National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023- 2031)

1. Other Cardiovascular diseases 166 13%

2. Cerebrovascular Disease 105 8%

3. Ischemic heart disease 102 8%

4. Other respiratory diseases 80 6%

5. Lower respiratory infections 68 5% Source: Maldives Health Statistics 2020, Health Information and Research Section, Health Information Management and Research Division, Ministry of Health, 2021. Figure 1: Proportion of deaths by main categories, 2020. 4 World Health Statistics 2019. Page 12 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Source: Maldives Health Statistics 2020, Health Information and Research Section, Health Information Management and Research Division, Ministry of Health, 2021. Figure 2: Number of NCD deaths by gender, 2020, Page 13 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Source: Maldives Health Statistics 2020, Health Information and Research Section, Health Information Management and Research Division, Ministry of Health, 2021. The leading causes of death among adults of age 18 years and above for the Maldives in 2020 were cardiovascular diseases (CVDs), followed by chronic respiratory diseases and cancer (malignant neoplasms). Respiratory diseases were also the second leading cause of death in children age 0-14 years. 3 Cardiovascular diseases accounted for 50% of all deaths in 2020. Almost 50% of cardiovascular deaths were due to other cardiovascular diseases (i.e., possibly difficult to code accurately), followed by cerebrovascular diseases and ischemic heart diseases.3 Cancer (Malignancies) accounted for the 3rd highest cause of death 2020, with 135 deaths respectively. Among females, breast, liver, oral and multiple myeloma were the commonest causes of death in 2020. Among males, lung, liver, prostate and pancreas cancers were the commonest causes of death in 2020.3 Genitourinary Diseases associated cause of death was found to be the fourth most common cause of mortality in Maldives, while diabetes very closely follows as the fifth leading cause. However, it is of note that genitourinary diseases are a mixed bag of diseases including chronic kidney diseases, genitourinary infections and some diseases of the reproductive system, and is more often listed as an associated cause as the disease itself may not lead directly to death. Nephritis and nephrosis accounted for the majority of genitourinary diseases, 62% of male deaths and 38% of female deaths. 3 Chronic genitourinary diseases where evidence of kidney damage and/or reduced kidney function lasts at least 3 months, is largely preventable sharing the same risk factors as the 4 globally commonest NCDs. Suicide accounted for 3.25 deaths per 1000 population in 2017. (Source: Maldives Police Service) 5 Over half of these were among young people between 15-29 years old.5 Morbidity due to NCDs NCDs accounted for the majority of admissions in tertiary hospitals in Maldives in 2020. 35% of inpatients in tertiary hospitals were admitted due to NCDs. Cardiovascular disease was the top disease condition leading to admission in tertiary hospitals, following delivery and factors influencing health status and condition with health services, which were the top reasons for admissions. Cardiovascular diseases were the main cause of morbidity (inpatients in tertiary facilities) and mortality in the Maldives in 2020, accounting for 19% of all admissions, with 2785 admissions in number. Genitourinary diseases accounted for 18% of all admissions (2690), Digestive diseases 17% (2464), Endocrine Disorders 8% (1231) and respiratory diseases for 9% (1277) of all admissions. 3 5 Mental Health – Maldives Quick Facts. Published by Ministry of Health, 10 th Oct 2019. Page 14 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) The majority of cardiovascular disease admissions were due to ischemic heart disease (40%), Cerebrovascular disease (26%), Hypertensive heart disease (17%) and other cardiovascular diseases (14%), for both men and women. Male admissions for double that of female admissions. As expected, the number of admissions increased with age, gradually increasing from 25-34 years with the majority of admissions above 65 years of age. (Figure 3) 3 Page 15 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Figure 3: Inpatients with cardiovascular diseases in tertiary facilities by age groups, 2020 Source: Maldives Health Statistics 2020, Health Information and Research Section, Health Information Management and Research Division, Ministry of Health, 2021. Respiratory diseases were the fifth most common disease category for inpatients with 1277 inpatients. The top respiratory disease admissions were due to Other respiratory disease (85%), Chronic Obstructive Pulmonary Disease (36%) and Asthma (20%). There were more female admissions than male. Respiratory disease admissions were spread out almost evenly across all age groups, with a peak of 55% in age above 54 years. 3 Figure 4: Inpatients with respiratory diseases in tertiary facilities by age groups, 2020 Page 16 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Source: Maldives Health Statistics 2020, Health Information and Research Section, Health Information Management and Research Division, Ministry of Health, 2021 Cancer accounted for 434 admissions in 2020. Excluding cancers that cannot be categorized or multiple categories, the highest is for other malignant neoplasm (30mouth and oropharynx cancers (14%) and breast cancer (10%). At present we do not have data on cancer survival rates in Maldives, which needs to be collected. Figure 5: Inpatients with malignant neoplasms in tertiary facilities by age groups, 2016 Genitourinary diseases were the second most common disease category for inpatients in 2020, with 2690 admissions, and also fourth cause of mortality in the Maldives. 3 It is of note that this is a mixed bag of diseases including chronic kidney disease, genitourinary infections and some diseases of the reproductive system. Figure 6: Inpatients with genitourinary disease in tertiary facilities by age groups, 2020 Page 17 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Source: Maldives Health Statistics 2020, Health Information and Research Section, Health Information Management and Research Division, Ministry of Health, 2021. Health care cost of NCDs In 2012, the Maldives introduced a universal health insurance scheme called Aasandha, which was expanded to Husnuvaa Aasandha from 2014 as an unlimited health insurance scheme provided by the government. This covers all in-patient and out-patient services in government sector health facilities and certain approved private sector services.6 Where treatment is not available in Maldives, Aasandha also covers treatment abroad for referred patients treated in higher centers approved by Aasandha, for which there are formalized agreements for payment. Many of the treatments for advanced stages of the main NCDs with highest mortality are not available in Maldives, thus require treatment abroad, incurring very high costs to the government, plus high out of pocket expenditures to patients and families. E.g., coronary heart surgery, diagnosis and initiating treatment of cancer, renal transplant and even laser photocoagulation for diabetic retinopathy have to be treated abroad. 6 Maldives Demographic and Health Survey 2016-17. Ministry of Health (MOH) [Maldives] and ICF. 2018. Malé, Maldives, and Rockville, Maryland, USA: MOH and ICF. Page 18 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Thus, despite social insurance, out of pocket expenditures for medical treatment in general was still high at 29.5% in 2014. There was a decrease from 49% in 2011.7 The UHC Service Coverage Index was 55% for Maldives in 2015, similar to the SEA regional average of 56%.6 In addition to health care costs, NCDs result in large economic burden to society, such as absenteeism and loss of productivity resulting from NCDs and NCD risk factors. We do not have figures of these costs for Maldives. Prevalence of NCDs The most recent prevalence data available are from the Maldives Demographic Health Survey (MDHS) 2016-17. The last STEPS Survey was conducted in 2021-2022. The key adult population surveyed in MDHS was between age 15 to 49 years, while STEPS survey covered adults aged 15 to 69 years. MDHS also covered atolls as well as Male’, while STEPS only covered Male’. Therefore, while both are presented here to give a comparison, caution should be applied to avoid looking for trends between the statistics of these surveys, due to the difference in populations and methodology. Cardiovascular disease: Only 1% or less of women and men age 15-49 years self-reported that they have ever had a heart attack, a stroke or renal failure. The prevalence of heart attack and stroke increased with age. There were no significant differences by area of residence, education or wealth.8 However, as self-reported data could only capture severe yet non-fatal cardiovascular events, these may only be a part of the tip of the iceberg. We do not have data on prevalence of less severe cardiovascular disease, which would be much higher. Chronic respiratory disease: 11% of women and 7% of men age 15-49 years reported that they had either chronic obstructive pulmonary disease (COPD) or asthma. COPD is more common among women in Malé region than those in other regions.16 This is also likely to be an underestimate, being self-reported. Cancer: According to MDHS 2016-17, only 1% or less of women and men age 15-49 reported to have ever had cancer, 16 which is again likely to be an underestimate due to self-reporting. According to the National Cancer Control Plan, lip, oral cavity and pharynx cancers were found to be the most commonly occurring cancer in the Maldives for the period 2012 – 2016, followed by breast cancer, prostate cancer and cancers of the digestive organs/tract (i.e., colorectal, liver, stomach), and thyroid cancer. lip, oral cavity and pharynx cancers were the most common cancer across all ages from 0 years through to 69 years. In females, the top cancers were breast cancer, lip, oral cavity and pharynx cancers, thyroid cancer, cancers of the digestive organs/tract (i.e., colorectal, liver, stomach), and leukemia and lymphomas. The 7 National Health Accounts, quoted in Maldives Health Statistics 2015-2016, Health Information and Research Section, Health Information Management and Research Division, Ministry of Health, 2019. 8 Maldives Demographic and Health Survey 2016-17. Ministry of Health (MOH) [Maldives] and ICF. 2018. Malé, Maldives, and Rockville, Maryland, USA: MOH and ICF. Page 19 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) top 5 cancers among males were lip, oral cavity and pharynx cancers, prostate cancer, cancers of the digestive organs/tract (i.e., colorectal, liver, stomach), lung cancer and lymphomas. Childhood cancers reported in age group 0-19 years accounted for 15% of all cancers reported between 2012 to 2016 (n=482). This age group consists of 37% if the population according to 2014 Census.9 Diabetes: According to MDHS 2016-17, 4% of women and 2% of men said they had been told by a doctor or other health professional that they had diabetes. 16 This amounts to approximately 5850 people living with diabetes in Maldives.10 Prevalence increased with age. Self-reported prevalence of diabetes did not differ significantly by area of residence, region, education or wealth.15 In 2020-2021, STEPS survey showed that 4.8% of people had been diagnosed with diabetes. 2.3% (3.1% of women were 1.6% of men) were diagnosed with diabetes within the past 12 months.11 The prevalence of diabetes in Maldives is somewhat low compared to global statistics, despite the high prevalence of obesity. The global prevalence of diabetes among adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014.12 It is possible that self-reporting in MDHS could miss some cases, thus under diagnosis of diabetes in the later MDHS is a possibility. Among those with diabetes, about half (51%) of women and 43% of men said they were taking prescribed medication; 3.8% of women and 12.5% of men were taking insulin. Large majorities of diabetic respondents said they were working to control their weight, cutting down on sugar, exercising and stopping smoking (Table 2).16 Table 2: People with diabetes who are currently taking treatment 9 The NCCP for Maldives 2019 -2023. Health Protection Agency, Ministry of Health 10 Derived from age specific population from the Maldives Population & Household Census 2014. National Bureau of Statistics, Ministry of Finance & Treasury, Maldives. 2015. 11 WHO STEPS survey on risk factors for noncommunicable diseases Maldives, 2020-2021. Health Protection Agency Maldives and World Health Organization Country Office for the Republic of Maldives.2023 12 Global report on diabetes. World Health Organization 2016. Available from: https://www.who.int/news- room/fact-sheets/detail/diabetes Page 20 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Source: Maldives Demographic and Health Survey 2016-17. Ministry of Health Maldives and ICF. 16 18 Hypertension: According to MDHS 2016-17, 4% of women and 2% of men said they had been told by a doctor or other health professional that they had hypertension on 2 or more occasions. 15 This amounts to approximately 5850 people living with hypertension in Maldives.16 Prevalence increased with age. Self-reported prevalence of hypertension did not differ significantly by area of residence, region, education or wealth. 16 However, since most of the hypertensive patients are asymptomatic, this self-reported prevalence may highly underestimate the true prevalence. Indeed, STEPS survey 2020-2021 showed that the prevalence of raised blood pressure (SBP ≥140 mmHg and/or DBP ≥90 mmHg or currently on medication for raised blood pressure) among the respondents was 23.9% (21.8% among men and 26.3% among women). 18 Table 3: People with diabetes who are currently taking treatment – MDHS 2016-17 Source: Maldives Demographic and Health Survey 2016-17. Ministry of Health Maldives and ICF.16 According to the STEPS survey 2020-2021, only 16.3% received treatment. The higher treatment rates in later MDHS could be due to self-reporting in MDHS, leading to people with more awareness admitting to having hypertension, thus being keener on Page 21 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) treatment with both medicines and lifestyle modification Therefore, Maldives requires more actions to improve detection and increase treatment and lifestyle management of hypertension and diabetes. Mental health: In 2017, 207 hospital admissions to IGMH were for mental health and behavioral conditions. Of these, 200 were Maldivians and 7 foreigners. 46% were males. Around 2 in 10 were repeat admissions.8 The survey of the Mental Health Situation in the Maldives (2003) revealed that 29.10% of the sample self-reported that they suffer from mental health conditions. The survey estimated that the prevalence of neurosis was 22.3% while the prevalence of psychoses was at 1%. Furthermore, twice as many women were found to suffer from depression, anxiety and somatic symptoms in comparison to men.13 Substance abuse: (4.4%) of students had ever used marijuana one or more times during their life. Of these, 69% had used drugs for the first time before age 14 years. Drug use was more common among boys (6.7%) than girls (1.7%).21 Thalassemia: Maldives has a relatively high prevalence of Thalassemia. 623 patients were taking treatment for Thalassemia in 2016. There were 3 Thalassemia deaths in 2015 and 6 deaths in 2016. A total of 9,543 and 6,091 people were screened for Thalassemia in 2015 and 2016 respectively. With these screenings, by 2015 and 2016, more than 400 males and females were registered in Maldives Blood Service (MBS). 22 new cases were detected in 2015 and 14 in 2016. More new patients were detected in the atolls. 15% of those screened in 2016 were found to be B- Thalassemia carriers.3 Disability: According to Household Income and Expenditure Survey (HIES) Maldives 2019, prevalence of disability stands at 9% of the population above 5 years age. Disability increased with age. The highest prevalence of disability was 58% at ages above 75 years. The prevalence of disability among children (aged 5-17 years) was 4%. Almost 35% of the population with disability experience multiple disability. Among them, most experience difficulty in two domains. Men tend to experience more difficulty by multiple kinds of disability. Majority of 13 Niyaz, H., & Naz, A. (2003). Mental health situation in the Maldives. Male': Ministry of Health. Page 22 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) them have disability in 2 or 3 domains. 14 According to the Maldives Demographic Health Survey (MDHS) 2016-17, the proportion of the household population with any disability declined as wealth increased.16 NCD RISK FACTORS STEPS survey 2020-2021 showed that dietary habits, high blood pressure, high body mass index and tobacco use were in the top five attributable risk factors for the burden of disease in the country.3 Population/city-based surveys show that the prevalence of NCD risk factors has not shown any decrease in the population in the past decade. Tobacco use: Tobacco use is highly prevalent in Maldives. MDHS 2016-17 showed that 42% of men smoked any type of tobacco. Smoking any type of tobacco was 2.7% among women.16 Almost all male smokers smoked cigarettes, while half of the women smokers smoked other types of tobacco (including hooka/shisha, bidis, cigars, pipes, and e-cigarettes). Among men who smoke cigarettes daily, majority of close to one-half (45%) smoke 15-24 cigarettes each day while 9% of daily cigarette smokers smoke 25 or more cigarettes each day. The highest prevalence of smoking was in the younger age group 20-24 years among men and in the older age group of 45-49 years among women.16 This was similar to STEPS survey 2020-2021, where smoking among women was highest among the age group of 45-69 years. 18 16 Smoking among adults seems to have increased by 2016-17, particularly among men (42%), when compared to the prevalence of 34.7% of men and 3.4% of women in the STEPS survey 2011, given that the MDHS covers a narrower age range than the STEPS survey. Smoking prevalence among people 15-65 years was 18.8% in 2011 STEPS Survey and 22% in 2004.18 In the STEPS Survey 2020-2021, 23.1% are current smokers out of which (35.6% are males and 7.6% are females), out of the current smokers, 87.1% are daily smokers and the most commonly used type is manufactured cigarettes. About 5% of the population also uses smokeless tobacco. The mean age at which the respondent’s started smoking was 18 years.18 However, smoking among adolescents has decreased slightly, according to Global School Health Surveys (GSHS). Tobacco uses among school going students aged 13-17 years showed a slight decrease in prevalence in 2014 with 12.3% (CI: 10.7-14.1) of students who currently used any tobacco products during at least one day during the past 30 days before the survey, 14 Maldives Bureau of Statistics, Ministry of National Planning & Infrastructure. Household Income & Expenditure Survey (HIES) Maldives 2019, available from: https://statisticsmaldives.gov.mv/demographic- characteristics-by-disability/ Page 23 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) compared to 14.7 (CI: 12.1-17.7) in 2009.15,16 Between 2009 and 2014, the Tobacco Control Act (2010) was implemented, and a regulation banning smoking in most public places was implemented from December 2012. However, it is alarming that the youngest age of initiation had decreased to less than 7 years of age in 2014, from 9 years age in 2009. 18 Another major concern is the high exposure to second hand smoke. MDHS showed that someone smoked indoors on a daily basis in more than 1 in five (22%) of households. It is alarming that 63.4% (CI 60.5-66.2) of school children aged 13- 17 years reported that people smoked in their presence on one or more days during the 7 days before the GSHS survey.22 The reports of Grade 1 student health screening conducted nationwide by the Ministry of Education showed that parental smoking and tobacco use was high (40%) among parents of Grade 1 students, exposing these young children to tobacco smoke and related health problems. Asthma was the commonest medical illness among these children, with 5.8% of children suffering from asthma. 17, 18 There was as strong association between asthma and parental smoking. Children whose parents smoked had a risk of 11 times that of children whose parents did not smoke (P<0.05).21 Parental tobacco use was higher in the atolls than Male’ (49% vs. 23%), indicating the need for more education and better implementation of tobacco control laws such as smoking bans in the atolls.24 There was a decrease in parental tobacco use from 47% in 2016 to 40% in 2018, indicating that addressing this risk factor during school health screenings at this key stage of life for a child and his/her parents may have helped to educate parents and reduce parental smoking and the risk to children to some extent.21 During this period media awareness campaigns and programs on the risks of tobacco were minimal. Unhealthy dietary practices: Fruit and vegetable consumption is very low among Maldivians. In Male City, 92.6% of men and 94.6% of women consumed only one serving of fruits and /or vegetables per day 19 far behind the WHO recommended serving of five portions of fruits and vegetables in a day. In a typical week, fruits were consumed on 3.3 days and vegetables on 3.8 days. Maldivians also appear to consume diet high in salt and saturated fats. There is no data of mean salt intake for Maldivian population. The expert opinions speculate that salt 15 Global School-based student Health Survey Maldives 2014. Ministry of Education, Republic of Maldives. 16 Global School-based student Health Survey Maldives 2009 Country Report. Ministry of Education, Republic of Maldives. Ministry of Health and Family; World Health Organization and Centre for Disease Control and Prevention. 17 School Health Screening Report 2018: Grade 1. Ministry of Education, Ministry of Defense and Ministry of Health of the Republic of Maldives. 18 School Health Screening Reports: Grade 1: 2016. Ministry of Education, Ministry of Defense and Ministry of Health of the Republic of Maldives. Page 24 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) consumption would be much higher than the recommended level of <5 g/day. 19 Consumption of sugary drinks and energy drinks has been trending over the recent years, with sugary drinks and energy drinks being heavily advertised. GHSH 2014 showed that 33.8% of students consumed carbonated soft drinks one or more times per day during the 30 days before the survey. This was higher among boys than girls (37.5% vs. 29.8%).21 An early start in healthy dietary practices is important for reducing NCDs, and breastfeeding and healthy feeding practices in infancy are key measures. According to the 2016-17 MDHS results, 64% of children under age 6 months were exclusively breastfed. 62.7% continued breastfeeding till 2 years. 16 The feeding practices of only half of children age 6-23 months (51%) in the Maldives meet the minimum standards with respect to all three IYCF practices (breastfeeding status, number of food groups, and times they were fed during the day or night before the survey). 76% of children had an adequately diverse diet in which they had been given foods from the appropriate number of food groups, and 70% had been fed the minimum number of times appropriate for their age. There was a slight decrease in the proportion of children age 6-23 months who were fed appropriately since MDHS 2009. Children in Malé (59%) and North Central region (58%) were more likely to fed according to the minimum acceptable dietary standards than those in South region (35%). The likelihood that a child is receiving the minimum acceptable diet generally improved with the mother’s education level and household wealth.16 Physical inactivity: According to the STEPS survey 2020-2021, 45.8% (47% men and 44.2% women) were not achieving the recommended level of physical activity. According to the GSHS 2009, only 25.5% of children achieved the required level of physical activities of 60 minutes per day. Boys were more physically active than girls (29.3% vs. 21.9%). 41.6% of students spent three or more hours per day doing sitting activities during a typical or usually. Sedentary behavior was more common in Male’ (46.2%) than in atolls (39.6%).22 More recent statistics on physical activity was not available, including the GSHS 2014. Obesity and Metabolic risk factors: According to MDHS 2014, almost half of women (49%) in the Maldives are overweight (BMI Between 25.0 and 29.9) or obese (BMI >30). 40% had normal weight for their height and 11% of women were thin. Mean BMI for women was 25.4. Over one third of men (35%) were either overweight or obese (BMI >25), while half (51%) had normal weight (BMI between 18.5 and 24.9), and 14% were thin (BMI below 18.5). The mean BMI for men age 15-49 was 23.5. (Figure 8) The proportion of women and men who are overweight or obese increases steadily with age. Overweight and obesity among women was higher in the atolls than in Male’, and 19 Interview with Dr. Ali Nazeem, MD (Internal Medicine), Indira Gandhi Memorial Hospital, Male’, April 17, 2014. Page 25 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) decreased with increasing education and also to some extent with increasing wealth. There was no particular pattern for men. 16 Page 26 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Figure 9: Nutritional status of men and women aged 15-49 years in 2016-17 Source: Maldives Demographic Health Survey 2016-17. Ministry of Health Maldives.16 GHSH 2014 showed that 15.8% of adolescents between age 13 and 17 years were overweight (>+1SD from median for BMI by age and sex), and 4.9% of students were obese. Being overweight was higher among girls (17.8%) than boys (13.7%). Being overweight was higher in Male’ (19.2%) than the atolls (14%). In Male’, being overweight was higher among younger children aged 13-15 years (23.1%) than the older ones aged 16-17 years (15.6%),21 indicating a possibility for obesity to continue to increase further. According to MDHS 2014, the proportion of children who were overweight decreased very slightly, from 6% to 5% from 2009. 5% of children were overweight, 15% of children were stunted and 9% were wasted or too thin for their height. The prevalence of stunting had decreased to 15% from 19% in 2009.16 Data on hypercholesterolemia was not available. Hypertension and diabetes are discussed above. Alcohol use: Overall prevalence of current drinkers is less than 1% as per the STEPS 2020-2021. Although this is encouraging, statistics suggest that a small portion of young children are taking up alcohol as well according to the GSHS 2009.22 Nearly 4% of children reported consuming alcohol and majority who consume in an amount to get drunk. (Alcohol use had not been assessed in GHSH 2014 due to an error in the question, however, majority (74.7%) of students who drank alcohol tried it for the first time at a young age – below 14 years.) Also, a similar proportion (4.4%) of students had ever used marijuana one or more times during their life. Of these, 69% had used drugs for the first time before age 14 years. 22 Page 27 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Air pollution: The estimated age-standardized mortality rate attributed to household and ambient air pollution in Maldives was 25.6 per 100,000 population, which is the lowest among countries of the SEAR.20 The limited ambient air quality monitoring results available from Male’ showed air pollution exceeding the WHO health standard in 28 of the 38 weekly samples (74%). The WHO ambient air quality standards for PM2.5 are 10ug/m3 (as an annual average), and 25ug/m3 for a 24-hour (99th percentile) value. These samples were taken as weekly high-volume samples from a single station in the capital Male over 12 months between January 2013 and January 2014. The results from this study (MCOH 2015) indicate the annual average PM2.5 in Male was 19ug/m3, compared to the MCOH remote site where the annual average was 13ug/m3. 21 Motor vehicle use: From 2007 to 2014 the number of vehicles has increased over 295%, despite the small size of Male’. Diesel consumption contributes to 80 % of Maldives carbon dioxide emissions and vast majority of diesel emission in the country comes from transport sector and energy generation.27,22 Less than 1% of households in the Maldives uses some type of solid fuel for cooking, with the vast majority using liquefied petroleum gas (LPG) or natural gas. 72% of households cook inside the house (96% of households in Malé region and 57% of households in other atolls); however, since 98% of households use clean fuel for cooking, cooking inside the house is not an important source of air pollution in Maldives. Rather, the most important source of smoke inside the home in the Maldives is due to smoking. In more than one in five households (22%), someone smoked inside the house on a daily basis.16 PROGRESS , CHALLENGES AND OPPORTUNITIES FOR CONTROL OF NCDS Health Master Plan (2016-2020) recognizes health promotion and NCD prevention as a key approach to improve population health. The two-year national strategic plan (2008-2010) for NCD was yet another clear step taken to address NCDs. Even though the Strategic Plan could not be implemented at a full scale, important milestones were achieved. The key ones were instituting NCD surveillance through NCD STEPS survey, creation of NCD Unit at the HPA, enactment of tobacco control laws in 2010, piloting PEN intervention and sensitizing political bodies in the country on NCDs. It was followed by the National Multisectoral Action Plan for the Prevention and Control of Noncommunicable Diseases 2016-2020. 20 World Health Statistics 2019 21 Maldives Breathe Life Implementation Plan (2019 – 2020) (Draft) shared by HPA Environmental Health program 22 http://breathelife2030.org/news/breathelife-welcomes-greater-male-region-maldives/ Page 28 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) The health system is well distributed and staffing levels of doctors, nurses and other health workers have improved in the past few years particularly through the hire of expatriates from outside. However, the high turnover of health care professionals is a challenge. The health centers and hospitals are equipped to provide basic level of care for all health services including NCDs, however the baseline coverage needs to be assessed. With the number of private health care providers on the rise, the coverage and options for NCD related services would also increase. Special attention must be paid in maintaining equity in access to NCD services due to geographical spread of islands. Sizeable numbers of NGOs are directly or indirectly engaged in prevention and control of NCDs and other health issues. NCDs need to be managed within the existing framework of the Maldives legal and governance structure creating an inclusive process for all sectors participation and contribution. While managing the basic health care services, the capacity of tertiary care facilities cannot be ignored. Currently, IGMH, regional Hospitals, Atoll Hospitals and ADK hospital provide the tertiary services; capacity improvement is required for advanced NCD management either through building the capacity of the institutions and/or developing better referral linkages within or outside the country. The State sponsored social health insurance scheme, Aasandha provides universal coverage which is an immense safety net for the Maldivians. However, the insurance scheme needs to be responsive to address the gaps that may arise with the surging population needing NCD medical care and to minimize out of pocket payments and catastrophic health expenditure. Urbanization and demand of physical space will also be a challenge for physical activity promotion. Ever increasing traffic volume and associated pedestrian accidents are a problem in Male’.23 This provides an invaluable opportunity to rethink the urban structural development, vehicle import policies and restructuring major cities like Male’ to enable long range planning. Sole dependence on the imported food products, the country needs strong domestic policies. Capacity strengthening is required at the MFDA to ensure proper regulation of the quality of imported food products and other goods. The globalization effects of trade are palpable with high use of tobacco, fast acculturation of beverage promotion and changing food habits in the country. With the implementation of a risk factor-based model of NCDs prevention and control, influences and conflict of interest of tobacco, food and beverage industries can be transparently managed. Existing school based healthy lifestyle programs, momentum in tobacco control laws, and the growing interest of NGOs for NCD prevention and control and recognition by non-health government sectors on NCDs as a cross sectorial issue holds a great opportunity for a true multisectoral response for NCDs in the Maldives. The Health Awards, given out annually in 23 Injury prevention program, HPA Page 29 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) connection with the World Health Day in recognition of excellence in healthcare services, has been instrumental in the healthcare facilities according greater importance to broaden their spheres of service, including those related to the control and management of NCDs. The government’s plans to restructure the capital city, with a focus to provide more recreational and socializing areas, and new initiatives for green spaces like such as Rasfannu beach area, free for use outdoor exercise areas in Male’, Hulhumale’ and several islands would result in tangible health outcomes, in the foreseeable future. Page 30 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) PART II- APPROACHES AND STRATEGIC ACTIONS PROCESS OF DEVELOPMENT OF THE MULTISECTORAL NCD ACTION PLAN The initial Action Plan (2016-2020) was developed through a multi-step process of consensus building of the stakeholders. A technical consultant of World Health Organization from WHO SEARO was appointed to initiate the discussion and gather views and suggestions from the stakeholders from April 13-May 6, 2014. The consultant did the desk review of the NCD response and met with stakeholders individually and in groups. Stakeholders were organized in thematic clusters and a two-day meeting was conducted on April 21-22, 2014. The recommendations of the stakeholders were compiled and the document was circulated for feedback. A final stakeholder consultation was held on April 30, 2014. Several activities in the plan were implemented, and the progress is detailed under the specific sections of this NCD MAP. The revised NCD Multisectoral Action Plan (2023-2031) was prepared by a national technical consultant through WHO. An evaluation was conducted using the WHO NCD MAP evaluation tool24 on the first NCD MAP and its implementation and the current situation of NCDs and risk factor prevalence in Maldives through desk review and series of meetings with HPA NCD prevention and control program and various stakeholders. Accordingly, a revised Action Plan was developed based on the current evidence-based Best Buys for NCD prevention and control25 and plans of the NCD prevention and control program and other programs of HPA and MOH, with inputs from a wide representation of stakeholders engaged by a series of meetings held through June-September 2019 with various stakeholders in groups, and where more inputs were needed, with individuals and specific organizations. Stakeholders were engaged from the following broad categories: a. HPA and MOH: the various departments and Divisions b. Health facilities in Male’ and the atolls c. Government organizations including ministries, implementing organizations and independent monitoring organizations d. Community based organizations (NGOs) e. Universities and institutions providing formal professional training and higher education f. Media 24 WHO toolkit for evaluating NCD MAP, available from: http://apps.who.int/nmh/ncd-map- toolkit/evaluating/tool-framework.html, http://apps.who.int/nmh/ncd-map-toolkit/evaluating/tool-steps.html 25 WHO. Tackling NCDs: "Best buys" and other recommended interventions for the prevention and control of noncommunicable diseases. 2017. WHO reference number: WHO/NMH/NVI/17.9 Available from: https://www.who.int/ncds/management/best-buys/en/ and https://www.who.int/ncds/management/WHO_Appendix_BestBuys.pdf Page 31 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) The complete list of stakeholders is given in the list of Abbreviations under Stakeholders involved Under the list of Abbreviations. The recommendations of stakeholders were incorporated and circulated by email among the stakeholders for further comments, which were incorporated accordingly as appropriate, and discussed for consensus and incorporated where opinions differed. CONTEXT Health Protection Agency (HPA) is the main public health organization responsible for NCD prevention in Maldives. HPA is a semi-independent organization headed by a Director General, under the Ministry of Health, and reports to the Minister of Health, who holds overall responsibility for the functions of HPA. The main unit responsible for NCD prevention and control is the Health Promotion & Chronic Diseases Division of HPA. This department looks after NCD prevention and control, mental health and health promotion. There is a Unit for NCD prevention and control within this Division. Other departments in HPA heavily involved in NCD prevention and control include the Population Health Division, of which Nutrition, Reproductive Health and Environmental Health sections play a large role. Other departments including, Communicable Disease Control Division, Public Health Surveillance Division and the sections under them do also have overlapping areas of work. Other technical departments in the Ministry of Health (MOH) that play a role include Maldives Food & Drug Authority (MFDA) which is responsible for regulation of food safety, and Health Information Management and Research Division (HIMRD) which collects, analyses and reports on the national disease burden statistics from health facilities and from the national Vital Registry System (VRS) through the National Bureau of Statistics. Ministry of Health (MOH) is overall responsible for the planning and provision of health services for the management of NCDs including diagnosis, screening, early detection and treatment through a network of health facilities nationwide. The main tertiary hospital, Indira Gandhi Memorial Hospital (IGMH), in the process of upgrading to a larger Dharumavantha Hospital with a higher capacity, is a government hospital independent from the Ministry of Health, functioning directly under the President’s Office (PO). MOH has a network of Regional and Atoll hospitals and Health Centers throughout the atolls. Each Regional or Atoll hospital, situated in the capital island of the atoll, caters to the needs of the atoll population and provide leadership to the health Centers catering to the populations of the islands, which are under these hospitals. Each Regional or Atoll hospital has a Public Health Unit providing preventive services. Island Health Centers provide preventive and curative services within the same premises. Urban primary care centers called Dhamanaveshi that provide preventive services were planned for cities such as Male’ City, Addu City in the south and Kulhudhuffushi in the north of Maldives. However, the process is slow. Dhamanaveshi was established only in Male’ since 2015 which has seen significant developments in NCD prevention and control services at PHC level. Addu Dhamanaveshi did not last long and was subsequently converted Page 32 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) back to a Health Center. MOH plans to upgrade regional hospitals to tertiary hospitals, during which process it is possible that the PHC services would change to Dhamanaveshi’s situated outside the hospital. The Republic of Maldives recognizes the increasing prevalence of NCD risk factors and the growing burden of NCDs in the population as a developmental issue. In order to tackle the rapidly growing NCD burden in a swift and evidence-based, effective manner, the National Multi-sectoral Action Plan for the control of NCDs (2023-2031) aims to provide a clear pathway in the nation’s pursuit to join the global fraternity to achieve the voluntary NCD targets for 2025 and 2030. The Action Plan builds on the past initiatives implemented under the National Multi-sectoral Action Plan for the control of NCDs (2016-2020) and the Maldives National Strategic Plan for Prevention and Control of NCDs 2008-2010. The Action Plan is also motivated by nation’s commitments made at the international and regional forums most important among them being; • The Political Declaration of the High-level Meeting of the United Nations General Assembly on the Prevention and Control of NCDs (September 2011) • Global Action Plan for the Prevention and Control of NCDs (2013-2020) endorsed through resolution WHA66.10 (May 2013) • Resolutions of the Twenty-ninth Meeting of the Health Ministers in SEARO, 2011. • The Clomo Declaration to Strengthen NCD Services at the primary health care, 2016 26 SCOPE AND LINKAGES The Multi-sectoral NCD Action Plan will cover five key modifiable risk factors (tobacco use and exposure, consumption of unhealthy diets, physical inactivity and alcohol use, air pollution) and five key NCDs accounting for the highest mortality (cardiovascular diseases, chronic obstructive pulmonary diseases, cancer, diabetes and mental health). Additionally, a small component has been included on management of chronic kidney diseases and Thalassemia, as these diseases also contribute significantly to the NCD burden in Maldives. The Action Plan will ensure a holistic multisectoral approach embracing policy, legal/regulatory and structural components necessary to address complex social determinants of NCDs and their risk factors. Most importantly, the Action Plan will have heavy reliance on partnerships with non-health stakeholders and their efforts to integrate NCD prevention strategies within their plans. Within the Health Sector, the Action Plan will build synergies with the existing programs such as tobacco control, nutrition, maternal and child health, environmental health, occupational health, injury prevention and road safety, communicable disease control, immunization, mental health and prevention of substance abuse to name a few. 26 • The Clomo Declaration to Strengthen NCD Services at the primary health care, 2016. http://www.searo.who.int/mediacentre/events/governance/rc/colombo_declaration_final.pdf?ua=1 Page 33 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) SOCIAL, ECONOMIC AND COMMERCIAL DETERMINANTS AND RISK FACTORS OF NCDS The action plan will be guided by the pyramidal framework shown below to prioritize NCD interventions. The framework portrays the influence of social determinants, effect of globalization and urbanization on the metabolic risk factors and subsequent development of the clinical NCD conditions. The increasing burden of NCDs is attributed to social determinants of health, in especially population ageing, rapid and unplanned urbanization, effects of globalization (such as trade and irresponsible marketing of unhealthy products), low literacy and poverty. The policies addressing social and economic determinants at the macro level have impacts on NCDs. The health sector related interventions generally targeted at the upper level of the pyramid are costlier while an intervention at the lower portion of the pyramid caters to larger population and are cost effective and multisectoral in nature. The framework demonstrates the need of a comprehensive approach addressing the various levels of determinants for implementing NCD prevention and control. Figure 10: Determinants of NCDs. Health sector Other sectors Source: Adapted from SEA Regional NCD Action Plan VISION For all people of the Republic of Maldives to enjoy the highest attainable status of health, well-being and quality of life at every age, free of preventable NCDs, avoidable disability and premature death. GOAL To reduce preventable morbidity, avoidable disability and premature mortality due to NCDs in the Republic of Maldives. Page 34 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) SPECIFIC OBJECTIVES

1. To raise the priority accorded to the prevention and control of noncommunicable diseases in the national agendas and policies according to international agreed development goals through strengthened international cooperation and advocacy

2. To strengthen national capacity, leadership, governance, multisectoral action and partnership to accelerate country response for the prevention and control of noncommunicable diseases

3. To reduce modifiable risk factors for noncommunicable diseases and underlying social determinants through creation of health-promoting environments

4. To strengthen and orient health systems to address the prevention and control of noncommunicable diseases and underlying social determinants through strengthening primary health care approach.

5. To promote and support national capacity for high quality surveillance and operational research development for the prevention and control of noncommunicable diseases. TARGETS FOR 2025 and 2030 The country goals for 2025 will align with the regional targets with only a slight variation in goal viii. However, with the slowing down of activities due to the Covid-19 pandemic, we have revised the plan to achieve these targets by 2031. This goal will target to reduce indoor tobacco smoke exposure and reduction of air pollution in general rather than focusing only on reducing household air pollution due to use of fossil fuels, which is very low in Maldives (<1% of households). All goals have been set as % relative reduction compared to baseline in year 2011 and 2015. (i) A 25% relative reduction in premature mortality from cardiovascular diseases, cancers, diabetes, chronic respiratory diseases, chronic renal diseases and psychological diseases; i.e. a. Relative reduction of mortality attributed to NCDs from 81% to 60% by 2025. b. Relative reduction of proportional mortality due to NCDs from 75% in 2015 to 56% by 2031 c. Relative reduction of the risk of premature death from CVD, cancer, diabetes, chronic respiratory disease between age 30 and 70 years from 16% in 2014 to 12% by 2030. (ii) Relative reduction of suicide mortality rate from 3.25 per 100,000 population in 2017 to 2.4 per 100,000 population by 2030. (iii) A 30% relative reduction in age standardized prevalence of current tobacco use in persons aged 15 years and older. This will amount to reducing tobacco prevalence from 18.8% (34.7% of men and 3.4% of women) in 2011 to less than 14% (less than 24% of men and less than 2.4% of women by 2030. (iv) Total abstinence of alcohol and other substances use. a. To maintain total alcohol per capita (≥15 years of age) consumption below 3 liters of pure alcohol per year since 2011. b. to maintain the alcohol, use among adults at below 1% (from 2011) c. reduction of prevalence of alcohol use of alcohol among adolescents from 4% in 2009 to 3.6% in 2031 (v) A 25% relative reduction in prevalence of insufficient physical activity, that is from 45.9% in 2011 to less than 34% in 2031. Page 35 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) (vi) A 30% relative reduction in mean population intake of salt/sodium from 8g/day in 2010 to 5.6 g/day by 2031. (vii) A 30% relative reduction in inadequate fruit & vegetable intake from 92.6% men, 94.6% women in 2011 to 70% by 2031. (viii) A 15% reduction of areca nut chewing (baseline to be assessed in next STEPS survey). (ix) A 25% relative reduction in prevalence of raised blood pressure, i.e., a reduction of hypertension prevalence from an estimated 16.6% in 2011 to less than 12.5% by 2031. (x) Halt the rise in obesity and diabetes, i.e., maintain the prevalence of obesity at not more than 26% and that of diabetes at not more than 4.7% by 2031. (xi) A 50% relative reduction in air pollution a. A 10% reduction in mortality rate attributed to household and ambient air pollution from 25.6 per 100,00 to 23.4 in 2018 per 100,000 by 2031. b. Prevalence of exposure to second hand smoke in homes, work places and public places in closed settings (e.g., restaurants, hotels, cafés), i.e., reduce the prevalence of exposure from 21.3% of exposure at home and 17.1% at work places to less than 11% and 9% respectively by 2031, baseline to be assessed for exposure in restaurants. (xii) A 25% reduction in ambient air quality and indoor air quality (PM2.5 particle concentration)- baseline to be measured (xiii) Above 50% of eligible people receive drug therapy and counseling (including glycemic control) to prevent heart attacks and stroke, i.e. to maintain the proportion of eligible people with hypertension, diabetes and hyperlipidemias receiving drug therapy and counseling for healthy lifestyle above the present baseline values (all above 50%-see section on monitoring) and increase brief intervention for stopping smoking from 15.4% of patients advised to above 50% of patients advised and above 80% of current smokers among the patients. (xiv) An 80% availability of affordable basic technologies and essential medicines, including generics, required to treat major NCDs in both public and private health facilities a. % of inhabited islands with health facilities that have pharmacies (baseline to be assessed) (Number of pharmacies (ALL inhabited islands have at least one pharmacy): 339 in 2017) b. % of health facilities where patients have access to at least 80% of the basic medicines and technologies identified in PEN protocols (baseline to be assessed under the Monitoring activities using basic technologies required under the PEN protocols) Please refer to Part IV- Monitoring the implementation and outcomes for indicators, sources of information and methods of measuring the target outcomes. GUIDING PRINCIPLES The NCD national action plan relies on the following overarching principles and approaches. Focus on equity: Policies and programs should aim to reduce inequalities in NCD burden due to social determinants such as education, gender, socioeconomic status and migrant status. Multi-sectoral actions and multi-stakeholder involvement: To address NCDs and their underlying social determinants and risk factors, functioning alliances are needed within the Page 36 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) health sector and with other sectors (such as agriculture, education, finance, information, sports, urban planning, trade, transport) involving multiple stakeholders including government, civil society, academia, the private sector and international organizations. Life-course approach: A life-course approach is key to prevention and control of NCDs, starting with maternal health, including preconception, antenatal and postnatal care, and maternal nutrition; and continuing through proper infant feeding practices, including promotion of breastfeeding and health promotion for children, adolescents and youth; followed by promotion of a healthy working life, healthy ageing and care for people with NCDs in later life. Balance between population-based and individual approaches. A comprehensive prevention and control strategy needs to balance an approach aimed at reducing risk factor levels in the population as a whole with one directed at high-risk individuals. Empowerment of people and communities: People and communities should be empowered to promote their own health and be active partners in managing disease. Health systems strengthening: Revitalization and reorientation of health care services are required for health promotion, disease prevention, early detection and integrated care, particularly at the primary care level. Universal health coverage: All people, particularly the poor and vulnerable, should have equitable access to health care, without discrimination, to nationally determined sets of the needed promotive, preventive, curative, rehabilitative and palliative basic health services, as well as essential, safe, affordable, effective and quality medicines and diagnostics without exposing the users to financial hardship. Evidence-based strategies: Policies and programs should be developed based on scientific evidence and/or best practice, cost-effectiveness, affordability, and public health principles. Appropriate monitoring and surveillance system should be placed for regular monitoring of the progress and results. Management of real, perceived or potential conflicts of interest: Public health policies for the prevention and control of NCDs should be protected from undue influence by any form of vested interest. Real, perceived or potential conflicts of interest must be acknowledged and managed. Strategic Priority Actions for NCD prevention and control The priority activities for the Republic of Maldives are structured around four strategic objectives, each having specific sub- objectives, with activities and sub-activities categorized under these: Page 37 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031)

1. Strategic Objective 1: Governance

2. Strategic Objective 2: Health promotion and risk factor reduction

3. Strategic Objective 3: Health systems strengthening for early detection and management of NCDs and their risk factors

4. Strategic Objective 4: NCD Surveillance, monitoring and evaluation and research Implementation of these strategic actions is expected to lead to a reduction in overall mortality from the five main NCDs including mental health and attempts to achieve the goals and targets for NCD prevention and controls. This is a multi-sectoral plan where actions will be implemented in close collaboration with other health programs within HPA and MOH, as well as through the programs of other sectors including government organizations, academia, civil society and private sector. Strategic Objective 1: Governance Actions under this area aim to • increase advocacy, • promote multi-sectoral partnerships, and; • strengthen capacity for effective leadership to accelerate and scale-up the national response to the NCD epidemic under the national government. There are 3 areas under this objective, and the key measures planned are described under these areas: Objective 1.1: Strengthen advocacy for NCD prevention and control Objective 1.2 Strengthen national coordination for multi-sectoral action on the prevention and control of NCDs Objective 1.3: Strengthen national NCD Leadership Objective 1.1: Strengthen advocacy for NCD prevention and control Key actions planned under this objective are as follows (Details, timelines and more actions are given in Annex 1. Numbers are activity/sub-activity numbers assigned in the tables.): • Form a permanent or regular NCD/Health promotion Advocacy network of NGOs and academic institutions, where HPA can regularly update on progress and alert about sudden challenges and threats to stop effective NCD prevention measures and mobilize rapid community response to advocate collectively to overcome these in a quick and timely manner – HPA should lead this network, as recommended by Maldives NCD Alliance and other NGOS. A Viber group could help with regular communication and rapid response to threats. • Capacity building of NGOs and academia to advocate – including trainings on how to advocate effectively, sharing of resources, latest international developments, policy briefs and IEC material for advocacy, etc. • Engage universities to advocate for effective NCD prevention and control measures, train and engage students on advocacy for effective NCD prevention and control measures (see roles of universities in Annex 2) Page 38 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) • Step up advocacy to MPs, Social council and Cabinet of Ministers by going to them and presenting on effective NCD prevention and control policy measures and Best Buys • Engage and build capacity of media to promote healthy lifestyles, advocate for Best Buys policy measures for NCD prevention and control and monitor implementation and industry interference including not accepting partnerships, sponsorships or funding from entities engaged in business or activities that are in conflict with the objectives of this plan. • Engage private sector for NCD prevention and control and promotion of healthy lifestyles through workplace screenings and healthy lifestyles initiatives, and resource mobilization through partnerships and sponsorships for conducting awareness programs, events promoting healthy lifestyles and NCD prevention activities. • Mobilize funding from a variety of sources – international and national, not limited to WHO. e.g., Dhiraagu/Ooredoo in providing health information to public through their portals, M- health applications, etc., Allied Insurance in incorporating NCD prevention into their product advertisements and promotional events, Banks and event organizers for organizing healthy events, guided by HPA or health related NGOs using approved guidelines, media partnerships for health promotion. Objective 1.2 Strengthen national coordination for multisectoral action on the prevention and control of NCDs The NCD prevention and control Unit of HPA is responsible for the national coordination of NCD prevention and control. A High Level NCD Steering Committee is to oversee the multisectoral activities for NCD action plan. The country needs to have more effective national coordination mechanisms for NCD prevention and control. Higher level political involvement in the coordinating mechanisms is a necessity, and also a stronger secretariat and technical capacity in HPA/MOH to effectively guide and coordinate activities of the High-Level Steering Committee, the health sector network throughout the country, and other relevant sectors and organizations. Below is a proposed outline for national coordination mechanisms for NCD prevention and control including some existing mechanisms as well as some proposed mechanisms, adopted from the WHO toolkit for preparing NCD MAP: Page 39 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Figure 11: Proposed structure for national coordination mechanism for NCD prevention and control High Level NCD Steering Committee (Co-chaired by Health Minister and another Minister from a key related area) Health Promotion Board HPA-NCD Division (Advisory board) (Technical lead organization) Tobacco Control Board (Advisory/statutory board) Technical Expert Committees Working groups for specific tasks (TEC) E.g. (Provide Scientific/ Technical • 25-25 campaign for NCD prevention guidance and prepare technical and promoting healthy lifestyles documents - e.g. :) • PEN working group • Smoke Free Public places • Cancer Registry regulation • Heart Disease Prevention and • Stroke management Guideline awareness • Stroke Prevention and awareness • Chronic Lung Disease prevention and Atoll/Cities Healthcare network awareness • Cancer prevention and awareness (Implementation) • Diabetes prevention and awareness • NCD Focal points • Kidney disease prevention and • Health facilities awareness • Public health services • Food based Dietary Guideline (nutrition) • Tobacco control Advocacy groups • Physical activity • Workplace health/ School health • Health promotion advocacy group • Surveillance for advocating policy measures for • Other issues e.g. communication enabling Healthy lifestyle • Coalition for Tobacco Free Maldives (tobacco control) • Nourishing Maldivians (healthy diets) Page 40 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) The NCD Unit in the Health Protection Agency will be the secretariat to the High Level NCD Taskforce and the coordination point for the Multisectoral NCD Action Plan. One of the key learnings from the past few years from all countries is the need to have a dedicated staff to be Secretariat and ensure ownership and implementation of Multisectoral NCD Action Plan. The current capacity of the Chronic Disease Division is inadequate to perform these functions effectively. The technical and secretarial roles of the HPA NCD program should be ideally separate, and very clearly defined.27 The NCD Unit therefore needs to be strengthened with additional human resources with the relevant capacities to perform the secretarial, coordination, technical guidance and implementation functions of the national action plan as shown the following: BOX 1: The key responsibilities of the NCD Division BOX 1: The key responsibilities of the NCD Unit As a Secretariat to the Multisectoral High Level NCD Taskforce: - Call regular meetings of the Multisectoral High Level NCD Taskforce - Prepare agenda, present issues and document the proceedings and circulate the minutes of the meetings to all stakeholders - Invite submission of issues to the stakeholders to be included in the meeting - Invite issue-based presenters from stakeholders when required - Complete the process of formation of subcommittees and Technical Expert Committees and provide assistance to the subcommittees and TECs - Prepare national reports related to NCD response and ensure timely submission and follow up with the Office of the President and the Cabinet - Prepare national reports related to NCD response and conduct proper dissemination of reports to the law makers, donors, UN agencies and other stakeholders As a coordination point: - Conduct and coordinate regular progress reviews among the stakeholders - Conduct stakeholder’s annual work planning workshop to develop NCD actions plans and ensure that plans are implemented in line with the Multisectoral NCD Action Plan - Ensure regular submission of the activity progress reports from stakeholders and compile the reports - Engage and orient stakeholders on the requirement and format of activity report - Advice stakeholders on issues related to implementation As an implementing agency: - Implement the NCD Action Plan and the various work plans of the NCD unit, its sub-units and MOH 27 Manju Rani, Sharmin Nusrat and Laura H Hawken. A qualitative study of governance of evolving response to non-communicable diseases in low-and middle- income countries: current status, risks and options, BMC Public Health 2012, 12:877. Available from: http://www.biomedcentral.com/1471-2458/12/877 Page 41 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) HIGH LEVEL NCD STEERING COMMITTEE OR TASK FORCE: A High Level NCD Steering Committee had been constituted under a special directive of the President to oversee the multisectoral activities for NCD action plan. This Taskforce is currently responsible for: • Guiding stakeholder implementation of multi-year work plans • Informing the government on the national policy and legal issues related to NCD prevention and control including ways to allocate greater financial resource for NCD response • Maintaining the momentum and national spirit for NCD response The High-Level Steering Committee was chaired by the Minister of Health, and constitutes of heads of various institutions including health professionals, media and sports, some of who are political appointees. However, there were no politicians in this committee other than the Minister of Health, and despite the co-chair being the head of the national media service (Public Service Media), the media contributions to NCD prevention and control were limited. This committee is currently not functional, as a fair number of politically appointed institutional heads have changed since the change of government in November 2018. HPA is in the process of re-constituting the High-Level Steering Committee. With the need to accelerate progress in NCD prevention and control, the country needs to have more effective national coordination mechanisms for NCD prevention and control. Several stakeholders recommend taking the present High Level NCD Steering Committed to a higher level, e.g. a Presidential Task Force of relevant cabinet ministers and institution heads to be chaired by the President or Vice President, with a Steering Committee chaired by the Minister of Health, similar to other countries that have achieved more success in NCD prevention and control28, in order to obtain a higher level political commitment and better multisectoral involvement of key government agencies. However, as the highest level politicians often have limited time to commit for regular meetings, evidence from other countries show that varying levels of political involvement can be mobilized successfully, thus the country has to adopt the best suited mechanism.30 Given our present political structures, it seems more practical for Maldives to continue the High Level Steering Committee led by the Minister of Health, while it is recommended to be co-chaired by another minister who can mobilize several other key sectors and the higher political level, such as Minister of Planning & Infrastructure, Minister of Environment, or Minister of Economic Development (Figure 11). It should also be political adequately represented by the parliament, government agencies, civil societies, NGOs and media organizations. Key government organizations in this 28 Multisectoral coordination mechanisms and responses to noncommunicable diseases in South-East Asia: Where are we in 2018? World Health Organization 2019. Page 42 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Steering Committee, in addition to the three ministers mentioned above could include Ministries of Housing & Urban Development, Transport & Civil Aviation, Fisheries, Agriculture & Marine Resources, Home Affairs, Finance, Education, Youth, Gender, Islamic Affairs. Independent organizations such as Human Rights Commission of Maldives, Maldives Media Council. Academic representation such as Maldives National University would be useful to include. As Maldives now has a Maldives NCD Alliance, they would be the most appropriate to represent civil society in the High-Level Steering Committee. Steering Committee members should be the highest level and most influential decision makers of the organization who can give the commitment, ideally heads of organizations, but where commitment is not possible, at least the next in line. It is most important that the secretariat for the committee, HPA is strengthened to mobilize the relevant members, provide adequate secretarial support and also provide the necessary technical guidance and support for decision making by the committee.30 The Steering Committee or Taskforce will meet once in four months or a minimum of three times a year, and called together as required should a need for an urgent intervention to get political commitment for a high output NCD prevention and control measure be required. Detailed terms of reference of the High Level NCD Steering Committee/Taskforce and the NCD Unit/Secretariat will be approved by the President. The High-Level Steering Committee and the Secretariat will come into function on the day of granting approval by the President. Advisory Boards: As agencies embrace the NCD Action Plan, at times stakeholders are likely to face unforeseen policy challenges, legal and implementation issues that need support and wisdom of the many. In such situations, formation of Advisory Boards empowers MOH with problem solving mechanisms through regular inputs from stakeholders and field experts or engaging in cross- sectoral consultations as necessitated by the issue at hand. The National Health Promotion Advisory Board (HPAB) that was newly formed requires strengthening of capacity and some expertise in the areas of public health and communication for behavioral impact, in order to provide evidence-based advice on plans and actions for effective health promotion. The HPAB also needs to develop a strong scope, mandates, membership and roles of members, including clauses to prevent conflicts of interest. A fairly well represented Tobacco control Board exists, with a strong legally defined mandate, and may benefit from a member who could contribute from a religious perspective. The TCB has strict rules excluding members who have direct tobacco industry involvement, and also current smokers. Page 43 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) TECHNICAL EXPERT COMMITTEES AND WORKING GROUPS The NCD Unit as a secretariat will propose formation of technical committees as and when deemed necessary. Constituting a permanent technical committee is not necessary as the issues in NCDs and lifestyle promotion is too diverse to rely on a fixed committee. HPA also needs to constitute Technical Expert Committees for specific tasks that require technical expertise, such as formulation of regulations, guidelines, technical papers for specific policy measures, etc. Example of members of the Scientific/Technical Expert Committee (TEC) on the National Lung Disease Control Program: • National NCD coordinator (NCD unit) – should provide leadership organizationally as well as technically • Clinical experts in Chronic Lung disease management (including asthma, COPD and TB) from medical school hospitals or national hospital (e.g., Consultant in Respiratory Medicine from IGMH Respiratory Medicine Clinic) • Pediatrician from a tertiary hospital • General practitioner with interest in chronic lung disease • Expert on Tobacco control • Representative from Environmental health/ Environment ministry • Social scientist • Psychologist, psychiatrist or specialist health professional providing care for mental health, alcohol and substance use problems • Health researcher • Schools’ representative • Workplace or occupational health representative It is important that the NCD program of HPA provides the lead not only organizationally, but also technically from a public health point of view in the TEC Committees, as is done by other HPA programs such as Immunization, Emergency Preparedness, etc. E.g., the program and secretariat should be able to provide the committees with the necessary scientific evidence for recommended actions, national statistics and situation analysis, and clear recommendations for evidence-based decision making, and should be able to present these in a manner that enables and promotes evidence-based decision making by the committees. The NCD unit needs to build its capacity to provide this expertise. Working groups or taskforces are technical groups which are formulated to perform specific tasks relative to the development and implementation of the policy, plans and programs. For Page 44 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) example, groups may be formed for the development of the National Cancer Control Programme or drafting a National Obesity Control Action Plan. Formation of TECs and Working Groups will be approved by the High Level NCD Taskforce. When an issue can be addressed by a single agency, Taskforce may call upon the designate agency present the issues through an official correspondence singed by the chair/vice chair of the Taskforce. Clear terms of reference with deliverables and time frame for the assignment will be stated in the letter. Subcommittee will be dissolved by the Taskforce after satisfactorily completing the task. The dissolution will also be officially conveyed through a written correspondence from the chair/vice chair of the High-Level Taskforce. Atoll Healthcare network The MOH and HPA have a strong network of health facilities and public health services (Public health units (PHUs) and Dhamanaveshi’s, with NCD Focal Points nominated from among the public health services for each atoll, and Male’, Hulhumale’ and Vili Male’. These are the implementers of the NCD Action Plan, and all other public health and curative services. The capacity of these implementing workforce needs to be built in order to implement the programs in this NCD MAP more effectively and efficiently to meet the targets of NCD prevention and control. They need better and regular trainings, sharing of information, mentoring and monitoring. New technologies to provide these such as internet-based video conference or web conference facilities and Viber groups for communication should be used to overcome the geographical limitations of providing face to face trainings and mentoring. Details and timelines of activities to improve the coordination mechanisms for NCD prevention and control are given in Annex 1. APPRAISAL AND CHANNEL OF COMMUNICATION A proper line of coordination and communication is a necessity to facilitate smooth coordination and timely flow of information. Information flow pertains to tracking the performance of stakeholders through routine submission of progress report to the Secretariat (NCD Unit) and onward submission of information to the President and Vice President. The flow chart in Figure 12 below depicts the channel and frequency of flow of reports from the stakeholders. Also see under Part IV-Monitoring the Implementation. Figure 12: Appraisal channels and frequency of reporting progress of activities for NCD MAP Page 45 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) President/ Cabinet 4 monthly NCD High Level Steering Committee 4 monthly NCD UNIT Monthly 3 monthly Established Boards and Stakeholders without a Committees board Objective 1.3: Strengthen national NCD Leadership With the huge challenges of combating NCDs, the targets can only be met by investing the best brains available in the country on NCD prevention and control, particularly NCD prevention. Unfortunately, compared to other countries, Maldives is lagging behind somewhat in NCD prevention and control, and despite expertise existing in the country, the Ministry of Health and HPA need to build adequate capacity and retain the expertise required to combat NCDs effectively. Below are actions to build the capacity of HPA to provide leadership in NCD prevention and the Primary care services under MOH for delivering NCD prevention, screening and treatment services (Details, timelines and more actions are given in Annex 1. Numbers are activity/sub-activity numbers assigned in the tables.): 1.3.1. Review structure of Chronic Diseases Division (NCDD) in HPA to include capacity for health promotion, surveillance and disease-specific prevention measures: • Skills /areas of qualifications required for NCD/Health promotion: - An epidemiologist for NCD Division to plan and focus on evidence-based NCD prevention and control actions and to guide and coordinate surveillance activities and prepare statistical requirements for advocacy and monitoring effectiveness and provide technical guidance and support to the various multi-sectoral coordinating committees and boards (Qualification: Masters in Epidemiology or Public health including modules in epidemiology and biostatistics) - One medical doctor with public health background plus clinical experience for disease specific prevention measures and coordinating activities with health care service providers (should have min. 1-2 years of clinical work as a registered doctor in a hospital or supervised setting) - Specific degree/masters in Health promotion and training in Communication for Behavioral Impact (COMBI) or Behavioral Change Communication (BCC) for planning behavioral change interventions - Sociology/psychology for planning behavioral change interventions Page 46 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) - Graphic design, video editing, and basic web-design/web maintenance for preparing IEC material in house and maintaining website (public health officer trained in these skills would be most ideal) • Establish a Health Promotion Unit in NCDD including: - a team leader (director) with specific training in health promotion (preferably also COMBI trained), - staff (preferably public health professionals trained for these) with skills in web- design/graphic design and basic video production to maintain active website on NCDs, develop basic IEC material on NCD prevention and control and health literacy for social media/mainstream media/print material and regularly share with public and health professionals through established official social media of HPA, - one community mobilization coordinator to mobilize community and maintain health promotion and networks (with sociology/psychology degree or PG qualification), - one media coordinator for media • Train one staff in Health promotion (degree / masters’ course), • COMBI training (available through WHO) for at least 2 staff in first year followed by all staff over 3 years • Dedicated Surveillance staff for NCD surveillance - at least 1 staff in NCD unit with responsibility to collect, compile all available NCD surveillance data necessary for advocacy and disease and risk factor monitoring, and update these regularly with ready access when required for various advocacy programs and meetings - 2-3 NCD surveillance staff placed in either NCD or Surveillance section of HPA, or HIMRD in MOH to establish and conduct regular NCD surveillance for disease burden and risk factors • Dedicated staff for Mental Health - At least 3 staff with public health background - Skills and capacities should include degree/masters in psychology and formal qualifications in psychological counseling • Relevant programs should have expertise in the area, e.g. - Nutrition program should have a Nutritionist in the department - Environmental and Occupational Health – should have specialists in Environmental Health, and in Occupational Health - Food scientists in MFDA Food section - Pharmacists in MFDA Drugs section - Staff trained in Biostatistics for Health Information Section in HIMRD 1.3.2. Technologies, infrastructure and material resources development of NCD section / HPA • Proper functional website and social media (Twitter. FB. YouTube for Videos • Video Teleconference training facilities to conduct trainings for atolls and islands • Facilities for IEC material preparation (web, graphics, AV material, etc.) • Licensed software for graphics, video editing, etc. 1.3.3. Strengthen capacity of public health workforce for the implementation of the NCD Action Plan in the peripheries in the atolls and Male’ Page 47 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) • Appropriate HR plans: Develop and finalize the planned career pathway and appropriate remuneration packages for public health professionals centrally (HPA) and in peripheries (primary, secondary and tertiary care levels) so as to retain and build capacity for effective NCD prevention and control (under section 3.3: Strengthening Health system) • Note that remunerations for central level staff in HPA should NOT be lower than those of peripheries, as these are the leading professionals guiding the peripheries. Higher qualifications would be ideally required for HPA staff (than those of peripheries) in order to maintain the higher functioning capacity. • Public health professionals’ remunerations should not be less than other allied health professionals of similar qualifications (degree/masters etc.) • Consider up to Master’s level (Public Health or Epidemiology) for atoll level as well (could be the head / team leader for public health) • Consider having a hospital epidemiologist (masters in epidemiology) for all Tertiary hospitals - for infection control, public health, surveillance and planning of services according to disease patterns in the area • Develop and finalize the planned career pathway and appropriate remuneration packages for dieticians and counsellors to Integrate services of dieticians and counsellors into health system recruitments and services provided. (under section 3.3: Strengthening Health system) • 3.2.3 Develop career tracks for health workers’ professionals through strengthening postgraduate training, with a special focus on NCDs, in various professional disciplines and career advancement for non-professional staff (under section 3.3: Strengthening Health system) • Sustain adequate staff in Public Health Units and Dhamanaveshi’s • Review structure and functions of Dhamanaveshi’s in the MOH health facilities structure for optimizing functionality - under the atoll / main hospital (see suggestions under section 3.3: Strengthening Health system) Dhamanaveshi function – prioritize as lifestyle and prevention centers, not treating sick people but mainly for public health only • Involve the Management of the hospital/health facility – importance of public health • Nurses to be utilized and close gap with public health (e.g., diabetes nurses, nurse educators, palliative care nurses, community nurses, etc.) • Engage universities and professional education institutions (lecturers) in technical work for NCD prevention and control through collaborations and serving in TEC Committees 1.3.4. Strengthen capacity of workforce for the implementation of the NCD Action Plan through trainings and academic capacity building and teaching/learning programs: • Identify training requirements for HPA and peripheries • Health promotion • Communication and media • Clinical areas – e.g., PEN, management of NCDs • Other areas such as legal, regulatory, etc. • University health sciences courses to be reviewed and updated to meet capacities required for NCD prevention and control – MNU FHS to lead and HPA to collaborate. Teaching/learning curricula on NCD prevention and control in university programs in Medicine, Nursing, PHC, Psychology and Counseling, Pharmacy and all health professional training courses to be updated to provide knowledge and skills on evidence based NCD prevention in keeping with WHO and adopted national recommendations, guidelines and Page 48 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) protocols. HPA to regularly share all guidelines and protocols with MNU and its teaching faculties. (See roles of academic institutions with details worked out from stakeholder consultations in Annex 3.) • Teaching of NCD prevention and healthy lifestyles to be incorporated as relevant into teaching of relevant academic courses training non-health professionals such as teachers, hospitality industry, media professionals, lawyers, etc. through the various faculties and courses of MNU and other universities – HPA to initiate communication, conduct meetings / workshops with relevant departments of MNU and form collaborations and working groups for long-term capacity development. • Public Health Seminars and conferences to build capacity of health professionals on evidence-based methods of prevention of NCDs 1.3.5. Integrate NCDs into social and development agenda (Health in all policies) and development plans and strategies • Government to include policies to prevent NCDs, particularly in national development and economic policies and plans (including incentivizing healthy industries and creating and facilitating enabling environments for NCD prevention, discouraging trade “investments”) and disincentives for industries that promote NCD risk factors, and policies to avoid conflicts of interest (See relevant activities under Objectives 2.1 To 2.6) 1.3.6. Improve mobilization of resources and funding: • The government needs to prioritize and dedicate funding for NCD prevention in proportion to the size of the problem and work required to be done • HPA should also explore funding from a wider variety of sources beyond WHO and MOH, including other international agencies and local private sector organizations that do not have conflicts of interest, e.g., banks, insurance companies, etc. • Engage universities and higher education institutions in NCD prevention and control to mobilize expertise while improving their capacities too. 1.3.7. 1.3.7. Develop disease specific Strategic Control Plans for prevention, early detection and treatment of the 5 main diseases • National Cancer Control Plan (NCCP) • National strategic plan for the control of cardiovascular disease (heart disease and stroke) • National strategic plan for the control of Chronic Respiratory Diseases • National strategic plan for the control of Diabetes • National strategic plan for the control of Mental Health 1.3.8. HPA to monitor health promotion activities throughout the country Strategic Objective 2: Health promotion and risk factor reduction Actions under this area aim to promote the development of population-wide interventions to reduce exposure to key risk factors. Effective implementation of these actions will lead to reduction in tobacco use; unhealthy diets focusing on increased intake of fruits and vegetables, reduced consumption of saturated fat, salt and sugar; reduction in harmful use of Page 49 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) alcohol; increase in physical activity; and reduction in indoor air pollution, particularly second- hand exposure to tobacco smoke. Objective 2.1: Reduce tobacco use Maldives has currently implemented some of the MPOWER measures under the FCTC only partially so far. After a long lag, some progress was made recently after securing a grant from Bloomberg Foundation, which helped to get some human resources for HPA to do the required technical work, build capacity and positive attitude among implementers and gather advocacy to enable passage of the legislature. Progress in implementing MPOWER tobacco control measures include: • a partial smoking ban since 2012 by a smoking ban regulation under the Tobacco Control Act of 2010 • implementation of Graphic Health Warnings on tobacco packaging covering 90% of the 2 main surfaces and banning sale of single cigarettes since 1st Dec 2019. • Taxation of cigarettes by 200% of the import CIF value as a Customs import duty. From 2021, other tobacco products are also covered, but tax increases are not adequate to control use. The current taxation structure does not allow higher taxes as in-country taxations are not included at present. GST is taken at standard rate of 6% only depending on the retailer’s eligibility for GST. • A Tobacco free Youth campaign #IChooseLife was conducted in 2015, resulting in renewed government support for tobacco control and the establishment of a new Tobacco Control Board (which had been previously disbanded for almost 2 years after its term ended). In addition to this, • Each year MOH gives awards to tobacco free businesses on World No Tobacco Day, creating incentives for good practice • In 2017 HPA made an attempt to award smoke free homes, but with limited results. The key actions under the action plan for 2023-2031 are given below in order of priority. Best Buys measures will be prioritized. The activities are in priority order below and of these, numbers 2.1.2 – 2.1.5 are the top-most priorities. (Details, timelines and more actions are given in Annex 1. Numbers are activity/sub-activity numbers assigned in the tables.): • 2.1.2. Review and revise present partial smoking ban to a comprehensive smoking ban to include all indoor and wider coverage of outdoor public places, workplaces and public transport, Comprehensive ban on smoking in all indoor public places, workplaces and public transport and improved implementation with community involvement clearly defined roles for all implementers, of the - publishing in gazette and implementation - by 2024 • 2.1.2.3. Full ban on water pipe tobacco (shisha/gudugudaa) and ENDS - import, sale and use (as hookah/shisha is a roadblock to implementing full smoking ban in restaurants, and given higher priority following Covid-19, being a significant threat to the spread of communicable diseases including acute respiratory infections (ARI), TB and hepatitis B) – 2024 • 2.1.3.3. Development of new graphic health warnings and messages and revise the requirements and standards appropriately to rotate GHWs annually in the implementation of regulation mandating Graphic health warnings on tobacco packs – by 2024 Page 50 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) • 2.1.2.4. Conducting an effective and sustained anti-tobacco mass media campaign – Tobacco Free Families campaign in 2023 and 2024 – using methods of communication for behavioral impact (see criteria in Box 1 below) • 2.1.4. Effective Tobacco taxation – to include ALL tobacco products, incremental taxation to keep up the inflation and economic growth and earmarking percentage of tax for prevention activities. Increase in import duty plus other taxes in total by at least 70% of the maximum retail price on all forms of tobacco products, and earmarking tobacco taxes for health protection and promotion. - 2021 onwards • 2.1.7.2. Gazette and implement Regulations for registering, licensing and regulating tobacco import and sales – by 2024 • 2.1.5. Formulating, publishing in gazette and enforcing a regulation for comprehensive ban on all forms of TAPS (Tobacco Advertising, Promotion and Sponsorship) including cross border TAPS and any kind of CSR activities by tobacco industry under the TCA – by 2024. • 2.1.6. Expanding tobacco cessation services through health facilities, drug rehabilitation services schools and counseling and youth outreach services. Establish a national toll-free Quitline and initiate cessation program – by 2023 • 2.1.1.5. implementation of FCTC article 5.3. Stopping tobacco industry interference in government policies as a written policy in MOH and across government institutions – by 2024 • 2.1.7.4. Conduct a tobacco economic study for use in advocacy - 2024 • 2.1.3.8. Implement tobacco free school program to prevent access of tobacco products to minors 2023-2024. • 2.1.8.1 Ratify the protocol on illicit trade - 2025 Page 51 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Box 2: Characteristics of an effective mass media anti-tobacco campaign Source: World Tobacco Atlas:29 Objective 2.2: To Promote healthy diets During the last 5 years, Maldives has achieved significant progress in promoting healthy diets across the life cycle, focusing on salt reduction, increasing intake of fruit and vegetables and reduction of sugars and fats. Progress is seen particularly with public awareness and building capacity of health professionals and teachers. However, many of the policy measures under the Global Strategy of Diet & Physical Activity are yet to be implemented. Below are some of the achievements: • Guidelines on healthy eating using locally available healthy foods and beverages for all ages ranging from pregnancy, infancy and early childhood (the First 1000 days of life), and adults (Adult Food Based Dietary Guideline (FBDG)), have been prepared and widely disseminated through health facilities and online with assistance from various donor agencies including UNICEF, WHO and FAO. All guidelines include guidance and messaging for salt reduction, adequate fruit and vegetable intake and reduction of sugar and fats. • A BCC campaign to promote healthy diet in the first 1000 days of life has been developed with assistance from UNICEF and Is currently ongoing. • A restriction of energy drinks and sugary drinks in schools has been established through an Education Ministry policy following a cabinet decree in 2018. • Energy drinks and fizzy drinks are currently taxed with a higher import duty than other food and drinks. • Atoll level programs are conducted to promote breastfeeding and healthy infant and young child feeding practices • School level programs are conducted by Ministry of Education to promote healthy diets. A guideline on healthy eating for school children has been published in 2018, and information about healthy diets are included in the school curriculum newly introduced during the last 5 years, however, teachers do need more training and confidence on delivering this information to children and parents. 29 World Tobacco Atlas. Online, available from: https://files.tobaccoatlas.org/wp- content/uploads/pdf/maldives-country-facts-en.pdf Page 52 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) • In 2019, the government began providing healthy breakfast to students at school as a pilot program and plan to expand it to all schools in 2021. • Agricultural policies promoting fruit and vegetable cultivation are in place, and implementation of Good Agri Practice (GAP) with incentives scheme for improving compliance was begun with the first module on food safety and hygiene. Below are the key activities under Objective 2.2: To Promote healthy diet. As Maldives has high intake of not only salt, but sugary drinks and fats, and adequate fruit and vegetable consumption is lower than 10% according to STEPS 2011, and the HPA nutrition program has subjectively observed paradoxical behavioral changes with food-related messaging on one nutrient only (e.g. messaging to reduce sugar resulting in higher fat intake, messaging to increase fruit and vegetable leading to people taking diets with mostly fruit only, etc.). Therefore, the HPA nutrition program has decided to focus on integrated guidelines, awareness material and campaigns for healthy diets which prioritize messaging on salt reduction, increasing intake of fruit and vegetables and reduction of sugars and fats as per the WHO recommendations for NCD prevention and control. As reducing areca nut chewing is not addressed by other programs, this is also included under the nutrition program and included in awareness messaging. Thus, all guidelines and awareness materials and programs of planned activities are also aligned with this. Below are the key priority actions planned, in order of priority. (Details, timelines and more actions are given in Annex 1. Numbers are activity/sub-activity numbers assigned in the tables.) Policy measures recommended under the Global Strategy of Diet & Physical Activity have been prioritized, and the first 6 items below are the highest, must-do priorities: • 2.2.1.1. Passage and implementation of Food Bill – by 2024 • 2.2.2.1. Passage and implementation of regulations for marketing of food & beverages to children and adolescents – by 2024 • Reduction of salt and trans fats in the supply chain through policies for food formulation (Submit paper to Social Council on reduction of salt and trans fats) • 2.2.3.1. Nutritional labeling on back and front of pack for both imported and domestically produced packaged foods – by 2023 • 2.2.3. Implement the National Food Based Dietary Guidelines (FBDG) for adults published and • 2.2.3.1. Conduct mass media BCC campaigns for various age groups of the life cycle • 2.2.4. Expand taxation of both domestic and imported sugary drinks and specific unhealthy food and beverage products high in salt, trans fats and saturated fats and carcinogens (processed meats) and ultra-processed foods identified by HPA/MFDA by developing and advocating for fiscal policy recommendations • 2.2.6. Continue Promoting breastfeeding and healthy infant and young child feeding practices through BCC campaign, capacity building of health professionals and strengthening implementation of BMS Code • 2.2.3. Agricultural policies – o 2.3.3.1. Promoting fruit and vegetable cultivation through incentive schemes o 2.2.10.5. Introduce disincentives for areca nut cultivation o 2.3.3.4. Implementation of Good Agri Practice (GAP) – develop and implement rest of the modules planned - with incentives scheme for improving compliance • 2.2.10.3. Regulation mandating health warnings on areca nut packaging - by 2025 Page 53 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) • 2.2.5. Develop policy measures and guidelines in collaboration with various stakeholders such as food producers, processors, retailers and consumers to promote affordability, availability and acceptability of healthier food products • Urban planning measures to facilitate access to fruit and vegetables: o Promoting home gardening and community gardening of fruit and vegetables by allocating gardening space for social housing/apartment complexes, building code to include structural allocations for growing potted plants in apartments, such as balconies with adequate safety measures o Enabling easy access to healthy foods such as fruit and vegetables at affordable prices – e.g., strategic placement of local markets in close proximity to highly populated areas o Utilizing green spaces / tree planting areas in cities for growing fruit trees with multiple outputs of aesthetic value and shade (also discouraging growing of areca nut trees for aesthetic purposes on streets and parks of cities where public can access the fruit easily) • To inform all the above policy measures, efforts will be made to enhance monitoring capacity, including: Dietary assessments such as total diet study and STEPS survey to understand dietary habits and practices and estimate intake of salt, fat, sugar, fruit and vegetables, and the key nutrient groups and define Minimum Residual Limits (MRLs). • 2.2.10.1. Adapt STEPS survey to assess salt, fat and sugar intake and areca nut consumption • 2.3.8. Improving laboratory capacity (in MFDA and through reference laboratories) • adaptation of a nutrient profile model for Maldives • 2.2.10.1 Prepare advocacy briefs and policies on replacement of saturated fat and trans-fat with unsaturated fat using media and public education - Implementing trans-fat elimination policies- (generating evidence and prepare and submit a Social Council paper) • 2.2.3. Schools, workplace and island level measures for implementing Food Based Dietary Guidelines: o FBDG compliant “healthy” restaurant incentives o Healthy balanced menus, excluding areca, tobacco, smoke-free o Challenge of Fast-food franchise outlets by introducing healthy options Objective 2.3 Promote physical activity During the last five years, several activities have been carried out to promote physical activity in Maldives. Successive governments have been highly committed to promoting physical activity. 15 outdoor gyms have been set up by Ministry of Health. Free to use sports grounds have been set-up in several islands by Ministry of Youth & Sports and various other organizations. The government aims to have at least some sports facilities and /or exercise facilities for almost every inhabited island. However, there are some unfortunate instances where unhealthy beverage industry has capitalized on promoting their products by sponsoring or constructing sports grounds in some islands. A lot of investment has been placed in promoting and improving sports in the country. Campaigns to promote physical activity including a multitude of active sports events for public, runs and walks have been widely conducted by the government and various private sector organizations and NGOs. The present government is conducting a campaign branded as “Dhulhaheyo-Hashiheyo campaign” including several such events at regular intervals. Page 54 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Below are the key priority actions planned, in order of priority. (Details, timelines and more actions are given in Annex 1. Numbers are activity/sub-activity numbers assigned in the tables.) Policy measures for creating enabling environments to increase physical activity with ease and affordability are prioritized.: • 2.3.1. Formulate and disseminate national physical activity guidelines by HPA – by 2024 • 2.3.2. Urban planning to include measures to promote physical activity through creating enabling environments, include these features in building codes and urban design codes, and include consultation from health sector as a must-do step in urban planning: o Improve walkability (also see under Objective 2.5. to Reduce air pollution) o Promote bicycle-friendly cities with appropriate facilities such as safe bicycle lanes, and safe parking facilities for bicycles (also see under Objective 2.5. to Reduce air pollution) o Improved public transport in the cities of Male, Hulhumale’, Addu, Kulhudhuffushi and other cities (also see under Objective 2.5. to Reduce air pollution) o Easily accessible exercise areas with minimal cost to the users in Males and major atolls (e.g., free to use sports grounds and outdoor gyms, indoor community gyms) o Create more green spaces in cities and islands (e.g., parks providing exercise, with greenery and smoke-free environments included) (also see under Objective 2.5. to Reduce air pollution) o Promote Home / community gardening and create enabling environments for gardening, particularly in urban areas (also see under Objective 2.2. To promote healthy diets) • 2.3.3. Policy measures to improve affordability of physical activity through gyms and sports programs, e.g., tax reductions for such services • 2.3.4. Carry out physical activity campaigns and social marketing - continue ongoing “Dhulhaheyo Hashiheyo” campaign of the government, and other BCC campaigns to promote physical activity in schools, workplaces and various settings (See details under Objective 2.6) • 2.3.5. Policy measures for healthy transport to promote physical activity - Formulate and implement Regulations for taxation of motored vehicles and vehicles with high emissions and Regulating vehicles imports / controlling vehicle smoke emissions (see Objective 2.5: Air pollution – activity 2.5.3.) Objective 2.4: to Reduce alcohol consumption among key population groups The prevalence of alcohol consumption is low in Maldives among adults as well as adolescents according to the STEPS and GSHS surveys. Three (3/3) Best Buys for Reducing Harmful Use of Alcohol have already been implemented in Maldives since several years: • High taxes on alcoholic beverages • Restrictions of alcohol advertising: (all forms of advertising are Illegal) • Restrictions on physical availability of alcohol: It is illegal to sell alcohol to any Maldivian While these measures were not actively introduced to reduce NCDs, but for implementing Islamic religious policies, the country has clearly benefitted from these measures, in conjunction with continuing awareness from a religious perspective, resulting in relatively low consumption of alcohol among adolescents and adults, compared to neighboring countries of the SEA region. However, some alcohol consumption exists among resort workers and substance users. While substance use is prevalent at similar rates as alcohol use, it is considered relatively high compared to other countries, Page 55 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) and substance users often consume alcohol as well. All substance uses prevention, treatment and rehabilitation programs under the National Drug Authority currently also concomitantly address alcohol addiction in their interventions. With Islamic policies highly integrated into the governance of the country, we adopt strategies to reduce total alcohol consumption and increase abstinence rather than restricting interventions only to harmful use. Below are the key priority actions planned. (Details, timelines and more actions are given in Annex 1. Numbers are activity/sub-activity numbers assigned in the tables.): • 2.4.1. Adoption relevant components of the Global Strategy to Reduce the Harmful Use of Alcohol in the Maldivian context to address use of alcohol • 2.4.2. Consultation with Ministry of Islamic Affairs to develop messages for public awareness and disseminate these messages integrated into NCD prevention messages. • 2.4.3. Ensure guidelines, medicines and services are available in health facilities and health professionals trained to detect and treat alcohol intoxication, harmful use and substance use, and for screening and providing brief intervention (PEN package) • 2.4.4. Improve implementation of alcohol restriction laws and policies by including measures to restrict alcohol consumption by Maldivians at tourist resorts and hotels (e.g. more stringent enforcement of regulations banning Maldivians from consuming and purchasing alcohol, restricting foreigners from taking alcohol bottles outside bars and restaurants in tourist establishments, restrict availability in licensed bars and restaurants of tourist hotels situated near schools and educational institutions.) • 2.4.5. Restrict or ban alcohol advertising and promotions - Assess prevalence of indirect advertisement of alcohol and alcohol like products in the Maldivian market and take counter- measures to stop indirect advertisement and promotion by food and beverage industry • 2.4.6. Include thorough assessment of alcohol use and substance use in STEPS survey and GSHS • 2.4.7. Monitoring drunk driving involving random breath tests through traffic Police Objective 2.5: To Reduce air pollution The National Environmental Health Action Plan (NEHAP 2015-2020)30 was a comprehensive plan covering the key areas of air pollution as well. A national Action Plan on Air Pollutants31 was recently published in 2019 by the Ministry of Environment, but the main actions were focused on reducing air pollutants in energy production and transport sectors, and was not consulted with Ministry of Health. HPA is currently preparing the Maldives Breathe Life Implementation Plan (2019-2020)32 for reducing air pollution with technical assistance from WHO. It has been drafted and consulted with stakeholders. 30 The National Environmental Health Action Plan (NEHAP: 2015-2020) Maldives. Report prepared by ENDEAVOR – Maldives: December 2014 31 National Action Plan on Air Pollutants: Determining nationally avoided emissions. Ministry of Environment, 2019. 32 Maldives Breathe Life Implementation Plan (2019-2020) (Draft). Health Protection Agency. Page 56 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Maldives Green Climate-Smart Hospitals: Policies and Strategies Report33 was published in 2018, including measures for reducing air pollution in health facilities. Some key activities to reduce air pollution were identified drawing from these plans and discussion with stakeholders. Below are the key priority actions planned, in order of priority. (Details, timelines and more actions are given in Annex 1. Numbers are activity/sub-activity numbers assigned in the tables.): • 2.5.1. Implement policy measures for reduction of motored vehicles and reduction of emissions, including: o Revise and set vehicle emission standards by Ministry of Environment o Formulate and implement Regulations for taxation of motored vehicles and vehicles with high emissions and Regulating vehicles imports / controlling vehicle smoke emissions o Improve public transport in the cities of Male, Hulhumale’, Addu, Kulhudhuffushi and all cities o Promote bicycle-friendly cities with appropriate road safety measures such as safe bicycle lanes, and facilities such as safe parking for bicycles o Improve walkability on streets o Green spaces (e.g., parks providing exercise, with greenery and smoke-free environments included) • 2.5.2. Incorporate the policy on smoke-free public places and homes into national action plans for air pollution prevention (HPA EH and MOEnv.) and create awareness and develop appropriate strategies to reduce exposure to second-hand tobacco smoke in households and indoor public places • 2.5.3. Conduct a study on air pollution in indoor public places and households to measure the extent of indoor air pollution and association with indoor smoking and other sources of indoor air pollution, and regular monitoring of indoor air pollution in key public places with high risk - in collaboration with MNU • 2.5.3. Monitoring of indoor and ambient air pollution - in collaboration with MNU (see under Objective 4: NCD Surveillance, Monitoring & evaluation and research) • 2.5.4. Prepare and implement guidelines and standards for industries with air pollution leading to lung disease, such as fiber boat building, preparation of smoked fish, etc. situated close to residential areas in islands. Objective 2.6: Promote healthy lifestyle behaviors to reduce NCDs in key settings Several activities have been conducted at community level in islands, schools and workplaces to promote healthy behaviors to reduce NCDs. Some key activities include: • The ongoing NCD 25 by 25 campaign conducted by HPA since 2018 – this campaign targets mainly youth and young adults and aims to promote health in workplaces, and various community settings at island level. An activity plan has been drawn for the campaign and various events and social media awareness has been conducted, however, mainstream media 33 Maldives Green Climate-Smart Hospitals: Policies and Strategies Report. World Health Organization and Health Care Without Harm. 2018. Page 57 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) coverage is poor and the campaign lacks, and needs inputs on BCC and health promotion expertise for improving effectiveness. This expertise is currently not available in HPA NCD program. • Several government organizations and NGOs have taken various measures to promote healthy lifestyles. Significant progress has been made in the education sector under Ministry of Education to promote healthy lifestyles in schools. Components addressing the key behavioral risk factors have been included in school curricula and School Health Officers have received training on these. A Food Guide for school children has been prepared by the Ministry of Education, and this year (2019) government introduced provision of a healthy breakfast in schools as a pilot program. Energy drinks and sugary drinks are banned in schools under a policy by the Ministry of Education. Physical activity is being promoted with a wide promotion of sports activities and introduction of Health and Physical Education within the school curriculum. Schools’ environments are smoke free by law under the Smoking ban regulation and Tobacco Control Act. • Ministry of Youth, Sports and Community Empowerment have also implemented various measures for promoting healthy lifestyles, including healthy events policies, smoke-free environments in youth centers and sports grounds, incorporating skills for reducing tobacco use, choosing healthy diet options and promoting physical activity through their youth peer educator programs and training programs for Sports Councilors and Youth Councilors recently appointed as focal points in each atoll for implementing MYSCE activities. • Healthy workplace programs and workplace health screening programs are being conducted by NGOs such as Cancer Society of Maldives, Diabetes Society of Maldives, SHE, Tiny Hearts of Maldives, etc. CSM has developed and disseminated a healthy workplace guide for cancer prevention. • A National Guideline on Occupational Safety and Health (OHS) Maldives has been drafted by Environmental Health program of HPA, which needs inputs from the NCD prevention and control program to incorporate healthy lifestyle measures for NCD prevention in it. Several activities are also planned by HPA, atoll and island level health facilities, and the various other sectors for promoting healthy lifestyles, and also for incorporating NCD prevention policy measures integrated into their own activities. Below are the key priority actions planned, in order of priority. (Details, timelines and more actions are given in Annex 1. Numbers are activity/sub-activity numbers assigned in the tables.): • Review and re-organize the ongoing awareness campaign for promoting healthy lifestyles - NCD 25-25 Campaign using BCC/COMBI methods with feedback from target groups, re- branding if required and more effective messaging and re-organization of activities with community feedback. As HPA does not have a COMBI trained staff in health promotion and NCD program, technical assistance would be required by external consultancy (by local or international expert/s) (activities detailed under NCD 25-25 campaign include promoting healthy lifestyles in a wide variety of settings including workplaces, schools, sports, leisure and events) • Integrate promoting the ABCs of healthy lifestyles and evidence-based measures for NCD risk factor control into: o all other HPA programs, including Occupational Health, School Health, Reproductive Health, Environmental Health, Communicable Diseases control, Immunization, Page 58 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Surveillance and Emergency Preparedness programs of HPA, activities of HIMRD and MFDA within the MOH, and o schools and educational institutions o other sector programs of various government institutions, o private sector and o civil society including school health, workplace health, youth health, various public events and urban planning (The table in Annex 1 gives details on these activities and also identifies the lead HPA programs and MOH departments responsible for the various activities. Annex 2 identifies roles for NCD prevention and control and promoting healthy lifestyles for some of the key government organizations and academic institutions.) • Formulate and disseminate guidelines for Workplace health and healthy lifestyles at work to promote healthy lifestyles in workplaces • Formulate and disseminate a Healthy Events Guide – there is a need to tap events, as these are very useful to promote healthy behaviors (from lessons learnt from the industries). Partner with event organizers and promote healthy events using the guide. • Improve public awareness on the key diseases with highest mortality (heart disease, stroke, cancer, asthma, COPD, diabetes, chronic kidney disease), including consequences, prevention, early detection and treatment – develop awareness material and disseminate regularly Strategic Objective 3: Health systems strengthening for early detection and management of NCDs and their risk factors Actions under this area aim to strengthen health systems, particularly the primary health care system. Full implementation of actions in this area will lead to improved access to health-care services, increased competence of primary health care workers to address NCDs, and empowerment of communities and individuals for self-care. Maldives has achieved some progress in NCD prevention and control during this period. Mainly in the areas of Health sector strengthening to treat NCDs, particularly at Primary Health Care (PHC) level, Cancer prevention, healthy diets and physical activity. • Package of Essential NCD interventions in Primary Health Care (PEN): One of the key successes is the preparation, dissemination, training and implementation of PEN toolkit34 for integrated management of diabetes and hypertension using a total risk approach to prevent cardiovascular disease (heart attacks and stroke) at Primary Health Care level. PEN is being implemented in 6 atolls at present, and HPA intends to cover all atolls and islands by 2030. Several atoll hospitals and island health centers run NCD clinics regularly providing regular follow-up for people with diabetes, high BP and hyperlipidemias. Significant progress has also been made in treatment of the major NCDs within Maldives, including PCI for coronary heart disease, cancer chemotherapy, dialysis for chronic renal disease and 34 Package of Essential Noncommunicable Diseases Programme (PEN Programme) at Primary Health Care. Health Protection Agency, Ministry of Health Maldives, World Health Organization Country Office for Maldives, 2017. Page 59 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) improvements in treating chronic respiratory diseases. Many of these conditions were referred abroad for treatment in the past. This has contributed to save health care costs, and also provide Maldivians with better access to timely treatment. A Mental Health institute was opened in IGMH this year (2019) with a wide range of care including psychiatrists, psychologists, counseling, speech therapy, occupational therapy and social workers, providing therapies many of which were not available in government sector with UHC coverage before. Two (2/2) Best Buys in Cancer prevention are currently being implemented: • 1) HPV vaccination was introduced this year (April 2019) for girls 10-14 years age • 2) Screening women 30-49 years for cervical cancer, referral and treatment through health facilities and mass screening programs: Guidance for conducting VIA screening was published by HPA35 in …. Outreach cervical and breast cancer screening programs (consisting of mainly breast examination) were conducted in 2018-2019, covering 4 atolls by HPA (Th., Gdh., Hdh., and Sh. atolls), and several other atolls by NGOs such as CSM and SHE. However, at present, only tertiary level health facilities in Male’ have walk-in cervical cancer screening through Well Woman Clinics. Colposcopy is available only at IGMH, plus one mobile Colposcopy machine at Dhamanaveshi Male’ for outreach programs, thus limiting VIA to outreach programs. • Mammography for breast cancer screening is functional and available to public in tertiary centers in Greater Male’ Region and in most of the Regional Hospitals. • Several breast cancer screening outreach programs (consisting of mainly breast examination and ultrasound) have been conducted in the atolls and Male’ (as workplaces screening programs) by NGOs such as CSM, who conduct annual community and workplace breast cancer screening programs. Objective 3.1: To improve early detection and effective treatment of people with NCDs or at high risk through a people-centered primary health care approach Capacity building is direly needed for PHC service. Currently PHC services in most atolls are well organized, however, in some key highly populated areas, there is some disorganization and lack of leadership, leaving service gaps in these large populations. E.g., In Addu, and Kulhudhuffushi, where the Regional hospital is being converted to Tertiary Hospitals, Dhamanaveshi’s for providing out of hospital PHC services were established, but the functionality has not been established due to lack of leadership and segregation from the main hospital, which had been otherwise responsible for the rest of the PHC services in the atoll. The services provided by Dhamanaveshi Male’ is also not adequate for the population and needs expanding to cover the population of Male’, and also needs improving of infrastructure and capacity to provide better NCD screening and PHC level treatment facilities. Given the infrastructure limitations, the current practice of Dhamanaveshi functioning similar to an island Health Center where any out-patient can walk in for consultation has led to the spread of 35 National Cervical Cancer Screening Program in Maldives (National Action plan for Implementation and Strategic Planning). Health Protection Agency, Ministry of Health Maldives. Available from: http://www.health.gov.mv/Uploads/Downloads/Informations//Informations(53).pdf Page 60 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) communicable diseases such as the very common Acute Respiratory Infections among well children and clients seeking preventive services, which needs to be prevented. A solution for a well functional structure of PHC services in the decentralized system which enables continuous provision of care is needed. Having public health services under non-health organizations such as Island councils had been unsuccessful in the past, leading to catastrophic damages such as the biggest Dengue epidemic in the country in 2011 which was attributed to system breakdown. Therefore, it is strongly advisable to deliver public health services in a decentralize manner through the health sector itself. Below is a proposed structure for PHC services considering the leadership capacities of the various institutions in the MOH: Figure 13: Proposed structure for prevention and health promotion services to deliver NCD MOH HPA RAH (Technical leader) (Administrative leader) PHC Supervisory Committee (HPA, RAHS, QARD) Dhamanaveshi's - Male' collaborate Dharumavantha/IGMH with Atoll/Regional Hospitals (Secondary Tertiary / Regional hospitals level) (function will be as Atoll/City level) (function will be as Atoll/City level) Preventive Health Center (PHC) Public Health Unit (PHU) - in hospital premises - in hospital premises Island collaborate Councils & + Reproductive Health Center Dhamanaveshi's with (Urban) community - in hospital premises of that City or atoll Dhamanaveshi's (Urban) Island Health Centers of that City or atoll Island Health Centers interventions It is important that Dhamanaveshi’s cover NCD preventive, screening and health promotional services with due priority. Recommendation is to make Dhamanaveshi’s as Healthy Lifestyle Centers as is done in countries like India and Sri Lanka with success. DVs can provide a range of preventive health services including immunization, growth & monitoring, maternal and child health services and NCD prevention and screening services. They could ideally run as polyclinics (as is done in Malaysia), with NCD Clinics or specific clinics for the main NCDs such as Diabetic clinics/NCD clinics, Respiratory clinics for patients with chronic respiratory disease, Thalassemia clinics, Well Woman Clinics, etc. with resident specialist Page 61 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) GPs and visiting specialists such as ophthalmologists for retinopathy screening, gynecologists for cervical cancer screening, etc. Staff for Dhamanaveshi’s could include Community Health workers, Registered Nurses who function as Community nurses, Specialist General Practitioner (GP) and Medical Officers, who may be mobilized (posted in rotation) from the Regional Hospital. Ideally Dhamanaveshi’s are run as satellite public health services under the management of the Atoll hospital or Regional Hospital (be it secondary or tertiary level). This would allow more sustainable mobilization of better-quality clinical staff (doctors and nurses) for preventive services by recruiting them to the hospital and posting them in rotation in the PHC services (since good quality doctors and nurses tend to be more ambitious and prefer working in hospitals than primary care facilities in the long term, while most would be happy to serve as rotational postings in Dhamanaveshis and island HCs). Rotations in PHC services would also familiarize doctors and nurses with practicing the guidelines for management of NCDs and their risk factors such as PEN, tobacco cessation, dietary and physical activity counseling, and thus help to bridge the gap between clinical and public health (preventive) services. Leadership and ownership by the atoll, regional or tertiary hospital in the area can also lead to better mentoring by appointing senior consultant doctors and nurses in the relevant departments to guide the teams in the peripheries, thus helping to get the leading clinicians on board to use the national guidelines, as well as improve mentoring for the PHC services. Even in Male’ and Hulhumale’, it would be ideal to have a Dhamanaveshi for each Neighborhood (Avah) under the management of Dharmavantha hospital (IGMH) and Hulhumale’ hospital respectively, where the hospital leads, owns and mentors the PHC services as part of their service provision to their catchment areas. With the restricted availability of space in Maldives, patients with communicable disease are best catered to in existing hospitals and Health Centers. However, depending on the available resources for an area including structural and human resource considerations, it may be required to accommodate such patients also as outpatients in the facility, in which case a separate entrance and flow for the curative general OPD patients from clients seeking preventive services should be arranged. It would be useful to have Maldives Health Quality Standards (MHQS) for structure and facilities of Dhamanaveshi’s and PHU’s with appropriate infection control measures to prevent the spread of communicable disease. Below are the key priority activities planned, in order of priority. The first four main bullet points are absolute priority. (Details, timelines and more actions are given in Annex 1. Numbers are activity/sub- activity numbers assigned in the tables.): • 3.1.1. Re-orient the structure and functions of Primary health care system to effectively deliver NCD interventions at PHC as per recommendations discussed above, with: o Decentralization of health centers and Dhamanaveshi’s under the main hospital for the atoll or city o Ownership, leadership and mentoring by the atoll hospitals for implementation in atolls and collaboration with island councils for community activities in the islands o Involvement of the highest level of health professionals in the area to take leadership and mentor o Improve peer coaching at health facility level Page 62 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) o Urban PHCs - Dhamanaveshi’s to be adopted as healthy lifestyle centers to provide principally public health services. • 3.1.2. Implementing PEN protocols/guidelines for integrated management of Hypertension, Diabetes and Hyperlipidemias - adopted and available and accessible to health professionals at all health facilities o Scale up PEN package intervention from two Atolls to all nineteen Atolls and greater Male’ area by 2024 o Update/revisions to PEN protocols (guidelines) and tools in 2020; Develop tools under PEN protocols, disseminate, train health professionals and implement/ use these tools at PHC level including: ▪ NCD Clinic booklet for patients for documenting treatment and follow-up ▪ educational material on healthy lifestyle and management for NCD patients ▪ tools for NCD screening, breast, cervical and oral cancer screening tools o Define services and service standards to be provided by NCD clinics o Appoint national doctors of consultant level and university lecturers of relevant subject areas as the trainer focal points for NCDs for sustaining the PEN action plan and provide TOT for these trainers. o Training of hospital NCD team including doctors, nurses and public health officers in all hospitals and in health centers o Disseminate PEN Health Screening tools (including NCD screening for mass screening and workplaces, and cancer screening including breast, cervical, oral cancers and Hep B screening) and Train health professionals in all atolls and Male’ to use the tools and conduct screenings and conduct a national NCD screening program throughout all islands – nationwide o Develop NCD education module and integrate NCD education in the home visit program of health workers • 3.1.3. Strengthen basic facilities of primary health care facilities for prevention and early diagnosis of breast cancer, cervical cancer and oral cancer o Integrated screening for cervical cancer (VIA / PAP) and breast cancer (breast examination and USS) as outreach camps to be conducted in the remaining atolls for islands where walk in facilities not available (not available in most) in collaboration with NGOs, Dhamanaveshi and hospitals in Male’ (IGMH, HH, ADK, TTH) o Integrated breast cancer and cervical cancer screening and awareness programs through well woman clinics established in all atolls, workplace screenings and outreach programs o Develop and disseminate oral health promotion and oral cancer screening protocol for primary care health workers o Train primary care workers on oral cancer screening and promotion of oral hygiene • 3.1.4 Improve coverage of HPV, hepatitis B, Influenza and relevant vaccinations o Continue HPV vaccination for 10–14-year-old girls through EPI program, and introduce vaccine for boys as well as girls by 2024 o Introduce hepatitis B vaccination for adult high-risk adult groups including health workforce with cost-cover or workplace financing schemes Page 63 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) o Introduce Hep B screening for cancer screening programs (for unvaccinated adults born before 1993-introduction of infant Hep B vaccination via EPI) with provision of vaccination to those eligible o PMTCT for Hep B protocols to be disseminated and practiced in all health facilities for antenatal and perinatal care o Hep B vaccines available at all pharmacies and health care facilities, at least secondary level and above o Routine annual Influenza vaccination for people with Chronic respiratory disease, Diabetes and CVD • 3.1.5 Strengthen education and awareness on early detection and treatment of common cancers including breast, cervical oral and colonic cancer and the main NCDs o Preparation of relevant patient education materials on the importance of early diagnosis and treatment for the 5 key NCDs (including lifestyle management) for use in health facilities and screening programs Mass media/social media communication on cancer signs and early care seeking and prepare leaflets for cancer education • 3.1.6. Integrate management of NCDs and lifestyle risk factors into the management of other illnesses and prevention programs o RH develop pregnancy education package to educate on key lifestyle measures - particularly tobacco cessation/SHS exposure reduction, physical activity and healthy diet counseling and education and diabetes care in pregnancy and integrate these 3 key lifestyle measures in routine RH counseling programs and maternal and child health programs: ▪ Pre-conceptional and pre-marriage counseling (should cover tobacco avoidance/cessation and folic acid supplementation as Must-have priority) ▪ Antenatal education (ANC records + educational material) and ANC care (include above 3 key lifestyle measures in the management program of all pregnant mothers as priority) ▪ Child health - Postnatal and first 1000 days of life (child health records – to include second-hand smoke exposure, diet and physical activity) ▪ First 5 years of life (include queries and basic guidance on second-hand smoke exposure, diet and physical activity in the child Record card and ask and follow-up in routine growth & Developmental assessments) o Integrate healthy lifestyle counseling (all 4 risk factors) into Mental health programs and psychological counseling ▪ Integrate into formal training programs for psychology and counseling ▪ Train existing counselors via CME programs on healthy lifestyle management using PEN protocols o Communicable Disease program to integrate healthy lifestyle education and counseling (all 4 risk factors) brief advice for patients with ARI, Influenza and other communicable diseases, HIV/AIDS and TB program for patients with HIV/AIDS and TB, work-permit medical check-ups, migrant health and check-ups and education sessions in preparation for hajj and umra pilgrimage and other educational material and programs Page 64 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Objective 3.2: to strengthen health care provision for NCDs through hospital/secondary and higher level health facilities – to improve early detection and effective treatment of people with NCDs or at high risk Health care provision for NCDs in the Secondary and Tertiary services should be expanded and integrated to cover prevention through the entire health system, in accordance with the Best Buys treatment measures for the key NCDs. At present, tertiary hospitals tend to push away preventive services to Dhamanaveshi’s or Public Health Units, with doctors and nurses minimizing their roles in prevention. This needs to be changed to include prevention as everyone’s responsibility and provide PHC services such as NCD risk factor management and screening at all levels and by all health professionals. It is recommended to decentralize atoll and City level PHC services under the direct purview and supervision of the Atoll, Regional or Tertiary Hospital of the area. This enables resource sharing and mentoring of the PHC staff by the higher-level hospital staff such as Consultant Physicians, Gynecologists, etc. The Atoll, Regional or Tertiary Hospital should conduct outreach NCD clinics, Well- woman clinics, health screening and monitoring programs for the Island HCs as well as the Dhamanaveshi’s under them. They may rotate staff such as Medical Officers and nurses on a mid-term basis such as 1-3 monthly, or opt for outreach joint clinics where the hospital and PHC staff work together in collaboration. This would help to strengthen mentoring from the hospital and peer coaching at the PHC level, and the following of published and disseminated guidelines for NCD prevention and control and disease and lifestyle management. Regular contact with these facilities through an NCD Focal Point, regular sharing of guidelines, incorporating questions from the guidelines in licensing exams, and including the current guidelines in university and professional training programs is key to achieving this. Page 65 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Figure 14: Model for PHC in a Secondary level Atoll Hospital Model for PHC in a Secondary level Atoll Hospital Medical/Nursing Preventive Service Department Departments Medical Records Department of Obstetrics Department Preventive Medicine & Lifestyle Centre & Gynaecology (PHU) (Medical record Collaborate with PHU for officers) Staff: Senior admin. Coordinator for island ANC/PNC/ WWC/ AHC/ HCs/DVs, CHOs, FHWs, counselors /mental Screenings health liaison officer (*Situated in hospital premises or in close Surveillance & proximity to hospital) Hospital statistics Department of Paediatrics Growth & Dev. Monitoring, Nutrition PNC, support child health Immunization (EPI, HPV, travel, optional) programs NCD clinic/ANC/PNC/ WWC/ AHC / FP Tobacco Cessation/Dietary/lifestyle counseling Department of Internal Home visit for bed-ridden patients (>65)* Medicine Awareness Sessions, Events, Health Physicians and MOs – to Screening support NCD clinic and lifestyle TB program (DOTs) counseling/screenings Disease Surveillance & outbreak response Support Lead & monitor islands and Collaborate with clinical teams for outreach Page 66 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Figure 15: Model for PHC services in a Tertiary Hospital Model for PHC services in a Tertiary Hospital HOD Clnical support Preventive Service Departments services Department of Obstetrics Medical Records Preventive Medicine & Lifestyle Centre & Gynaecology Department (PHU) Reproductive Health (Medical record Staff: Senior admin. Coordinator for island Unit) officers) HCs/DVs, Epidemiologist/MPH, CHOs, dieticians, CH nurse, counselors, Well Woman Clinic, Psychologist / mental health liaison officer screening ANC/PNC Family Planning Surveillance & (*Situated in hospital premises or in close Hospital statistics proximity to hospital) Adolescent HC/sevices, Immunization (dT, HPV) NCD clinic, Tobacco Cessation/ Dietary/ Department of Paediatrics lifestyle counseling PNC, support child health Home visit for bed-ridden patients (>65)* programs Awareness Sessions, Events, Health Screening Department of Medicine Immunization, TB program (DOTs) support NCD services Disease Surveillance & outbreak response Psychiatrist and Lead & monitor islands & DVs and psychologist to support Collaborate with clinical teams for mental health services outreach Specific actions for early detection and management of the main NCDs and risk factors in secondary hospital level and above are listed below. Of these, no. the first 3 items are the top-most priorities. (Details, timelines and more actions are given in Annex 1. Numbers are activity/sub-activity numbers assigned in the tables.): • Public health units are already established in all secondary level hospitals and to be maintained, and Preventive Medicine Units established in all Tertiary level hospitals to provide Lifestyle counseling (tobacco cessation, dietary, physical activity, stress management) and screening for NCD risk factors (see Figure 12 for a model for PHC services in Secondary level Health Care facilities, and Figure 13 for a model for PHC services in Tertiary level Health Care facilities • 3.2.1. Prevention and Management of CVDs o Cardiac center with Cath-lab for PCI available in Male’ (IGMH) and 2 regions-North & South o Stroke Centers in IGMH and one regional tertiary center o Developing screening guidelines for early detection of hypertension, diabetes and hyperlipidemias under PEN protocols. People 40 years and older will be prioritized for annual screening. Page 67 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) o Clinical management guidelines for management of the following conditions compiled/updated, disseminated, incorporated into licensing exams and available at all hospitals (secondary level and above) and accessible to doctors, nurses and health professionals: ▪ Clinical management guidelines for management of Acute coronary syndrome (including treatment of MI with aspirin/clopidogrel, thrombolysis or PCI), stable coronary heart disease, ▪ Clinical management guidelines for management of Acute stroke (including iv thrombolysis for ischemic stroke at appropriate facilities), chronic care of stroke patients ▪ PEN guidelines for integrated management of Hypertension, Diabetes and Hyperlipidemias adopted and available and accessible to health professionals at all hospitals o Specialized NCD clinics for patients with Hypertension, Diabetes and Hyperlipidemias offering medical treatment, lifestyle counseling and regular follow-up to be conducted in hospitals – in collaboration with public health Units or Preventive Medicine Units and RHC’s at atoll/secondary level and above o Medical Nutrition (Dietician) services to be made available (free of cost to patient) by trained and licensed dieticians (preferably Maldivian) in all Tertiary level hospitals and secondary level hospitals with ICU facilities • 3.2.2. Prevention, early detection and Management of Cancers: o Expand provision of cancer diagnostics, chemotherapy and palliative care to 4 specialized cancer centers, with diagnostics including CT/MRI facilities and laboratory diagnostics (pathology). Immune-histochemistry and frozen section to be made available at national laboratory (IGMH), and 2 centers for oncosurgery o Establish a national cancer hospital for diagnosis and treatment of cancer in Maldives o Palliative care including opioid analgesics for pain relief of terminal cancer care to be available at all hospitals – atoll /secondary level and above, and health professionals in these facilities trained to provide palliative care o Introduction of cost-covered age-specific cancer screening packages o Establishment of Well-woman clinics through Reproductive Health Services at all hospitals – secondary level and above providing walk-in screening for breast, cervical cancer and other preventable cancers, immunization and lifestyle management o Mammography/ USG for breast cancer screening and Colposcopy for cervical cancer screening available at tertiary and regional hospitals o Dental services with ability to take biopsies for suspected oral cancer to be available at all regional and tertiary hospitals o Colonic cancer screening with Fecal occult blood available at hospitals secondary level and above o Colonoscopy for colonic cancer screening available at all tertiary hospitals in Male’ and 2 regions – North and South • 3.2.3. Management of chronic respiratory diseases o Functional ICU facilities with invasive/non-invasive ventilation available at all Regional/Tertiary level hospitals and above Page 68 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) o Respiratory Medicine Centers with facilities to assess Pulmonary functions, diagnose and treat TB and Drug-resistant TB and provide non-invasive ventilatory support established in Male’ and 2 regions o Clinical management guidelines for Asthma and COPD compiled and available and accessible to health professionals at all hospitals o Ensuring availability of core treatments and technologies for managing asthma and COPD, particularly inhaled steroids and beta agonists • 3.2.4. Management of diabetes o National Diabetes and Metabolic Center (center of excellence) for management and follow-up of patients with diabetes established in Male’ and tertiary hospitals to be developed in 5 regions providing Total risk diabetes management Including lifestyle management, insulin use, foot care, home glucose monitoring for people on insulin and relevant self-care, where patients can be referred from atolls for specialist care and back-referred for continuing care o Clinical management Guidelines for managing Diabetes and Gestational Diabetes and its complications using total risk approach, compiled, available and accessible at all hospitals o Ophthalmology services to treat diabetic and hypertensive retinopathy with laser photocoagulation available in Male’ (incorporate into national eye Health plans) o Screening for diabetic retinopathy and Podiatric (Diabetic foot care) services to be integrated into NCD Clinics services in all hospitals • 3.2.5. management of chronic renal disease o Dialysis for End-stage Renal Failure available in Male’, Hulhumale’ and 6 Regional hospitals o Renal transplant service established in Male’ o Support and follow-up services at the primary level facilities • 3.2.6 Mental Health: o Psychiatrists, psychologist counseling services to be made available in all tertiary hospitals o Counseling services to be made available in all atoll level hospitals o Mental health Liaison officer to be appointed for each atoll to coordinate mental health activities o Mental Health GAP training on diagnosing and managing key mental health conditions conducted annually to cover health professionals at PHC level • 3.2.7 Management of Thalassemia and its complications at atoll hospital level o Ensure availability of national guidelines for management of Thalassemia o Arrangements for regular follow-up and management of patients with thalassemia at NCD clinics, or where larger patient numbers, to conduct regular follow-up clinics at atoll hospital level and above (including provision of regular transfusions, iron chelation therapy, lifestyle management (with specific dietary recommendations) and monitoring for complications including diabetes, CCF and appropriate referral) o Thalassemia screening tests available at all hospitals in all atolls and Thalassemia DNA test available at IGMH o Networking of Blood banks in hospitals of nearby islands at least in Male’ for sharing of resources and Blood donor networks to encourage voluntary donations Page 69 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) o Incorporation of steps to discourage smoking /tobacco use before blood donation as part of blood donation protocols. Objective 3.3: To strengthen health systems for prevention, early detection and management of NCDs and improved access to health services Below are the key actions planned. (Details, timelines and more actions are given in Annex 1. Numbers are activity/sub-activity numbers assigned in the tables.): • A sustainable PHC Service delivery structure for sustaining and improving preventive services for NCD prevention and control through the healthcare sector from PHC to tertiary care is needed very much. The above-mentioned models (Sections 3.1 and 3.2 Figures 11-13) for providing prevention and health promotion services through all levels of healthcare services is a key measure for health system strengthening. • Strengthen healthcare workforce capacity for managing knowledge and skills on NCDs including addressing and the risk factors: Sustainability and capacity building of health professionals is an essential component. Establishing a formal job structure and improving remuneration schemes for public health professionals is a key need to strengthen capacity that already exists in the country, but is subject to brain drain within country unless urgent action is taken. • Health professional capacities needed for NCD prevention and control in new specialized areas should be identified and relevant professionals recruited to provide these services. E.g., dieticians for clinical as well as public health services in hospitals of Tertiary level and hospitals with ICU facilities, endocrinologists in specialized centers such as IGMH, trained medical and nursing teams for specialized services such as Percutaneous cardiac interventions (PCI), stroke care, palliative care for cancer, diabetes care, ophthalmologists, chiropodists, physiotherapists and occupational therapists for rehabilitation, counselors, clinical psychologists, etc. • A national integrated health information software platform enabling health professionals to access patient treatment records across all health facilities would be very useful for managing patient with NCD, and following up their treatment during and after referrals and treatment in other centers, in order to keep track of patient treatment in a highly mobile population. Measures to Incorporate NCD risk factor management as part of treatment by incorporating key prompts/ reminders and treatment Advice into doctors’/nurses’ notes and other relevant documentation through the software would help immensely. • Ensuring ready supply of medicines and technology for NCD care is an important measure. Also is a need for arranging continuation of medications for patients with NCDs and risk factors such as hypertension through the Aasandha prescription scheme with checks to prevent overdose or erroneous use of medication. Objective 3.4: Community-based approaches Provision of preventive services through community services such as schools, NDA and drug rehabilitation services, community based mental health services, particularly for early detection in schools, home visits for screening, prevention, health promotion and for integrated management of Page 70 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) chronic care for patients with disability and elderly, environment and occupational health services needs to be expanded. Activities are detailed in the tables in Annex 1. • Strengthen capacity of NCD prevention services in schools o Train school health officers to provide tobacco cessation, dietary counseling and physical activity guidance for students, and provide these services in-school o Build capacity and career pathways for School health officers to improve capacity and acceptability of their work among parents and teachers • Provision of NCD prevention services in youth centers o Integrate healthy lifestyle promotion including prevention of tobacco use, healthy diets and physical activity in life skill education for outreach programs for youth o Integrate lifestyle counseling including tobacco cessation, diet and physical activity in youth counseling services provided through youth centers o Train atoll/island youth counselors and sports counselors for promoting healthy lifestyle and early detection of risk factors and referral for treatment and establish links with atoll/island health facility NCD Focal points for support and referral • Integrate NCD prevention services into services for managing substance use: o Train counselors of one Community Service Center, six detox centers, and one methadone clinic to integrate tobacco cessation*, healthy diets and physical activity into their counseling and treatment services o Revise SOPs and treatment protocols to include tobacco cessation in assessment and treatment and implement tobacco cessation as an integrated part of treatment for substance use disorders o Revise SOPs to include healthy diet and physical activity in the management of clients and implement it as an integrated part of management of substance use disorders o Train core trainers in NDA to train counselors and prevention counselors to incorporate tobacco prevention into substance use prevention programs • Develop patient education/self-care guidelines for prevention and control of NCDs (e.g., patient treatment booklets with self-care information provided to patients, and fliers for diabetes, COPD, Cancers and other chronic diseases to provide at the health facility during consultation) • Encourage the formation of community coalitions and patient groups, and build their capacity: o Promote Diabetes support groups and Cancer Support Group and train patients to engage as peer counselors in Male and other islands, o Engage people with NCDs as advocates and peer outreach programs in areas of high need Page 71 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Strategic Objective 4: NCD Surveillance, monitoring and evaluation, and research This area includes key actions for strengthening surveillance, monitoring and research. The desired outcome is to improve availability and use of data for evidence-based policy and NCD program development. This is an area that is in dire need of strengthening. Below are the key priority actions planned, in order of priority. (Details, timelines and more actions are given in Annex 1.) Objective 4.1: NCD Surveillance There is no dedicated unit for NCD surveillance in MOH or HPA yet. HPA Surveillance unit is dedicated only to communicable disease surveillance at present, and needs more capacity in order to accommodate NCD surveillance. HPA has attempted to collect and maintain statistics on NCD prevalence through health facilities, but with little success. Some progress has been made, including: • A national Cancer Registry was established in HPA in 2018 and data of cancer patients is being collected from health facilities that are providing cancer treatment. • Adoption and use of DHIS software for collecting morbidity and mortality statistics from health facilities with assistance from WHO, trainings for Medical Records staff on data entry and doctors on ICD coding and death certification conducted, and the database introduced to health facilities by Planning and International Health (HIMRD) Division of MOH in 2019. This department collects statistics from the Vital Registration System (VRS) and mortality and morbidity (disease burden) statistics from health facilities. Below are the key priority actions planned for NCD Surveillance, in order of priority. (Details, timelines and more actions are given in Annex 1. Numbers are activity/sub-activity numbers assigned in the tables.): 4.1.1. Institutionalize NCD surveillance by creating an NCD surveillance unit in HPA (within either NCD Division or Surveillance/Epi and Emergency preparedness Division) to undertake NCD surveillance Recruit additional three staff for surveillance, with an additional epidemiologist for the Chronic Diseases Division (see section 1.3. on Strengthening NCD leadership for details) 4.1.2. 4.1.2.1. Mapping of the statistics required for NCD monitoring, planning and advocacy with sources (e.g., HIMRD, DNR, MBS (MNPHI), Atoll NCD clinics and cessation clinics, Aasandha, MOE school health surveys, annual student health screening reports, Customs, Police, MOED, MOEE, MOFA, etc.), regularly collect available updates of surveys and reports from the various sources and prepare a repository of reports for regular use – by NCD program 4.1.3. Strengthen collection and analysis of data for monitoring NCD disease burden (currently collected by HIMRD Division) to add: o analysis of premature mortality from the main disease categories and main 5 NCDs and psychiatric conditions from VRS, o hospitalization LOS through the DHIS, o health care costs by top 5 disease categories through Aasandha Page 72 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) 4.1.4. Develop cancer registry further to include risk factor profiles as well as disease and treatment information and establish electronic cancer registry by obtaining and adopting CanReg software. 4.1.5. Sustain population-based surveillance by continuing integrated risk factors surveys among adults (WHO STEPs Survey) and among adolescents (GSHS) every 3 to 5 years and Integrate surveillance for NCDs into national health surveys and routine statistics 4.1.5.1. STEPS survey for NCD risk factors among adults to be accelerated to 2021; include in STEPS survey more thorough assessment for consumption of fruit and vegetables, salt, fats and sugary drinks, areca nut chewing, and all tobacco products, alcohol use, substance use, physical activity components on walkability and availability of enabling environment for bicycle riding and exercise, and metabolic risk factors including hyperlipidemias, proportion of diabetes and hypertension diagnosed, controlled and received lifestyle interventions and other relevant questions to measure indicators, targets and outcomes of the NCD MAP to be included. 4.1.5.2. and 3. For children and adolescents: GSHS and nationwide School health screenings to include tobacco, alcohol, substance use, physical activity, dietary practices, particularly consumption of fruit and vegetable, salt, fats, sugary drinks, BMI, exposure to advertisement and promotions of unhealthy foods and tobacco and outcomes of policy interventions to reduce NCD risk factors. 4.1.5.4. Integrate surveillance for NCDs into national health surveys and routine statistics collection for collecting statistics for advocacy: o Customs import statistics and taxes for tobacco, sugary drinks and other unhealthy commodities o Taxes and fines from MIRA o Mandating sales statistics by regulations for registration of tobacco importers and distributers, sugary drinks importers and distributors o Expenditure and consumption surveys among public, including products of tobacco, alcohol and foods, particularly fruit and vegetables, sugary drinks and foods high in salt and fats and trans fats: in collaboration with National Bureau of Statistics o Fires caused by smoking or lit cigarettes: MNDF Fire & Rescue Department o Surveillance and monitoring of ambient air quality and indoor air quality and association with indoor smoking: MNU (Using air quality monitors) Objective 4.2: Monitoring & evaluation Monitoring & Evaluation is an area requiring additional strengthening in order to implement the activities of the NCD MAP efficiently and accelerate NCD prevention and control. While the NCD program has been monitoring the progress, it is a very challenging task, and some of the targets and indicators for the previous NCD MAP are yet to be assessed formally. Monitoring needs to go hand in hand with mentoring, for which HPA and MOH need to build their capacity for mentoring, as well as get adequate human resources and equipment/material resources to conduct close monitoring. Below are the key priority actions planned for Monitoring & Evaluation, in order of priority. (Details, timelines and more actions are given in Annex 1. Numbers are activity/sub-activity numbers assigned in the tables.) Page 73 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) 4.2.1. Strengthen monitoring for NCD prevention and control and the MAP in HPA and MOH, by inter- department collaboration between HPA, RAHS, QARD and the various programs of HPA o Prepare specific monitoring tools to measure the targets and indicators under the NCD MAP by December 2021 o Collect information for monitoring using these tools from relevant organizations o Conduct monitoring along with mentoring in atolls through teleconference and visits to atolls and islands o Strengthen staff capacity for effective monitoring and mentoring 4.2.3. Design and conduct evaluation of NCD interventions periodically: o six monthly progress reviews and meetings among stakeholders to discuss ways forward o Conduct mid-term evaluation in 2025 and end line evaluation in 2030, publish, disseminate to key stakeholders and review activities, at end line review to develop new NCD MAP for next 5 years 4.2.5. Strengthen and conduct regular monitoring of specific NCD prevention and control measures: o Introduce compliance monitoring program for tobacco control regulations using modern technologies for reporting, recording and responding, e.g., Viber group monitoring o Monitoring compliance to food standards, nutritional labeling and MRL in food content o Monitoring of Industry interference with public health measures: in collaboration with ACC, HRCM, TM Objective 4.2: Research Maldives is yet to develop a research culture. While there is ongoing research on NCD, most are student research, that are limited to observational studies assessing knowledge and attitudes to various risk factors. Students of Masters courses are now gradually exploring policy research areas. However, there is a lack of operational research evidence on NCD burden, costs, risk factors and effectiveness of control measures to support advocacy for introducing evidence-based NCD prevention and control measures. Below are the key priority actions planned for Research on NCDs, in order of priority. (Details, timelines and more actions are given in Annex 1. Numbers are activity/sub-activity numbers assigned in the tables.): • 4.3.1 Develop, implement and monitor a priority national research agenda for prevention and control of NCDs o Institute a national technical working group to discuss future research priorities for NCDs and their risk factors • 4.3.2 Strengthen national capacity for research and development by establishing collaborations with universities and trainings o Establish long-term collaborations with universities (particularly state universities such as MNU, MIU) for capacity building in research, including updating NCD research priorities regularly and planning and conducting trainings for MOH capacity building. o Train National Health Research Council on NCD ethical issues o Training on operational research from MNU research for HPA and health and other faculties including FHS, School of nursing, School of Medicine, etc. • 4.3.3 Strengthen collaboration between national and regional research centers Page 74 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) o Mapping of other organizations conducting NCD related research that can be mobilized for research (e.g., universities, educational institutions, MBS (MNPHI), other ministries, NGOs, etc. (health and non-health), share research needs identified and mobilize these organizations for conducting research. o Arrange collaborations/ study visits for national researchers to visit regional research centers to acquire NCD research development skills • 4.3.4. Conduct specific collaborative researches on NCD risk factors Some areas useful to conduct research on NCDs and their risk factors include: o Research on NCDs and their risk factors, including STEPS survey, cross-sectional studies and longer-term cohort studies o Health Economic and Policy research o Media research: - types of media used, different viewing times and patterns by audiences of different age groups / social groups o Assessing effectiveness of activities/interventions for NCD prevention and control implemented in Maldives o Studies and Laws and regulations for NCD prevention and control: identifying effective regulations and effective methods of implementation, assessing effectiveness in achieving targets, compliance and identifying methods to improving compliance o Consumption patterns and consumer preferences o A total diet study: by MFDA+HPA in collaboration with MNU o Survey on walkability and availability of enabling environment for bicycle riding in Male’, greater Male’ and selected key cities and atoll capitols o Studies on indoor air quality in indoor public places (esp. restaurants) and homes and the association with indoor smoking o Religion (Islamic perspectives on NCD risk factors) o History/Culture/traditions - Origins/time of introduction of unhealthy habits (to look for hints that make them unpopular, e.g., late introduction, people died young, etc.) - Historical details of healthy behaviors in history to popularize o Sociology - Behavioral change impacts/examples PART III- MANAGEMENT FRAMEWORK The implementation of the Multisectoral Action Plan requires engagement of relevant stakeholders from the government, non-government bodies and private sectors. NCD prevention and control being a multidimensional and cross cutting in nature, effective mechanisms are required to coordinate for a successful implementation of the Action Plan. The NCD program of the health promotion and chronic diseases Division of HPA will technically lead, coordinate and monitor the implementation of the NCD Action Plan, while the Ministry of Health and the High Level NCD Steering Committee will lead the implementation. Annex 1 gives a matrix of activities by Strategic objectives including timelines and process indicators. Page 75 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) ROLE OF STAKEHOLDERS Roles of key ministries and stakeholders are noted under “Responsible organizations” in the matrix of activity tables in Annex 1 (by activity). Annex 2 gives specific roles for key government institutions and academic institutions by institution, for ease of identifying, as the tables in Annex 1 maybe too complex. The action plan will remain flexible to include any partners not envisaged or included at the time development of the plan, or to revise changes in roles of stakeholders in future. PART IV- MONITORING THE IMPLEMENTATION AND OUTCOMES HPA (NCD program) will be overall responsible for monitoring implementation of the NCD MAP. As health facilities are under RAHS Division in MOH, and monitored by QARD, a NCD MAP monitoring committee including HPA (NCD program), RAHS, QARD and the other key programs of HPA that play a lead role in the NCD MAP, such as Nutrition program, Environmental Health, Reproductive Health. The performance of Ministry of Health and other stakeholders will be monitored by the Office of the President through routine submission of progress report to the Secretariat (NCD Unit) and onward submission of information to the President and Vice President. The flow chart in Figure 12 under Strategic Objective 1 shows the flow of monitoring and reporting to HPA MCD Unit from among the stakeholders and from MOH to the President/Vice President. Monitoring plans have been prepared and some monitoring tools are available. These need to be updated to measure target outcomes and indicators for the revised NCD MAP (2023-2031). MONITORING AND MEASURING THE ACHEIVEMENT OF TARGETS AND OUTCOMES The first step in monitoring is for HPA NCD unit to clearly identify baselines for the specific targets that are not currently available. A monitoring form will be developed to include the new targets as well. The following will be the main targets to achieve by 2030 under the NCD MAP and the indicators to measure the outcomes: Table 4: NCD Targets, Indicators for monitoring and methods of measuring Targets for 2025 Indicator Baseline Target Sources and methods value value for measuring (2015) (2030) /assessing (i) Premature a. Mortality attributed to 84% (in 60% VRS, modeling by WHO mortality NCDs (proportional 2018)36 from mortality) cardiovascula b. Mortality rate attributed to To be 25% VRS, analyzed by r diseases, cardiovascular disease, calculate relativ HIMRD cancers, cancer, diabetes or chronic d e diabetes, respiratory disease per reduct chronic 100,000 population by 25% ion 36 World Health Organization - Noncommunicable Diseases (NCD) Country Profiles, 2018. Available from: https://www.who.int/nmh/countries/mdv_en.pdf?ua=1 Page 76 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) respiratory c. Proportional Mortality due 75% 56% diseases, to NCDs – reduce by 25% chronic renal d. Risk of premature death 16% (in 12% From VRS data tables diseases and from CVD, cancer, diabetes, 2014)39 shared to WHO and psychological chronic respiratory disease estimated by WHO diseases - a between age 30 and exact 25% relative age 70 (%) reduction (ii) Suicide a. Suicide mortality rate (per 3.25 per 2.4; Police stats and VRS – mortality – 100 000 population) 100,000 maint can be calculated by 25% (2017) 39 ain <3 HIMRD, also to be sent reduction per to WHO 100,0 00 (iii) Tobacco use a. age standardized 25.7% 18% STEPS – 30% prevalence of current (2020 reduction tobacco smoking, adults STEPS) aged 15+ (%) b. men (%) 35.6% 24.9% STEPS c. women (%) 7.6% 5.3% STEPS (iv) Harmful use a. Total alcohol per capita 3 (2016 2.7 STEPS of alcohol – consumption, adults aged WHO) 39 10% relative 15+ (liters of pure reduction alcohol/year) – 10% relative decrease b. Prevalence of alcohol use <5% Maint STEPS among adults (%) (2020) ain <1% c. Prevalence of alcohol use 4 (2009 3.6 GSHS among adolescents (13-17 GSHS) years) (v) Physical a. Physical inactivity, adults 50 (2020 37.5 STEPS inactivity - aged 15+ (%) STEPS) 25% relative reduction (vi) Salt/Sodium a. Mean population salt 8.8 g/day 5.6 STEPS intake – 30% intake, adults aged 20+ (2TEPS g/day relative (g/day) 2020) reduction (vii) Inadequate a. % population adults 15+ not92.6% 70% STEPS Fruit & eating adequate fruits and men, vegetable vegetables daily 94.6% intake – 30% women reduction (STEPS 2020) (viii) Areca nut b. areca nut chewing – among 56.2% 47.7% STEPS chewing – adults 15+ (%) (STEPS 15% 2020) reduction Page 77 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) (ix) Raised blood a. Age standardized 13.6% 10.2 STEPS pressure - prevalence of Raised blood (STEPS 25% relative pressure (SBP≥140 or 2020) reduction DBP≥90, adults aged 18+ (%) (x) Diabetes – a. Prevalence of Raised blood 14 (STEPS <14 STEPS halt the rise glucose, adults aged 18+ (%) 2020) (xi) Obesity – halt a. Prevalence of Obesity, 20 (STEPS <20 STEPS the rise adults aged 18+ (%) 2020) b. Obesity, adolescents aged 4.9 (GSHS <5 GSHS 13-17 (%) 2009) (xii) Air pollution 1) Mortality rate attributed 25.6 per 23.4 WHO – modeling of – significant to household and ambient 100,000 deaths from air relative air pollution per 100,000 (2018 pollution related reduction population – relative WHO) disease (ARI in children reduction by 10% <5yrs, IHD, stroke, COPD and lung cancer in adults>25yrs) and exposure of the population to air pollutants (for outdoor/ ambient: annual mean concentration of PM2.5 particulate matter, for indoor/ household: proportion of population relying primarily on polluting fuels for cooking) 2) Ambient (outdoor) air pollution – 25% reduction a) Exceedance of WHO To be 25% Air quality monitors guidelines level for measure reduct through MNU annual PM2.5 d ion concentration in ambient air (proportion) b) No. of vehicles To be 10% Stats from Transport registered / in use in the measure reduct Authority country d ion 3) Indoor and Household air pollution – 50% reduction a) Population exposed to 33.9% 23% STEPS second-hand Tobacco (2020 smoke at home, adults STEPS) 15+ (%) b) Population exposed to 40% 20% GSHS second-hand Tobacco (parental smoke at home, smoking children of Grade 1 (%) – Grade 1 screening 2016) Page 78 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) c) Population exposed to 10.4% 8.55% STEPS second-hand tobacco (2020s smoke at work, adults STEPS) 15+ (%) d) Population exposed to To be 25% STEPS second-hand tobacco measure reduct smoke in enclosed d ion public places, adults 15+ (%) e) Population with primary <1% Maint STEPS reliance on solid fuels (2017ain for cooking MDHS)<1% (xiii) Drug therapy 1) Proportion of population at To be 10% STEPS to prevent high risk for CVD (>30%) or measure reduct heart attacks with existing CVD (%) d ion and strokes 2) Proportion of high-risk To be >50% STEPS persons receiving any drug measure for all therapy and counselling to d sub- prevent heart attacks and comp strokes (%) onent s below a) Proportion of people To be >50% STEPS with CVD risk >30% who measure are on anti-platelet d (aspirin or clopidogrel) and lipid lowering drugs b) Hypertension: i) Currently taking drugs 17% >50% STEPS prescribed by doctor (2011 among those STEPS) diagnosed ii) Advised by health 15.4% >50% STEPS professional or health (2011 of worker to stop smoking STEPS) smoke rs iii) Advised by health 55.5% Maint STEPS professional to reduce (2011 ain salt intake STEPS) >55% iv) Advised by health 53.8% Maint STEPS professional to lose (2011 ain weight STEPS) >54% v) Advised by health 60.2% Maint STEPS professional do more (2011 ain exercise STEPS) >60% c) Diabetes: i) Currently taking oral oral >50% STEPS drugs or insulin drugs prescribed for diabetes 63.2% among those Insulin previously diagnosed 19.4% Page 79 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) (2011 STEPS) ii) Advised by health To be >50% STEPS professional worker to measure stop smoking d iii) Advised by health To be >50% STEPS professional to reduce measure salt intake d iv) Advised by health To be >50% STEPS professional to lose measure weight d v) Advised by health To be >50% STEPS professional do more measure exercise d 2) Proportion of people >50% STEPS diagnosed with diabetes and hypertension who are controlled a) Diabetes: % controlled 5.3% >50% STEPS (2020 STEPS) b) Hypertension: % 8.8% >50% STEPS controlled men, 9.8% women (2020 STEPS) 3) Proportion of primary To be >80% M&E forms for health health care centers measure facilities, using PEN reported as offering CVD d tools risk stratification (using CVD risk calculation charts or online calculators) 4) Reported having CVD 50% >50% guidelines that are utilized (2016 in at least 50% of health WHO) 39 facilities (xiv) Essential NCD 1) Number of essential NCD 7 out of 8 out M&E forms using PEN medicines medicines reported as 10 (2016 of 10 tools to identify and basic “generally available” at PHC WHO) 39 (>80% essential medicines technologies level ) and technologies, to treat major administered to health NCDs facilities through atoll a) % of inhabited islands To be >80% NCD focal points with health facilities that measure have pharmacies d (baseline to be assessed) (Number of pharmacies (ALL inhabited islands have at least one pharmacy): 339 in 2017) Page 80 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) b) % of health facilities To be >80% where patients have measure access to at least 80% of d the basic medicines and technologies identified in PEN protocols 2) Number of essential NCD 4 out of 6 5 out technologies reported as (2016 of 6 “generally available" at PHC WHO) 39 level HPA NCD program will gather baseline indicators for measuring the achievement of the above targets and outcomes in collaboration with HIMRD, WHO and relevant departments and organizations as soon as possible, within the year 2021, and then reassess for outcome indicators in 2030. PROCESS MONITORING OF THE WORK PLAN The national M& E protocol for the Multisectoral National NCD Action Plan will be finalized through a stakeholder meeting and seek endorsement of the High-Level Taskforce. NCD Steering Committee. The Steering Committee will monitor the progress of activities through HPA NCD Unit, which should be technically responsible for monitoring. The Steering Committee should report to the Cabinet or Presidential Taskforce on a 6 monthly basis. All stakeholders will be accountable for their work plans. HPA will seek responsible NCD Focal points from all stakeholder organizations for coordination, leading the implementation and monitoring. For institutions outside the health sector, this may be the “Health Focal Point” for all health issues, or a member of the health team of the organization. The work plan will be integrated within their sectoral plans. Monitoring will be done together with mentoring and providing feedback and guidance. In order to track the implementation progress, stakeholder meetings will be held in the first quarter for orientation, and three-monthly activity progress reports will be collected by the NCD Unit/Secretariat at the end of March, June, September and December. Meetings will be held with the progress reports 6 monthly to actively review progress and provide feedback and guidance. Monitoring forms for activity reporting will be developed by a small Working Group consisting of HPA technical staff and selected key stakeholders. Stakeholders will be oriented on the coordination protocol and reporting format. During the subsequent years of implementation, any new coming members will also be oriented on the coordination protocol and reporting format. The NCD Unit will review the progress and provide feedback within the 14 working days of the receipt of activity reports. The feedback will include the progress against the set indicators, and suggestions on how to improve activities for achieving the targets. Two-way feedback will be provided through stakeholder meetings and teleconference with atoll and city health facility NCD Focal points. Monitoring visits will be conducted to atolls for monitoring and mentoring some key activities, such as PEN implementation. The progress for 2030 will be measured through few critical process indicators and short term and medium-term outcome indicators. The key indicators are defined for each risk factor, diseases and other service delivery areas. Process and short-term indicators are aimed towards mid-term plan (2025) and the medium term and few long-term indicators are expected to be achieved by 2030. The Page 81 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) majority of the long-term indicators should be achieved by 2030, along with those indicators for the targets for 2030. Indicators for each activity and sub-activity are detailed in the matrix of activities and timelines in Annex 1. A summary of critical indicators to be used for tracking the progress of the Multisectoral NCD Action Plan along their means of verifications and key assumptions are described in the detailed tables in Annex 2. Page 82 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) CRITICAL FACTORS OF THE ACTION PLAN Several factors are critical to the success of the Action Plan as listed below. Faltering of one or more of these factors will severely risk the success of the Action Plan. These factors must be therefore closely managed at every stage of implementation. • Political stability and commitment of the government to evidence-based NCD prevention and control is positive and sustained • Proposed legislation and regulations to support policies are endorsed • The Health Promotion & Chronic Diseases (NCD) Division in HPA/MOH is strengthened with the required strength of capable staff to lead the implementation of NCD prevention and control effectively • Other stakeholders including the enforcement agencies are empowered with adequate knowledge and resources and effectively participate in implementing the NCD action plan • Proposed boards/ committees are diligently able to meet and function • Annual work planning and review exercises are conducted routinely • Adequate financial resources are committed • WHO and other donors provide continued partnership, support and guidance at the country level REFERENCES AND DOCUMENTS CONSULTED There are no sources in the current document. Documents consulted are referenced at the bottom of each page. In addition to the documents referenced in relevant places above, the following documents were also consulted.

1. WHO NCD MAP tool, available from: http://apps.who.int/ncd-multisectoral-plantool/home.html http://apps.who.int/nmh/ncd-map-toolkit/developing/tool-template.html

2. WHO toolkit for evaluating NCD MAP, available from: http://apps.who.int/nmh/ncd-map-toolkit/evaluating/tool-framework.html http://apps.who.int/nmh/ncd-map-toolkit/evaluating/tool-steps.html

3. WHO. Tackling NCDs: "Best buys" and other recommended interventions for the prevention and control of noncommunicable diseases. 2017. WHO reference number: WHO/NMH/NVI/17.9 Available from: https://www.who.int/ncds/management/best- buys/en/ and https://www.who.int/ncds/management/WHO_Appendix_BestBuys.pdf

4. WHO, World Economic Forum. From Burden to “Best Buys”: Reducing the Economic Impact of Non-Communicable Diseases in Low- and Middle-Income Countries. 2011. REF: 100811

5. The Global Strategy on Diet, Physical Activity and Health. Available from: https://www.who.int/dietphysicalactivity/strategy/eb11344/strategy_english_web.pdf

6. Multisectoral Action Plan for Prevention & Control of Non-communicable Diseases in Maldives (NCD MAP) (2016-2020). Health Protection Agency, Ministry of Health

7. National Cancer Control Plan (unpublished). Health Protection Agency, Ministry of Health

8. National Food Based Dietary Guideline Implementation Plan. Health Protection Agency, Ministry of Health (unpublished) Page 83 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031)

9. First 1000 days SBCC strategy Final Endorsed Version_6.8.2018. Health Protection Agency, Ministry of Health

10. National Eye Health Plan. Health Protection Agency, Ministry of Health

11. National Action Plan for Air Pollution. Ministry of Environment

12. NCD 25-25 Campaign plans. NCD program, Health Protection Agency, Ministry of Health. Unpublished

13. List of priority activities identified for Govt. pledge to increase budget for awareness on the risks of tobacco, areca nut and sugary drinks

14. Maldives Demographic Health Survey 2009

15. Maldives Demographic Health Survey 2016-17

16. Strategy for Prevention of Cervical Cancer, Health Protection Agency, Ministry of Health.

17. Health Master Plan 2015-2020, Affordable and Quality Health Care for All, Ministry of Health, Republic of Maldives

18. WHO STEPS survey on risk factors for noncommunicable diseases Maldives, 2020-2021

19. Action plan for the prevention and control of noncommunicable diseases in South-East Asia, 2013-2020, World Health Organization

20. Global Action Plan for the prevention and control of noncommunicable diseases 2013-2020

21. Tobacco Control Act (Law 15/2010), Maldives

22. School Health Policy 2011, Ministry of education and Ministry of Health and Family, Republic of Maldives

23. National Standard for Labelling (Draft), MFDA-FCD STAN 4-2014

24. Government Strategic Action Plan (SAP) 2019

25. UN SDGs Page 84 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031)

ANNEX 1: Activities for the implementation of the NCD MAP 2023-2031 (Matrix included with this Action plan - attached) Page 85 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031)

ANNEX 2: INDICATORS FOR PROCESS MONITORING OF THE NCD MAP WORK PLAN Table 5: Indicators and means of verification (Mov) for Strengthening NCD Governance Process Short term indicators Medium term indicators Long term indicators Strengthening advocacy Formation of an NGOs and academia Implementation of NCD through community- NCD/Health promotion actively advocate for Best Buys policy based organizations Advocacy network of NCD Best Buys measures measures prioritized in NGOs and academia using effective methods NCD MAP (See tables (MoV: active Viber (Mov: no. of official below) group, TOR for the letters sent, social media network and its posts, position papers members) published, petitions, Capacity building contributions to online workshops held (Mov: newspaper articles, no. of advocacy training appearances on TV/radio workshops held for programs, advocacy NGOs and academia) spots) Capacity building of Media sensitization Qualitative improvement Improved public media for promoting workshops, training of media depiction of knowledge, attitudes healthy lifestyles and workshops held, Media NCDs and risk factors and and practice of healthy NCD prevention briefs, IEC material media promoting lifestyles (STEPS survey, prepared (Mov: no. of healthy lifestyles (Mov: GSHS) workshops, no. of IEC Questions on exposure material/media briefs to tobacco/ unhealthy prepared) food promotions in STEPS survey, no. of media programs per year covering segments on NCD prevention or risk factors though media survey – by MMI/ Journalism students) Strengthening national Establishment of multi- Functional high-level Implementation of NCD coordination for NCD sectoral High level NCD committee, conducting Best Buys policy prevention and control Steering Committee or regular productive measures prioritized in Taskforce with higher meetings and making NCD MAP (See tables leadership by VP or co- evidence-based below) chaired by a minister decisions for NCD who is able to mobilize prevention and control several other sectors (MoV: Meeting minutes) (MoV: MOH/HPA: High level Committee meeting minutes) Establishment/ Functioning Advisory Implementation of NCD sustaining of Advisory Boards, TECs, working Best Buys measures Boards, TECs, working groups providing Page 86 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term indicators Long term indicators groups for implementing evidence-based prioritized in NCD MAP the various activities decisions and outputs (See tables below) (Mov: TORs, appointee (Mov: minutes of board lists/letters/meeting meetings, finalized/ minutes) published regulations, standards, guidelines, IEC material) Strengthening of HPA Adequate staff with Committees, boards, Implementation of NCD capacity for secretariat appropriate capacities TECs, working groups Best Buys measures functions for identified and in-service, and advocacy groups prioritized in NCD MAP coordinating and adequate facilities actively functioning and (See tables below) providing technical identified and mobilized satisfied with support support to the boards, (Mov: HPA NCD provided by secretariat, committees, working program) timely and professional groups and advocacy documentation of groups and health and minutes and output other sector focal point documents, provision of networks technical documents such as current research evidence and available guidance for perusal and decision making (Mov: meeting minutes, feedback from members) Strengthening of HPA HPA structure of Chronic Staff are retained and Implementation of NCD capacity for NCD Diseases Division (NCDD) functional, facilities Best Buys measures prevention and control includes an available and functional, prioritized in NCD MAP leadership and epidemiologist and units Implementation of (See tables below) implementing effective for Health Promotion activities in NCD MAP in NCD prevention and and NCD Surveillance process, appropriate control measures with adequate staff technical guidance possessing relevant skills provided for boards, identified in the section, committees and other the staff are recruited, sectors, evidence-based Appropriate equipment advocacy briefs and facilities for effective published and communication and disseminated, effective health promotion IEC material produced procured and disseminated, HPA (Mov: HPA) website functional. (Mov: HPA DG, website/social media, feedback from members of boards and committees) Relevant training provided for staff Page 87 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Table 6: Tobacco control indicators and means of verification (Mov) Process Short term indicators Medium term indicators Long term indicators Graphic health warnings Regulation gazette with Public awareness about Prevalence of tobacco with annually rotating this requirement health effects through use among adolescent warnings and ban of included (already in Jan pictorial warning on and adults (Mov: STEPS single cigarettes 2019), tobacco packages and GSHS) implemented New warnings developed Demand for quit services and Standards/ - number of people guideline/ requirements seeking services to quit document updated with smoking from health these and other facilities loopholes covered and (Mov: gazette Assessment through (Mov: gazette STEP survey and GSHS by document) inclusion of questions on Pictorial warning and GHW, KAP surveys with packaging of tobacco questions relating to products seen in the GHWs and ban of single market (good cigs - mobilizing compliance), university student Compliance check research, Cessation program through decoy service monitoring purchase attempts for reports of HPA) tobacco laws as a quality improvement tool (Mov: analysis of compliance rates from regular compliance check operations by HPA and number of violations by Police and MIRA software) Revision of present Decrease of smoking in Exposure to second hand Prevalence of tobacco partial smoking ban public places, work tobacco smoke by use among adolescent regulation to a places, restaurants and children and adults in and adults (Mov: STEPS Comprehensive ban on waiting areas to board public places, health and GSHS) smoking in all indoor public transport (Mov: facilities, educational Number and proportion public places, workplaces analysis of compliance institutions, public of deaths and admission and public transport, check operations and fine transport and LOS due to heart educational and health collection software of workplaces decreased disease, stroke, institutes and improved Police/MIRA by HPA, KAP (Mov: School Health respiratory diseases implementation studies via student Screening reports, GSHS, (particularly (Mov: Gazette revised research by universities) STEPS, KAP studies by asthma/COPD) (Mov: regulation and Intense enforcement university students) Maldives Health guidelines) operation program for STEPs survey indicator Statistics from health compliance checks in on % of adults reporting facilities and VRS smoke free zones and exposure to SHS in public analyzed and published designated smoking places. by HIMRD) Page 88 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term indicators Long term indicators areas mobilizing various Number and proportion implementers and of Deaths and admission volunteers (Mov: Written LOS due to heart disease, work plans/SOPs for stroke, respiratory police, HPA/public health diseases (particularly units, City/ Island asthma/COPD) (Mov: Councils and volunteers Maldives Health for joint enforcement Statistics from health activities, compliance facilities and VRS check reports of analyzed and published operations, compliance by HIMRD annually) and violations analyzed via Police/ MIRA software) Conducting an effective Health professionals, Exposure to second hand Prevalence of tobacco and sustained anti- NGOs, academic tobacco smoke by use among adolescent tobacco mass media institutions and schools children and adults in and adults (Mov: STEPS campaign – Tobacco Free actively engaging in public places, health and GSHS) Families campaign advocating for tobacco facilities, educational (Mov: Annual reports of smoke free households, institutions, public HPA, High Level NCD schools, educational transport including taskforce, FCTC institutions, work places waiting areas and implementation reports and public places, workplaces decreased sent to WHO) Mass media and social (Mov: School Health media campaign material Screening reports, GSHS, broadcast/published and STEPS, KAP studies by seen by public university students, (Mov: Annual reports of PM25 air pollution levels HPA, KAP studies by at public places such as university students) restaurants and transport waiting areas) Revision of tobacco Highest tobacco tax rates Tobacco consumers Prevalence of tobacco taxation policies (Mov: to apply to ALL tobacco reporting reducing/ use among adolescent Recommendation by products (including quitting tobacco use due and adults (Mov: STEPS TCB/MOH sent to shisha, ENDS, and to high cost and GSHS) relevant ministries (MO smokeless tobacco (Mov: Survey Finance / Citizens Majlis), products), questionnaire adapted Publication of tobacco Tobacco product prices for STEPS and GSHS taxation policy increase significantly collected five yearly) document/ legislature) Incremental tobacco tax Demand for quit services and import duty - number of people collection adjusted to seeking services to quit inflation and economic smoking from health growth with a target of facilities 70% taxes as a percent of (Mov: Cessation service final prices by year 2021 monitoring reports – onwards HPA) Page 89 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term indicators Long term indicators Earmarking percentage of tax for prevention activities (Mov: Annual Govt. budget reports, Annual revenue report of Customs) Regulations for Regulation gazette, Products entering the Prevalence of tobacco registering, licensing and License issued for market are well known use among adolescent regulating tobacco imported products by MOH in advance and and adults (Mov: STEPS import and sales gazette License issued for any new product and GSHS) and implemented (Mov: packaging and sales for identified before going gazette regulation) local businesses I keeping to market, MOH able to with regulation regulate new products Licenses cancelled or better (Mov: Licensing temporarily suspended in authority (MFDA) and case of any violation of HPA/TCB reports) tobacco control Exposure of adolescents regulations by the party to new tobacco products Regular compliance (Mov: GSHS/GYTS checks conducted by survey, KAP studies by implementing university students) organizations (Mov: compliance checks, reports of HPA, MFDA, MED and other sectors) Formulating, publishing Regulation formulated Reduced exposure of Prevalence of tobacco in gazette and enforcing and published in gazette adolescents and adults use among adolescent a regulation for (Mov: gazette to TAPS (Mov: GSHS, and adults (Mov: STEPS comprehensive ban on publication of regulation) STEPs survey - questions and GSHS) all forms of TAPS Regular compliance added) (Tobacco Advertising, checks and operations Promotion and mobilizing various Sponsorship) including implementers and cross border TAPS and volunteers (Mov: any kind of CSR activities Written work plans/ by tobacco industry SOPs for MFDA/ under the TCA (Mov: Customs/ MED/ MIRA, gazette regulation) HPA/ public health units, City/ Island Councils and volunteers for joint enforcement activities, compliance check reports of operations, compliance and violations analyzed via Page 90 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term indicators Long term indicators MFDA/ Customs/ MIRA software) Strengthening tobacco Initiate cessation Establish national toll Prevalence of tobacco cessation program and capacity free Quitline use among adolescent building of health (Mov: STEP survey and adults (Mov: STEPS professional in health indicator on % of tobacco and GSHS) facilities, schools, youth smokers advised by HW centers and substance to quit smoking; use rehabilitation percentage of adults that services in all atolls for have heard about quit tobacco cessation (Mov: line or used it.) HPA reports, no. of trainings held and no. of participants trained, health facility cessation service monitoring reports of HPA) Implementation of FCTC Circular sent to govt. Compliance by govt. article 5.3. Stopping organizations by organizations and NGOs tobacco industry MOH/PO, Policy (Mov: compliance interference in document gazette checks through NCD government policies as a Advocated by NGOs MAP monitoring written policy in MOH (Mov: gazette document, reports) and across government reports) institutions Ban of shisha and ENDS Banning regulation Access to shisha or ENDS Prevalence of tobacco gazette and publicized, products reported by use among adolescent Implemented and adolescents and adults and adults (Mov: STEPS compliance checks (Mov: GSHS/GYTS and GSHS) conducted (Mov: survey, KAP studies by compliance check reports university students) and analysis for violations via Police/MIRA software) Table 7: Indicators for promotion of healthy diet and means of verification (Mov) Process Short term indicators Medium term Long term indicators indicators Passage and Gazette publication of Food Act Age standardized implementation of (Mov: gazette document) mean population Food Bill intake of salt (sodium Passage and Gazette and implementation of Decreased chloride) per day in implementation of regulation (Mov: gazette advertisement of non- grams in persons aged regulations for regulation, publication and alcoholic beverages 18+ years marketing of food & public announcement of high in sugar and foods beverages to children high in salt, saturated Page 91 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term Long term indicators indicators and adolescents requirements for food fatty acids, trans fat or Population achieving (Mov: gazette advertisements) sugar (Mov: Study of recommended level of regulation) Compliance/ number of advertisement in media servings of fruits and violations (Mov: MFDA reports) by vegetables HPA/NGOs/university students) Consumption of food Adoption of policies Policy paper re-submitted and Decrease market containing trans-fat to reduce food presented to Social Council for availability of food and hydrogenated products high in salt, advocating to establish products with high vegetable oil trans fats and government policy (Mov: content of salt, trans fat hydrogenated submitted Social Council paper) and hydrogenated oils Mean population vegetable oils in food Monitoring of food contents of (Mov: Annual market consumption of free supply (Mov: salt and saturated fatty acids inspection reports of sugars Published policy and trans-fat levels (Mov: MFDA/HPA) documents) Annual market inspection Prevalence of areca reports of MFDA/HPA) nut chewing among Nutritional labeling on Regulation for packaging and Increase awareness of adults and back and front of pack labeling of food products salt, free sugar and fat adolescents for both imported and revised/ updated with content of diets domestically requirements for nutritional consumed in Prevalence of obesity produced packaged labeling on back and front of population (Mov: and being overweight foods pack and gazette (Mov: gazette STEPS, GSHS surveys) regulation) (Mov: STEPS, GSHS MFDA laboratory capacity surveys) upgraded to test for nutritional content required under regulation (Mov: reports of MFDA) Compliance for nutritional labeling at import and retail market (Mov: MFDA annual reports of stats on import compliance checking, annual market inspection reports by MFDA/MED, stats of violations and fines by MIRA stats, market surveys by university students) Adoption of national BCC for promoting diet low in Increase awareness of dietary salt, fats, sugar and high in fruit dietary recommendation for and vegetables as integrated recommendations in all age groups and for healthy diet campaigns for population (Mov: STEPS different conditions adults, school children and and GSHS and midterm and information youth conducted and end line evaluation integrated into (Mov: Awareness material and reports) national BCC & mass messaging published on media campaign websites/social media, airtime (Mov: Published mass for promoting healthy diets and Page 92 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term Long term indicators indicators media and BCC healthy lifestyle, Activity reports strategy) of HPA, MOUs with media) Implement the Adult Food Based Dietary Guidelines (FBDG) published (Mov: IEC material produced, no. of trainings held and no. of participants trained, HPA Activity reports) Expand Taxation of Published taxation policy and Consumption of sugary both domestic and tax rates (Mov: publication in drinks (reduced), imported sugary gazette) consumption of other drinks and identified Annual statistics of Customs and foods identified: salt, specific unhealthy MIRA on tax collected (Mov: trans fats and saturated food and beverage Customs and MIRA statistics) fats, hydrogenated products high in salt, Price of commodities taxed vegetable oils and trans fats and (Mov: Market survey by processed meats (Mov: hydrogenated university students/MED, Income expenditure vegetable oils and Income Expenditure Survey by survey, STEPS) carcinogens MBS (MNPHI)) (processed meats) and ultra-processed foods identified by HPA/MFDA Mandating Health Regulation mandating health Awareness of the risks warnings on areca nut warnings (preferably graphic) of areca nut use among packages on packages of areca nut adolescents and adults containing products gazette and (Mov: KAP survey by implemented (Mov: gazette university students, regulation, reports of Prevalence of areca nut compliance checks for package chewing among warnings in retain market) adolescents and adults (Mov: GSHS, STEPS survey - added questions, KAP survey by university students) Implement Policy papers submitted to Increased production Agricultural incentives Social Council, decisions made, and availability of local for fruit & vegetable policy published in gazette fruit and vegetables, cultivation, and for (Mov: Published Policy reduced prices (Mov: Good Agricultural documents in gazette/, market survey, annual Practice; and published public notices/news reports of MOFAMR) disincentives for areca detailing incentive schemes in nut cultivation and official govt. websites production Urban planning Easy access to local markets in Increased availability measures to facilitate cities and access to fruit and Page 93 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term Long term indicators indicators access to fruit and Home gardening of fruit and vegetables for people vegetables vegetables increased living in cities (Mov: Growing of fruit trees in streets household surveys by of cities increased City councils, surveys by (Mov: City Council reports for university students) Male’, Hulhumale, Addu, Kulhudhufushi, household surveys by City councils) Table 8: Indicators for physical activity promotion and means of verification (Mov) Process Short term indicators Medium term Long term indicators indicators Develop and Dissemination of guidelines and Awareness on the Prevalence of disseminate national messages on social media and other recommendations insufficient physical activity media programs (Mov: BCC and mass of physical activity physical activity guidelines for all age media campaign strategy annual among people of all among children groups in various report) age groups (school and adolescents settings No. of trainings held for health children, youth and defines as less (Mov: Print/ online professionals, no. of professionals adults (Mov: Mid- than 60 minutes documents of national trained, term evaluation of moderate to physical activity health professionals’ awareness of report of BCC and vigorous guidelines) physical activity recommendations mass media intensity activity (Mov: post-training assessments and campaign and STEPs daily reports - HPA) and GSHS) Age standardized Incorporate urban MOH/HPA and a health NGO to be Streets conducive prevalence of structural designs that represented in Urban Planning for pedestrians and insufficient enable physical activity committee established at bicycle riding in physical activity in Male’ city, MHUD/MNPI. main cities persons aged Hulhumale’, Addu, Urban structural requirements that (Mov: STEPS survey - 18+years Kulhudhuffushi and enable physical activity to be included added questions (defined as less other developing urban in long term design plans, Building Walkability and than 150 minute settings (Mov: Building Code and Urban design bicycle friendliness of moderate- Codes, SOPs and work codes/requirements. (Mov: Building survey) intensity activity plans of MHUD, MNPI, Code, Urban design requirements No. of islands and per week, or LGA, City councils and documents published) city neighborhoods equivalent) Island councils) Urban design promoting walkability with free to access and bicycle use – no. of cities and atoll sports or exercise capital islands with adequate bicycle facilities lanes and bicycle parking facilities, no. People participating of pedestrian designated streets in regular physical (walking only) in Male’ city and activity at public overcrowded islands (Mov: Activity grounds and and progress reports of MHUD/ MNPI swimming areas Urban Planning Committee and City/ increased Island councils) Page 94 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term Long term indicators indicators No. of islands and city neighborhoods (Mov: Annual with free to access sports grounds, assessment report/ parks or exercise facilities survey on use of (Mov: MYSCE report, Physical public grounds by verification of sites) Councils/HPA) No. of homes/ apartments that have allocated space or permission to do home gardening (Mov: survey by City/island councils) *Public transport Policy measures to Paper on Taxation recommendations Affordability of gyms improve affordability of submitted to Cabinet and Majlis (Mov: and exercise physical activity through paper submitted) facilities improved gyms and sports Passage and inclusion of taxation (Mov: Income programs, e.g., tax recommendations by govt. expenditure survey reductions for such (Mov: Taxation policy documents by MBS (MNPHI), services published in gazette) market survey by university research students) Continue ongoing BCC campaign with social media Weekly Physical “Dhulhaheyo awareness and Events conducted activity (practices) Hashiheyo” campaign of (reports of relevant ministries and improved (Mov: the government, and MOH/HPA) STEPS survey) other BCC campaigns to promote physical activity Assumptions: Greater leadership by school systems, City Council and Ministry of Urban Development and Infrastructure and funds available for health promotion Table 9: Indicators for prevention and control of alcohol use Process Short term indicators Medium term Long term indicators indicators Developing socially Key Messages identified by HPA in Population Prevalence of alcohol acceptable consultation with health awareness on the use/harmful use reduced, messages on alcohol professionals, NGOs, and target risks of alcohol increased alcohol abstinence for groups, consumption and abstinence among adults public awareness Discussions held with Ministry of alcohol abstinence and adolescents. Islamic Affairs to adopt socially (Mov: STEPS, GSHS (Mov: STEPS, GSHS) acceptable messages in keeping with surveys) Islamic religious teachings (Mov: meeting minutes, developed messages and IEC material) IEC material developed and disseminated Page 95 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term Long term indicators indicators Adopt of relevant Increase educational programs on Population Prevalence of alcohol components on alcohol abstinence among young awareness on use/harmful use reduced, Global Strategy on people (Mov: Annual activity reports alcohol abstinence increased alcohol Reducing Harmful of stakeholders compiled by NCD policy (Mov: STEPS abstinence among young Use of Alcohol (Mov: Unit) survey) people. Published policy (Mov: STEPS, GSHS) document) Incidence of deaths from alcohol intoxication reduced (Mov: Maldives Health Statistics by PHI) Guidelines and Protocols for alcohol use included in Improved Prevalence of alcohol use services made PEN package detection and and harmful use reduced, available in health Treatment guidelines for alcohol treatment of increased alcohol facilities and health intoxication, harmful use and alcohol intoxication abstinence. professionals substance use prepared and available and harmful use, (Mov: STEPS) trained to detect for use in all health facilities. through health Incidence of deaths from and treat alcohol Treatment protocols for alcohol facilities and drug alcohol intoxication intoxication, dependence available and practiced rehabilitation reduced (Mov: Maldives harmful use and in Drug rehabilitation facilities under facilities Health Statistics by PHI) substance use, and NDA for screening and (MoV: published guidelines, providing brief monitoring reports from health intervention facilities complied by HPA NCD unit) Monitoring/ % of Alcohol breath tests tested Alcohol involved Reduced mortality from reducing drunk positive annually, road accidents and road traffic accidents driving through alcohol-involved (Mov: Maldives Health traffic Police crime (Mov: Statistics) Published joint annual report of HPA and police) Measures to restrict Legislature restricting foreigners Alcohol Prevalence of alcohol alcohol from taking alcohol bottles outside consumption use/harmful use reduced, consumption by bars and restaurants in tourist among resort increased abstinence. Maldivians at tourist establishments, restricting workers and youth (Mov: STEPS, GSHS) resorts and hotels availability in licensed bars and 15+ reduced (STEPS restaurants of tourist hotels situated survey) near schools and educational institutions (Mov: legislature published in gazette) Page 96 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Table 10: Indicators to Reduce Air pollution Process Short term indicators Medium term Long term indicators indicators Policy measures for Vehicle emission standards revised No. of vehicles Ambient air reduction of and published by MoEnv. (Mov: compliant with safe pollution levels motored vehicles published standards) emission standards (PM2.5 particle and reduction of (Customs statistics) levels) in main Regulations for taxation of motored emissions vehicles and vehicles with high Streets conducive for cities reduced emissions and for Regulating vehicles environment-friendly imports / controlling vehicle smoke transport such as emissions formulated and gazette. walking and bicycle (Mov: gazette regulation) riding in main cities, Time taken to travel Availability and adequacy of public between 2 fixed transport in the cities of Male, Hulhumale’, Addu Kulhudhuffushi and destinations all cities, including time taken to travel (Mov: STEPS survey - between 2 fixed destinations (Mov: added questions survey by City councils for adequacy Walkability and and public satisfaction with public bicycle friendliness transport) survey) Urban design promoting walkability and bicycle use – no. of cities and atoll capital islands with adequate bicycle lanes and bicycle parking facilities, no. of pedestrian designated streets (walking only) in Male’ city and overcrowded islands (Mov: Activity and progress reports of MHUD/ MNPI Urban Planning Committee and City/ island councils) No. of populated islands / City neighborhoods with at least one large green space (e.g., parks providing exercise, with greenery and smoke- free environments included) Incorporating policy Environmental Health and Air pollution Proportion of indoor Indoor air pollution on smoke (including Action Plans contain integrated public places that are levels (PM2.5 tobacco smoke)- activities promoting smoke-free public maintained as fully particle levels) in free public places places and homes (Mov: Action Plans, smoke-free key indoor public and homes into policy documents) (compliance to places and social national action smoking bans) (Mov: housing buildings plans for air Compliance of Smoking bans compliance reports of reduced pollution implementation – (Mov: compliance HPA/ Police/ MIRA) prevention (HPA EH reports of HPA/ Police/ MIRA) Proportion of homes and MOEnv.) that are free from tobacco smoke, cooking smoke or any other smoke (Mov: Page 97 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term Long term indicators indicators household survey such as MDHS, STEPS questions added) Conduct a study on Study proposal written, funds sought Improved awareness Indoor air pollution air pollution in and mobilized, study conducted by of sources of indoor levels (PM2.5 indoor public places MNU, results presented in academic air pollution in particle levels) in and households to sessions, advocacy forums and media, Maldives among key indoor public measure the extent and study results published in peer public and politicians places and social of indoor air reviewed journal, shared with (MoV: STEPS, Tweets housing buildings pollution and HPA/MOH for further advocacy. of MOE and key association with (MoV: publications of study results in politicians, policy indoor smoking and journal and media, policy papers based papers referencing other sources of on or quoting/referencing study) study) indoor air pollution - in collaboration with MNU Regular Monitoring Technical committee formed and Ambient and Indoor Ambient and of ambient and places selected for indoor and ambient air pollution levels Indoor air pollution indoor air pollution air pollution monitoring, considering (PM2.5 particle levels (PM2.5 - in collaboration public health impact and available levels) in key outdoor particle levels) in with MNU resources, guidelines for monitoring and indoor public key outdoor and developed (MoV: Guideline including places indoor public key places and methods of monitoring) places Equipment placed / fixed and monitoring established (MoV: regular measurements of PM2.5 particle levels) Guidelines and Guidelines and standards prepared Compliance to Ambient air standards for (Mov: published document) guidelines pollution levels industries leading Trainings conducted for (PM2.5 particle to lung disease implementation of guidelines (MoV: levels) related with air No. of trainings held; no. of persons pollution such as trained) fiber boat building, and preparation of smoked fish close to residential areas in islands Table 11: Indicators for Promote healthy behaviors to reduce NCDs in key settings and means of verification (Mov) Process Short term indicators Medium term Long term indicators indicators Formulate and Guidelines for Workplace health Healthy workplace Reduction in disseminate and healthy lifestyles at work policies implemented prevalence of Page 98 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term Long term indicators indicators guidelines for published and disseminated by print (MoV: no. of tobacco use Workplace health and and soft via MOH/HPA websites and workplaces among adults and healthy lifestyles at social media implementing selected young people, work (MoV: published guideline) policies from the Increase in Trainings conducted for health guidelines – e.g., physical activity, professionals and workplace HR smoke free Decrease in teams on implementing the workplaces, healthy obesity guidelines for creating awareness at canteen, area for Decrease of sugar, workplaces physical activity, safe salt and fat (MoV: No. of trainings held; no. of bicycle parking) consumption persons trained) Increase of fruit No. of workplace health awareness and vegetable activities conducted (MoV: no. of consumption activities, no. of workplaces (MoV: STEPS covered, no. of people covered) survey, GSHS) Formulate and Healthy Events Guide published and No./percentage of disseminate a Healthy disseminated by print and soft via healthy events and Events Guide MOH/HPA websites and social healthy media media franchise programs (MoV: published guideline) with following Trainings conducted for health features: professionals, island council staff on - smoke-free and implementing the guidelines actively discouraging (MoV: No. of trainings held; no. of tobacco use, persons trained) - encouraging healthy No. of awareness activities eating, conducted to promote healthy - encouraging physical events (MoV: no. of activities, no. of activity, event organizers and workplaces - no unhealthy covered, no. of people covered) sponsorships (MoV: No./percentage of healthy events and healthy media franchise programs) Review and re- Consultant hired. Review of NCD 25- Increased public organize the ongoing - 25 Campaign conducted and revised awareness, improved NCD 25-25 Campaign plan using COMBI methods attitudes and improved using BCC/COMBI prepared, suggestions from target practice of healthy methods with groups and stakeholders collected, lifestyles (MoV: KAP feedback from target brand, IEC material and activities study, on key NCD risk groups, re-branding if identified and prepared with target factors among target required and more group inputs. population: tobacco effective messaging New campaign launched and use, reduction of and activities. conducted second-hand smoke MoV: campaign reports, IEC exposure, physical material, access to campaign activity, intake of fruit material and messaging on social and vegetables, foods Page 99 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term Long term indicators indicators media and mainstream media, pre- high in sugar, salt, fats and post-survey of target behaviors and areca nut chewing, to change, i.e., tobacco use, STEPS survey, GSHS) reduction of second-hand smoke exposure, physical activity, intake of fruit and vegetables, foods high in sugar, salt, fats and areca nut chewing) Healthy lifestyle Physical activity programs School children are promotion in schools integrated into curriculum as school aware and engage in (Mov: Annual work wide policy and practice to achieve physical activity plans targeting national physical activity promoting sessions at healthy lifestyle recommendations at school setting school (Mov: GSHS) promotion) (Mov: Annual progress report of MOE) Conduct healthy Number of organizations integrating More workers involved lifestyle programs at work place healthy lifestyle in physical activity at workplace (Mov: promotion in key corporate and work place (Mov: Signed MoUs of government settings (Mov: Activity Evaluation report on participating reports of the pilot workplaces) piloting work place stakeholder and HPA) healthy lifestyle promotion in five selected organizations) Integrate promoting Inclusion of addressing the main Improved public the ABCs of healthy NCD risk factors in Maldives awareness and lifestyles and (tobacco use and second-hand attitudes towards key evidence-based smoke exposure, healthy diets, healthy lifestyles for measures for NCD risk physical activity and mental health preventing NCDs (MoV: factor control into in public awareness messaging, STEPS survey, GSHS) other relevant HPA health professional guidelines and programs policy measures of other HPA programs, particularly: - ARI prevention - Reproductive health including pre-marital counseling, antenatal education programs, maternal and child health - Environmental health and air pollution (MoV: IEC material, guidelines and policy documents) Improve public IEC Material for public on Heart Improved public Reduced mortality awareness on the key disease, stroke, cancer, asthma, awareness of the top 5 from Heart diseases with highest COPD, diabetes, chronic kidney NCDs and how to Disease, Stroke, mortality (heart disease produced and disseminated prevent these diseases, cancer, asthma, disease, stroke, (MoV: IEC material published on screen for early COPD, diabetes, cancer, asthma, HPA website/social media and print) detection and improve chronic kidney Page 100 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term Long term indicators indicators COPD, diabetes, outcomes with regular disease. (MoV: chronic kidney Awareness conducted regularly treatment and follow- Maldives Health disease), including every year on Awareness days for up with health Statistics of MOH – consequences, these diseases (World Heart Day, professionals, analyzed by prevention, early World Cancer Day, World Asthma (MoV: KAP survey by HIMRD) detection and Day, COPD Day, World Diabetes university students) treatment Day, World Kidney Day and World Improved healthy Stroke Day) lifestyle practices (MoV: reports of activities (MoV: STEPS survey, conducted and IEC material GSHS) published on HPA website/social Increased no. of people media and print) screening for NCDs (MoV: Health screening data and reports) Improved compliance to treatment (MoV: NCD clinic statistics) Table 12: Indicators for early detection and management of NCDs and their risk factors and means of verification (Mov) Process Short term indicators Medium term indicators Long term indicators Re-orient the Availability of NCD clinics and Improved access for Universal health structure and supportive services for NCD risk factor treatment of NCDs and their coverage and functions of management – No. of atolls and cities risk factors and reduced equitable access to Primary where following services are available service gaps – prevention, early health care and functioning in health facilities of % of patients with NCDs on detection and system to PHC and secondary/tertiary care level: regular treatment, % unable treatment of NCDs effectively - NCD clinic or diabetic clinics / asthma- to consult for 1 month Reduction in deliver NCD COPD clinics beyond the due date, % premature mortality, interventions - tobacco cessation counseling patients who missed more and reduced hospital at PHC services, than 2 days of medication admission and LOS - dietary counseling services due to unable to get regular from the main NCDs - Well woman clinics medicines on time - CVDs (heart disease No. and % of PHC facilities (Health % of patients received timely and stroke) centers and Dhamanaveshi’s) risk factor management - Cancer providing holistic NCD treatment counseling, - Chronic respiratory including risk factor management and No. of clients seeking tobacco diseases regular follow-ups according to PEN cessation counseling, % who - Diabetes package, no. of centers effectively received counseling, % on - Chronic renal running NCD clinics with regular waitlist for more than 1 diseases follow-up. month, - Mental health No. and % of Dhamanaveshi’s having No. of clients seeking dietary (MoV: Maldives the required staff with necessary advice/ counseling, % who Health Statistics from Page 101 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term indicators Long term indicators capacities to effectively provide NCD received counseling, % on PHI, WHO country services (includes Medical Officers, waitlist for more than 1 status reports from public health staff, and nurses) month, World Health No. and % of PHC facilities having (MoV: HPA/MOH Reports) adequate resources for providing NCD (HIMRD/QARD) monitoring services stats collected from Health Improvement in No. of PHC facilities with arrangements facility service and activity cancer survival rates for referral with appropriate reports, community surveys – MoV: Calculated mechanisms for NCD patients student research) using stats from No. and % of PHC facilities where staff National Cancer are mentored and have access to a Improved control rates for Registry, Masters health professional with higher diabetes and hypertension level student capacity to receive guidance for and improved quality of life, research) managing patients with NCD at the increased abstinence (quit PHC facility itself rates) among tobacco users, Reduced govt. No. and % of PHC facilities where staff increased fruit & vegetable healthcare are peer coaching is conducted intake, reduced intake of salt, expenditure for No. of patients with diabetes, sugar, fats and improved treating the above 6 hypertension, hypercholesterolemia weight among obese and diseases receiving regular treatment from NCD overweight, increased level (MoV: National clinics of physical activity, increased Health Accounts, No. of patients and clients received alcohol abstinence rates Aasandha) tobacco cessation services (Mov: Clinic activity reports, No. of patients and clients received health facility annual reports dietary counseling on service statistics, Three No. of persons screened for NCDs yearly clinical audit reports in through the health facility (walk-in plus health facilities by HPA/MOH camps/outreach programs) QARD) (MoV: HPA’s annual monitoring reports of health facilities by No. of new patients with HPA/MOH QARD – monitoring diabetes, hypertension, conducted using PEN assessment hypercholesterolemia, tools) tobacco use, overweight, CVD risk >30% and suspected cancer of breast, cervix and oral cavity who are detected and referred for treatment and mean age of detection (MoV: STEPS survey, Screening reports/Annual report of HPA, health facilities and NGOs conducting screenings) Implementing No. of atolls where Health No. or NCD patients treated PEN professionals in health facilities trained and counselled using PEN guidelines for for PEN and no. of trainings held, no. of protocol integrated people trained (MoV: HPA reports of Improved control rates for management trainings) diabetes and hypertension Page 102 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term indicators Long term indicators of and improved quality of life, Hypertension, No. of atolls where PEN is increased abstinence (quit Diabetes and implemented in health facilities, no. of rates) among tobacco users, Hyperlipidemi atolls having NCD Clinics, % of health increased fruit & vegetable as and NCD facilities using PEN protocols, intake, reduced intake of salt, risk factors in % of centers where guidelines are sugar, fats and improved all health available, easily accessible and use is weight among obese and facilities actively promoted, overweight, increased level (Mov: MOHG % of health facilities were health of physical activity, increased training professionals skilled on PEN alcohol abstinence rates activity intervention (Mov: Clinic activity reports, reports) (Mov: Three yearly clinical audit report health facility annual reports by HPA/MOH QARD) on service statistics, Three yearly clinical audit reports in No. of health screenings and cancer health facilities by HPA/MOH screenings conducted per year using QARD) PEN protocols and tools (MoV: Screening reports/Annual report of No. of new patients with HPA, health facilities and NGOs diabetes, hypertension, conducting screenings) hypercholesterolemia, tobacco use, overweight, CVD risk >30%, and suspected cancer of breast, cervix and oral cavity who are detected and referred for treatment, mean age of detection, CVD risk status at detection (MoV: STEPS survey, MDHS, Screening reports/Annual report of HPA, health facilities and NGOs conducting screenings) Strengthening No. of atolls where well –Woman Increase uptake of eligible Reduction in basic facilities clinics are run effectively in at least women for routine breast premature mortality of primary main hospitals) cancer and cervical screening from cancers in health care No. of health facilities providing breast, programs, no. and % who are general and facilities for cervical and oral cancer screening detected (positive on specifically breast, prevention services screening) and referred for cervical and oral and early No. of regions where mammography is treatment, mean age of cancer diagnosis of available and functioning detection (MoV: Maldives breast, No. of atolls where colposcopy is (Mov: Annual WWC Health Statistics from cervical and available for cervical cancer screening screening records of MOH for PHI, WHO country oral cancers (Mov: MOHG activity reports) women aged 30-49 screened status reports from No. of atolls where health for cervical cancer) World Health professionals trained, no. of trainings Number of people screened Reports) held, no. of health professionals for oral cancers at health trained (MoV: HPA monitoring reports, centers, no. and % who are Improvement in annual reports) detected (positive on cancer survival rates Page 103 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term indicators Long term indicators screening) and referred for MoV: Calculated treatment, mean age of using stats from detection, National Cancer (Mov: Annual activity reports Registry, Masters on oral cancer screening – level student HPA and MOH HIMRD/QARD) research) Reduced govt. healthcare expenditure for treating cancer, particularly breast, cervical and oral cancer Improve HPV vaccination coverage among 10– HPV vaccination coverage Reduction in coverage of 14-year-olds (HPA immunization among 10–14-year-olds (HPA incidence of cervical HPV, hepatitis coverage reports) immunization coverage cancer, liver cancer B, Influenza reports) and relevant Hepatitis B vaccination coverage for Reduction in vaccinations children and high-risk adults - health Hepatitis B vaccination premature mortality, professionals, dialysis patients (Mov: coverage for children and and reduced hospital HPA immunization coverage reports, high-risk adults - health admission and LOS clinical audit in Dialysis units in health professionals, dialysis from: facilities) patients (Mov: HPA - Cancer immunization coverage - CVDs (heart disease Influenza vaccine coverage for patients reports, clinical audit in and stroke) with chronic respiratory disease and Dialysis units in health - Chronic respiratory CVDs facilities) diseases Influenza vaccine coverage for patients with chronic respiratory disease and CVDs Integration of • RH: the 3 key lifestyle measures No. of patients receiving Reduction in management (tobacco avoidance/cessation, services for healthy lifestyle premature mortality, of NCDs and healthy diets and physical activity) within the identified service and reduced hospital lifestyle risk integrated into routine RH areas: admission and LOS factors into counseling and awareness programs • tobacco cessation from: the and maternal and child health • No. of persons receiving - Cancer management programs: dietary counseling - CVDs (heart disease of other o Pre-conceptional and pre- • Physical activity counseling and stroke) illnesses and marriage counseling (covers • Psychological counseling - Chronic respiratory prevention tobacco avoidance/cessation and Quit rates for tobacco use diseases and programs folic acid supplementation as % of overweight/obese respiratory diseases Must-have priorities) persons achieving healthy (overall) o Antenatal education (ANC records BMI - Diabetes + educational material) and ANC care (include above 3 key lifestyle Page 104 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term indicators Long term indicators measures in the management (MoV: service stats from - Perinatal mortality program of all pregnant mothers health facilities collected by and NICU as priority) HPA/HIMRD, health facility admissions o Child health - Postnatal and first annual reports) 1000 days of life (child health records –include key messages on second-hand avoiding smoke exposure, diet and physical activity) o First 5 years of life (include queries and basic guidance on avoiding second-hand smoke exposure, diet and physical activity in the child Record card and ask and follow-up in routine growth & Developmental assessments) • healthy lifestyle counseling (all 4 risk factors) integrated into Mental health programs and psychological counseling o included in client management protocols o included in training programs o No. of trainings conducted for health professionals o No. of people trained • Communicable Disease program: healthy lifestyle education and counseling (3 key lifestyle measures (tobacco avoidance/cessation, healthy diets and physical activity, and alcohol use where it is a risk factor)) included in all treatment guidelines and awareness material for patients with: o ARI, Influenza and other communicable diseases o TB o HIV/AIDS o work-permit medical check-ups and migrant health o check-ups and education sessions in preparation for hajj and umra pilgrimage (MoV: guidelines, protocols, IEC materials produced and published by HPA, reports on trainings conducted, Annual reports of HPA) Page 105 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term indicators Long term indicators Guidelines for Clinical management guidelines for Availability, accessibility and Reduction in management management of the following utilization of guidelines in premature mortality, of the key conditions compiled/updated, health facilities (PHC, and reduced hospital NCDs disseminated, incorporated into secondary, tertiary levels) admission and LOS implemented licensing exams and available at all (MoV: MOH website for from: hospitals (secondary level and above) published guidelines, audit of - CVDs (heart disease and accessible to doctors, nurses and availability, accessibility and and stroke) health professionals: utilization of guidelines in - Cancer • PEN guidelines for integrated health facilities) - Chronic respiratory management of Hypertension, diseases and Diabetes and Hyperlipidemias respiratory diseases • Clinical management guidelines for (overall) management of Acute coronary - Diabetes syndrome (including treatment of Improvement in MI with aspirin/clopidogrel, cancer survival rates thrombolysis or PCI), stable coronary Reduction of cost of heart disease, care for the key • Clinical management guidelines for NCDs: management of Acute stroke - CVDs (heart disease (including iv thrombolysis for and stroke) ischemic stroke at appropriate - Cancer facilities), chronic care of stroke - Chronic respiratory patients diseases and • Clinical management guidelines for respiratory diseases management of Asthma and COPD (overall) • Diabetes and Gestational Diabetes - Diabetes and its complications using total risk - Chronic renal approach failure • oIncorporation of steps to - Mental health discourage smoking /tobacco use - Thalassemia before blood donation as part of blood donation protocols. (MoV: MOH website for published guidelines, audit of availability, accessibility and utilization of guidelines in health facilities) Essential • Cardiac center with Cath-lab for PCI Service utilization (no. and %, treatments for available in Male’ (IGMH) and 2 Service gaps – no. I waitlist, key NCDs at regions-North & South average time from wait- secondary and • Stroke Centers in IGMH and one listing to receiving service, higher-level regional tertiary center no. of Referrals due to lack of facilities • No. and % of atoll/secondary level services: and above where Specialized NCD % of patients received timely clinics for patients with risk factor management Hypertension, Diabetes and counseling, Hyperlipidemias offering medical No. of clients seeking tobacco treatment, lifestyle counseling and cessation counseling, % who regular follow-up to be conducted in received counseling, % on Page 106 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term indicators Long term indicators hospitals – in collaboration with waitlist for more than 1- public health Units or Preventive month, average time from Medicine Units and RHC’s wait-listing to receiving • % of Tertiary level hospitals and services, secondary level hospitals with ICU No. of clients seeking dietary facilities where Medical Nutrition advice/ counseling, % who (Dietician) services available (free of received counseling, % on cost to patient) by trained and waitlist for more than 1 licensed dieticians month, • cancer diagnostics, chemotherapy No. of clients screening for and palliative care to 4 specialized NCDs and cancers (breast and cancer centers, with diagnostics cervical in particular) from including CT/MRI facilities and health facilities, laboratory diagnostics (pathology). % of patients with mental Immune-histochemistry and frozen illness on regular treatment, section to be made available at % unable to get national laboratory (IGMH), and 2 appointments for treatment centers for oncosurgery or therapies for >1 month • % of hospitals where Palliative care beyond the due date, % including opioid analgesics for pain patients who missed more relief of terminal cancer care is than 1 week of medication available – atoll /secondary level and due to inability to get regular above medicines on time • No. of health professional trained in Improved control of: palliative care - Diabetes • No. and % of tertiary and regional - Hypertension hospitals where Mammography/ - Asthma and COPD USG for breast cancer screening and - Thalassemia Colposcopy for cervical cancer (MoV: health facility activity screening available reports, service statistics • No. and % of Regional/Tertiary level collected by HIMRD, NCD hospitals and above where monitoring stats collected by Functional ICU facilities with HPA) invasive/non-invasive ventilation Cost of care for the key NCDs: available - CVDs (heart disease and • Ophthalmology services to treat stroke) diabetic and hypertensive - Cancer retinopathy with laser - Chronic respiratory photocoagulation available in Male’ diseases and respiratory • Screening for diabetic retinopathy diseases (overall) and Podiatric (Diabetic foot care) - Diabetes services to be integrated into NCD - Chronic renal failure Clinics services in all hospitals - Mental health • Dialysis for End-stage Renal Failure - Thalassemia available in Male’, Hulhumale’ and 6 (MoV: Health facility service Regional hospitals stats collected by HIMRD, Aasandha stats on referrals • Renal transplant service established and cost) in Male’ Page 107 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term indicators Long term indicators • No. and % of tertiary hospitals with Psychiatrists, psychologist Better quality of life for counseling services cancer patients receiving • No. and % atoll level hospitals with opioid analgesics Counseling services available (Mov: Three yearly clinical • No. of health professionals trained in audit report) Mental Health GAP training on diagnosing and managing key mental health conditions annually • Thalassemia screening tests available at all hospitals in all atolls and Thalassemia DNA test available at IGMH • Arrangements for regular follow-up and management of patients with thalassemia at NCD clinics or regular follow-up clinics at atoll hospital level and above (including provision of regular transfusions, iron chelation therapy, lifestyle management (MoV: MOH Annual reports, services stats collected from health facilities by HIMRD, health facility reports) Strengthening Formal job structure and improving Improved retention of public Reduction of NCD risk healthcare remuneration schemes for public health staff with higher factors: workforce health professionals established and capacities: no. of staff with Tobacco use capacity for implemented Masters in HPA in service for Salt intake managing (MoV: Civil Service Commission over 3 years, no. of public Sugar intake knowledge reports, MOH HR, publication in govt. health staff with BSc and Fruit and vegetable and skills on gazette) Diploma level in health consumption NCDs facilities in atolls and islands (increased) including Improved retention of public health in service for over 3 years Increased physical addressing staff with higher capacities: no. of staff (MoV: stats of human activity and the risk with Masters in HPA in service for over resources for health from Reduction in obesity factors 1 year, no. of public health staff with MOH HR/HPA) BSc and Diploma level in health Improved service delivery Reduction in facilities in atolls and islands in service - no. of patients utilizing premature mortality, for over 1 year these services mentioned, and reduced hospital (MoV: stats of human resources for particularly preventive admission and LOS health from MOH HR/HPA) services such as NCD clinics, from: tobacco cessation, dietary - CVDs (heart disease Health professionals with capacities counseling and stroke) needed for NCD prevention and - service gaps- average - Cancer control identified and recruited to waiting time to receive - Chronic respiratory provide services: service, no. in waitlist diseases and - dieticians for clinical and public respiratory diseases health services in all Tertiary (overall) Page 108 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term indicators Long term indicators hospitals and hospitals with ICU - improved quit rates in - Diabetes facilities, tobacco cessation clinics - Mental illness and - endocrinologists in specialized and NCD clinics Suicide centers such as IGMH, - improved BMI (% of normal - trained medical and nursing teams BMI) for Percutaneous cardiac - increase in no. of breast, interventions (PCI), cervical and oral cancers - trained medical and nursing teams detected for stroke care, Improved control of: - trained medical and nursing teams - Diabetes for palliative care for cancer - Hypertension - trained medical and nursing teams - Asthma and COPD for diabetes care - Thalassemia - ophthalmologists (MoV: health facility activity - chiropodists reports, service statistics - physiotherapists and occupational collected by HIMRD, NCD therapists for rehabilitation monitoring stats collected by - counselors, clinical psychologists HPA) and mental health professionals Increased abstinence and (MoV: stats of human resources for quit rates among tobacco health from MOH HR/RAHS/QARD) users, increased fruit & vegetable intake, reduced intake of salt, sugar, fats and improved weight among obese and overweight, increased alcohol abstinence rates (Mov: Clinic activity reports, health facility annual reports on service statistics, Three yearly clinical audit reports in health facilities by HPA/MOH QARD) A national National HIS developed including Improved follow-up and integrated features that enable good treatment control of NCDs health practices, such as: - Diabetes information - visibility of existing chronic disease - Hypertension system (HIS) diagnoses in patient profile - Asthma and COPD software - Measures to Incorporate NCD risk - Thalassemia platform factor management in treatment: Improved quality of life of enabling key prompts/ reminders in cancer patients health treatment Advice into doctors’ notes (MoV: health facility activity professionals /nurses’ notes and other relevant reports, monitoring statistics to access documentation collected by HPA) patient - Prompting / appointments and treatment reminders for Follow-ups and records across regular check-ups all health - Enabling Referrals and Follow-up facilities and after referrals Page 109 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term indicators Long term indicators enabling (MoV: MOH project reports, IGMH holistic reports) management HIS implemented at all health facilities in govt. sector, expanded to private sector also. (MoV: MOH annual reports, Audit of health facilities) Utilization of the HIS for NCD management (% of health professionals using the HIS for risk factor management, arranging follow- ups, arranging referral, tracking management after referral) (MoV: Audit of HIS usage and end user feedback collected by MOH QARD/IS depts) Ensuring Availability of basic medicines, tests, Non-interrupted refill of NCD Reduction in ready supply equipment/devices and tools for drugs and supplies by premature mortality, of medicines managing NCDs (identified in PEN patients - % of patients who and reduced hospital and protocols) at health facilities of all got all medicines without admission and LOS technology for levels. stock out for >2 days / >1 from the main NCDs NCD care MoV: clinical audit week. - CVDs (heart disease Timely refill of stocks at pharmacies patients who missed more and stroke) (Mov: Annual stock monitoring than 1 week of medication - Cancer assessment at pharmacy outlets, due to inability to get regular - Chronic respiratory prescription audit and patient medicines on time diseases interviews by MFDA/HPA) (Mov: clinical audits, patient - Diabetes System for continuation of feedback (student research) - Chronic renal medications for patients with NCDs Improved control rates for diseases and risk factors such as hypertension diabetes and hypertension - Mental health through the Aasandha prescription and hypercholesterolemia (MoV: Maldives scheme with checks to prevent Health Statistics from overdose or erroneous use of PHI, WHO country medication status reports from (MoV: Aasandha annual reports, World Health Pharmacy Audits) Reports) Improving Preventive services and mental health Improved access for Reduction on overall access and treatments covered by Aasandha: treatment of NCD risk factors, healthcare universal - Tobacco cessation counseling screening and mental health expenditure, and coverage for - Treatments and medication for and reduced service gaps – categorical costs on: NCD tobacco cessation, harmful use of % of patients received timely - CVDs (heart disease prevention alcohol, and substance abuse risk factor management and stroke) services - Dietician consultation and counseling, - Cancer counseling No. of clients seeking tobacco - Chronic respiratory - NCD screening packages (inclusive of cessation counseling, diseases health education and prevention) No. of clients seeking dietary - Diabetes advice/ counseling, Page 110 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term indicators Long term indicators - Well woman clinic package (inclusive No. of clients screening for - Chronic renal of health education and prevention) NCDs and cancers (breast and diseases - Psychological counseling cervical in particular) from - Mental health - Psychological assessment and health facilities, therapies % of patients with mental Reduction in (MoV: list of Aasandha covered illness on regular treatment, premature mortality, services on Aasandha website, (MoV: HPA/MOH and reduced hospital Aasandha annual reports) (HIMRD/QARD) monitoring admission and LOS stats collected from Health from the main NCDs facility service and activity - CVDs (heart disease reports, clinical audits, and stroke) community surveys – student - Cancer research) - Chronic respiratory diseases - Diabetes - Chronic renal diseases - Mental health (MoV: Maldives Health Statistics from PHI, WHO country status reports from World Health Reports) Community based approaches Strengthening No. of schools where school health Reduction of NCD risk factors Reduction of NCD risk capacity of officers are trained to provide tobacco among children and factors among NCD cessation, dietary counseling and adolescents <15 years children and prevention physical activity guidance for students, • Tobacco uses and exposure adolescents <15 services in No. of school health officers trained to second hand smoke years schools per year • Salt intake • Tobacco uses and No. of schools providing these services • Sugar intake exposure to second (tobacco cessation, dietary counseling • Fruit and vegetable hand smoke and physical activity guidance for consumption (increased) • Salt intake students) in-school • Increased physical activity • Sugar intake (MoV: Reports of Education Ministry) • Reduction in obesity • Fruit and vegetable o Career pathways for School health • Alcohol consumption consumption officers aligned with public health • Substance use (increased) career pathway (structure) prepared, • Suicidal thoughts • Increased physical passed and implemented (MoV: GSHS) activity (MoV: CSC reports, structure published • Reduction in in govt. gazette) obesity • Alcohol consumption • Substance use • Suicide and self- harm attempts Page 111 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term indicators Long term indicators (MoV: GSHS, STEPS, DNR, Maldives Police Service) Provision of • Healthy lifestyle promotion Reduction of NCD risk factors Reduction of NCD risk NCD including prevention of tobacco among young people 15-25 factors among young prevention use, healthy diets and physical years people 15-25 years services in activity integrated into life skill • Tobacco uses and exposure • Tobacco uses and youth centers education for outreach programs to second hand smoke exposure to second for youth – no. of programs • Salt intake hand smoke conducted including these • Sugar intake • Salt intake components • Fruit and vegetable • Sugar intake • lifestyle counseling including consumption (increased) • Fruit and vegetable tobacco cessation, diet and physical • Increased physical activity consumption activity integrated into youth • Reduction in obesity (increased) counseling services provided • Alcohol consumption • Increased physical through youth centers – no. of • Substance use activity youth centers in islands providing • Suicidal thoughts • Reduction in these services (MoV: GSHS, STEPS) obesity • No. of atoll/island youth counselors • Alcohol and sports counselors trained for consumption promoting healthy lifestyle and • Substance use early detection of risk factors and • Suicidal thoughts, referral for treatment, no. of suicide and self- trainings held harm attempts • No. of islands where links (MoV: GSHS, STEPS, established between youth center DNR, Maldives Police and atoll/island health facility NCD Service) Focal points for support and referral Integrating • SOPs and treatment protocols for • Improved treatment Reduction of NCD clients undergoing treatment for success rate for abstinence premature deaths prevention substance use revised to include: from substance use from substance use, services into - tobacco cessation in • Reduced relapse rate of alcohol use and services for assessment and management substance use suicide managing - healthy diet and physical • Reduced tobacco uses substance use activity in assessment and among former substance management users and those undergoing (Note: alcohol use is already rehabilitation programs included under substance use • Improved nutritional status rehabilitation programs in Maldives, and BMI among former but the above 3 risk factors are not substance users and those integrated) undergoing rehabilitation • Tobacco cessation, healthy diet and programs physical activity included as an • Improved physical activity integrated part of treatment for among former substance substance use disorders users and those undergoing implemented rehabilitation programs • No. of centers where counselors are • Improved mental wellbeing trained and no. of counselors among former substance Page 112 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Process Short term indicators Medium term indicators Long term indicators trained from Community Service users who quit, and those Centers, detox centers, methadone undergoing rehabilitation clinics to integrate tobacco programs cessation*, healthy diets and • Improved stress and physical activity into their mental wellbeing among counseling and treatment services, their families • No. of Core trainers in NDA trained (MoV: Pre- and post- to train counselors and prevention treatment assessments, program staff on integrating follow-up tobacco prevention into substance assessments/Surveys among use prevention programs youth who have completed (MoV: monitoring reports from NDA) rehabilitation programs) Developing • NCD Patient treatment booklets with Improved knowledge, Reduction in patient self-care information developed attitude and practice of premature mortality, education/self provided to patients followed up at healthy behavior and medical reduced hospital -care NCD Clinics treatment of NCDs admission, LOS from guidelines for • Information leaflets/fliers on (MoV: student surveys) the main NCDs: prevention diabetes, COPD, Cancers and other - CVDs (heart disease and control of chronic diseases developed, Improved control of diabetes, and stroke) NCDs disseminated online, printed and hypertension and - Cancer available at health facilities, provided hypercholesterolemia - Chronic respiratory to patients at consultation (MoV: Health facility diseases (MoV: access to these materials) statistics, STEPS survey) - Diabetes Encouraging • Diabetes support groups formed and Improved knowledge, - Chronic renal the formation functioning in major islands, patients attitude and practice of diseases of community trained to engage as peer counselors healthy behavior and medical - Mental health coalitions and for diabetes in Male and other treatment of NCDs (MoV: Maldives patient islands (MoV: student surveys) Health Statistics from groups, and • Cancer Support Group and PHI, WHO country build their • patients trained to engage as peer Improved control of diabetes, status reports from capacity counselors for cancer in Male and hypertension and World Health other islands, hypercholesterolemia Reports) • People with NCDs and members of (MoV: Health facility support groups engaged as statistics, STEPS survey) Improved quality of advocates and peer outreach life among people programs in areas of high need Improved cancer survival and with these NCDs reduced relapse rates (MoV: study/survey) (analysis from Cancer Improved cancer registry) survival rates (analysis from Cancer registry) Page 113 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031)

ANNEX 3: Roles of government organizations and academic institutions in the implementation of the NCD MAP A. Roles of government organizations in the implementation of the NCD MAP and relevant departments in HPA that guide and coordinate with these institutions General roles of ALL government institutions and independent bodies: ➢ Promoting healthy lifestyles (ABCs) at workplace through fun activities and screening programs and enabling workplace policies (e.g., establishing smoke-free workplaces, encouraging staff to quit smoking at job interviews/appraisals, ensuring healthy canteens/availability of healthy food and drinks at workplaces, facilities and arrangements to promote physical activity at work, e.g., taking stairs, safe bicycle parking facilities, staff exercise/sports facilities at or near the workplace) ➢ Implementation of institution policies to avoid conflict of interest from unhealthy industries that pose threats to health from NCDs – e.g., accepting donations, sponsorships, etc. from unhealthy industries (tobacco promotion in any form – is illegal under Tobacco Control Act 2010; institutional policies to avoid sponsorships and donations from industries marketing energy drinks, sugary drinks, areca nut and other unhealthy commodities) ➢ Measures to avoid investing in businesses that promote unhealthy commodities and NCD risk factors (e.g., tobacco, energy drinks, areca nut, sedentary lifestyle (e.g., gaming centers with only sitting-to-play facilities)) ➢ Include health considerations and consult with MOH/HPA on measures to minimize health impacts on any major activities and action plans for national development Organization Roles and Activities HPA/MOH Tasks to do by HPA/ MOH department providing guidance MOEd ➢Promoting Healthy lifestyle ABCs in HPA NCD/ ➢ Share guidance and schools through Curriculum and extra- Nutrition recommendations by HPA activities, including building capacity of /RH ➢ Collaborations for teachers to deliver healthy lifestyle awareness and training, messages and promote healthy ➢ Technical assistance from lifestyles health sector for ➢Creating enabling environments in conducting trainings school: smoke-free environments, healthy canteens and availability of healthy foods/limit unhealthy foods, promoting physical activity over sedentariness ➢Include detection of NCD risk factors and unhealthy lifestyle habits in School Health Screening ➢Building capacity of School Health Officers to provide lifestyle education and early detection of unhealthy lifestyle habits and lifestyle counseling Page 114 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles and Activities HPA/MOH Tasks to do by HPA/ MOH department providing guidance (including tobacco cessation and dietary counseling) for school children ➢Tobacco Free Schools program to prevent access of tobacco products to minors MHEd ➢School leavers – awareness sessions – HPA NCD, ➢ HPA to share guidance with career guidance/ study guidance Nutrition, MHED, programs and IEC material to include RH ➢ Developing and sharing importance of healthy lifestyle for messages, arranging success educators from health ➢Student loans to include covering study sector for programs programs on prevention and health conducted by MHEd. promotion MoGFSS ➢Elderly – Ranveyla – healthy ageing for HPA NCD / ➢ HPA to share pen package elders to include all aspects in ABCs of RH for messaging healthy lifestyle (tobacco cessation and ➢ Assist technically to SHS prevention, healthy diet. physical incorporate ABCs of healthy activity and mental health) lifestyle into all health ➢Programs for parents of school children awareness programs (preparation: as caregivers) ➢Children- Child protection (child abuse laws to include deliberate exposure to tobacco smoke, giving tobacco and drugs to children, or keeping these accessible to children, and poor provision of nutritional needs as an offence) ➢Women – awareness generation on harmful effects of tobacco and SHS, areca nut, tobacco control laws as women’s right to health protection, areca nut, sugary drinks, marketing tactics targeted at women ➢Women’s orgs – active in many islands to be mobilized for health promotion and protection – mobilize for promoting healthy lifestyles, compliance checks on violation of tobacco control laws, TAPS ➢Women empowerment programs to include business incentives for businesses that promote healthy lifestyles, e.g., agriculture, exercise, and disincentives for unhealthy businesses (Note: no business incentives should be offered for tobacco trade in any form under Tobacco Control Act) Page 115 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles and Activities HPA/MOH Tasks to do by HPA/ MOH department providing guidance ➢Programs for persons with disabilities (PWDs) to include ABCs of healthy lifestyle (tobacco cessation and SHS prevention, healthy diet. physical activity and mental health) ➢Integrate tobacco cessation and lifestyle counseling into psychological counseling services for individuals MYSCE ➢Youth counselors appointed to each HPA (NCD/ ➢ HPA to provide guidance: atoll – tasks include counseling and RH) o To share IEC material on phone counseling – to include healthy healthy lifestyle and lifestyle counseling or referral guidelines on PEN, tobacco ➢Sports counselors (SC’s) appointed for cessation and FBDG for use promoting physical activity at island by MYSCE level – to be regularly given orientation o To assist MYSCE to by MYSCE, including healthy lifestyle integrate components on (by HPA). Tasks include setting up of healthy lifestyle in trainings sports grounds, outdoor gyms, moodhu for YCs, SCs, youth kasrath and other physical activity volunteers, etc., when programs needed, to arrange health ➢Sports – healthy lifestyle to increase sector resource persons to performance conduct collaborative ➢National sports teams (e.g., football, trainings (in Male’ as well as volley, basketball, teams, athletes, etc.) atolls through public health to be mobilized as champions for personnel) healthy lifestyle (e.g., Tobacco free ➢ - To assist in establishing Champions, Champions of healthy Youth Health Cafés and diets, mental health, etc.) training staff/ volunteers ➢Youth Health Café: providing services such as counseling, physical activity, awareness programs – to integrate NCD prevention (e.g., tobacco cessation, healthy diet, physical activity into holistic counseling, NCD components in health screening, etc. ➢Youth peer education/leadership programs – life skills to include age- appropriate awareness and advocacy for enabling healthy lifestyles (ABCs), including tobacco free schools and educational institutes, choosing healthy food and drinks, providing healthy choices for youth, industry influence, etc. ➢Career guidance/development programs – integrate healthy lifestyle ABCs Page 116 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles and Activities HPA/MOH Tasks to do by HPA/ MOH department providing guidance ➢Youth Enterprise/SME schemes – to exclude tobacco, areca, ED, carcinogens, (in collaboration with MOED) ➢Events – as platform for promoting healthy lifestyles (ABCs) – e.g., Hafthaares, musical and entertainment shows, etc. ➢Gyms, yoga classes, etc. – to provide special rates for youth, free offers, etc. ➢Parenting classes – to include components on – promoting healthy lifestyle (ABCs) for adolescents: e.g., tobacco cessation and smoke free homes and environments for children’s serious risks of areca nut consumption and how to prevent, providing healthy diet choices, enabling physical activity, dealing with substance use, tobacco use, early mental health problems, etc. among children and adolescents ➢Community based orgs (island level NGOs, youth groups and sports groups) – to be mobilized for health promotion and protection – mobilize for promoting healthy lifestyles, compliance checks on violation of tobacco control laws, TAPS MOFAMR ➢Food safety –Good Agricultural Practice HPA Nutr. / ➢ GAP – food hygiene (GAP) standards and implementation MFDA / modules developed and ➢Agricultural incentives for fruit and HPA NCD being introduced, other vegetable cultivation and fisheries modules including rational ➢Disincentives for areca nut cultivation use of pesticides and and industry chemicals to be developed, ➢Educational programs for farmers on farmers trained and nutrition and shifting away from areca implemented. nut cultivation ➢ Disincentives for areca nut have to be worked on technically and then taken to political level MOEnv ➢Air pollution – national action plan with HPA EH*/ ➢ HPA to actively guide and HPA (indoor air pollution - tobacco NCD engage MOEnv smoke exposure and smoke-free o request to include tobacco environments should be included for smoke exposure and ambient air pollution – policy measures smoke-free environments, to reduce motor vehicle emissions policy measures for through enabling environments - given reducing vehicle emissions in NCD MAP - to be included) and other measures Page 117 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles and Activities HPA/MOH Tasks to do by HPA/ MOH department providing guidance ➢Occupational risk factors – again identified in NCD MAP enabling environments: smoke-free under the national Action workplaces, healthy canteens, bicycle Plan for Air Pollution parking and exercise space in ➢ share plans, communicate workplace should be included under concerns, and engage occupational safety measures MOEnv in integrating ➢Policies to avoid conflicts of interest implementation through influence of industries promoting unhealthy products – e.g., avoid receipt/use of donations of dust- bins with tobacco promotions (with ash trays and product logos) AG (Attorney ➢Legal recommendations and facilitation HPA NCD, ➢ Conduct sensitization General’s of passage of effective regulations for Nutr, EH, programs for lawyers and Office) NCD prevention and control (Best Buys MOH judges on legislative measures identified and prioritized in HIMRD priorities for NCD the relevant sections) prevention and control, ➢Attend civil court cases – defend public tactics of unhealthy health interests as priority vs. business industries and the health profits to unhealthy industries and economic implications ➢Sensitize legal professionals on health of resulting NCDs by and environment to bring them on HPA/MOH board (strict liability) ➢ Engage AGO in boards and ➢Legislative agenda – to include key technical groups working (Best Buys) legislature for NCD on NCD prevention and prevention and control - with MOH control legislative measures inputs and support from other ➢ Send formal written stakeholders recommendations for ➢Mobilize Public involvement – for legislative agenda to AGO advocacy to introduce legislature, and to improve compliance during implementation President Office ➢Policy decisions on NCD prevention HPA (NCD), ➢ MOH to engage PO, (see NCD Best Buys), inclusion of NCD MOH- through regular prevention and control in govt. HIMRD communications Strategic Action Plan (SAP) ➢ Report to PO on activities ➢Appropriate engagement in NCD and progress of NCD MAP prevention and control leadership such and support required as monitoring progress of MOH, ➢ Engage PO technical / membership/co-chairing in NCD high policy level in relevant NCD level committee, etc. prevention and control ➢Investing (foreign “investments”) in committees – esp. High- unhealthy commodities such as level steering committee tobacco, ED, areca nut, sugary drinks – to be avoided govt. policies ➢Trade agreements to exempt unhealthy commodities from receiving Page 118 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles and Activities HPA/MOH Tasks to do by HPA/ MOH department providing guidance undue benefits in order to protect public health ➢Taxation of unhealthy products (tobacco ED. Sugary drinks, remove sugar subsidy)/subsidization of healthy products – fruit and vegetables, agriculture, etc. tax incentives/discounts for healthy businesses (e.g., gyms, restaurants compliant with full smoking bans, etc.), disincentives such as higher GSTs for unhealthy businesses – e.g., restaurants with smoking areas/ shisha lounges, areca nut production and trade, sedentary video game parlors, etc. MOF (Finance) ➢Investing (foreign investments) in HPA NCD, ➢ HPA to initiate, guide unhealthy commodities such as DG/DDG, relevant ministries, tobacco, ED, areca nut, sugary drinks – MOH HR, sensitize public and to be avoided through govt. policies MOH advocate on taxation of and appropriate trade communications Finance sugary drinks, etc. revision ➢Aids/donations – avoid unhealthy of “essential food items” in products/services keeping with current ➢Taxation (*led by MOF) of unhealthy dietary recommendations. products & services (tobacco, energy drinks. Cancer causing products (areca ➢ HPA to follow-up with MOF nut, processed meats), sugary on the progress of 20M drinks/sugar/high sugar foods, motor budget for AWARENESS on vehicles /subsidization of or zero tax on tobacco, supari and sugary healthy products and services (Fruit & drinks under manifesto/SAP Veg, whole meal grains and flours, organic products, healthy & smoke- free restaurants, gyms), remove sugar subsidies and subsidize Fruit & Veg instead. ➢Consider financial incentives such as tax discounts or lower rates for good practice and good compliance with regulations ➢Adequate Budget allocation for health promotion and public health strengthening, particularly investing in public health (See Best Buys) (MOH) – includes proper remuneration of public health professionals and increasing capacity of public health workforce to cater to the increased work required to combat NCDs (this is an investment as Page 119 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles and Activities HPA/MOH Tasks to do by HPA/ MOH department providing guidance it has been shown to reduce the huge financial costs of treating these NCDs) MED ➢Trade policies for NCD prevention and HPA NCD/ ➢ MOH should clearly identify control (see Best Buys) Nutr/ the needs to MED, ➢Trade agreements and trade MFDA ➢ HPA to engage MED on negotiations (*led by MED) - their roles through written International trade agreements should communications, not compromise health protection of discussions and through Maldivians – unhealthy products like membership in boards and tobacco, areca nuts should be technical groups for NCD exempted from receiving benefits prevention and control. ➢Investing (foreign investments) in unhealthy commodities like tobacco, ➢ To follow up with MED on ED, areca nut, sugary drinks – to be list of “Investments” – does avoided/ exempted through govt. it contain tobacco? – policies and appropriate trade Should remove tobacco communications from list to stop NEW ➢Taxation of unhealthy products & “investments”. services /subsidization of healthy products and services ➢Incentivization of healthy businesses locally – e.g., SME loan schemes to prioritize / tax incentives/free advertisement on websites for: gyms, exercise and sports centers/schools, etc., agriculture ➢Implementation of trade policies and regulations for NCD prevention and control ➢Single window project – for businesses/imports - WIP ➢Data sharing for surveillance MOFA(Foreign) ➢International reporting on trade, HPA (NCD)/ ➢ MOH should clearly identify human rights, etc. to include country MOH the needs to MOFA, Health policies for NCD prevention and HIMRD Minister should be made control, e.g., that Maldives is party to aware FCTC and the requirements for tobacco ➢ HPA NCD to initiate and import and trade, food safety and (in guide – communicate to future when implemented) nutritional HIMRD, labeling requirements, trade policies to ➢ PIIR to communicate with reduce air pollution, etc. MOFA/ external ➢FCTC implementation – organizations o MPOWER implementation o Article 5.3 (measures to stop tobacco industry interference in govt. policies) o Ratification of the protocol to eliminate illicit trade of tobacco Page 120 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles and Activities HPA/MOH Tasks to do by HPA/ MOH department providing guidance ➢Transparency and appropriate trade communications to provide timely information to potential business investors regarding govt. policies for NCD prevention and control ➢International trade negotiations – (led by MED) – Health Minister should be on board ➢Investing (foreign investments) in unhealthy commodities like tobacco, ED, areca nut, sugary drinks – to be avoided (led by MED) / exempted through govt. policies and appropriate trade communications ➢Mobilize Foreign aids, grant funds, scholarships, etc. for NCD prevention and control Majlis idhaaraa ➢Policy decisions – HPA NCD, ➢ Initiate and communicate o Food Bill, Nutr, EH with relevant organizations o Taxation of unhealthy products & ➢ Prepare advocacy briefs services /subsidization of healthy and advocate, mobilizing products and services NGOs and academia ➢ Healthy workplace at majlis – smoke- ➢ Work on ways to open free, healthy food, exercise communications, e.g., via promoting, annual health screening offering health screening by for majlis members DV or NGO MTCA (Min. of ➢Planning Enabling environments for HPA EH ➢ HPA to actively write to Transport and promoting physically active and (lead) / NCD MTCA requesting to involve Civil Aviation) environmentally friendly transport: HPA and engage in plans o Improve walkability, and follow-up, o Improve cyclability (in designing of ➢ HPA to share all relevant streets and highways) and provide plans and guidelines of HPA safe bicycle parking, with MTCA o improve public transport systems ➢ Engage MTCA as members o restriction of motor vehicle in technical working groups imports (overall, as well as high of HPA emission vehicles)/ increased taxation o integrate NCD prevention measures with Road Safety measures o multi-sectoral stakeholder discussions held by MTCA to always include health sector (HPA at central level, health facilities in atolls/islands) o Implement Smoking ban in all public vehicles Page 121 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles and Activities HPA/MOH Tasks to do by HPA/ MOH department providing guidance MNPHI (Min. of ➢City/island planning for enabling HPA EH ➢ Prepare guidance National environments: (lead) / NCD documents defining Planning, o smoke-free environments, requirements clearly Housing & o healthy transport- safe bicycle ➢ Communicate with MNPHI Infrastructure) parking, and walkability, public on actions needed and transport initiate discussions, share o Green spaces guidance docs o cultivation of fruit and vegetables ➢ Promote concepts among in cities/islands (e.g., suitable fruit public and politicians by trees lining streets and parks advocacy and awareness (exempt areca nut), providing ➢ Prepare advocacy gardening areas for social documents and housing/apartment complexes) share/present to MHINP ➢Housing planning/building codes for and higher-level policy enabling environments: makers o Mandate smoke-free indoors for all ➢ Advocate to public and public buildings, commercial politicians, mobilize NGOs buildings and shared ownership and academia in advocacy buildings with common areas, o healthy transport- safe bicycle parking, and walkability on pavements near homes o home gardening of fruit and vegetables (e.g., potted plants) – building code to enable adequately safe spaces such as balconies, terraces etc. ➢ consult/involve health sector in preparation of plans and regulations ➢ improve inter-sector communication Male’ City ➢Implementing enabling environments HPA NCD/ ➢ Initiate communication Council/HDC/ in Male’ City/Hulhumale’: EH ➢ Prepare guidance material Addu City o smoke-free environments/Male’ CD/MFDA and advocacy documents Council City, (food and share o healthy transport-walkability, safety) ➢ Advocate to public and cyclability, safe bicycle parking, politicians, mobilize NGOs improved public transport and academia in advocacy o access to affordable fruit and vegetables - strategic placement of local markets in highly populated areas o cultivation of fruit and vegetables – providing home gardening space for social housing, growing fruit trees for aesthetic/shade purposes in streets, parks (avoiding areca nut trees in these places Page 122 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles and Activities HPA/MOH Tasks to do by HPA/ MOH department providing guidance ➢implementation of regulations for NCD prevention and control – e.g., tobacco control regulations, food safety, BMS code, future regulations for restricting advertisements of unhealthy products ➢Use of resources to educate public – TVs, billboards, etc. for NCD prevention messages ➢consult /involve health sector LGA (Local Govt. ➢implementation of regulations – esp. HPA NCD/ ➢ Initiate communication Authority) commercial establishments – tobacco EH ➢ Prepare guidance material control laws, food labeling, etc. and advocacy documents and share ➢ Advocate to public and local politicians through atoll public health network, mobilize local youth, women’s orgs, NGOs and academia in advocacy MOHA (Home ➢Prisons HPA NCD/ ➢ Initiate communication. Affairs) o Awareness generation and CD (HIV/TB ➢ Need to communicate sensitization of law enforcers on prog) separately with relevant tobacco control laws sub-departments: o make smoke-free for prisoners and o Maldives Police Service guards, o LGA o ban provision of tobacco to o Maldives Correctional prisoners and guards services (Inspector of o tobacco cessation support to Prisons) prisoners and prison staff o National events section o prisoners should get continuing NCD ➢ Provide guidance on actions medications through family required o encourage physical activity ➢ Facilitate public health o healthy balanced meals (low participation to promote salt/fat/sugar, more vegetables) healthy lifestyles via atoll o cultivation of vegetables and fruit PHUs in atoll level activities ➢Police, other implementers of smoking conducted by MOHA ban/tobacco laws ➢Workplace health and screening programs ➢Awareness programs for youth, island level community leaders – (invite MOH/HPA but very poor response (2-3 a year) – prevention and screening opportunities ➢National events – for messages, healthy events ➢Administrative councils – LGA, - require capacity (staff) and guidance for Page 123 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles and Activities HPA/MOH Tasks to do by HPA/ MOH department providing guidance implementing regulatory measures and including health promotion and NCD prevention in their routine work and social activities MPS (Maldives ➢Strengthen implementation of tobacco HPA NCD/ ➢ Lead and communicate Police Service) control laws, including trainings and EH with relevant organizations TOT for capacity building, use of to implement community friendly methods and ➢ Include in EH plans techniques, etc. throughout atolls ➢Explore roles of Environmental Police in controlling Air pollution and tobacco control laws ➢Include ABC in exercise programs and youth awareness programs ➢Workplace health programs (include ABC), and screening programs, establish smoke free environments (Polatte)) ➢Medical services to include lifestyle counseling and NCD clinics Maldives ➢Implementation of tobacco control HPA NCD ➢ Lead and communicate Customs Service regulations, taxation of unhealthy with relevant organizations (MCS) products (tobacco, ED, sugary drinks, to implement etc.) ➢ Provide guidance ➢Check illicit trade of tobacco, ENDS MOD (Defense) ➢Fire prevention – to include messages HPA NCD / ➢ Lead and communicate / MNDF on smoking, Surveillance data needed EPR/IHR with relevant organizations for tobacco control to implement ➢Exercise /” moodhu kasrath” programs ➢ Incorporate in HPA plans to include quit smoking (full ABC) and IEC material ➢Medical services to include lifestyle counseling and NCD clinics ➢Internal workplace policies to promote healthy lifestyles (ABCs) among personnel NDMA ➢Displaced persons in disaster: HPA EPR ➢ HPA has to provide ➢Ensure people with NCDs get timely (lead)/ NCD guidance for NDMA, supply of regular medications ➢ lead and communicate with ➢Accepting Donations – clear policy to relevant organizations to exclude unhealthy products such as implement (tobacco, areca nut, energy drinks, fizzy ➢ drinks, junk food, etc.) ➢Avoid conflict of interest – e.g., donations and CSR from tobacco industry, energy drink industry, etc. ➢ Page 124 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles and Activities HPA/MOH Tasks to do by HPA/ MOH department providing guidance ACC ➢Monitoring for corruption activity by HPA NCD/ ➢ Lead and communicate unhealthy industries such as tobacco, EH/ Nutr/ with relevant organizations ED, sugary drinks, etc. MFDA to implement ➢Educating public about how tobacco ➢ Provide awareness / industry and other unhealthy industries guidance on what actions bring (e.g., Bithufangi) are needed, what are the ➢Medicines quality breaches and examples ➢Roadworthiness/vehicle imports HRCM ➢Monitoring for corruption activity by HPA NCD/ ➢ HPA to send questions for unhealthy industries such as tobacco, EH/ Nutr/ HRCM Quiz ED, sugary drinks, etc. RH/ MFDA ➢Implementation of public health ➢ Provide awareness / regulations and health measures for guidance for HRCM on HR prevention related to prevention and ➢Education of public: public health, what actions o Annual Human Rights (HR) Quiz to are needed to protect include questions on rights and public health (prepare NCD prevention (in collaboration advocacy docs, meetings, with HPA) awareness sessions, etc.) o MOT (Tourism) ➢Audits of resorts – MOT looks for HPA NCD, ➢ MMPRC to be involved in smoking ban implementation in Nutr incentivizing by free restaurants (as per present regulation), advertising for fully smoke- restaurant food safety and health-as free restaurants, smoke per present regulations, staff free rooms, healthy accommodation for occupational restaurants, etc. health and safety) ➢Incentivize healthy resorts, Guest houses and Safaris: o Promote tobacco free Maldives o Free advertisement of smoke-free resorts and guest houses, safaris and restaurants, and those serving healthy food and drinks on tourism websites o Concessions for fully smoke-free guest-houses/safaris/resorts o Incentivize restaurants providing healthy food at affordable prices o Disincentives for shisha lounges, such as higher taxes, or a licensing fee and gradually ban them (as they are a serious threat to the health of tourists) o Incentives for gyms and sports promoting physical activity in tourist establishments Page 125 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles and Activities HPA/MOH Tasks to do by HPA/ MOH department providing guidance ➢Implementation of tobacco control law in restaurants of tourist establishments, including no advertisements directly or indirectly through menus, photos on websites, etc., no sale of single cigs ➢Prevent / disincentivize “investing” (foreign investments) in unhealthy commodities like tobacco (e.g., shisha lounges), ED, areca nut, sugary drinks, etc. MCST (Min. of ➢Health systems (HIS) to incorporate HPA NCD. ➢ MOH has to send request Communication, NCD information (MOH has to send /MOH IT for assistance on HIS if Science & request if needed – inadequate needed Technology)/ resources at present), ➢ Need proper information NCIT ➢Use of IT for health education in databases with sharing of peripheries info (e.g., vaccination ➢(software development at cost) status, etc.) -? NCIT ➢Govt. ministry websites standardization (development) ➢E-community program for providing awareness for small islands (run by island council) (SAARC Dev. Fund) Fuvamulah – IT park / hub ➢Knowledge Foundation – knowledge hub (a year later - 2021) ➢Comprehensive ban on all forms of TAPS in all media MIA (Min. of ➢Messaging on alcohol for public to be HPA NCD / ➢ Initiate and communicate Islamic Affairs) discussed between HPA and MIA Nutr. / RH with relevant organizations ➢Need to address Trade of unhealthy to implement commodities like tobacco, areca, ED, cancer-causing substances, sugary drinks ➢Provide expert advice/ recommendations (Lafaa dhinun) – need Islamic directives/fatwahs on trade of unhealthy commodities above, second-hand smoking & smoke free public places ➢Educational programs e.g., Khuthba, Dharus, etc. to include messaging on social responsibilities and trade of unhealthy commodities, in addition to healthy lifestyles individuals to reduce NCD risk (all 3 main components- tobacco, SHS, healthy diets, physical activity), mental health, etc. Page 126 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles and Activities HPA/MOH Tasks to do by HPA/ MOH department providing guidance ➢Halaal certification ➢Healthy Ramadan, hajj pilgrimage, etc. promote healthy lifestyles in relation to events/activities of religious significance, e.g., tobacco cessation in Ramadan / preparation for hajj, healthy diets and physical activity in Ramadan, etc. MACH (Min.of ➢Measures to promote healthy lifestyles HPA NCD/ ➢ Initiate and communicate Arts, Culture & through tradition and “sagaafee” Health with relevant organizations Heritage) activities promo to implement ➢Measures to break cultural links of /avoid promoting tobacco, areca nut use ➢Need research and accurate information on the history of introduction of tobacco, alcohol, areca nut use and unhealthy substances to find ways of educating public on negative aspects / “uncool factors” (e.g. Portuguese – introducing these, early deaths among kind who used these, etc.) ➢Tobacco free heritage sites Maldives ➢Assist MOH in generation and Health Info ➢ Lead and communicate Bureau of validation of mortality rates for given section of with relevant organizations Statistics (MBS years, including: HIMRD to implement / include in (MNPHI)) o premature mortality rates (MOH)/ research and statistics. (mortality below age 70 yrs.) HPA (NCD) Start communications 1 o Premature mortality by ICD (main) year before planned category surveys. ➢Incorporate NCD and NCD risk-factor ➢ HPA NCD to prepare related questions into surveys (HIES, guidance and list of stats Economic survey, DHS and other required from surveys and national surveys) communicate with Health ➢Household income and expenditure Information Section of survey (HIES) – include spending on HIMRD various tobacco products including ➢ HIMRD to communicate purchase at restaurants, shisha, etc., with MBS (MNPHI) analyses spending on fruit & vegetables, areca nut products, energy Note: Timings of surveys by drinks, sugary drinks, foods high in salt MBS for collaborating: and fats and trans fats, etc. - average • HIES every 5 yrs. – last and percentage in proportion to total 2019, next ~2024. expenditure on food • Population & Housing + ➢Surveillance of pricing and census – planned 2024, consumption of tobacco, areca nut, every 10 yrs. Page 127 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles and Activities HPA/MOH Tasks to do by HPA/ MOH department providing guidance energy drinks, etc. under trade/ • Economic census – planned economic surveillance 2024 with population & housing census Page 128 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) B. Roles of academic institutions in the implementation of the NCD MAP and relevant departments in HPA that coordinate with these institutions General roles of ALL academic institutions and independent bodies: ➢ Main role: CAPACITY BUILDING ➢ Contribute to national technical capacity/expertise (e.g., Technical Committees, advisory boards, etc.) ➢ ***Incorporating relevant teaching in curricula ➢ Grassroot level education and advocacy (for public) through student assignments ➢ Advocacy through university activities (large youth population!): forums, events, etc. ➢ Research – Surveillance (surveys participation) ➢ Promoting healthy lifestyles (ABCs) at study and work through fun activities and screening programs and creating enabling environment through healthy university/workplace policies (smoke-free college/workplace (NO designated smoking areas at all!), encouraging to quit – cessation services through health services??), healthy canteens/availability of healthy food, student orientation programs ➢ Policies to avoid conflict of interest – donations, sponsorships, etc. from unhealthy industries (tobacco - illegal under TCA) ➢ Collaboration/partnerships with HPA (Technical expertise, technical work-e.g., preparation of IEC material, guidelines, etc., research) ➢ Universities to directly work with WHO to access funding and technical assistance for NCD prevention General tasks for HPA to do in order to engage academic institutions: • Routinely share and update all guidelines and tools with universities for use in teaching/learning • HPA to engage universities in technical work through collaborations, membership in TEC Committees, advisory boards, and MOUs for long-term collaboration • Build capacity of universities by providing international training opportunities and exposure through study visits etc. for university lecturers engaged in work with HPA. • HPA (NCD) to initiate and coordinate with all Schools, faculties and departments and courses of MNU that need to incorporate relevant teachings related to NCD prevention. Organize an initial stakeholder meeting with relevant departments of MNU and main universities to share and further develop tasks defined in NCD Action Plan. Organization Roles Tasks to do by HPA/ MOH ➢ MNU-FHS ➢Expand NCD curriculum for PHC courses. ➢HPA to upload all NCD and NCD Include: risk factor management o NCD policies and programs (national guidelines on website. and international) – as mandatory to ➢HPA to specifically share with know course content for ALL students health sciences teaching of all level of courses, more detailed faculties all NCD related for PHC Degree and MPH students guidelines on PEN, tobacco cessation, Food Based Dietary Page 129 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles Tasks to do by HPA/ MOH o Key healthy lifestyle (ABCS) measures guideline (FBDG), any other for NCD prevention at community NCD related prevention or level and individual level treatment guidelines, and o Knowledge/skills in Behavioral change update universities regularly on communication (BCC)/ COMBI releasing or updating any methods guidelines. o Work with all courses in FHS (PHC, ➢Provide training opportunities Pharmacy, Psychology, Counseling, on NCD prevention for Health management, Occupational lecturers, Guest lecturer and Health, etc.) as relevant to technical experts incorporate teaching/learning of ➢Sharing NCD surveillance data knowledge and skills needed to for analysis implement current clinical guides for ➢Identify areas of need for NCD total risk approach to managing related research and patients and clients into teaching: PEN communicate to university and protocols, tobacco cessation, Food FHS. Based Dietary Guideline (FBDG), and ➢HPA NCD program to provide other relevant guidelines visiting lecturer to update o Assignments/community projects/ students on national NCD practical experience in community prevention programs and hospitals to include/focus on NCD ➢HPA to form collaboration with prevention and advocacy FHS for capacity building on o Conduct awareness on NCD NCD prevention programs. prevention to the community through student projects and practical activities ➢Research on NCD risk factors, effectiveness of control measures, operational research – funded research by lecturers + encourage student research ➢Involve in national capacity building for NCD prevention – conduct or provide resource persons to conduct trainings for non-university health professionals, non- health stakeholders and volunteers. MNU-School of ➢Expand NCD curriculum for Diploma, ➢HPA to specifically share with Nursing, Degree, Masters courses to include health sciences teaching following: faculties all NCD related ➢NCD prevention and control policies and guidelines on PEN, tobacco programs (national) – mandatory to cessation, Food Based Dietary know for ALL students of all level of guideline (FBDG), any other courses (for national-HPA visiting lecturer NCD related prevention or can brief on programs, for international, treatment guidelines, and mandatory task to search WHO/CDC for update universities regularly on effective NCD prevention measures and releasing or updating any describe briefly) guidelines. ➢For all courses as relevant: Incorporate ➢Provide training opportunities teaching/learning to provide knowledge on NCD prevention for lecturers and skills to implement current clinical ➢Identify areas of need for NCD guides for total risk approach to related research and Page 130 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles Tasks to do by HPA/ MOH managing patients and clients into communicate to university and teaching: PEN protocols, tobacco SN. cessation, FBDG and any other NCD ➢HPA NCD program to provide related guidelines. visiting lecturer to update ➢Behavioral change communication (BCC)/ students on national NCD COMBI (briefly) prevention programs ➢Include/ expand assignments/community ➢HPA to form collaboration with projects to focus on NCD prevention and SN for capacity building and advocacy conducting of NCD prevention ➢Research on NCD risk factors, programs through teaching / effectiveness of control measures, learning activities. operational research – funded research by lecturers + encourage student research ➢When assigning students to study available research on healthy lifestyle recommendations, guide them to search WHO recommendations, the available national guides for Maldives, and recommendations of CDC, NHS, World Heart Federation, World Cancer Federation, etc. which base their recommendations on systematic reviews and research, instead of searching Pubmed for individual research articles. ➢Involve in national capacity building for NCD prevention – conduct or provide resource persons to conduct trainings for non-university health professionals, non- health stakeholders and volunteers. School of ➢NCD prevention and control policies and ➢HPA to specifically share with Medicine programs (national and international) – health sciences teaching mandatory to know for ALL students of faculties all NCD related all level of courses (for national-HPA guidelines on PEN, tobacco visiting lecturer can brief on programs, cessation, Food Based Dietary for international, mandatory task to guideline (FBDG), any other search WHO/CDC for effective NCD NCD related prevention or prevention measures and describe treatment guidelines, and briefly) update universities regularly on ➢For all courses as relevant: Incorporate releasing or updating any current clinical guides for total risk guidelines. approach to managing patients and ➢Provide training opportunities clients into teaching: PEN protocols, on NCD prevention for lecturers tobacco cessation, FBDG, and any other ➢Identify areas of need for NCD national NCD related guidelines related research and ➢Behavioral change communication (BCC)/ communicate to university and COMBI (basic concepts) SM. ➢Include assignments/community projects ➢HPA NCD program to provide to focus on NCD prevention and visiting lecturer to update advocacy students on national NCD prevention programs Page 131 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles Tasks to do by HPA/ MOH ➢Research on NCD risk factors, ➢HPA to form collaboration with effectiveness of control measures, SM for capacity building and operational research – funded research conducting of NCD prevention by lecturers + encourage student programs through teaching / research learning activities. ➢When assigning students to study available research on healthy lifestyle recommendations, guide them to search WHO recommendations, the available national guides for Maldives, and recommendations of CDC, NHS, World Heart Federation, World Cancer Federation, etc. which base their recommendations on systematic reviews and research, instead of searching Pubmed for individual research articles. ➢Involve in national capacity building for NCD prevention – conduct or provide resource persons to conduct trainings for non-university health professionals, non- health stakeholders and volunteers. IUM, MNU-FIS ➢Research on Islamic perspective on HPA (NCD program) to initiate (Islamic unhealthy lifestyle, unhealthy products: communication with IUM and studies) tobacco, areca nut, cancer causing foods, MNU-FIS and form collaborations energy drinks, etc. in addition to alcohol to implement these activities ➢Research on Islamic perspective/rulings on trade of unhealthy commodities, Govt. / public responsibilities to protect children and youth from these risks ➢Incorporating key relevant information on NCD risk factors into curricula and teaching/learning activities of students ➢Educating public – Deliver awareness to public on tobacco, alcohol, substance abuse, mental health including both individual and societal responsibilities - involve health sector for guidance ➢Advocacy for healthy lifestyles, mental health and NCD prevention ➢Provide guidance to health sector on appropriate messaging on alcohol and other NCD risk factors in keeping with Islamic principles MNU-Faculty ➢To build capacity of students to teach HPA (NCD program) to initiate of Education, NCD related curricular content to school communication with MNU and NIE (MOE) children form collaborations to implement ➢Include NCD risk factor prevention these activities with the relevant components in the Education curricula departments ➢Share existing guidelines e.g., School Identify areas of research needed Food Guide, FBDG, teacher guides for NCD prevention and control Page 132 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles Tasks to do by HPA/ MOH available from CDC, etc. and incorporate and communicate with university into teaching/learning and departments. ➢Capacity building and CPD for existing teachers in schools to build confidence in teaching/delivering curricular content on NCD prevention and healthy lifestyles (ABCs) to students MNU-Faculty ➢Incorporate into teaching – methods of HPA (NCD program) to initiate of Arts promoting healthy lifestyle (ABCs) communication with MNU and (Journalism, ➢Assignments on creative production, etc. form collaborations to implement Visual arts to include creative ways of promoting these activities with the relevant courses), the ABCs of healthy lifestyle departments Maldives ➢Collaborations with HPA to produce Identify areas of research needed Media educational material through students for NCD prevention and control institute ➢Journalism Ethics to include awareness and communicate with university on industry influence and avoiding and departments. indirect advertisement through AV/online/print media productions, news articles, etc., promoting health (not unethical!) ➢Policies to avoid unhealthy sponsorships (targeted) ➢Media research o type of media used, different viewing times etc. by different age groups / social groups o effective methods of promoting health through various media, comparisons with successful countries ➢ MNU-Faculty ➢Incorporating in teaching/learning: HPA (NCD program) to initiate of Arts (law, o Laws and regulations to control NCDs communication with MNU and political o NCD prevention and control policies form collaborations to implement sciences and Best Buys Research on their these activities with the relevant courses) effectiveness and legal factors that departments improve effective implementation Identify areas of research needed (other successful country case studies for NCD prevention and control compared with Maldivian case and communicate with university studies) and departments. MNU-Faculty ➢Incorporating in teaching/learning HPA (NCD program) to initiate of Hospitality o Promoting healthy foods & beverages, communication with MNU and & Tourism tasty/interesting recipes, cookery form collaborations to implement studies, Cooks programs, competitions, etc. these activities with the relevant Guild o Promoting health in hospitality departments industry Identify areas of research needed o Limiting use of unhealthy “fast” foods for NCD prevention and control in recipes and communicate with university o Policies to avoid unhealthy and departments. sponsorships (targeted) o Promoting ABCs and enabling environments in hospitality industry Page 133 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles Tasks to do by HPA/ MOH (e.g. Incentives for fully smoke-free restaurants (no shisha too!), non- smoking rooms, ways to promote the concepts among public/customers promoting healthy diets and physical activity ➢Research: effective methods of promoting healthy foods, physical activity and smoke-free environments in hospitality industry MNU research ➢Research on NCD policies, ➢HPA (NCD program) together center (RAR) implementation of policy actions, NCD with MOH HIMRD (Health Info burden studies, ecological studies on section) to initiate effects of risk factor reduction with communication with MNU and implementation of key policy measures form collaborations to ➢More quantitative studies – Case control, implement these activities with cohort studies in addition to STEPS MNU RAR. survey ➢Identify areas of research ➢Collaborative research with HPA/MOH needed for NCD prevention and (e.g. STEPS survey, DHS), operational control and communicate with research university and RAR. ➢Generating Statistics for advocacy ➢Develop collaboration (through through research MOU or suitable means) with ➢ RAR to take lead and facilitate NCD MNU RAR for regular sharing of related research in other faculties, priority research needs, which schools and departments of MNU – share of these were conducted and identified priority areas for research with research findings/publications other faculties and follow-up on any between RAR and HPA/MOH. research conducted and published or presented, share relevant publications/abstracts and progress with HPA on a regular basis. MNU-Students ➢Developing written University policies for HPA (NCD) to initiate and creating enabling environments for coordinate with MNU to healthy lifestyle (e.g. smoke free incorporate relevant teachings environments, healthy canteens and related to NCD prevention and adequate facilities for physical activity, university policies for promoting e.g. safe bicycle parking, indoor sports healthy lifestyle among students areas, etc.) and avoiding conflicts of and teachers. interest (e.g. policies to avoid funding and collaborations with unhealthy industries such as tobacco, energy drinks, unhealthy food industries, etc. avoiding advertently or inadvertently promoting unhealthy commodities and practices in university activities), ➢disseminating to students, staff and all concerned, and ➢ensuring implementation Page 134 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Organization Roles Tasks to do by HPA/ MOH MNU-Quality ➢Overall coordination and implementation HPA (NCD) to initiate and of general measures mentioned above coordinate with MNU to throughout the university incorporate relevant teachings ➢Ensure updated teaching/learning on related to NCD prevention and NCDs in all faculties and courses university policies for promoting identified above healthy lifestyle among students and teachers. Villa College, ➢Incorporating NCD prevention and ➢HPA (NCD program) to initiate MI college healthy lifestyle (ABCs) in communication with colleges teaching/learning and form collaborations to o Expand NCD curriculum for PHC/MPH implement these activities. o NCD policies and programs – ➢Identify areas of research mandatory to know needed for NCD prevention and o For all courses as relevant: control and communicate with Incorporate current clinical guides for the colleges. total risk approach to managing patients and clients into teaching: PEN protocols, tobacco cessation, FBDG o Assignments/community projects to focus on NCD prevention and advocacy ➢Research on priority NCD topics – more quantitative studies ➢Work collaborations – e.g. graphics students for preparing IEC material Dhivehi ➢Incorporating NCD prevention and ➢HPA (NCD program) to initiate Bahuge healthy lifestyle (ABCs) in communication with Dhivehi Academy teaching/learning Bahuge Academy and form ➢Awareness programs for members of collaborations to implement DBA and Dhivehi language scholars, these activities. teachers and artistes to remove ➢Conduct meetings / programs examples of unhealthy practices used in with Dhivehi Bahuge Academy teaching of Dhivehi language (e.g. to reach and involve scholars tobacco use, areca nut chewing, etc.) and and artistes use healthy lifestyle examples instead ➢Identify areas of historical ➢Research on History/Culture/traditions research needed for NCD needed to promote healthy lifestyles: prevention and control and o Origins/time of introduction of communicate with the unhealthy habits (to look for facts that academy, form collaborations make them unpopular, e.g. late with relevant departments. introduction, people died young, etc.) o Details of healthy behaviors in history to popularize (e.g., healthy foods, fruit/vegetable/ less oily foods, active lifestyle, etc.) ➢Collaborative work for effectively promoting healthy lifestyles and NCD prevention: o Poems (Lhen), songs, drama, stories, etc. for public awareness and promotion Page 135 of 137 National Multi-sectoral Action Plan for the Prevention and Control of Noncommunicable Diseases in Maldives (2023-2031) Page 136 of 137