a given period of time, for example 10 years. 65

ANNEX 4:

ANNEX 4: GLOBAL VOLUNTARY NCD TARGETS BY 2025 66 REFERENCES 1. World Population Prospects – 2017 revision. New York: United Nations Population Division; 2017. (https://esa.un.org/unpd/wpp/, accessed 17 August 2018). 2. Oxford Poverty and Human Development Initiative (2016). “Ethiopia Country Briefing”, Multidimensional Poverty Index Data Bank. OPHI, University of Oxford. Available @ https://ophi. org.uk/multidimensional-poverty-index/mpi-country-briefings/ 3. World Bank. https://www.worldbank.org/en/country/ethiopia/overview 4. UNESCO. http://uis.unesco.org/en/country/et 5. Federal Democratic Republic of Ethiopia Ministry of Health. Ethiopia’s sixth National Health Accounts, 2013/2014. Addis Ababa, Ethiopia: Federal Ministry of Health, 2017. Accessed online at https://www.hfgproject.org/ethiopia-health-accounts-201314/ 6. Central Statistical Agency (CSA) [Ethiopia] and ICF. 2016. Ethiopia Demographic and Health Survey 2016: Key Indicators Report. Addis Ababa, Ethiopia, and Rockville, Maryland, USA. CSA and ICF. 7. Federal Democratic Republic of Ethiopia Ministry of Health. Health and health related indicators 2013/2014. 8. National Planning Commission and UN-Ethiopia. Assessment of Ethiopia’s Progress towards the Millennium Development Goals. 2015 9. Transitional Government of Ethiopia. Health Policy of the Transitional government of Ethiopia. Addis Ababa, Ethiopia. 1993 10. Federal Democratic Republic of Ethiopia, Ministry of health. Health Sector Development Program IV (2010/2011-2014/2015). 2010. 11. Federal Democratic Republic of Ethiopia, Ministry of Health. Health sector transformation plan, 2015/16–2019/20. Addis Ababa, Ethiopia. 2015. 12. Institute for Health Metrics and Evaluation (IHME). GBD Compare Data Visualization. Seattle, WA: IHME, University of Washington, 2016. Available from http:// vizhub.healthdata.org/gbd- compare. (Accessed June 13, 2018) 13. Ethiopian Public Health Institute (Federal Ministry of Health) and World Health Organization. 2016. Ethiopia STEPS report on risk factors for non-communicable diseases and prevalence of selected NCDs. Addis Ababa, Ethiopia. Ethiopian Public Health Institute. 14. Assessment of khat (Catha edulis Forsk). Accessed online at http://www.who.int/medicines/areas/ quality_safety/4.4KhatCritReview.pdf on June 19, 2018. 15. Hassan NAG, Gunaid AA, Murray-Lyon IM. Khat (Catha edulis): health aspects of khat chewing. East. Mediterr. Heal. J. 2007; 13(3):706–718. 16. Tefera W, Asfaw A, Gilliland F, et al. Indoor and outdoor air Pollution related health problem in Ethiopia: Review of related Literature. Ethiop J Health Dev 2016; 30(1): 5–16. 17. Central Statistics Agency (CSA). 2012. Ethiopian Welfare Monitoring Survey 2011 report. Addis Ababa, Ethiopia. CSA. 18. GBD 2015 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990– 2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388: 1659–724. 67 19. Central Statistical Agency (CSA) [Ethiopia] and ICF. 2016. Ethiopia Demographic and Health Survey 2016: Key Indicators Report. Addis Ababa, Ethiopia, and Rockville, Maryland, USA. CSA and ICF. 20. Melaku Z, Alemayehu M, Oli K, Tizazu G. Pattern of admissions to the medical intensive care unit of Addis Ababa University Teaching Hospital. Ethiop Med J 2006;44(1):33-42. 21. Mamo Y, Oli K. Trends of acute myocardial infarction admissions over a decade, Tikur Anbessa Hospital. Ethiop Med J 2001;39(3):193-202. 22. Zenebe G, Alemayeu M, Asmara J. Characteristics and outcomes of Stroke at Tikur Anbessa Teaching Hospital, Ethiopia. Ethiopian Med J 2005; 43(4): 251-8. 23. Engel ME, Haileamlak A, Zuhlke L, Lemmer CE, Nkepu S, et al. Prevalence of rheumatic heart disease in 4720 asymptomatic scholars from South Africa and Ethiopia. Heart 2015; 0: 1-6. Doi:10.1136/heartjnl-2015-307444. 24. Yadeta D, Hailu A, Haileamlak A, Gedlu E, Guteta S, et al. Prevalence of rheumatic heart disease among school children in Ethiopia: A multisite echocardiographic-based screening. International Journal of Cardiology 2016; 221: 260-263. http://dx.doi.org/10.1016/j.ijcard.2016.06.232. 25. Gemechu T, Mahmoud H, Parry EH, Phillips D and Jacob MH. Community-based prevalence study of rheumatic heart disease in rural Ethiopia. European Journal of Preventive Cardiology 2017; 0(00): 1-7. doi: 10.1177/2047487316687104. 26. Yadeta D, Guteta S, Alemayehu B, et al. Spectrum of cardiovascular diseases in six main referral hospitals of Ethiopia. Heart Asia 2017; 9(2): e010829. 27. Gunther G, Asmera J and Parry E. Death from rheumatic heart disease in rural Ethiopia. The Lancet 2006; 367. www.thelancet.com. 28. Abebe N, Kebede T, and Addise D. Diabetes in Ethiopia 2000-2016 – prevalence and related acute and chronic complications; a systematic review. Africa Journal of Diabetes Medicine 2017; 25(2): 7-12. 29. Memirie ST, Habtemariam MK, Asefa M, et al. Estimates of cancer incidence in Ethiopia in 2015 using population-based registry data. Journal of Global Oncology 2018; doi10.1200/JGO.17.00175. 30. Negash A, Alem A, Kebede D, Deyessa N, Shibre T, et al. Prevalence and clinical characteristics of bipolar I disorder in Butajira, Ethiopia: A community-based study. Journal of Affective Disorders. 2005; 87: 193-201. 31. Kebede D, Alem A, Shibre T, Negash A, Fekadu A, et al. Onset and clinical course of schizophrenia in Butajira -Ethiopia. Social Psychiatry and Psychiatric Epidemiology. 2003; 38(11): 625-631. 32. Fekadu A, Medhin G, Kebede D, Alem A, Cleare AJ, et al. Excess mortality in severe mental illness: 10 years population-based cohort study in rural Ethiopia. The British Journal of Psychiatry. 2015; 206: 289-296. Doi:10.1192/bjp.bp.114.149112. 33. Tekle-Haimanot R, Forsgren L and Ekstedt J. Incidence of Epilepsy in rural central Ethiopia. Epilepsia. 1997; 38(5): 541-546. 34. The Global Asthma Report 2014. Auckland, New Zealand: Global Asthma Network, 2014 35. To T, Stanojevic S, Moores G, Gershon AS, Bateman ED, et al. Global asthma prevalence in adults: findings from the cross-sectional world health survey. BMC Public Health 2012; 12:204. http:// www.biomedcentral.com/1471-2458/12/204 36. Bayisa T, Parkeh M, Bekele A, Schluger N, Oumer F, et al. Profile and risk factors of patients with obstructive airway diseases at Tikur Anbessa Specialized Hospital chest clinic, Addis Ababa, 68 Ethiopia. Ethiop Med J 2017; 55(2):97-102. 37. Berhane Y, Worku A, Bejiga A, et al. Prevalence and causes of blindness and low vision in Ethiopia. Ethiop J Health Dev 2007;21(3):204-210. 38. Rose J, Weiser TG, Hider P, et al. Estimated need for surgery worldwide based on prevalence of diseases: a modelling strategy for the WHO Global Health Estimate. Lancet Glob Health 2015;3 (S2): S13–20. 39. Ethiopian Public Health Institute, Federal Ministry of Health, ICF International. 2014. Ethiopia Service Provision Assessment Plus-Census 2014. Addis Ababa, Ethiopia. 40. Ethiopian Public Health Institute, Federal Ministry of Health, World Health Organization. 2018. Ethiopia Services Availability and Readiness Assessment (SARA) Survey 2018; Summary Report. Addis Ababa, Ethiopia. 41. Federal Democratic Republic of Ethiopia Ministry of Health. August 2017. Ethiopian Health Accounts Household Health Service Utilization and Expenditure Survey 2015/2016, Addis Ababa, Ethiopia. 42. Jamison DT, Alwan A, Mock CN, et al. Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition. Lancet 2017. 43. World Health Organization. Making fair choices on the path to universal health coverage. Geneva: World Health Organization; 2014. 44. Norheim OF, Jha P, Admasu K, et al. Avoiding 40% of the premature deaths in each country, 2010- 30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health. Lancet 2015; 385:239-252. 45. Federal Ministry of Health of Ethiopia. 2005. Ethiopia essential health service package. Addis Ababa, Ethiopia. 46. Federal Ministry of Health. Envisioning Ethiopia’s path towards universal health coverage through strengthening primary health care. Draft-2. Addis Ababa: Federal Ministry of Health; 2015. 47. United Nations General Assembly Resolution A/RES/66/2. Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. New York: United Nations; 2012. (https://digitallibrary.un.org/record/720106/ files/A_ RES_66_2-EN.pdf, accessed 16 August 2018). 48. Global action plan for the prevention and control of noncommunicable diseases 2013–2020. Geneva: World Health Organization; 2013. (http://www.who.int/nmh/events/ncd_action_plan/ en/, accessed 16 August 2018). 49. Transforming our world: the 2030 Agenda for Sustainable Development. New York: United Nations; 2015. (https://sustainabledevelopment. un.org/post2015/transformingourworld, accessed 16 August 2018). 50. Global status report on alcohol and health 2018. Geneva: World Health Organization; 2018. 51. Federal Ministry of Health of Ethiopia. Addressing the Impact of Noncommunicable Diseases and Injuries in Ethiopia. The Ethiopia NCDI Commission Report Summary. November 2018. 52. WHO and UNDP. The Case for Investment for NCDs Prevention and Control in Ethiopia. 2018. 69

National Strategic Plan for the Prevention and Control of Major Non-Communicable Diseases 2013-2017 EFY (2020/21-2024/25)

عن هذا القانون

أين تقرؤه

النص