National Multisectoral Action Plan for the Prevention and Control of Noncommunicable Diseases (2018-2027)

KINGDOM OF CAMBODIA NATION RELIGION KING ROYAL GOVERNMENT OF CAMBODIA NATIONAL MULTISECTORAL ACTION PLAN FOR THE PREVENTION AND CONTROL OF NONCOMMUNICABLE DISEASES 2018- 2027 Prepared by the Ministry of Health June 2018 ******** Message of Samdech Akka Moha Sena Padei Techo Hun Sen Prime Minister of the Kingdom of Cambodia In Support of the Prevention and Control of National Multisectoral Action Plan for Noncommunicable Diseases 2018-2027 The national multisectoral action plan for the prevention and control of noncommunicable diseases (2018-2027) is a Royal Government of Cambodia's response to the growing challenges of cardiovascular disease, cancer, chronic respiratory disease and diabetes. These four noncommunicable diseases (NCDs) account for almost half of all deaths in Cambodia and are projected to rise further as a consequence of changing lifestyles and environments. NCDs are chronic diseases that cause disabilities, and loss of ability to work and are threatening to exacerbate poverty, and exert an enormous cost on health care. But there are effective measures to prevent and control NCDs to be implemented since 80% of NCDs can be prevented by addressing four main challenges: tobacco use, harmful use of alcohol, unhealthy diet and lack of physical activity. NCDs are not only a health problem but also a challenge to development, which threatens Cambodia's economic growth, the effort to reduce poverty of population and society as a whole. The epidemic of NCDs in Cambodia cannot be tackled by the Ministry of Health alone. Many of the underlying causes of noncommunicable diseases and their determinants lie outside the health sector, in the foods that are available, and the environments we live in. This multisectoral action plan outlines actions for a range of relevant ministries and describes how that action will be implemented, building on the priorities outlined in the Ministry of Health’s National Strategic Plan for the Prevention and Control of NCDs (2013 2020). This national action plan demonstrates that the Royal Government of Cambodia is taking the issue of noncommunicable diseases as a priority and the Royal Government is involved in responding to the new challenges posed by noncommunicable diseases. The Royal Government of Cambodia asks that all relevant ministries and development partners consider NCDs a priority issue and that they work together to implement actions in this national multisectoral action plan so that Cambodia will be able to reduce this preventable and costly disease burden. Phnom Penh, Date ………………………. 2018 Prime Minister Samdech Akka Moha Sena Padei Techo Hun Sen 1 Table of Contents 1. Background ............................................................................................................. 2 1.1 Policy ............................................................................................................ 2 1.2 Situation ........................................................................................................ 4 1.3 Priority Problems ........................................................................................... 7 2. Strategy ................................................................................................................... 7 2.1 Coordination and collaboration ...................................................................... 8 2.2 Implementation Strategy ............................................................................... 8 3. Action Plan .............................................................................................................. 8 3.1 Scope of the Plan .......................................................................................... 9 3.2 Work matrix ................................................................................................. 13 Strategy 1- Reduce population exposure to noncommunicable disease risk factors14 Objective - Prevent NCDs due to tobacco and alcohol use, unhealthy diet and physical inactivity .................................................................................................. 14 Strategy 2- Strengthen multisectoral governance and resources for NCDs ......... 20 Objective - Develop an integrated and coordinated approach to addressing NCDs to ensure balanced, effective and equal use of limited resources ............................. 20 4. Schedule for Drafting Laws and Legal Instruments .......................................... 21 5. Cost ........................................................................................................................ 22 6. Monitoring and Evaluation ................................................................................... 22 7. Conclusion ............................................................................................................ 23 8. Appendices ........................................................................................................... 25 Appendix 1 - Schedule of actions and responsible partners ................................ 25 Appendix 2 - High-level indicator framework for multisectoral action plan on NCDs in Cambodia.............................................................................................................. 31 9. References ............................................................................................................ 33 2 1. Background Social development and economic growth from year to year in combination with lifestyle changes drive the increase of noncommunicable diseases (NCDs). Cambodian people are facing four main NCDs, including cardiovascular disease, cancer, chronic respiratory disease and diabetes. In 2014, noncommunicable diseases caused 52% of deaths in Cambodia, and this figure is projected to rise. Cardiovascular diseases are the most common NCDs in Cambodia, causing 24% of all deaths. Cancers cause 13%, respiratory diseases 5% and diabetes directly 2% of all deaths in Cambodia (1). The four main NCDs are a severe health problem and are on the rise in Cambodia. There is a combination of risk factors for these diseases such as tobacco use, harmful use of alcohol, unhealthy diet, quality and safety of foods, quality and safety of production materials, environmental pollution and lack of physical activity and so on. 1.1 Policy This national multisectoral action plan for the prevention and control of noncommunicable diseases 2018- 2027 outlines measures by Royal of Government of Cambodia (RGC) to respond to the growing challenges of the four NCDs, namely cardiovascular disease, cancer, chronic respiratory disease and diabetes that Cambodia is facing. Preventing and controlling NCDs are an urgent priority for Cambodia. Most of underlying causes of NCDs and their risk factors lie outside the control of the health sector. The health sector alone however cannot prevent and control NCDs. This multisectoral action plan is required to create enabling environments, in homes, villages and cities, and in the whole society, so that healthy choices are the easy choices. To achieve this, we require the multi-sectoral action plan to break the cycle of poverty and noncommunicable diseases. Preventing and controlling NCDs and their risk factors will create a positive impact not only on health but also on productivity and socio-economic development. RGC has so far been paying attention, and in the future will pay attention, to the health sector, a priority sector, as well as to other relevant sectors involved in protecting public health. Therefore, the RGC and relevant agencies have developed a number of policies, regulations and legal instruments as follows: The third rectangular strategy of RGC in the fifth legislature of the national assembly: The RGC's strategic goal is to continue to implement the health sector strategic plan, which aims at improving the well-being and nutritional status of the general population and reducing maternal, new-born and child mortality through the strengthening and expansion of quality, effective and efficient health care services. 3 Reduce morbidity and mortality due to NCDs, chronic diseases and public health problems related to food safety, drug, alcohol, and tobacco use, road traffic accidents, disasters, the environment and climate change (Rectangular strategy, Angle 2, promote health and nutrition). The law to approve Cambodia's accession to the tobacco control convention (2006). The law on tobacco control (2015). The law on the "management of the quality and safety of products, goods and services" (2000) The law on the "management of pesticides and fertilizers" (2012). The law to "approve Cambodia's accession to the Stockholm convention on insoluble organic pollutants." The law to "approve Cambodia's accession to the Basel convention on the control of the transportation movement and disposal of hazardous waste" (2015). The law on "environmental protection and natural resource management" (1996). Sub-decree No. 107 ANKr.BK dated 14 July 2017 on the establishment of the committee for tobacco control. Sub-decree No. 107 ANKr.BK dated 22 October 2015 on printing of health warning messages in Khmer language and pictorial on tobacco product packages. Sub-decree No. 150 ANKr.BK dated 26 March 2014 on the revision of value added tax on some goods. Sub-decree No. 43 ANKr.BK dated 16 March 2016 on measures for banning of smoking or blowing the smoke of tobacco products at workplaces and public places. Sub-decree No. 69 ANKr.BK dated 20 October 2003 on the "management of iodized salt business" Sub-decree No. 180 ANKr.BK dated 20 October 2009 on the "management of classification and labelling of chemicals". Sub-decree No. 27 ANKr.BK dated 06 April 1999 on "water pollution control". Sub-decree No. 36 ANKr.BK dated 27 April 1999 on "solid waste management". Sub-decree No. 42 ANKr.BK dated 10 July 2000 on "air and noise pollution control". Sub-decree No. 133 ANKr.BK dated 18 November 2005 on the "marketing of products for infant and young child feeding". RGC's circular No. 03 SR on "quality management and measures to control the quality and safety of products, goods and foods containing chemicals" (2000). Letter No. 1271 SChN dated 07 October 2008 on the "investigation and prevention of the importation and distribution of formulas containing banned Melamine." Inter-ministerial Prakas No. 868 OuRTh.BK dated 22 October 2010 on the "implementation and coordination of agencies responsible for the food safety management system from farm to table (2010). Inter-ministerial Prakas No. 401 SHV.BK on the "enforcement of control of unsafe food products, plants, animals, animal products, fisheries and fish products imported into the Kingdom of Cambodia." 4 Prakas No. 183 MOC/SM 2006 on "banned chemicals on food products" (2006). Prakas No. 099 BrK.KSK dated 10 March 2008 on the "introduction of good agriculture practice measures in the production of fruits and fresh vegetables". Prakas No. 598 BrK.KSK dated 15 December 2003 on "pesticide lists in the Kingdom of Cambodia". Prakas No. 002 BrK.KSK dated 13 January 2007 on "lists of maximum residue levels of pesticides in products originated from plants". Prakas No. 166 MIH/2015 dated 15 June 2015 on "Technical Regulation CTR 004: 2015 for Polyethylene Terephthalate bottles for storing food products" (2015). Prakas No. 168 MIH/2015 dated 15 June 2015 on "Technical Regulation CTR 006: 2015 for natural mineral water production" (2015). Prakas No. 169 MIH/2015 dated 15 June 2015 "Technical Regulation CTR 007: 2015 for food contamination and pollution" (2015). Prakas No. 170 MIH/2015 dated 15 June 2015 on "Technical Regulation CTR 008: 2015 for food additives" (2015). Prakas No. 165 ABS/OuABS dated 15 March 2016 on the "Certification of Marketing of food products and certification of sanitation for food products." 1.2 Situation NCDs are the main cause of disability and mortality, and a major threat to development in Cambodia. The burden of disease is high and rising: Cardiovascular disease, cancers, chronic respiratory disease and diabetes are a large and growing problem in Cambodia. In 2014 NCDs caused 52% of all deaths among Cambodians and this figure is projected to rise. Cardiovascular diseases (stroke and heart disease) are the most common NCDs in Cambodia, accounting for 24% of all deaths. Cancers account for 13%, chronic respiratory disease 4% and diabetes 2% of all deaths in Cambodia (1). The leading and emerging cancer in Cambodia is cervical cancer, followed by liver, lung, and breast and stomach cancer (2). With regard to mortality liver and lung cancer cause the most deaths among all cancer related deaths every year. Today these NCDs are killing Cambodians in productive age. More than one half of men and more than one third of women that die from NCDs are under 60 (3). Behavioural and environmental NCD risk factors are common across Cambodia: These four major NCDs share common risk factors namely unhealthy diet, physical inactivity, tobacco use and harmful use of alcohol. Indoor air pollution from solid fuel use, and incense smoke (15) is a major contributing factor to chronic respiratory diseases and lung cancer in women as well as to deaths from respiratory infections in children. Exposure to these risk factors is spreading all over Cambodia. Currently 2 million 5 Cambodians use tobacco with 42.5% of adult males smoking cigarettes (4). Over half the population are exposed to environmental tobacco smoke (ETS) at home or work (5), and 47% of children live in homes with people who smoke in their presence (6). Nine out of 10 Cambodians rely on solid fuels for cooking (7) and over 8 in 10 do not eat enough fruit and vegetables to protect them from NCDs (5). Already 1 in 5 adults have high cholesterol and 1 in 10 have high blood pressure, indicating a diet that is too high in trans and saturated fats and salt (5). With constant economic growth over time some of our people are not aware of risk factors that cause adverse health effects on their health and well-being and the environment is increasingly promoting the development of NCDs. Between 2003 and 2008 the importation of various products such as soft drinks, candies, cane sugar, beer and motor vehicles into Cambodia increased dramatically affecting dietary habits and physical activity, and the trend is most probably continuing (8). Furthermore, tobacco and alcohol tax level is very low, and cigarette prices are the lowest in the region (9). NCDs exacerbate poverty and threaten Cambodia’s other development goals: NCDs have a disproportionate impact on the poor making household poverty worse and undermining poverty reduction efforts. Previously NCDs were considered to be the diseases of the wealthy, but this trend has been reversed. In many countries NCDs are now more common and more fatal amongst the poor (10). In Cambodia, a number of NCD risk factors are more common in the predominantly poor rural population compared to urban dwellers – including tobacco use, solid fuel use, incense (15), insufficient fruit and vegetable consumption and harmful use of alcohol (5). Under-nutrition in-utero and during childhood increases the risk of developing cardiovascular disease and diabetes later in life. The high rates of child and maternal under-nutrition mean that many Cambodians are born with a higher risk of NCDs, especially the poor. NCDs may contribute to posing a threat to the realization of Cambodia millennium development goals (CMDG) including child nutrition, education, gender equity, environmental sustainability and household economic development, spending more money on tobacco and alcohol and spending less money on food, healthcare for women and children, and education especially for girls. In Cambodia households spend an average of 4% of their total earnings on tobacco and less on education, clothes and food (11). Cambodia’s poorest citizens spend 10% or over of their income on cigarettes (4). This undermines CMDG2 to achieve universal education, CMDG3 to promote gender equity, and CMDGs 4 and 5 to reduce maternal and infant mortality. Likewise alcohol use results in increased domestic violence, accidents at the workplace and deaths due to traffic accidents. Tobacco and betel quid use in pregnancy increases infant mortality. Solid fuel use, and incense smoke are not just a major contributor to respiratory disease deaths in 6 Cambodian women and children, but is also a major contributor to climate change, undermining Cambodia’s CMDG7 to ensure environmental sustainability. NCDs have so far posed a serious threat to CMDG 1, to eliminate extreme poverty and hunger. NCDs are a high expenditure for the government and for households, reducing economic development. Through health system costs and lost productivity, NCDs cost low income countries US$25 per person per year (12). Each 10% rise in NCDs is associated with 0.5% lower rates of annual economic growth. Another analysis in 2010 found NCDs cost developing countries between 0.02-6.8% of GDP- an economic burden greater than malaria in the 1960s or HIV/AIDS in the 1990s (13). The high cost of long-term health care and medicines for NCDs, along with loss of income, pushes many Cambodian families deeper into poverty. In 2010 over 1 in 4 households had to borrow money or sell assets to pay for health care (7). Where care is not affordable, or comes too late, premature NCD deaths rob households of their main financial providers. Treatment of NCDs is usually long-lasting, often for rest of the life, and the price of the treatment tends to increase with advancing the disease. Therefore, successful prevention of NCDs has also a huge economic impact, for individuals, families, and for the whole society. NCDs threaten Cambodia's health systems: Even the richest health systems in the world are facing challenges in responding to the rising demand for NCD treatment. No country can fully address the treatment of NCD epidemic. The Cambodian health system is already swamped by more NCD patients than it is able to treat. Based on the current high level of risk factors in the population, and the rapid increase in unhealthy diets and alcohol consumption, NCD deaths in Cambodia is projected to rise. Globally, NCD deaths are projected to increase by 15% between 2010 and 2020 (to 44 million deaths), with the highest numbers predicted in the Western Pacific Region (12.3 million deaths) (14). If this trend continues unabated, Cambodia is facing a tsunami of additional NCD patients in the coming years that the health system will simply be unable to treat. To avoid this, prevention and early detection policies must be urgently implemented. Main NCDs in Cambodia share preventable risk factors and causes as listed in table below: 7 Key causes and risk factors for Cambodia's priority NCDs: Diseases CVD Cancer Respiratory Disease Diabetes Cervix Liver Lung Breast Stomach Behavioural causes Tobacco use         Alcohol    Unhealthy diet    Physical inactivity    Indoor air pollution    Physiological causes Hypertension   High cholesterol   Overweight    Most NCDs can be prevented: 80% of NCDs are preventable and a range of highly cost-effective interventions exist (13). Even people who do develop NCDs can usually remain well, productive members of their families and society, through a mixture of primary health care and supported self management. Most of the reduction in NCD deaths comes from primary prevention and reducing the levels of major NCD risk factors in the whole population, with a smaller gain coming from secondary prevention and treatment of individual patients. Therefore, a cost effective package consists of population wide policy measures together with individual interventions for people at high risk. The cost of implementing measures for reduction of NCD risk factors (to control alcohol and tobacco, and reduce salt and trans/saturated fat in food) is estimated to cost less than US$0.40 per person each year in low income countries (12). In comparison, NCDs are estimated to cost low income countries US$25 per person per year. 1.3 Priority Problems NCDs are the main cause of disability and mortality, and a major threat to Cambodia's socio-economic development. Figures in 2014 shown that NCDs caused 52% of all deaths in Cambodia. NCDs, particularly cardiovascular disease, cancer, chronic respiratory disease and diabetes, are a major public health problem and are rising in Cambodia. 2. Strategy To reduce Cambodian people's risk of NCDs, the plan consists of 2 main components: Prevention of more Cambodians from developing NCDs and mitigate the severity of NCD patients so as to prevent them from being people with disability and premature death. 8 The national strategy for the prevention and control of NCDs is a multi-sectoral strategy and is in the policy on public health including food safety, tobacco and harmful use of use and phyical inactivity. Each strategy is outlined its main activities. This strategy is based on the National Strategic Plan for the Prevention and Control of NCDs 2013-2020, which is a part of the Health Strategic Plan 2008-2015 and on the National Strategic Plan on Tobacco Education and Reduction 2011-2015. The best use of our limited resources is crucial. It is very important that we need to define strategies to address major causes of NCDs, leading to disability or dealth. We cannot have a separate strategy for a particular NCD as it would lead to too many strategies and to competing priorities, and make our efforts duplicated . As such this requires intersectoral collaboration. 2.1 Coordination and collaboration The ministry of health is responsible for leading, coordinating, collaborating and mobilizing relevant institutions to implement the National Multisectoral Action Plan for the Prevention and Control of NCDs by reducing risk factors of NCDs such as tobacco use and harmful use of alcohol, unhealthy diet and physical inactivity. 2.2 Implementation Strategy Studies on the four main NCDs, we identified their major causes that are interrelated or multiple causes in a person. We therefore define a number of multisectoral strategies as follows: Control tobacco and alcohol use. Reduce the use of plastic bags and bottles. Raise awareness of unhealthy diet for health Ensure effectiveness management of product quality and safety (food and non food products). Maintain health through physical activity. Raise awareness of the dangers of indoor air pollution. Provide effective screening, treatment and palliative care and promote multisectoral collaboration to addres other causes. 3. Action Plan 9 The detailed action plan in matrix table reflects all activities that require multisectoral actions in order to prevent escalating burden of NCDs and as well as treatment. All activities are prioritized for implementation in the short, medium and long term. 3.1 Scope of the Plan The National Multisectoral Action Plan for the Prevention and Control of NCDs - whether implemented in the short, medium or long term – must cover general population of all ages, including those at risk of and with NCDs. The Ministry of Health and implementation mechanism for the national multisectoral action plan continue collaborating and more encouragements to enhance cooperation with developmetn partners and private sectors through engagement in projects of other sectors and providing financial support, and actual coodinations. The multisectoral interventions of relevant ministries/agencies and development partners are essential since the major causes are under their competences as follows: Government institutions Main responsibilities Ministry of Health Lead, coordinate and mobilize relevant agencies to propose, develop and implement national multi-sectoral action plans, laws, sub-degrees, and other regulations for the prevention and control of noncommunicable diseases through reduction of NCD risk factors such as tobacco use, harmful use of alcohol, unhealthy diet, and physical inactivity. National Center for Health Promotion is a secretariat to control tobacco use and harmful use of alcohol. Department of Preventive Medicine is a secretariat for unhealthy diet and physical inactivity program. Unhealthy diet program includes reduction of salt/sodium intake and engagement in a study for production of potassium-enriched salt and less sodium. Strengthen health professional capacities to prevent and control of NCDs. Create preventive and treatment services for NCDs in public health facilities. Collaborate with research institutions to conduct national survey for NCD risk factors. Establish research and surveillance mechanism for NCDs. 10 Ministry of Education, Youth and Sport Integrate health education contents on prevention of noncommunicable diseases, including unhealthy diet related risk factor, and healthy lifestyle into general school curriculum. Promote physical activity in school settings. Ensure free smoking environment in schools. Ensure school environment without unhealthy food and drinks. Develop a sub-degree on banning advertisement of alcohol, unhealthy food products and drinks at sport events and sport settings. Promote hygiene and good environment in school settings at all levels. Ministry of Industry and Handicraft Reduce salt content of major dietary sources of sodium. Explore feasibility of low sodium (potassium enriched) salt production in Cambodia. Prepare a program for standard iodized salt. Take action to prohibit the use of toxic chemicals and trans-fat in food (substitute for polyunsaturated fats) Expand and promote cooking by using renewable engery stoves and the national energy efficent cooking stove program. Stregnthen the management and storage of chemicals used by factories and small manufactoring businesses. Strengthen and promote good manufacturing practice (GMP) and good hygience practice (GHP) in factories and small manufacturing businesses. Ministry of Economy and Finance Increase tax on tobacco step by step as necessary. Increase tax on alcohol and drinks with high sugar content step by step as necessary. Explore a financial mechanism to increase demand for healthy foods and to reduce demand for unhealthy options (subsidies and taxations). Ministry of Interior - Enforce laws related to public health problems. Ministry of Commerce - Manage the quality, safety and appropriateness of products (food and non-food products except medicines and cosmetics). Protect the health and interests of consumers and crack down on fraud. Ministry of Land Management, Urban Create an enabling environment for physical activity and harmonization through urbanization and management. 11 Planning and Construction Ministry of Information Enforce the ban on advertisement and promotion of tobacco, alcohol and unhealthy food and beverage products. Raise public awareness of healthy diet and physical activity via both government and private mass media. Ministry of Mines and Energy Control and raise awareness of substances that affect the public health as a result to mining businesses and fuel consumption. Ministry of Cults and Religions Raise awareness of health in religious programs especially in Buddhist sessions linked with society and other religious ceremonies. Engage in reducing air pollution in pagodas and churches. Ministry of Labour and Vocational Training Promote healthy diet and physical activity at the workplace (focusing first on workplaces with low income, e.g. garment factories). Increase inspections on the activities of some professions that use substances or factors that can cause NCDs. Develop regulations required for preventing diseases. Ministry of Planning - Develop and oversee the implementation of the national action plan for salt reduction. Integrate dietary risks into national and sub-national strategic plans for nutrition. Ministry of Agriculture, Forestry and Fisheries Explore various mechanisms to make agricultural produce safer for consumers through promoting the production of local fruits and vegetables. Enforce laws and regulations related to hygiene control and phytosanitary for plants and animal products. Strengthen the management and control of veterinary products and drug residue control. Enforce animal health and production law. Ministry of Environment Improve environmental quality:  Manage solid/liquid waste.  Manage hazardous substances and waste.  Manage the use of plastic bags.  Control air pollution. Implement environment friendly standards. Implement sustainable lifestyle and green development. Implement environmental impact assessment on development plan. 12 Enforce law and regulations effectively. Ministry of Tourism - Promote tourist sporting events. Promote further movements for clean cities, clean resorts and good services. Enhance quality control on foods in tourism industry. Enhance control and raising awareness of smoke free environment in tourism industry. Ministry of Women's Affairs Increase awareness among citizens, especially women and children, of NCDs and their risk factors and healthy lifestyle. Ministry of Public Works and Transport Strengthen the technical inspection mechanism for vehicles. Promote tree planting along national roads and major provincial roads. Strengthen and promote urban public transport. Develop greenhouse inventories (from vehicles). Encourage the change of automobile transport to railway transport. National Committee for Disaster Management Lead, manage and coordinate all activities related to disaster management and environmental health. Ministry of Culture and Fine Arts Raise awareness among youth through the promotion of art and cultural activities. Engage in reduction of harmful use of alcohol and air pollution in traditional areas. Ministry of National Defense Promote healthy diet and physical activity at regional divisions across the country. Widely raise awareness on effects of tobacco smoke and alcohol among military personnel (senior cadets, junior cadets and privates) National Committee for the Environment and Health Oversee the implementation of multisectoral action plan. Ensure responsibilities of relevant ministries Local Authorities Main responsibilities Implement smoke free environment. Implement restriction of tobacco sales. Support the implementation of banning alcohol and tobacco advertisement. 13 Expand healthy city/community initiatives. Private Sector Main responsibilities All employers - Implement smoke free workplaces. Provide healthy food choices in company canteens. Engage in an education and implementation of healthy workplace program. 3.2 Work matrix The work matrix to be implemented in the short, medium and long term in this national multisectoral action plan must respond effectively to the multisectoral strategies and indicators set for addressing to control the main common causes of NCDs in Cambodia. 14 Strategy 1- Reduce population exposure to noncommunicable disease risk factors Objective - Prevent NCDs due to tobacco and alcohol use, unhealthy diet and physical inactivity Activities Indicators Responsible Ministries/Agencies Time Funding Source 2018 2019 2020 2021 2022 2027 1. Accelerate tobocco control 1.1. Enforce tobacco control law Prevalence of tobacco use among men and women over 18 All ministries/agencies Sub-national administration x x x x x x Sub-national administration 1.2 Enforce the law on tobacco control with focus on measures to create smoke free environment at the workplaces and in plubic places. Prevalence of tobacco use amongh adolescents All ministries/agencies Sub-national administration x x x x x x Sub-national administration 1.3 Continue to enforce the sub-decree on health warning messages and the sub decree banning tobacco advertisement based on the tobacco control law. Exposure to smoke in the environment Ministry of Health Ministry of Commerce Ministry of Information Ministry of Interior Ministry of Environment Sub-national administration x x x x x x Ministry of Health and Development Partners Sub-national administration 1.4 Increase tobacco taxation Tobacco tax rate - Ministry of Health Ministry of Economic and Finance Sub-national administration x x x x x x Sub-national administration 1.5 Create health foundation Health foundation existed - Ministry of Health Ministry of Economic and Finance Sub-national administration x x x x x Sub-national administration 15 1.6 Disseminate laws and sub-decrees widely. Number of disseminations All ministries/agencies Sub-national administration x x x x x x All ministries /agencies, and local authorities Sub-national administration 1.7 Provide sufficient education and information for the public on the impact of tobacco use on health, the economy and the environment. Knowledge of population on the impact of tobacco use on health, the economy and the environment All ministries/agencies Sub-national administration x x x x x x Ministry of Health, and Development Partners Sub-national administration 1.8 Establish services for counseling and quit smoking at health facilities Number of services for quit smoking Ministry of Health Sub-national administration x x x x x x Ministry of Health and Development Partners Sub-national administration 1.9 Conduct research on tobacco use, the quantity of tobacco produced for export and of tobacco import, prices, raw materials, machinery, income, growing. Annual report disseminated (quantity of tobacco imported and exported, tobacco prices increasing or dicreasing) Ministry of Health and relevant ministries Sub-national administration x x x x x Ministry of Health and Develiopment Partners Sub-national administration 1.10 Create and operizationalize a sienctic and laboratory team to test tobacco products especially their standards of elements and effect of tobacco use. Scientific and laboratory team created Ministry of Health Relevant ministries and Development Partners Sub-national administration x x x x x Ministry of Health and Development Partners Sub-national administration 16 1.11 Monitor and enforce laws and sub decrees. Law and sub-decrees enforced Ministry of Health Relevant ministries and Development Partners Sub-national administration x x x x x Ministry of Health and Development Partners Sub-national administration 1.12 Evaluate the effectiveness of tobacco control policy implementation Evaluation report - Ministry of Health Relevant ministries and Development Partners Sub-national administration x x Ministry of Health and Development Partners Sub-national administration 2. Alcohol control 2.1. Increase tax on alcohol. - Alcohol taxation - Ministry of Economic and Finance Sub-national administration x x x x x x Ministry of Health and Development Partners Sub-national administration 2.2. Advocate for the adoption of the law on alchol control. Prevalence of binge drinking among adults Ministry of Health Relevant ministries/agencies and Development Partners Sub-national administration x x x x x x Ministry of Health and Development Partners Sub-national administration 2.3 Implement the measure to control advertisement, promotion, and sponsorship of alcohol. Reduced advertisement, promotion, and sponsorship of alcohol Ministry of Health Relevant ministries/agencies and Development Partners Sub-national administration x x x x x x Ministry of Health and Development Partners Sub-national administration 17 2.4 Implement the measure to control distribution, sales, use of alcohol, and point of sales, and measure to print health warning on alcohol products. Exisisted the measure to control distribution, sales, use of alcohol, and point of sales, and measure to print health warning on alcohol products Ministry of Health Relevant ministries/agencies and Development Partners Sub-national administration x x x x x x Ministry of Health and Development Partners Sub-national administration 2.5 Take action to enforce alcohol breathalysing in compliace with the land traffic law. Total alcohol consumption per capita (>18 years) per calendar year, of pure alcohol National road safety committee Relevant agencies Sub-national administration x x x x x x Ministry of Health, Ministry of Information, Ministry of Interior, and Development Partners 2.6 Provide sufficient education and information for the public on the impact of alcohol on health, the economy and the enironment. Knowledge of population on the impact of alcohol on health, the economy and the enironment due to alcohol use Ministry of Health Relevant ministries/agencies and development partners Sub-national administration x x x x x x Ministry of Health and Development Partners Sub-national administration 2.7 Enforce the law on alochol control Implemented law on alochol control Ministry of Health Relevant agencies and development partners Sub-national administration x x x x Ministry of Health and Development Partners Sub-national administration 2.8 Provide counseling on the dangers of alcohol use. Number of providing counseling Ministry of health Relevant agencies and development partners Sub-national administration x x x x Ministry of Health and Development Partners Sub-national administration 18 3. Promote healthy diet and physical activity 3.1 Conduct a national survey on salt use. - Mean salt/sodium intake among population aged over 18 Prevalence of overweigh/obesity among adults aged over 18 Prevalence of high blood glucose among adults aged over 18 Prevalence of high blood pressure among adults aged over 18 Consumers received options for quality, safe and appropriate products that cause NCDs Prevalence of adults aged over 18 consuming <5 servings of fruit and vegetables per day Proportion of adult population aged over 18 with lack of physical activity Number of schools implementing the health promotioning school program Ministry of Health Sub-national administration x x Sub-national administration 3.2 Promote healthy diet and physical activity through the healthy city program Ministry of Health Ministry of Educaiton, Youth and Sport Relevant ministries Sub-national administration x x x x x x Sub-national administration 3.3 Promote healthy diet and physical activity in shools. Ministry of Educaiton, Youth and Sport Relevant ministries Sub-national administration x x x x x x Sub-national administration 3.4 Raise public awareness about healthy diet and physical activity through mass media. Ministry of Health Ministry of Information Relevant ministries Sub-national administration x x x x x x Sub-national administration 3.5 Develop and implement the national action plan on salt reduction Ministry of Health Ministry of Industry and Handicraft Ministry of Planning Sub-national administration x x x x x x Sub-national administration 3.6 Replace trans-fat with unsaturated fat - Ministry of Industry and Handicraft Relevant ministries Sub-national administration x x Sub-national administration 19 3.7 Develop national guideline on nutrition for all sectors National Nutrition Committee Sub-national administration x x Sub-national administration 3.8 Strenghthen the management of advertisements (food and non-food products) that are fraud, misleading or cheating about the quality and safety of products to be used without following established regulations. Ministry of Information Relevant ministries Sub-national administration x x x x Sub-national administration 3.9 Manage taxes on foods and subsidies - Ministry of Commerce Relevant ministries Sub-national administration x x x Sub-national administration 3.10 Replace saturated fat with unsaturated fat Ministry of Industry and Handicraft Relevant ministries Sub-national administration x x x Sub-national administration 3.11 Provide health and safety education at low income workplaces Ministry of Health Ministry of Labour and Vocational Training Relevant ministries x x x Sub-national administration 3.12 Reduce consumption of plastic products Ministry of Commerce Sub-national administration x x x x x x Sub-national administration 4. Reduce exposure to indoor air pollution 4.1 Expand the national efficent cooking stove program Proportion of households relying on solid fuels for cooking Proportion of households having efficient cooking stoves Number of efficient cooking stoves distributed by program Relevant ministries Sub-national administration x x x x x x Sub-national administration 4.2 Promote alternative cooking fuels - Relevant ministries Sub-national administration x x x Sub-national administration 20 Strategy 2- Strengthen multisectoral governance and resources for NCDs Objective - Develop an integrated and coordinated approach to addressing NCDs to ensure balanced, effective and equal use of limited resources Activity Indicator Responsible ministry/agency Time Resource 2018 2019 2020 2021 2022 2027 1. Develop multisectoral actional plan and accountability mechanism 1.1. Establish a whole-of government mechanism to oversee implementation of multisectoral action plan for the prevention and control of NCDs. Establish an inter ministerial committee for the prevention and control of NCDs that will function during the development of plans (at national and sub-national levels) Ministry of Health Sub-national administration x Ministry of Health and Development Partners Sub-national administration 2. Create an NCD fund from tobacco and alocohol taxes 2.1. Create a fund for health promotion and prevention of NCDs based on tobacco and alcohol taxation Created fund for health promotion and collected budget Ministry of Health Ministry of Economic and Finance Sub-national administration x x x x x Sub-national administration 21 4. Schedule for Drafting Laws and Legal Instruments The four main NCD trend in Cambodia is rising among people in both urban and rural areas and this is a concern that Royal Government of Cambodia needs to pay attention to as early as possible. Laws and regulations that have been adopted as follows: Prakas on lists of maximum residue levels of pesticides in products originated from plants (2007). Law on tobacco control (2015). Sub-decree on printing of health warning messages in Khmer language and pictorial on tobacco product packages (2015). Law on animal health and production (2016). Prakas on legal procedures for printing of health warning messages in Khmer language and pictorial on tobacco product packages (2016). Prakas on pack display of tobacco products at point of sales (2015). Sub-decree on measures for banning of smoking or blowing the smoke of tobacco products at workplaces and public places (2016). Prakas on sign for banning of smoking or blowing the smoke of tobacco products (2016). Prakas on procedures to conduct tobacco control inspection for tobacco control inspectors of the Ministry of Health (2016). Sub-decree on establishment and functioning of the committee for tobacco control (2017). Laws and sub-decrees that currently are under development include: Law on food safety. Law on alcohol control. Monitor number of smokers and take stronger actions to enforce the law on tobacco adopted in 2015. Given that NCDs are developing rapidly while various laws are being made, Royal Government of Cambodia must pay attention to and take early actions to address alcohol and food products that are seriously affecting the health of our Cambodian people. Multisectoral mechanisms such as inter-ministerial prakases must be set up and implemented effectively to ensure the success of this multisectoral action plan as indicated in each matrix. 22 5. Cost In order to implement the National Multisectoral Action Plan for the Prevention and Control of NCDs 2017-2026, there is a need to use the national budget through relevant ministries in their respective budgets and that of development partners, the private sectors, civil societies and philanthropists. 6. Monitoring and Evaluation The Ministry of Health is the leading agency responsible for montoring and evaluation of the implementation of MSA in colaboration with relevant ministries to ensure its success and to achieve outcomes based on each indicator and on activities indicated in the matrix and using existing or new mechanisms. Data collected from various sources as well as from research studies conducted by agencies responsible for NCDs in MoH need to be well documented as the baseline for monitoring and evaluation for future NCD trends and for effective interventions in Cambodia. For the period 2018-2027 monitoring and evaluation will be implemented in two stages: first stage is from 2018- 2022 and second stage is from 2023-2027. Initial monitoring and evaluation is critical for the initial steps of multisectoral action plan and outlining some more steps for final evulation in 2027. All strategies proposed in the multisectoral action plan are the basis for achieving outcomes and indicators through the effort of MoH and other relevant government ministries with the support of development partners and other organizations. National Targets of the National Multisectoral Action Plan for the Prevention and Control of NCDs in Cambodia: Indicators Baseline 2010 Target 2027 Prevalence of heavy episodic drinking among adults aged 25-64 Men 45.1% Women 4.6% Men 42.1% Women 4.3% Prevalence of adult aged 25- 64 with lack of physical activity 10.6% 9.9% Mean population intake of salt/sodium 30% relative reduction in mean population intake of salt/sodium 23 Prevalence of daily tobacco use among men and women over 18 years Men 39.2% Women 3.4% Men 29% Women 2.0% Prevalence of high blood pressure among adults aged 25-64 11.2% 9.3% Prevalence of diabetes among adults aged 25-64 2.9% 2.9% Prevalence of obesity among adults aged 25-64 1.9% 1.9% 7. Conclusion Health is determined by multiple factors outside the direct control of the health sector, such as education, income, and the conditions where the people live, work, and play. Decisions made in other sectors can either positively or negatively affect the determinants of health. It is an approach to policy making in which decision-makers in other sectors routinely consider health outcomes, including benefits, harms, and health related-costs. And vice versa, health is an important factor and contributor for wellbeing and productivity of the nation. Multisectoral action plan is most commonly implemented by national and local governments, but can also be applied to decision-making of development partners and private sectors. Different ministries and Council of Ministers create the legal and financial basis for national, regional and local level government activities through policy making, legislation and budgeting, and set the regulatory environment for business and other private sector activities. The most effective interventions to address NCDs are policies which reduce the most common shared risk factors at a population level: unhealthy diet (especially excess consumption of salt, trans- and saturated fats and sugar), tobacco use, harmful use of alcohol, physical inactivity and indoor and outdoor air pollution. To ensure effective collaboration and commitment for multisectoral action plan on health, an intergovernmental coordinating body needs to be set. The domain of the previous Inter ministerial Committee on Environmental Health has been revised to cover the different aspects related to NCD prevention and control, and the body is renamed as Inter ministerial Committee on Environment and Health. The Inter-ministerial Committee for Education and Reduction of Tobacco Use continues its action as an intergovernmental body for implementation Framework Convention on Tobacco Control in Cambodia. Establishment of an Inter-ministerial Committee on Alcohol is under consideration. Due to chronic nature of NCDs, and high cost of their treatment, prevention is the only way to go for NCD control. Most of the needed activities have low-cost, high cost-effectiveness, 24 and are achievable and affordable also in low-income countries. Establishment of health promotion fund, and earmarking part of the increased tobacco and alcohol tax revenues for the fund, would create the needed financial resources. 25 8. Appendices Appendix 1 - Schedule of actions and responsible partners Table summarizes the timetable of activities to achieve the strategic priority objectives by 2027. This table also outlines the government agency responsible for implementing each activity. Timeframe Responsible agencies Area of Action 1 - Reduce population exposure to noncommunicable disease risk factors 1.1 Accelerate tobacco control Short-term action Enforce tobacco control law 2018 Ministry of Health, Tobacco Taxation Working Group Tobacco Taxation Working Group to finalize plan to implement regular increases on tobacco taxation 2018 Tobacco Taxation Working Group, Ministry of Economic and Finance, Ministry of Health Expand implementation and enforcement of smoke-free environments sub decree 2018 Inter-ministerial committee, Ministry of Health, Capital/provincial halls Enforce sub-decree on advertising ban and health warning messages in Khmer language and pictorial on tobacco product packages 2018 Ministry of Health, Ministry of Information, Ministry of Tourism Establish services for counseling and quit smoking at health facilities 2018 Ministry of Health Implement tobacco tax increases. 2018 Ministry of Economic and Finance, Ministry of Health Medium-term actions 26 Continue to implement regular/annual tobacco taxation increases Continue Ministry of Economic and Finance, Ministry of Health Implement measures for banning of smoking or blowing the smoke of tobacco products at workplaces and public places, measure of advertising ban, health warning messages in Khmer language and pictorial on tobacco product packages. Continue Ministry of Health, and Inter-Ministerial Committee Enforce sub-decree that requires pictorial warning labels Continue Ministry of Health, Inter-ministerial Committee Dedicate percentage of health foundation to implement NCD prevention, law and regulations on tobacco control. 2018 Continue Ministry of Economic and Finance, Ministry of Health and relevant ministries/agencies Restricting sale of tobacco and regulating vendors Continue Ministry of Health, Ministry of Commerce, local authorities Expanding smoke-free environments to cover all enclosed public spaces (including transportation and private workplaces/businesses) Continue National Center for Health Promotion, Ministry of Health, Inter-Ministerial Committee, local authorities Long-term actions Continue to implement regular/annual tobacco taxation increases Ministry of Economic and Finance Continue to implement laws and regulations related to tobacco products 2018 Ministry of Health and other relevant ministries 1.2. Scale up alcohol control Short-term actions Establish Inter-Ministerial Committee for Alcohol Control 2018 Council of ministers and Ministry of Health 27 Ministry of Health to work with Ministry of Economic and Finance to increase alcohol taxation 2018 Ministry of Economic and Finance and Ministry of Health Develop sub-decree to restrict alcohol advertising, promotion and sponsorship 2018 Ministry of Health, National Committee for Road Safety Enforce road traffic law Continue National Committee for Road Safety Enforce sub-decree on alcohol advertising restrictions (including raising public awareness of the ban) 2018 Relevant ministries/agencies Medium-term actions Develop law on alcohol control 2018 Inter-Ministerial Committee, and Ministry of Health Dedicate percentage of incomes from health foundation for NCD prevention and control (reference document) 2018 Ministry of Economic and Finance and Ministry of Health Expand the ban on alcohol advertisement 2018 Ministry of Health, Ministry of Information, and Local authorities Implement the measure to control distribution, sales, use of alcohol, and point of sales, and measure to print health warning on alcohol products 2019 Ministry of Health and relevant ministries Long-term actions Offer counselling for hazardous drinking in primary care 2018 Ministry of Health, Health centres 28 1.3. Promote healthy diet and physical activity Short-term actions Pilot interventions to reduce salt or excessive sodium consumption 2018 Ministry of Health, Ministry of Industry and Handicraft, Ministry of Planning Strengthen healthy city in the capitals/provinces:  Launch the health promoting schools in the capitals/provinces  Explore other strategies to make healthy diets the norm in the capital/provinces (e.g. working with food vendors) 2018 Ministry of Health Ministry of Education, Youth, and Sport Provincial Health Departments Begin multi-sectoral discussions on how to reduce salt content of foods 2018 Ministry of Health, Ministry of Industry and Handicraft, Ministry of Planning Raise public awareness about healthy diet and physical activity through mass media of all forms 2018 Ministry of Health, Ministry of Information, and other media outlets Begin multi-sectoral discussions on substituting trans-fats for polyunsaturated fats 2018 Ministry of Health and Ministry of Industry and Handicraft Medium-term actions Develop a national action plan for salt reduction 2018 Ministry of Health, Ministry of Industry and Handicraft, Ministry of Planning Implement the national action plan for salt reduction Continue Ministry of Health, Ministry of Industry and Handicraft, Ministry of Planning Include NCD dietary risk in the national nutrition strategy 2018 Ministry of Health, National Nutrition Committee 29 Expand the health promoting schools, environment, and hygiene in school settings at all levels Continue Ministry of Education, Youth, and Sport Integrate all aspects of nutrition for all age groups into the roles and responsibilities of the national technical working group for nutrition Continue Technical Working Group for Nutrition Develop the national guideline on nutrition (covering all aspects of nutrition and all age group) Continue Technical Working Group for Nutrition Long-term actions Restrict marketing of unhealthy food and beverages to children Ministry of Information, Ministry of Health, Ministry of Industry and Handicraft Promote healthy diets and physical activity through the workplace where do not have health education programme Ministry of Health, Ministry of Labour and Vocational Training, and private sectors Explore financing mechanisms (subsidies and taxation) to make healthy diets more affordable & available Ministry of Economic and Finance, Ministry of Health, Ministry of Agriculture, Forestry and Fisheries, and Ministry of Industry and Handicraft 1.4. Reduce exposure to indoor air pollution Short-term actions Expand National Efficient Cook-Stove Programme Continue Ministry of Industry and Handicraft Ministry of Agriculture, Forestry and Fisheries Medium-term actions Long-term actions 30 Promote use of alternative cooking fuels Area of action 2 - Strengthen multisectoral governance and resources for NCDs 2.1. Develop national multisectoral action plan for the prevention and control of NCDs and establish a whole of government mechanism to oversee its implementation Short-term actions Establish a national mechanism to oversee the implementation of the national multisectoral action plan for the prevention and control of NCDs 2018 Improve capacity and coordination on NCD prevention and control within the Ministry of Health 2018 Medium-term actions Create a specific fund for NCD prevention and control from tobacco and alcohol taxation 2018 Ministry of Health, Ministry of Economic and Finance 31 Appendix 2 - High-level indicator framework for multisectoral action plan on NCDs in Cambodia Indicator Baseline Frequency Source Level reported Notes Action Area 1. Reduce population exposure to common factors 1.1 Accelerate tobacco control Prevalence of daily tobacco use in men and women >18 years* Men = 43.3% in 2011 Women = 17.2% in 2011 Every 4-5 years STEPS & NATSC surveys National (by gender, age & rural/urban) Exposure for environmental tobacco smoke Every 5 years STEPS National (by gender, age & rural/urban) 1.2 Scale up alcohol control Total alcohol consumption per capita (>15 years) per calendar year, of pure alcohol* 4.77 litres (2005) Annual WHO, FAO & industry data National Alternative indicator: % of adults 25-64 years who engaged in heavy episodic drinking in the last 30 days (from STEPS) Prevalence of binge drinking among adults 25 64 years Every 5 years STEPS National 1.3 Promote healthy diets (especially salt reduction) Prevalence of overweight or obesity among adults 25-64 years* 15.4% (2010) Every 5 years STEPS survey National (by gender, age & rural/urban) 2015 STEPS survey will include adults aged 18-64, but indicator should be kept to 25 64 years to allow comparison with 2010 Mean population salt consumption* n/a 2013, 2015, then every 5 years National salt consumption survey/STEPS survey National Will have baseline in 2013 Prevalence of raised blood glucose or diabetes among adults 25-64 years* 2.9% (2010) Every 5 years STEPS survey National (by gender, age & rural/urban) 32 Prevalence of hypertension among adults 25-64 years* 11.2% (2010) Every 5 years STEPS survey National (by gender, age & rural/urban) Percentage of adults 25 64 consuming <5 servings of fruit and vegetables per day* 84.3% (2010) Every 5 years STEPS survey National (by gender, age & rural/urban) Proportion of adult population (25-64 years) being physically active outside work* Every 5 years STEPS National (by gender, age & rural/urban) 1.4 Reduce exposure to indoor air pollution Proportion of households relying on solid fuels for cooking 89% (2010) Every 5 years DHS survey National (urban/rural) Proportion of households having an efficient cook stove Every 5 years DHS National (urban/rural) *These indicators are similar to the ones proposed in the global monitoring framework that were discussed at WHA in May 2013. Detailed explanations about how to calculate these indicators are given in the national strategic plan for NCD prevention and control 2013-2020. 33 9. References 1. World Health Organization. Noncommunicable Disease Country Profile 2014. Available at http://www.who.int/nmh/publications/ncd-profiles-2014/en/ 2. International Agency for Research on Cancer. GLOBOCAN 2008: Cambodia. 2010. Available at http://globocan.iarc.fr/factsheet.asp#BOTH 3. WHO Regional Office for the Western Pacific. Noncommunicable Diseases in the Western Pacific Region. A profile. World Health Organization, 2012. 4. National Institute of Statistics, Ministry of Planning. 2011 National Adult Tobacco Survey of Cambodia. Ministry of Planning, Kingdom of Cambodia, 2011. 5. University of Health Sciences & Preventive Medicine Department, Ministry of Health. Prevalence of Non-communicable Disease Risk Factors in Cambodia. STEPS Survey Country Report, September 2010. Ministry of Health, Kingdom of Cambodia, 2010. 6. 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