The National Integrated Policy for Non-Communicable Diseases Prevention and Control in The Gambia 2012-2016

1. Reduce the major risk factors (tobacco use, alcohol consumption, physical inactivity and unhealthy diet)

2. Strengthen capacity of health personnel, institutions and other stakeholders for the identification of the major risk factors and to use comprehensive approach for health promotion and primary prevention.

3. Strengthen capacity of health system to prevent, diagnose and manage NCDs through standard guidelines and protocol appropriate to various levels of health care.

4. Develop a national surveillance system for NCDs and their risk factors Guiding principles The principles and values that guide the formulation and implementation of the National Integrated NCDs Policy include:

1. Using the policy as the main frame work for the planning and implementation of all NCD intervention programmes;

2. Protection of the rights to health;

3. Accountability, Equity and social justice;

4. Access to affordable and sustainable NCD prevention and control services;

5. Using evidence based information for planning, implementation monitoring and evaluation of programmes;

6. Cultural appropriateness of prevention and control programmes;

7. Community and family empowerment and participation;

8. Enhancing harmonisation of the NCD Policy with other national and sectoral policies

9. Promote partnership for the prevention, management and control of NCDs;

10. Population-wide health promotion and disease prevention activities.

11. Secure resources using a budget line to support program implementation Policy development process In response to recommendations from WHO and West African Health Organization (WAHO), in Ouagadougou in July 2009, the MoH&SW initiated the development of the National NCD policy in 2010.A joint delegation of WHO and WAHO Officials facilitated a sub-regional meeting in Banjul (in March 2010) to guide the five English Speaking West African countries in NCD Policy development. A draft policy outline was presented at this meeting and the policy development process was accelerated. The first draft was completed in June 2010 and reviewed internally by a multi-sectoral group in August, 2011. Working together to reduce the burden of NCDs in The Gambia 11 The Gambia NCD Policy 2012-2016 The Scope of the NCD Policy and Strategy Even though The Gambia has made significant improvements in maternal and child health indicators over the years, communicable diseases, such as malaria, tuberculosis, HIV/AIDS, are still some of the leading causes of morbidity and mortality. The country is also faced with the burden of non-communicable diseases (NCDs) such as diabetes, cancer, chronic respiratory infections and hypertension, asthma, mental ill-health and road traffic injuries. NCDs are as a consequence of unhealthy diet and lifestyle such as tobacco use, physical inactivity and harmful use of alcohol constitute a major public health problem and are known, for both their high financial and social cost for families, communities and countries. Like many developing countries, The Gambia is experiencing the double burden of malnutrition where overweight and obesity co-exist with under-nutrition. The emergence and prevalence of Diet-related NCDs can be largely attributed to changes in dietary habits and poor physical activity patterns, termed the ‘nutrition transition’ and the adoption of a more westernised lifestyle due to economic development and market globalisation. The increase in life expectancy and changes in lifestyles have resulted in increased tobacco use, consumption of unhealthy diets and physical inactivity. These demographic, nutritional and epidemiological transitions further aggravate the NCDs burden. The NCD Policy and Action Plan will be implemented within a five-year period with emphasis on the following national priority NCDs/conditions: • diabetes, • hypertension, • Cardiovascular diseases • cancers • chronic respiratory diseases • road traffic injuries The national priority risk factors are: • Harmful use of alcohol • Smoking, • physical in-activity, Working together to reduce the burden of NCDs in The Gambia 12 The Gambia NCD Policy 2012-2016 Management and coordination The National Integrated NCDs Policy will address the above risk factors, bearing in mind that the social and economic determinants of NCDs lay outside the health sector. A Multi-sectoral Technical Working Group comprising representatives from a number of ministries, civil society and NGOs involved in health will be set up. Institutions to be represented in the Working Group are MoHSW, Ministry of Youth and Sports, Trade, Local Government, Agriculture, Education; the National Nutrition Agency, The Gambia Diabetes Association, Association of Health Journalists, the WHO Country Office, Medical Research Council, Ministry of Works Construction and Infrastructure and the Private Sector. The Group will be chaired by the MoH&SW. The task of the Working Group will include the following: • Monitor the implementation of the National Policy and Action Plan; • Advocate for inclusion of NCD indicators in the National Health Management Information System; • Support the process of establishing NCDs risk factor surveillance system; • Strengthen cooperation among stakeholders; • Access and analyze emerging issues related to NCDs; • Advocate for the establishment of NCD Unit within the MoHSW for the prevention and management of NCDs. • Support the mobilization of resources for the implementation of NCDs The MoH&SW, through NCD programme, will coordinate implementation of the policy and act as technical adviser to all implementing partners in conjunction with the WHO Country Office, The Gambia. A National Multi-sectoral Advisory Committee for NCDs prevention and management will be established to promote inter-sectoral collaboration, resource mobilization and programme implementation. PRIORITY AREAS FOR ACTION Legislative and Regulatory measures The promotion of positive behavior and healthy life style through Health Promotion and Education is essential for the prevention and control of NCDs. However, Health Education/Promotion and advocacy alone may not be adequate. It is therefore important that legislative and regulatory mechanisms are put in place to complement health promotion interventions. The policy will therefore advocate for: a) Full enforcement of the Food and Public Health Acts b) full enforcement of the Prohibition of smoking (public places) Act of 1998 Working together to reduce the burden of NCDs in The Gambia 13 The Gambia NCD Policy 2012-2016 c) Developing and supporting mechanisms for controlling unsubstantiated claims in advertisements of un-healthy food stuffs and other products in the local and mass media. Organization and Service Delivery At the moment, NCDs service delivery is inadequate and needs to be improved at all levels of the health care delivery. Since NCDs constitute an important public health problem in the country, their prevention and management calls for reorientation of health services and concerted efforts at all levels of health care delivery. In this regard, NCDs prevention and control will be an integral part of primary health care. The policy recommends that: a) An adequate structure is established for the organization, management and coordination of NCD programme implementation. b) Capacity is built and the requisite resources made available at all public and private hospitals and health facilities for the diagnosis, treatment, management, prevention and control of NCDs. c) Strengthen the health system? d) People suffering from NCDs and the communities at large are empowered for the proper management and control of NCDs and develop ownership for programs to be implemented Capacity building The effective prevention and control of NCDs require the availability of a competent work force at all levels of health care delivery and other partner institutions. It is important that the capacity gaps are identified and addressed at all levels. NCDs should be an integral component of the curricular of all health training institutions. For the retention of skilled staff, the conditions of service affecting public sector health workers will be reviewed and emerging issues addressed accordingly. Intersectoral collaboration and partnership Intersectoral partnership is essential for the prevention and control of NCDs. This will be achieved through active consultations, harmonization of interventions and joint planning among government departments, the private sector, civil society organizations including traditional medicines practitioners, NGOs, faith based organizations and CBOs. Since the health sector only sees the outcome of complex interactions among an array of risk factors that lie beyond the purview of the mainstream health, it will be important to get other sectors fully participate in prevention and control of NCDs. The MoH&SW, the National Multi-sectoral Advisory Committee, the Multi-sectoral Working Group and other existing structures will be instrumental in fostering partnership at all levels. Community participation and empowerment are key components in the prevention and control of NCDs as well as strengthening collaboration and partnership between the different stakeholders. Social networks at the community level will be mobilized Working together to reduce the burden of NCDs in The Gambia 14 The Gambia NCD Policy 2012-2016 to take an active role in the prevention and control of NCDs in their various social contexts. The policy will specifically advocate for partnership amongst the following sectors for effective implementation: a) The Ministries of Basic and Secondary Education and Health and Social Welfare to work collaboratively in support of the school health particularly the health-promoting school initiative. Through this initiative, most of the NCDs risk factors can be addressed. b) The Ministry of Agriculture to support initiatives that will enhance the production or cultivation of vegetables and other food stuff, and make them affordable for public consumption. c) The Ministries of Youths and Sports and Land; and Municipalities to encourage and or support the establishment of recreational centers at strategic locations in support of physical activity, and to make such facilities accessible and affordable to the general public. d) All government ministries and work places to create supportive environment for staff to engage in some form of physical activities at their work places. e) Ministry of works, construction and infrastructure to advocate for ‘active transport’ in the revised transport policy to allow walking, cycling and other forms of physical activity on the roads. f) Proactive engagement and support to the frontline communicators, CBOs and other organized community groups for promoting healthy lifestyles and positive health seeking behavior. National Health Management Information System Health Management Information System (HMIS) is critical for the efficient management of health service delivery. It is also important for evidence based planning, informed decision making, monitoring and evaluation of health services. Presently, the NHMIS indicators include NCDs such as diabetes, hypertension, asthma, cancer and cardiac disorders in the national data collection tools and database. However, access to data on NCDs at both Public and Private Health Facilities is still a problem. Measures will be taken to improve data collection on NCDs from these facilities. Information data related to NCDs will be integrated in the routine HMIS of the MOH&SW Establishment of an NCD Unit The establishment of an NCD Unit in the MoHSW is critical for the effective coordination and implementation of the NCD policy. As efforts directed at prevention and control of NCDs involves a large number of stake holders and sectors, it is important that a structure exist for coordination and management. The policy recommends that the NCD Unit be established by 2012. Research NCD prevention and management interventions will be based on research findings and best practices. In The Gambia, there is limited capacity and funding for research Working together to reduce the burden of NCDs in The Gambia 15 The Gambia NCD Policy 2012-2016 on NCDs. Therefore a coordinated research agenda is an essential element for the promotion, prevention and control of NCDs in the country. The policy will put emphasis on building national capacity and mobilize funds for research on NCDs. In addition, the policy lays emphasis on collaboration at national, sub-regional and international levels to promote and support research on NCDs. Tackling Major NCD Risk Factor In The Gambia, the proliferation of modern supermarkets, fast food outlets, increase in motor vehicle ownership, to name but a few, create a tendency for people to slowly but surely abandon their traditional diets and lifestyles and engage in risky lifestyles. Physical activity and personal fitness contribute to the proper maintenance of energy balance, and to health and health wellbeing in general. Lifestyle programmes offering a combination of exercise and diet would be most appropriate for the primary prevention of nutrition-related conditions such as obesity, high blood pressure and hypercholesterolemia. In The Gambia, like many West African countries, the scarcity of financial and human resources, as well as inadequate infrastructure would suggest emphasizing more on primary preventive measures through the promotion of healthy lifestyles, and advocacy at all levels. The constant availability and easy access to tobacco, alcohol and diets high in fats and sugars in The Gambia, increases risks for overweight, obesity, and nutrition related NCDs such as diabetes, hypertension and some forms of cancers. These risk factors were thought to be problems of developed countries but they are now established in developing countries as well. Advocacy, Social Mobilisation, Behaviour Change Communication and Community Empowerment Advocacy is about bringing an issue to the attention of those in authority or to mobilize support and get commitment to a course. Any national strategy geared towards prevention and control of NCDs must engage key policy and decision-makers in the public and private sector to solicit their commitment and support. The policy will emphasise the need for the MoH&SW and its partners in the public, private and civil society to undertake aggressive health promotion activities. Social mobilization encompasses mobilizing all the social actors and allies that have a stake in an issue so that they can take affirmative action with regards to the promotion of healthy lifestyles and positive health care seeking behaviour. A coalition of social actors will be supported at various levels and settings and mobilised for action. These social actors will play a pivotal role in advocacy and health promotion. Working together to reduce the burden of NCDs in The Gambia 16 The Gambia NCD Policy 2012-2016 Behaviour Change Communication (BCC) is a set of organized communication interventions and processes aimed at promoting healthy behaviour and lifestyle. BCC is therefore key to empowering communities to prevent and manage NCDs. Community participation is essential to the successful implementation of NCD programmes and activities. This policy recognizes the fact that communities are active participants and have a role in influencing change in social norms and behaviour in the context of NCD prevention and control. The production and use of appropriate communication materials is important in advocacy, social mobilisation and community empowerment. This policy places emphasis on the timely production and dissemination of relevant communication support materials to complement participatory methods of communication at community level. Media Participation Taking cognizance of the low level of literacy and health communication needs of communities in the country, media participation is important in the prevention, control and management of NCDs. Therefore the policy emphasizes building strong partnership amongst the media, health sector and other stakeholders such as Ministries of Information Communication and Technology and Basic and Secondary Education for the implementation of the policy. Both public and private media houses will be involved in the implementation of the policy. Financing and Resources Mobilization As NCDs are chronic conditions, the cost involved in their prevention and management can take a significant share of the national budget of a country. The mobilization and allocation of financial resources must be ensured in order to promote healthy life styles and manage patients at all levels. Over the years, the health sector has benefitted from a lot of international funding mainly from the Global Fund, GAVI, IDB, ADB and WB, but there has not been any provision for NCD prevention and control. Henceforth the health sector will mainstream NCD prevention, management and control in its negotiation with funding agencies. Even though there is demonstrable Government commitment to NCD prevention and control, there are serious funding gaps in the national budget that need to be addressed. The Ministry of Health and Social Welfare will advocate for budgetary allocation to the NCD programme. The MoH&SW will advocate for the introduction of National Health Insurance Scheme (NHIS) geared towards the management of NCDs. The MoH&SW will also negotiate for the payment of revenue accruing from taxation on tobacco and alcohol to the programme. Adequate financing for NCD prevention, management and control activities will be ensured by rational cost estimation and a specific annual budgetary allocation. Working together to reduce the burden of NCDs in The Gambia 17 The Gambia NCD Policy 2012-2016 IMPLEMENTATION ARRANGEMENT The plan will be implemented under the leadership of the MOH&SW; coordinating mechanisms will be put in place to support the efficiency of the interventions. The implementation of the policy and action plan of the Policy will be coordinated by the NCD programme unit in collaboration with key partners (public, private, civil society), A Multi-sectoral Technical Working Group (MTWG) will guide the implementation process, while the National Multisectoral Advisory Committee (NMAC) will address policy issues and advice the MoH&SW as necessary. The planned activities will have a budget, specific time-frames and indicators. In addition, responsible key partners will be identified and supported to ensure efficient implementation of the action plan. Monitoring & Evaluation Monitoring and Evaluation (M&E) constitute a major component of the policy. Evaluation has to do with measuring outcomes and impacts. Monitoring and Evaluation will be carried out systematically at all levels in accordance with standard protocols. Monitoring and Evaluation reports will include both the status of implementation of the NCD strategic plan and achievement of expected results. The reports will be presented by the NCD Programme Unit to the Director of Health Promotion and Protection for onward forwarding to the Permanent Secretary. The NCD programme will provide direction and monitor the implementation of the policy and action plan. Monitoring and evaluation guidelines and tools will be developed by the NCD Programme Unit in consultation with partners and stakeholders which will be based on supportive supervision. Working together to reduce the burden of NCDs in The Gambia 18 The Gambia NCD Policy 2012-2016 References: The following documents were used as reference materials for the development of the policy: The Gambia National Health Policy (2010 -2015) and Strategic Plan (2010 – 2014); The Global Strategy on NCDs Prevention and Control and the 2008 – 2013 Action Plan of the Global Strategy for prevention and control of NCDs; The data from the situation analysis in The Gambia including results of surveys, and reports; WHO Country Cooperation Strategy 2008-2013; Non-communicable Diseases: A Strategy for the African Region; Situational Analysis Report on NCDs, Ministry of Health 2001; The National Nutrition Policy 2000 -2004. The Gambia STEP Wise survey Report, (2010) Working together to reduce the burden of NCDs in The Gambia 19