Better Health, Better Lives: Combating Non-Communicable Diseases in the Context of Norwegian Development Policy (2020-2024)

Norwegian Ministry of Foreign Affairs Strategy Norwegian Ministry of Health and Care Services Better Health, Better Lives Combating Non-Communicable Diseases in the Context of Norwegian Development Policy (2020-2024) Contents Preface 5 Summary: The battle against non-communicable diseases in low-income countries 7 Goals and guidelines 11 Goals 11 International guidelines 11 Norway’s development policy guidelines 12 Public health and non-communicable diseases in a development perspective 15 Global public health is changing 15 Global health aid 15 Non-communicable diseases and attributable risk factors 16 Non-communicable diseases in a development perspective 18 Priority focus areas 21 Global leadership 21 Preventing and reducing risks 23 Strengthening health systems – with emphasis on primary health care 27 Global public goods 30 Other areas 31 Implementation of the strategy 35 Development aid funds 35 Political efforts 36 Potential channels and partners 36 Follow-up 37 3 Foto: © WHO GCM/NCD/SAS Becker Preface Global public health has changed significantly ii) Strengthening primary health care by impro- since the start of the millennium. There has been a ving prevention, diagnosis and treatment of substantial reduction in the percentage of people non-communicable diseases, and ensuring who die from communicable diseases such as everyone has access to health care subsidised by tuberculosis, polio, AIDS and malaria, in part due to the public authorities. successful vaccination and treatment programmes iii) Strengthening global public goods, including as well as other measures. The same is true of normative work, access to health data and health child mortality. Today, non-communicable diseases information, digitalisation and research. are the biggest killers worldwide, with the most prevalent being cardiovascular diseases, cancer, The strategy is based on the important principles respiratory diseases, diabetes and mental disorders. that underpin the SDGs and our development policy. This means that the poorest and most vulnerable In recent years, we have seen a strong upward trend will be reached – no one will be left behind – and in the number of deaths from non-communicable that everyone is entitled to good health. The strategy diseases (NCDs) in low-income countries. In Africa, comprises measures within most of the priority the proportion of NCD deaths, as compared to total focus areas in Norwegian development policy, deaths, is expected to increase from around 35 per with emphasis on health, education, sustainable cent today to over 50 per cent by 2030. Certain risk food systems, climate and environment, renewable factors increase the likelihood of developing these energy, humanitarian efforts, needs of people with diseases: Tobacco, harmful use of alcohol, unhealthy disabilities, digitalisation and good governance. diets, insufficient physical activity and air pollution. Tobacco and air pollution are the two risk factors The strategy builds on experiences from Norwegian that cause the highest number of deaths. public health work where everyone has access to health services, as well as from international aid The Norwegian Government wishes to contribute and development cooperation. It focuses on low- in the battle against non-communicable diseases income countries in particular, and advocates an in low-income countries. This work will be included approach that helps to achieve the SDGs and to in health related development cooperation and implement the World Health Organization’s (WHO) will help achieve several of the UN Sustainable Global Action Plan for the Prevention and Control of Development Goals (SDGs). The strategy sets out a Noncommunicable Diseases. In addition to having plan for this work for the period 2020 to 2024. This consequences for the individual, non-communicable strategy positions Norway to play a leading role in diseases also negatively affect a country’s economic expanding work on NCDs in international health development. It is particularly important to prioritise and development policy as well as ensuring practical actions in a manner that protects people from health action in low-income countries. The strategy will threats and ensures fair and equal access to health focus on the following three main areas: services based on Universal Health Coverage. This will result in the greatest health benefit. This is in line i) Preventing and reducing risk through concrete with the declaration on Universal Health Coverage measures across sectors to prevent disease and adopted by the UN General Assembly in 2019. premature death, where regulation, taxation and multi-sectoral measures will be important. The There is global consensus on the measures needed initiative will target risk factors that also affect to prevent and control non-communicable diseases children and young people. and to reverse the negative trend. We need to fight NCDs and turn a global crisis into a success story. Norway wishes to contribute to this goal, and to save millions of lives, ensuring that people enjoy better health throughout their lives and encouraging positive economic development in low-income countries.

Dag-Inge Ulstein Bent Høie Minister of International Development Minister of Health and Care Services 5 Foto: Shutterstock Summary: The battle against non- communicable diseases in low-income countries - Norway’s contribution The global burden and threat of noncommunicable diseases (NCDs) constitutes a major public health challenge that undermines social and economic development throughout the world, and inter alia has the effect of increasing inequalities between countries and within populations. (WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases, 2013–2020i) Norway will be at the forefront in the battle The strategy is based on WHO’s Best Buys and other against non-communicable diseases in low-income recommendations to prevent and control non- countries. Our vision is a world where as few communicable diseases, in line with SDG 3: Ensure people as possible die as a result of these diseases, healthy lives and promote well-being for all at all ages. particularly before they reach the age of 70. If fully implemented, it will contribute to a healthier population and support economic growth in low- The non-communicable diseases covered by income countries. The 16 WHO Best Buys could help the strategy are based on the 5 x 5 NCD Agenda to save more than 8 million premature deaths in low adopted by the UN. Five priority diseases are and lower-middle income countries by 2030. The addressed: cardiovascular diseases, cancer, total costs of not taking action on NCDs in low- and respiratory diseases, diabetes and mental disorders, middle-income countries is estimated to be more and five risk factors; tobacco, air pollution, harmful than USD 7 trillion over 15 years which is three times use of alcohol, unhealthy diets and insufficient Africa’s total annual GDP. physical activity. A large-scale global effort to combat NCDs would Non-communicable diseases lead to premature thus save millions of lives, help ensure a healthier death and reduce quality of life, and they can population and support economic growth in low- also have major economic consequences for the income countries. This will be crucial to achieving individual and their family. These diseases often several of the SDGs, and not just the health-related have a chronic course leading to long-term and goals. expensive treatment. The cost to society is very high, both as a result of the high cost of treatment and The strategy includes efforts to strengthen primary care, and the fact that many people die prematurely, health care, measures to prevent diseases by during their most economically productive years. reducing risk, and measures to improve global public goods. Emphasis is placed on efforts targeting the risk factors that cause the greatest morbidity and mortality in low-income countries. 7 THE GOVERNMENT WILL: • Help to prevent non-communicable diseases • Support the work on taxation and regulation through development cooperation by of products that are harmful to health such contributing to healthy and sustainably as tobacco and alcohol, and on emissions produced food; a healthy environment with of air pollutants in low- and middle-income clean air and clean energy; opportunities countries. Assist countries that request for physical activity; access to high-quality assistance to tax products that are harmful to education; and stronger tobacco and alcohol health as well as emissions of air pollutants. regulations. Emphasis shall be given to social Work through the Norwegian Tax for sustainability and reducing health inequalities Development (Skatt for utvikling) programme from childhood to old age. will be important in this context.

• Help to strengthen implementation of WHO’s • Strengthen efforts to ensure healthy nutrition Global Action Plan for the Prevention and in line with WHO’s advice on healthy dietsiv, Control of Noncommunicable Diseasesi in including reducing salt, sugar, saturated fats low-income countries, and help to implement and trans fats. Promote breastfeeding and the UN resolutions on non-communicable measures to improve mothers’ nutrition diseases adopted at the high-level meetings in before and during pregnancy, to ensure 2011, 2014 and 2018. healthy growth and lifelong health benefits. Work to improve children and young people’s • Show global leadership and cooperate with knowledge of health, diet and physical activity, relevant actors in well-coordinated efforts to and ensure good access to healthy food and combat non-communicable diseases. activity at school, in cooperation with relevant multilateral actors. • Help to strengthen implementation of the WHO Framework Convention on Tobacco • Strengthen efforts to reduce the number of Control (FCTC)ii in low-income countries, in deaths caused by air pollution, in line with particular implementation of health-related SDG Target 3.9. We will work to support global tobacco taxes. Support the SAFER initiative commitments and effective measures to improve on alcohol control, which helps countries to air quality, in cooperation with WHO and other reduce harmful use of alcohol and related relevant organisations, forums and countries. health, social and economic consequencesiii. We will encourage more countries to take part in the BreatheLife campaignv and endorse WHO’s initiative to improve air quality by 2030, in line with its Air Quality Guidelines. We will also promote pollution-free cooking through the initiative ‘Renewable Energy in Norwegian Development Policy’. 8 • Support the work on achieving SDG Target • Through board representation and budget 3.8 for Universal Health Coverage, and draw allocations, ensure that organisations such as attention to primary health care as being the Global Fund to Fight AIDS, Tuberculosis the best way a country can provide health and Malaria (GFATM) and GAVI, The Vaccine services to its entire population, irrespective of Alliance also contribute to achieving Universal income level, including the poorest and most Health Coverage, through their involvement in vulnerable groups. This entails the inclusion of low-income countries, and thus help combat the most cost-effective measures to combat non-communicable diseases. non-communicable diseases in primary health care services, with emphasis on prevention • Strengthen efforts in digital health as part of and diagnosis, as well as treatment of the most the follow-up of the White Paper on digital common non-communicable diseases, for transformation and development policyvii, example: including continuing support to improve - the prevention of cervical cancer, including the quality of health data and health data through HPV vaccination; registers at country level; and development - diagnosis and treatment of high blood of digital health information systems in low- pressure; income countries, in cooperation with the - advice on diet and nutrition, including University of Oslo and the Norwegian Institute breastfeeding; of Public Health, among others. Contribute - promotion of healthy physical activity; to the global knowledge base on combating - prevention of tobacco use, harmful alcohol non-communicable diseases through relevant consumption and air pollution exposures. research programmes and cooperation between institutions. • Support mental health initiatives including implementation of WHO's Mental Health • Support efforts to improve access to medical Action Planvi; and help ensure that mental equipment and medication in areas hit by crises health becomes an integral part of the and conflict in order to prevent/treat non- prevention and treatment services offered by communicable diseases. the primary health care and education sector from early childhood. Cooperation with WHO, • Strengthen efforts to prevent non- authorities and national and local civil society communicable diseases by focusing on organisations will be important in this context. education in development policy, including through health-promotion and preventive health services at school.

9 Foto: Shutterstock Goals and guidelines There is international consensus that deaths from NCDs can be largely prevented or delayed by implementing a variety of cost-effective, affordable, and evidence-based interventions. Member States endorsed a menu of policy options and cost-effective interventions entitled “Best buys and other recommended interventions for the prevention and control of NCDs”, at the World Health Assembly in Resolution WHA70.11 in May 2017. (Time to deliver. Report of the WHO Independent High-Level Commission on Noncommunicable Diseases) Goals areas, important arenas and synergies that can be This strategy describes how Norway’s health related achieved. The strategy also describes the intended development cooperation can be designed to ensure results of these efforts. it addresses the shift in the global burden of disease from communicable to non-communicable diseases. International guidelines The strategy’s overriding goal is to help reduce the number of premature deaths from non- The World Health Assembly adopted the Global communicable diseases in low-income countries by Action Plan for the Prevention and Control of one- third by 2030 and promote mental health and Noncommunicable Diseases in 2013, with the goal of wellbeing (SDG Target 3.4), and to generally improve achieving a 25 per cent reduction in premature NCD people’s health throughout the life-course. deaths between 2010 and 2025. The probability of dying prematurely from non-communicable diseases Emphasis is placed on universal measures that also declined from 22 per cent in 2010 to 18 per cent in reach the poorest and most vulnerable groups. The 2016 according to WHO’s report to the World Health strategy will be a response to the shift in the global Assembly in 2019. The total number of deaths burden from communicable to non-communicable caused by these diseases has, however, increased diseases, and will be adapted to the needs in low- due to global population growth. income countries in line with the objectives of Norwegian development policy. The strategy will also As a result of adoption by UN member states of be a means of following up the UN’s three high-level the 2030 Agenda for Sustainable Development declarations on non-communicable diseases. This in 2015, the target figure for the reduction in will require efforts that target multiple SDGs. premature deaths was changed to one-third by 2030 (SDG Target 3.4). Other health targets under SDG 3 The strategy aims to consolidate Norway’s work on are also relevant, including 3.5 on harmful use of combating non-communicable diseases as part of alcohol, 3.8 on Universal Health Coverage, 3.9 on its development cooperation by identifying focus reducing the number of deaths from air pollution 11 and 3.a on strengthening the implementation of the Norway’s development policy guidelines WHO Framework Convention on Tobacco Control (FCTC). Combating non-communicable diseases is The strategy is based on the important goals also important for reaching a number of the other and principles that underpin our foreign and SDGs, the following in particular: development policy. The main goal of the initiative is to help combat poverty and promote economic development and welfare in low-income countries. • SDG 1 on ending poverty – low- and middle- The initiative will be designed to ensure that we income countries are particularly at risk due reach the poorest and most vulnerable groups, to the cost of treating non-communicable and help us achieve the main objective of the 2030 diseases, loss of income etc. Agenda – that no one is to be left behind. As a basis for the initiative, countries must prioritise actions • SDG 2 on ending hunger – unhealthy diets and to combat non-communicable diseases in national undernutrition are important risk factors for policy. Countries are also expected to develop a non-communicable diseases. plan for this work to the extent such a plan does not already exist, including how to increase financial • SDG 4 on quality education – training and investments in national health services. education are important for understanding the risk of non-communicable diseases, parti- Health is a priority area in Norwegian foreign and cularly linked to tobacco and harmful use of development policy. Norway has a leading role in alcohol as well as diet and activity. global health. The goal of Norway’s international health cooperation is to prevent and effectively • SDG 7 on clean energy – which is important combat disease and to help achieve SDG 3 on for improving both indoor and outdoor air health. quality. For example, 3.8 million people die from indoor air pollution every year due to The 2030 Sustainable Development Agenda requires using inefficient and polluting cookstoves to us to work across sectors, and coordinated efforts make food. Pollution-free alternatives in sectors that affect public health are particularly are needed. important. WHO recommends a Health in All Policies approach. This strategy therefore comprises • SDG 13 on climate action – emissions of gre- measures within most of the priority areas in enhouse gases and air pollutants come from Norwegian development policy – health, education, the same sources, which means that measures sustainable food systems, climate and environment, to reduce emissions will positively affect the renewable energy, humanitarian efforts, people with climate and people’s health. Moreover, rising disabilities, digitalisation and good governance. temperatures will also increase mortality from e.g. cardiovascular diseases.

Foto: Freepik Three high-level UN General Assembly meetings have been held to mobilise political support for combating non-communicable diseases, in 2011, 2014 and 2018 respectively. The status reports regularly presented to the World Health Assembly nonetheless indicate that not enough progress is being made around the world to achieve the stipulated targets for reducing premature death. The reports indicate that low- and middle-income countries face the biggest challenges. 12 Risk factor/ WHO published a list of 88 recommended interventions in 2017. The ”Best Buys” are disease group the 16 most cost-effective interventions (they do not include air pollution and mental health since the ”5 x 5 Agenda” incorporating those two key risks was adopted in 2018). • Increase excise taxes and prices on tobacco products • Implement plain/standardized packaging and/or large graphic health warnings on all tobacco packages • Enact and enforce comprehensive bans on tobacco advertising, promotion and Tobacco sponsorship • Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public places, public transport • Implement effective mass media campaigns that educate the public about the harms of smoking/tobacco use and second hand smoke • Increase excise taxes on alcoholic beverages Harmful use of • Enact and enforce bans or comprehensive restrictions on exposure to alcohol alcohol advertising (across multiple types of media) • Enact and enforce restrictions on the physical availability of retail alcohol via reduced hours of sale • Reduce salt intake through the reformulation of food products to contain less salt and the setting of target levels for the amount of salt in foods and meals • Reduce salt intake through the establishment of a supportive environment in public Unhealthy diet institutions such as hospitals, schools, workplaces and nursing homes, to enable lower sodium options to be provided • Reduce salt intake through a behaviour change communication and mass media campaign • Reduce salt intake through the implementation of front-of-pack labelling • Implement community wide public education and awareness campaign for physical Physical activity which includes a mass media campaign combined with other community based inactivity education, motivational and environmental programs aimed at supporting behavioural change of physical activity levels • Drug therapy (including glycaemic control for diabetes mellitus and control of hypertension using a total risk approach) and counselling to individuals who have had Cardiovascular a heart attack or stroke and to persons with high risk (≥ 30%) of a fatal and non-fatal diseases and cardiovascular event in the next 10 years >>Drug therapy (including glycaemic control diabetes for diabetes mellitus and control of hypertension using a total risk approach) and counselling to individuals who have had a heart attack or stroke and to persons with moderate to high risk (≥ 20%) of a fatal and non-fatal cardiovascular event in the next 10 years Cancer • Vaccination against human papillomavirus (2 doses) of 9–13 year old girls • Prevention of cervical cancer by screening and treatment Best Buys and other recommended interventions for the prevention and control of Noncommunicable Diseases updated (2017) Appendix 3 of the Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020 https://www.who.int/ncds/management/WHO_Appendix_BestBuys.pdf

13 Foto: Shutterstock Public health and non-communicable diseases in a development perspective Within countries at all levels of development, non-communicable diseases affect the poorest people and those furthest behind in particular, and their increased risk of dying prematurely from non-communicable diseases is, therefore, a marker of the devastating impact of the high burden of non-communicable diseases on the lives of the poor, their untold suffering and the threat to sustainable development. (The UN Secretary-General’s report: Progress on the prevention and control of non-communicable diseases, December 2017). Global public health is changing In sub-Saharan Africa, it is projected that non- The global health situation is changing. Over the communicable diseases will cause around half of all past decades, we have seen a strong global decrease deaths by 2030. As well as disease and the reduced in communicable diseases and a sharp increase in quality of life and income of both the individual non-communicable diseases as the biggest cause and their family, the reduction in productivity of morbidity and mortality. This is mainly due to also constitutes a serious threat to economic the success of the battle against communicable development. diseases so that people live longer as well as lifestyle changes, due in part to rapid urbanisation. Non-communicable diseases caused 71 per cent Global health aid of all deaths around the world in 2017. In terms of premature deaths before the age of 70, non- Between 12 and 14 per cent of total global aid communicable diseases account for around three- goes to the health sector, which is one of the social quarters of the total. The largest percentage (86 per sectors that receives most support. Total global cent) of premature deaths occur in low- and middle- health aid almost tripled from around USD 12 income countries. billion to USD 34 billion between 2000 and 2010. Investments to combat non-communicable diseases As mentioned earlier, the UN has adopted a 5 x 5 also tripled during this period, but from a very low Agenda for its efforts to combat non-communicable level; from USD 146 million to USD 432 million. At diseases. This Agenda covers five diseases and five the end of the decade, measures to combat non- risk factors: tobacco and harmful use of alcohol; communicable diseases received just over 1 per cent unhealthy diets; insufficient physical activity and of all health-related aid. air pollution. The latter is mainly due to emissions from cars and other vehicles; from cooking over an Norway actively participated in the global effort open flame or cookstoves that use coal, charcoal and to achieve the UN Millennium Development wood; from the open burning of waste and forests; Goals (2000-2015). Norway’s efforts particularly from agriculture and industry and from coal fired targeted women’s, children’s and young people’s power plants and other energy production. health, sexual and reproductive health and 15 rights, innovation and combating communicable disabilities and increased health expenditure. diseases. These areas have also been a key focus For example, mental disorders constitute a in Norwegian health related development aid after major burden for society in all parts of the world. 2015. In contrast, non-communicable diseases were Depression is one of the main causes of disabilities. less of a priority, and as of 2018 only 1-2 per cent of all Norwegian health-related development aid was The prevalence of non-communicable diseases is allocated to this area. mainly linked to the five risk factors mentioned above. Several of these risk factors also have a Non-communicable diseases and bearing on mental health, including harmful use of attributable risk factors alcohol, although there are also other reasons for mental disorders. A brief review of the individual risk Non-communicable diseases are defined as long- factors follows below. term, chronic diseases that are not transmitted from person to person, but rather develop as the Tobacco is one of the main causes of morbidity and result of a combination of genetic, physiological and mortality around the world. Tobacco kills over environmental factors and lifestyle habits. Globally, 8 million people every year. Of these deaths, over more than 80 per cent of deaths caused by non- 1 million can be ascribed to exposure to second communicable diseases come from the following hand smoking. More than one billion people in five groups of diseases (figures from 2017viii): the world smoke, which corresponds to one fifth of the world’s population aged over 15. The total • Cardiovascular diseases – 17.9 million global costs of smoking are estimated to be around • Cancer – 9 million USD 1.4 trillion each year, which corresponds to • Chronic respiratory diseases – 3.9 million around 1.8 per cent of global GDP. Around 100 • Diabetes – 1.6 million million people died as a result of smoking in the • Mental disorders – an estimated 800,000 people 20th century, most of whom lived in high-income commit suicide each year. Studies also show countries. If current smoking behaviour continues, considerable excess mortality from other non- one billion people will die from smoking in the 21st communicable diseases among people with century, mainly in low- and middle-income countries. serious mental disorders. Tobacco and alcohol are important risk factors for A large percentage of these deaths occur among non-communicable diseases, and they are also older people in high-income countries. However, linked to depression and anxiety. Tobacco is an among people under the age of 70, a comparatively important factor in premature death among people larger proportion of deaths from non-communicable with mental disorders. diseases occur in low- and middle-income countries. Sub-Saharan Africa has the lowest average age of Air pollution is one of the three most important death from non-communicable diseases. Premature risk factors for premature death, and the biggest deaths caused by non-communicable diseases can single health-related environmental risk factor by be avoided through a systematic focus on prevention far. Today, 90 per cent of the world’s population measures. breathe air containing high levels of pollution, exceeding WHO’s air quality guidelines limits. A total For the sake of comparison, data (2017) for the total of 7 million people died prematurely as a result of number of deaths globally from the three biggest exposure to air quality that was harmful to health communicable diseases show the following (bearing in 2016, according to WHO. It is calculated that 4.2 in mind that deaths from the diseases listed largely million of these deaths were due to outdoor air occur in low- and middle-income countries): pollution, while indoor air pollution claimed 3.8 million lives1. About 600,000 children under fifteen • Tuberculosis – 1.6 million die because of such pollution annually, largely as • HIV/AIDS – 1 million a result of respiratory illnesses. This represents • Malaria – 0.6 million around 10 per cent of deaths among children in this age category. Air pollution crosses national borders. Non-communicable diseases also contribute to

1. It is estimated that a combination of indoor and outdoor pollution caused around 1 million of these deaths. 16 Foto: Shutterstock This means that improving air quality requires measures both within countries and through organised cooperation between countries that pollute each other. Greenhouse gas emissions often come from the same sources as the emissions that pollute the air, which means that efforts to improve air quality also generally help to limit climate change. The link between insufficient physical activity and disease is well documented. Morbidity and mortality caused by cardiovascular diseases, diabetes and a range of cancers are particularly linked to physical inactivity. Inactivity is also a risk factor for mental health, as people with mental disorders are often Unhealthy diet is an important risk factor for less physically active. A study of 1.9 million people non-communicable diseases. The significance of in 168 countries found that around 23 per cent of diet on the burden of non-communicable diseases all men and women are less physically active than has been systematically reviewed in 195 countries WHO’s recommendations on physical activity for for the period 1990-2017 in the Global Burden of adults, of at least 150 minutes per week. This is a Disease project (GBD)ix. The three leading nutritional bigger problem in high-income countries than in risk factors for mortality and disability-adjusted life low-income countries. There are major differences in years, both globally and in many countries, is high the activity levels of men and women around salt intake, low whole-wheat intake and low intake of the world. fruit and vegetables. Undernutrition has long been recognised as a major Foto: Abraham Thiga Mwaura/WHO problem among the poor. Children under five face a number of challenges. Globally, 15 per cent are born with a low birth weight, 22 per cent of children under five have stunted growth and 7 per cent are underweight. It is estimated that half of all infant mortality is due to undernutrition. Undernutrition also significantly contributes to poor physical, mental and social development. Children with stunted growth will, for example, be less resistant to infections and more likely to die from diarrhoea and non-communicable diseases such as respiratory diseases later in life. It is estimated that stunted growth among children reduces GDP per person by up to 11 per cent in Africa and up to 9 per cent in parts of Asia. Harmful use of alcohol caused around 3 million deaths around the world in 2016. Harmful use of Up to 2 billion people in the world are classified as alcohol causes significantly more deaths among men being overweight. The prevalence of overweight than among women. Just under half of the world’s and obesity in children is increasing around the population aged over 15 drink alcohol. Alcohol world, and it is estimated that 254 million children consumption is increasing globally, from 5.9 litres and young people aged from 5 to 19 will suffer of pure alcohol per person aged over 15 in 1990 to from obesity in 2030. Although this trend appears 6.5 litres per person in 2017. The percentage varies to be declining slightly in a number of high- between regions and is lower in African countries income countries, there is rapid growth in obesity and in the Middle East than in the rest of the world. prevalence in Asia and Africa. In 2018, around three This means that the international alcohol industry quarters of all overweight children aged under regards Africa as an important market for expanding five lived in Asia and Africa. The number of obese its business. Alcohol is also considered a risk factor children aged under five in Africa has increased by for a range of mental disorders. 44 per cent since 2000.

17 Non-communicable diseases in a geographical regions are large and increasing. The development perspective increase in the prevalence of non-communicable diseases has for years been highlighted as a major NCDs are both cause and consequence of poverty. threat to the economic development of low-income The jeopardy presented by NCDs is amplified by countries. The percentage of premature deaths poor education (SDG 4), gender inequalities (SDG 5), is high in these countries, and it is often the most economic dysfunction (SDG 8), urban degradation productive segment of the employable population (SDG 11), and unsustainable production and who die or end up with a reduced capacity to work. consumption (SDG 12). The costs linked to non-communicable diseases in (Richard Horton, The Lancet, May 2019) low- and middle-income countries are estimated to be USD 7 trillion over the next 15 years. Non-communicable diseases do not only cause death, reduce quality of life, and lead to premature The poorest countries have a double burden of death for the individual. They may also hit the disease. These countries face the largest population individual’s family hard in that an income is lost growth over the next 30 years. This will lead to a and the patient has to be cared for at home. They strong increase in demand for services relating can also be a barrier to a country’s economic to pregnancy, childbirth and postnatal care, and development. a greater need for measures to ensure the health and nutritional status of infants and children. At The goal of Universal Health Coverage is to ensure the same time, these countries face rapidly growing that everyone has access to essential health challenges from non-communicable diseases linked services, and that the use of health services does to increased exposure to risk factors as a result of, not generate financial difficulties for the population. among other things, rapid urbanisation. The poorest Very few countries have succeeded in implementing countries are also those with the weakest health Universal Health Coverage. Many people spend services, and they lack the health personnel required a large part of their household budget on paying to address these challenges. for health services, and are, as a result, forced into extreme poverty. This applies, not least, to people A positive correlation has been found between good suffering from non-communicable diseases, as these health and growth in GDP, where an increase in life diseases often have a chronic course requiring long- expectancy increases GDP. Priorities linked to the term and expensive treatment. funding of health systems and the choice of services can have a major impact on the cost efficiency of There is a broad link between low income, low health investments, and influence social inequality socio-economic status and non-communicable in a health perspective. Programmes intended diseases. People who live in poverty are most at risk to combat non-communicable diseases should of poor health due to non-communicable diseases, therefore focus on promoting equal access to and of dying from them. The disparities between services and measures to avoid social inequality.

18 Despite WHO making clear recommendations THE URBAN POOR – AN EXAMPLE on the measures that should be implemented, FROM RWANDA and calculations showing that many measures Urbanisation, with the subsequent changes are profitable, there is a consistently low level of it entails for lifestyle habits, is driving the implementation in many countries, including in low- development of non-communicable diseases, income countries. A number of potential challenges including in sub-Saharan Africa. Looking toward could explain why measures are not implemented, 2030, the urban poor may be the group most including the following: vulnerable to non-communicable diseases. Large numbers of the poor living in urban areas • Most countries have to address many important have limited access to organised markets, few health challenges. Measures to combat non- opportunities for physical activity and poor living communicable diseases often lose out in the battle conditions (a risk factor for exposure to for political attention and prioritisation. air pollution). • The public administration has limited capacity to incorporate the knowledge available, including This correlation was clearly observed in Rwanda WHO’s recommendations on measures to combat in 2015, where non-communicable diseases non-communicable diseases, into national accounted for 35 per cent of all deaths, 52 per regulations and legislation. cent of all out-patient consultations and 22 per • Robust health systems and a good knowledge cent of all hospital admissions. The majority of the base for policy development are important burden of non-communicable diseases in Rwanda preconditions for addressing the major challenges comprised congenital deformities, depression, that low-income countries face. In many instances, asthma, epilepsy, chronic obstructive pulmonary these preconditions are not in place. disease, diabetes and cervical cancer. While the • Not all countries have primary health care services burden of disease in high-income countries is that offer simple diagnosis and treatment of the driven by traditional risk factors, the burden most common non-communicable diseases. Many of non-communicable diseases in Rwanda is countries also lack systems for reliable access to strongly linked to malnutrition, infections and quality medication. environmental pollution. These risk factors are • The administrative procedures for shielding policy exacerbated by poverty and poor living conditions development from the unwanted influence of in the cities. The urban poor also have poor access commercial actors is limited. In the final instance, to health care services, including diagnosis and protecting policy processes against corruption treatment, and health campaigns do not and threats can also be challenging. Over time, reach them. the influence of external actors can lead to health authorities ceasing to propose measures that may provoke negative reactions.

Foto: © WHO GCM/NCD/Anna Wang 19 Foto: Shutterstock Priority focus areas The 2011 Political Declaration on the Prevention and Control of NCDs urged presidents and prime ministers to take chronic diseases much more seriously. Today, NCDs are embedded in the Sustainable Development Goals (SDG 3.4). Civil society mobilisation has benefited from a rejuvenated NCD Alliance. The knowledge base for policy action has never been better. Yet even those who led efforts to secure a Political Declaration admit that progress has been inadequate and disappointingly slow. Countries are struggling. There is little money available. Health systems are still too weak to deliver quality services. (Richard Horton, The Lancet, July 2017). Norway will help to prevent poor health and ii) Strengthening primary health care by improving premature deaths from non-communicable diseases prevention, diagnosis and treatment of certain in low-income countries, with particular attention non-communicable diseases; to the poor and vulnerable, by reducing leading risk iii) Strengthening global public goods. factors discussed in the previous chapters. Global leadership Through development cooperation, Norway will help to facilitate healthy lifestyle habits; with healthy food Norway will be at the forefront of global initiatives to that is produced sustainably; a healthy environment reduce non-communicable diseases and risk factors with clean air and clean energy; opportunities for in low-income countries. Cooperating with WHO is physical activity; access to quality education and a key element in this context, but Norway will also stronger tobacco and alcohol regulations. Emphasis endeavour to ensure that other relevant multilateral will be placed on social sustainability and reducing organisations intensify their efforts. health inequalities from childhood to old age, where equality and non-discrimination will be important Our support will be anchored in WHO-recommended factors. Norway will continue to be a driver in multi- measures for combating non-communicable lateral cooperation on non-communicable diseases diseases and risk factors. We will also support and in efforts to achieve Universal Health Coverage, international efforts to ensure Universal Health especially through WHO. Norway will also help Coverage. ensure that mental health becomes an integral part of the prevention and treatment services available. The Global Coordination Mechanism on the Prevention and Control of Noncommunicable Norway will help to focus more attention on non- diseases (GCM) was established by WHO’s communicable diseases in international development member countries in 2014. GCM is a platform and health policy. Encouraging other countries and facilitating cooperation across multiple actors and actors to join the field and make a common effort will sectors to help counteract the health threat from be important. The Norwegian initiative will also focus non-communicable diseases. In addition, a UN on the following three main areas: Interagency Task Force (IATF) has been established for non-communicable diseases, tasked with i) Reducing risk factors through concrete measures coordinating UN organisations’ efforts to reduce in various sectors to prevent disease and prema- premature deaths from NCDs. IATF has established ture death; a Catalytic Trust Fund that will coordinate funds

21 to implement the measures defined by WHO as the most cost-effective. Norway will consider THE GOVERNMENT WILL: cooperating with GCM and IATF since both are • Show global leadership and cooperate with important forums in this respect. relevant actors to ensure well-coordinated and consolidated efforts to achieve the objectives of There is no global agreement regulating air quality, combating non-communicable diseases. despite large numbers of people in most countries • Help to strengthen implementation of WHO’s being exposed to harmful air pollution. Europe is the Global Action Plan for the Prevention and Con- only region subject to legally binding conventions trol of Noncommunicable Diseases. on air pollution, including the Convention on Long- • Build capacity in the field in low-income range Transboundary Air Pollution of United Nations countries through WHO and other partners, Economic Commission for Europe (UNECE CLRTAP) including academic and administrative capacity and the EU directive on air quality. Norway has to plan and implement regulations and other spearheaded global efforts to improve air quality, measures linked to combating non-communi- and, among other things, led the initiative for a cable diseases. resolution on air pollution and health, which was • Work to support global commitments and adopted by the World Health Assembly in 2015x. The effective measures to prevent air quality that resolution urges member states to intensify their is harmful to health, in cooperation with WHO efforts to prevent the detrimental health impacts of and other relevant organisations, forums and air pollution. In 2017, the UN Environment Assembly countries. The goal will be to comply with WHO’s (UNEA 3) also adopted a resolution on reducing air guidelines on air quality and support regional pollution in order to improve air quality globallyxi. initiatives to establish cooperation on reducing transboundary air pollution. In connection with the follow-up of the • Through board representation, ensure that aforementioned resolutions and the First WHO relevant UN organisations and other multila- Global Conference on Air Pollution and Health teral organisations participate in global efforts in 2018, we will endeavour to strengthen global to combat non-communicable diseases. commitments and effective measures to prevent air quality that is harmful to health, in cooperation with WHO, and other relevant organisations and forums. The goal should be to comply with WHO’s guidelines on air quality. In September 2019, Norway endorsed WHO’s Foto: © WHO GCM/NCD/Anna Wang initiative to improve air quality by 2030, in line with WHO guidelines. The initiative also highlights the links between climate and air pollution, and possibilities for implementing win-win measures to address both. Norway will endeavour to ensure that more countries join the initiative. 22 Preventing and reducing risks 90 per cent of the world’s population is exposed to polluted air, and around one-half to unsafe The unsolved paradox is that policies that would drinking water and poor sanitary conditions. Climate produce the greatest health impact receive the least change leads to drought, floods and heatwaves, attention. Why? Here is the alarming truth: our which increase the burden of disease. Exposure to economies are incentivised to earn vast private wealth environmental toxins and other chemicals that are by increasing public risks for NCDs. Until that truth is harmful to health and the environment through accepted and addressed, NCDs will remain part of an the sale of unhealthy or unsafe products, and unchecked planetary emergency. inadequate handling of related pollution and waste (Richard Horton, The Lancet, May 2019) constantly present new health-related challenges. Action is required across sectors to combat Non-communicable diseases represent a long-term environmental problems, i.e. energy, transport, challenge for national health systems. Prevention agriculture, infrastructure, urban planning, the is important in order to reduce pressure on health working environment and health. services. A great deal can be achieved through regulation, taxation and multi-sectoral measures. Antimicrobial resistance (AMR) is another growing It is important that focus be placed on addressing health threat that may have a major negative impact NCD risk factors early in life. Helping to achieve on the treatment of non-communicable diseases, a good, safe environment and healthy lifestyle such as certain forms of cancer. WHO’s Global Action habits for children and young people will generate Plan on AMRxii was adopted in 2015. Its goal is to significant health benefits for a society for decades ensure that infections and diseases can be prevented to come. Measures at population level, i.e. measures and treated by effective and safe medication, that benefit everyone and not just certain groups; available to everyone who needs them for as long as that focus on risk factors; and that improve the possible. environment in which children and young people grow up and their lifestyle habits, will therefore be Commercial health determinants are policies, the most effective means of reducing the burden of regulations or economic drivers that may influence non-communicable diseases. our decisions about factors such as food choices or the use of stimulants. The effective prevention A country’s health policy must be based on factors of non-communicable diseases often runs against that affect health (health determinants). Examples strong commercial interests. Producing and selling of such social and economic determinants of alcohol, tobacco, and unhealthy food and drinks are health include: access to education; decent work; huge industries in which supply and demand are and community health services. Examples of increasing, particularly in low- and middle-income environmental determinants, include features such countries. Trade and international investment as the quality of the local environment, including agreements can affect a country’s ability to regulate clean air, absence of noise; and access to mobility, such commercial health determinants. Trade can including walking and cycling paths. produce economic and social benefits, particularly for low-income countries. However, trade can also Addressing social and environmental risks to contribute to increasing consumption of tobacco health can also reduce risk factors that stimulate and other products that increase prevalence of non- mental disorders, as well as associated stigma and communicable diseases. Countries face challenges discrimination. Good health is not only produced by then, in encouraging trade and investments, while investing in the health sector. Rather, the prevention safeguarding public health. of non-communicable diseases requires intersectoral efforts. Addressing such social and environmental Regulation and taxation are important instruments risks to health can also help reduce risk factors that for limiting access to and consumption of products stimulate mental disorders, and associated stigma that are harmful to health. In most cases, these and discrimination. instruments have proven to be very effective, leading to a decline in demand. The introduction WHO concludes that altogether, environmental of such instruments has been met with resistance health risks lead to 13 million deaths per year, which from commercial actors with a strong interest in is around a quarter of all deaths worldwide. Around maintaining their market shares.

23 Foto: Shutterstock The WHO-led initiative SAFER was launched in 2018, which helps countries to reduce harmful use of alcohol and related health, social and economic consequences. SAFER includes strategies intended to limit the availability of alcohol; promote measures to prevent driving under the influence of alcohol; provide better access to screening and treatment; uphold prohibitions and restrictions in alcohol advertising and increase the price of alcohol through taxation policy. WHO is also in the process of reviewing the member states’ status with regard to their implementation of the strategy to reduce the harmful use of alcohol from 2010xiii. The Measures targeting tobacco and alcohol status report and the proposed road ahead will be The WHO Framework Convention on Tobacco discussed at the World Health Assembly in 2020. Control (FCTC) entered into force in 2005, and there are presently 181 parties to the convention. It is the Also see the discussion of tax on, among other first legally binding convention negotiated under things, tobacco and alcohol. the auspices of WHO aimed at reducing morbidity and mortality. The provisions of the convention address the need for international standards and THE GOVERNMENT WILL: guidelines for tobacco control in a number of areas, • Help to strengthen implementation of WHO’s including the prices of and tax on tobacco; tobacco Framework Convention on Tobacco Control sales to minors; tobacco advertising and sponsoring; (FCTC)ii, i­n low-income countries, in particular smuggling and passive smoking. The convention is the implementation of the provisions on the unique as it is the first and only international legal use of health-related tobacco taxes. agreement regulating the use and marketing of a • Support the SAFER initiative on alcohol controliii, legal product. which helps countries to reduce harmful use of alcohol and related health, social and Norway has been an active driving force and economic consequences. supporter of the FCTC since the start, supporting its work through meetings of the parties and via the programme cooperation agreement with Healthy diet and physical activity WHO. Norway has channelled funding to the FCTC We must get the world moving. Increasing physical 2030 project in 2019, which aims to accelerate the activity is not an issue that can be solved solely by implementation of tobacco control in low- and the education sector, or the transport sector: actions middle-income countries. The following countries are needed by all sectors. Our job is to create a world are so far parties to the FCTC 2030 project: Cape that will help our children to be active and make cities Verde, Cambodia, Chad, Colombia, Egypt, El easier for people to walk and cycle. (Tedros Adhanom Salvador, Georgia, Jordan, Madagascar, Myanmar, Ghebreyesus, Director-General of WHO) Nepal, Samoa, Sierra Leone, Sri Lanka and Zambia. Undernutrition in childhood increases the risk Further efforts are still needed to support of obesity and chronic nutrition-related diseases implementation of tobacco control measures in later in life. This has a major impact on society. It low-income countries. Article 5.3 is an important is important to have a lifecycle perspective with provision in the convention, which obliges the respect to nutrition and health. A large number parties to ensure that the tobacco industry does not of people cannot afford to meet their family’s influence tobacco policy design. The provision forms minimum requirement for food, and more and more the basis for the full implementation of the other people have greater access to cheap, industrially- provisions in the convention. The methods used by processed, unhealthy food. This has led to the the tobacco industry to delay, dilute and prevent scope of undernutrition and malnutrition becoming the introduction of effective tobacco measures have unacceptably high. been well documented.

24 There is a period of 1,000 days, beginning at conception to about two years of age, when THE GOVERNMENT WILL: nutrition is critical to ensuring the cognitive and • Strengthen efforts to ensure healthy nutrition physical development of the developing foetus and in line with WHO’s advice on healthy dietiv, newborn child. Measures to improve the nutrition including reducing salt, sugar, saturated fats of mothers before and during pregnancy; promote and trans fats. Promote breast-feeding and breastfeeding; and reduce overweight and obesity in measures to improve mothers’ nutrition before young children will thus lead to healthy growth and and during pregnancy, to ensure healthy growth lifelong health benefits. Measures to educate and and lifelong health benefits. This must be seen disseminate information about healthy diets and in conjunction with the action plan on sustai- lifestyles to young people are also important. When nable food systems in Norwegian foreign and young people acquire knowledge about health, development policyxiv, where the main goal is to diet and physical activity, they are more likely to increase food security. The plan contains a improve their families’ nutrition and diet. Regulating dedicated nutrition programme. the marketing of unhealthy foods and beverages, • Work to improve children and young people’s including tax policies that raise prices, will also be an knowledge of health, diet and physical activity, important means of enabling children, young people and ensure good access to healthy food and and adults to make good dietary choices. activity at school, in cooperation with relevant multilateral actors. Norway’s efforts in this area will be carried out in conjunction with the Government’s action plan on sustainable food systems in Norwegian foreign and Foto: © WHO GCM/NCD/Anna Wang development policyxiv, which was launched in 2019. The main goal of the action plan is to increase food security, which includes better nutrition. The plan also includes a dedicated nutrition programme, which addresses the direct and underlying causes of malnutrition. This includes, among other things, support to health care professionals for awareness- raising; provision of guidance with regards to maternal and early childhood nutrition and health; as well as measures to improve the nutrition of school children, young people and adults. With respect to physical activity, global data indicate that 23 per cent of all adults and 81 per cent of young people are not active enough, with reference Improving indoor and outdoor air quality to WHO’s recommendations on physical activity. Air pollution kills 7 million people a year and can WHO has developed the toolkit ACTIVE, which be characterised as a global health crisis. Norway comprises measures that aim to help more people has been a driving force in the international work become active every day, through; active societies on reducing air pollution for some time, in close (campaigns to promote active lifestyles); active cooperation with: the World Health Organization environments (infrastructure that promotes cycling, (WHO), the World Bank and the Climate and Clean walking etc.); active people (engaging people of all Air Coalition (CCAC), among others. The CCAC, in ages in regular physical activity); and active systems turn, is a coalition comprising 67 countries, 57 civil (strengthening leadership, governance, partnerships society organisations and 18 intergovernmental etc. to support policy implementation that increases organisations, including WHO, the World Bank, the activity). UN Development Programme, the UN Environment Programme and the UN Food and Agriculture Organization. Norway has also led regional work on air pollution, under the auspices of the United Nations Economic Commission for Europe’s Convention on Long-range Transboundary Air Pollution.

25 Norway’s support of WHO’s air quality activities has Norway’s efforts supporting cleaner household formed an important element of Norway’s efforts in energy solutions can be further enhanced through the area of non-communicable diseases to date. This this initiative. It will be important to ensure that all has resulted in air pollution climbing to the top of clean cooking programmes and activities supported the international political agenda. WHO also has an by aid funds from Norway comply with WHO’s important normative function, and Norwegian funds guidelines on indoor air quality. have been used, among other things, to develop WHO Air Quality Guidelines, which specify levels of pollutants that are harmful to health. Today, THE GOVERNMENT WILL: more than 90 per cent of the world’s inhabitants • Intensify efforts to reduce air pollution. breathe air that contains pollution above the WHO- Cooperation with WHO will continue to recommended levels. be important, as well as other multilateral organisations such as the UN Environment Norway has also contributed to the initiation, Programme, the World Bank, the Climate foundation and continued operation of the and Clean Air Coalition, the Clean Cooking BreatheLife campaignv (breathelife2030.org), which Alliance, the UNECE Convention on Long- mobilises national and local authorities to implement range Transboundary Air Pollution and the measures that provide cleaner air in line with International Centre for Integrated Mountain WHO’s Air Quality Guidelines as well as reducing Development (ICIMOD). The overriding goal climate emissions. The campaign is led by WHO, will be to comply with WHO Air Quality the UN Environment Programme, the World Bank Guidelines. The first goal is to reduce the and the Climate and Clean Air Coalition. Today, 63 number of deaths by two-thirds by 2030, in countries, regions and cities, home to 271 million line with the Geneva Action Plan for Clean Air, people, are members of the campaign, including which was presented at the First WHO Global cities in developed countries, such as: Oslo, Paris, Conference on Air Pollution and Health in 2018. London and Washington DC and cities in developing • Help ensure that more countries and cities countries such as: Accra, Ghana; Kathmandu, Nepal participate in the BreatheLife campaignv with and Bangalore, India. Another one of the campaign’s the goal of improving air quality in line with goals is to mobilize the health sector, in particular, to WHO’s recommendations. contribute to the battle for clean air. • Promote pollution-free cooking through the initiative ‘Renewable energy in Norwegian With regards to household air quality, more than development policy’. three billion people in the world still cook over an open flame or use polluting cookstoves. Consequent indoor air pollution, particularly affects the health Taxes on products and pollution that harm health of women and children who spend the most time If we want to improve global health, we have to tax around the stove. WHO has published guidelines things that are killing us. (Lawrence H. Summers, for indoor air quality, These guidelines set targets Co-chair, Bloomberg Task Force on Fiscal Policy for for emissions of pollutants from cookstoves, as Health) well as making recommendations against the use of unprocessed coal or kerosene as household Tobacco, harmful use of alcohol, consumption of fuels. The guidelines also recommend shifting to unhealthy food and drinks and air pollution have cleaner fuels, such as LPG, electricity and ethanol, as health impacts that impose a high cost on society. alternatives to the use of coal, charcoal and the use The greatest increase in mortality as a result of of unimproved biomass stoves. It will be important these risk factors is found in low- and middle-income to ensure that the guidelines are implemented, countries. The Bloomberg reportxv on taxes on and Norway can contribute to this goal through its tobacco, alcohol and sugary beverages was launched cooperation with WHO and other organizations. in April 2019. One of its main conclusions was that up to 50 million lives could be saved over 50 years if 50 The initiative ‘Renewable energy in Norwegian per cent higher excise taxes were levied on tobacco, development policy’ has also supported a number of alcohol and sugary beverages across the world. Such market-based solutions and models for expanding taxes have been demonstrated to have the greatest the use of cleaner and more effective cookstoves. health benefits for young people and the poor.

26 Excise taxes currently constitute a very modest source of public income in most low- and middle- THE GOVERNMENT WILL: income countries. The possibilities generated by • Support the work on taxation and regulation effective excise taxes, both with respect to reducing of products that are harmful to health such as consumption and generating more income, suggest tobacco and alcohol, and on emissions of air that more countries will request assistance in this pollutants in low- and middle-income countries. area over time. It should be noted here that The • Assist countries that request assistance to tax Framework Convention on Tobacco Control includes products that are harmful to health as well a commitment to take health considerations into as emissions of air pollutants. Work through account when implementing tobacco price and tax the Norwegian Tax for Development (Skatt for measures. utvikling) programme will be important in this context. Examples from countries that have introduced taxes show good results. Brazil increased the price of tobacco by more than 30 per cent between 2012 and 2016, which led to a 50 per cent reduction in Foto: Freepik tobacco consumption. Mexico introduced a tax on sugary beverages in 2014, which led to a price hike of around 10 per cent. The tax led to a reduction in consumption, and generated USD 1 billion in revenue for the state. According to the World Bank’s calculations, the world can only achieve the SDG goal of reducing premature deaths from non-communicable diseases by one-third by 2030 through investments in multi- sectoral measures. This needs to include higher taxes on, and more regulation of tobacco and emissions that cause air pollution, among other Strengthening health systems – with things, as well as the elimination of subsidies on emphasis on primary health care fossil fuels. The action plan from the third Funding for Development conference in Addis Ababa in 2015 Norwegian development cooperation in the field of highlighted countries’ responsibility to fund public health has traditionally emphasised services aimed services, through taxation, among other things. at preventing and treating communicable diseases; services linked to reproductive health and child The Norwegian ‘Tax for Development’ Skatt for health; and diseases linked to malnutrition. Less utvikling programme is linked to the funding of the emphasis has been placed on the health sector’s SDGs and pledged to double Norwegian taxation- role in promoting good health throughout the related aid from 2015 to 2020. The Norwegian life course and on preventing and treating non- Tax Administration has an agreement with the communicable diseases. Norwegian Agency for Development Cooperation (Norad) on the provision of relevant guidance and With regards to the SDGs, Target 3.8 sets forth the capacity building to the public sector in low-income goal of achieving Universal Health Coverage by 2030, countries requesting assistance. including protection from financial risk in connection with treatment, access to basic health services and The Knowledge Bank in Norad was established to access to safe and effective medication and vaccines. coordinate and strengthen technical cooperation The goal of Universal Health Coverage is also a in areas where Norway has special expertise and cornerstone of WHO’s general programme of work sought-after experience. Tax for Development is for the period 2019–2023, and the Director-General organised under the Knowledge Bank and can be of WHO has made it one of the agency’s flagship used as a channel for capacity-building in excise priorities. taxes that can have a positive effect on public health.

27 Universal Health Coverage Universal Health Coverage, based on strengthening Universal Health Coverage requires countries to primary health care services. Among other things, develop their primary health care services. While this is expressed through Norway’s support for many countries currently offer health services WHO’s Universal Health Coverage programmes and through a centralised hospital structure that is activities, as well as its involvement in the UN High primarily only available to a small percentage of the Level Meeting on UHC in September 2019. population with the ability to pay, Universal Health Coverage is achieved by ensuring that primary It is also important to ensure coherence between health care services are available to everyone, the aims and activities all of the global health including in rural areas. Access to health services organizations that Norway supports. The Global must be based on public co-funding, so that no one Action Plan for Healthy Lives and Well-being for All, is forced into poverty because of the high cost of initiated by the heads of state of Ghana, Norway and treatment. Germany, launched in September 2019, constitutes a cooperation platform for the global health The effective introduction of Universal Health organisations to help achieve the health-related Coverage requires national ownership and SDGs, including Target 3.8 on Universal Health funding. It is not the aid provider’s task to finance Coverage. the operation of a country’s health services. The countries must start by prioritising the services that will benefit most people, and further develop the THE GOVERNMENT WILL: services in a sustainable manner within national • Support WHO’s work on SDG Target 3.8 on funding frameworks. Universal Health Coverage, and draw attention to primary health care as being the best way WHO has an important role to play, both with a country can provide health services to its respect to providing guidance to countries in entire population, irrespective of income level, connection with establishing a good public health including the poorest and most system, and helping countries to deliver these vulnerable groups. services. To be capable of delivering such services, • Through board representation and budget many countries will have to strengthen the legal, allocations, ensure that organisations such as financial, administrative and management aspects the Global Fund to Fight AIDS, Tuberculosis of their health system; increase the number of and Malaria (GFATM) and GAVI, The Vaccine health workers delivering services; and undertake Alliance contribute to the work on Universal measures that increase access to medicines. Health Coverage through their involvement in low-income countries, and thus help combat Universal Health Coverage, as it is framed by Target non-communicable diseases. 3.8 of the SDGs, is the best tool for protecting • Ensure the inclusion of the most profitable particularly vulnerable and weak groups. A health measures to combat non-communicable system based on Universal Health Coverage will diseases in primary health care services, give weak and vulnerable groups access to a with emphasis on prevention, diagnosis well-considered and comprehensive set of basic and treatment of the most common non- health services including: diagnosis, treatment and communicable diseases, and reducing NCD follow-up as well as access to medication, vaccines, risk factors. antibiotics and health checks.

Universal Health Coverage is the most cost-effective Mental health way of securing services for everyone, and thereby People with mental disorders often experience of meeting the important goal of Agenda 2030 and exclusion and degrading treatment. Many Norwegian development policy to leave no one countries have inadequate legislation to safeguard behind. Universal Health Coverage should also the rights of people with mental disorders. It is ensure that people with mental disorders can access estimated that around 80 per cent of people in treatment without stigmatization. low- and middle-income countries who have a serious mental disorder do not receive adequate Norway should continue to reiterate its political treatment. The figure is around 40 per cent for and technical support for the goal of achieving high-income countries. As a result of stigmatization 28 and discrimination, the rights of people with mental disorders are often violated. Many people THE GOVERNMENT WILL: experience restrictions in connection with the right • Support efforts within the mental health field, to work, education, reproductive rights and the including helping to implement the measures in broader right to good health. WHO’s Mental Health Action Planvi. Cooperation with WHO, authorities and national and local The World Health Organization has adopted a civil society organisations will be important in Mental Health Action Plan for 2013-2020vi. The plan this context. Integrating mental health in other has now been extended to 2030. The plan concludes priority areas such as early childhood education, that mental health is an integral part of the concept and collecting data on mental health will also of health on which WHO is based: Health is a state of be important elements in this work, cf. the complete physical, mental and social well-being and not Government’s White Paper on digitalisation in merely the absence of disease or infirmity. development policy. • Contribute to ensuring that the work on risk The plan has four goals that all countries must factors and treatment in the primary health make efforts to achieve. These aim to strengthen care services includes both mental and physical leadership and governance in mental health; to health, and that mental health is adequately ensure that primary health care services include integrated. mental health and social services in a holistic and integral manner; to implement strategies to promote good mental health; to prevent mental disorders Preventing cervical cancer from early childhood; and to strengthen information Certain types of non-communicable diseases are systems, knowledge and research in mental health. associated with infection. One of these is cervical WHO supports member state implementation of the cancer, which is linked to human papillomavirus action plan; WHO has developed a range of tools in (HPV). This type of cancer is very common in the field and offers training to individual countries. low-income countries and is thus relevant to this strategy. More than 250,000 women die of cervical In Norway, a number of expert institutions and cancer every year, and 85 per cent of these deaths civil society groups have long experience in the take place in the least developed countries. The development of mental health services in low- number of deaths is expected to rise by 50 per cent income countries. Although, mental health has by 2030. not always had a well-defined place in Norwegian global health initiatives, in 2014 Norad sought to WHO’s goal is to eliminate cervical cancer as a public address the gap with a report on mental health health problem, and it will present a strategy on in international aid and development policy. The this to the World Health Assembly in 2020. This goal report highlights opportunities to address mental can only be achieved through a combination of HPV health in the human rights context, as well as vaccinations, screening and cancer treatment. One combat stigmatization, as potential areas of focus. of the strategy’s goals is for 90 per cent of all girls Integrating programmes on mental health into under 13 to be vaccinated with the HPV vaccine; Universal Health Coverage can serve the multiple 70 per cent of women between the ages of 35 and purposes of combating stigma; strengthening 45 to be screened; and 90 per cent of all women human rights; and strengthening health systems. diagnosed with cervical cancer to receive cancer treatment. Norad also has a funding scheme for organisations and projects that focus on people with disabilities, Norway has made major investments in GAVI, The which also covers work on mental disorders. Vaccine Alliance, contributing to around 10 per cent of GAVIs total budget. To date, GAVI has helped to introduce the HPV vaccine in six countries and vaccinated 1.5 million girls. The HPV vaccination programme is in the process of being expanded, and now aims to vaccinate 30 million girls between the ages of 9 and 14 by 2020. This could prevent up to 1 million deaths in the long term.

29 Global public goods THE GOVERNMENT WILL: • Support WHO’s plan to eliminate cervical Global public goods include normative work; access cancer as a public health problem. to health data and health information; digitalisation • Support HPV vaccination and screening and research on reducing risk factors; primary programmes to prevent cervical cancer health care services and introduction of functions; through WHO and GAVI. product development and market changes linked to non-communicable diseases. Normative work Foto: © WHO/M.VillaMonge WHO is a key actor in work that aims to achieve the SDG Target 3.4 of reducing premature deaths from non-communicable diseases by one-third by 2030. WHO is the UN’s normative body on health and a key partner for Norway and all countries that prioritise global health challenges. The organisation’s remit is to contribute to better health for all and to be the leading coordinating body for international health cooperation. To these ends, WHO sets global guidelines; helps member states develop national health policies and norms in line with these guidelines; and provides technical support to countries for their implementation. Preventing and treating high blood pressure WHO has developed guidance on measures to Cardiovascular diseases are among the non- prevent and control non-communicable diseases, communicable diseases that cause the biggest and is engaged in supporting the implementation burden of disease and premature death. One of of such measures in member states to prevent and the most important risk factors for cardiovascular treat non-communicable diseases. disease is hypertension, or high blood pressure. According to WHO, more than 1 billion people suffer To intensify efforts to achieve the health-related from untreated high blood pressure. This is linked to SDGs, Ghana, Norway and Germany took the a high dietary intake of salt among other things. initiative in 2018 to prepare a Global Action Plan It is therefore important to reduce the salt content for Healthy Lives and Well-being for All for the main in food. global health actors. WHO is leading this work, with the support of eleven other UN and multilateral In order to expand treatment options for high blood organisations and the UN Secretary-General. pressure, primary health care services in low-income The plan was launched in September 2019 at the countries must be reformed and strengthened. UN General Assembly. The plan is playing a key Ensuring universal access to hypertension diagnosis, role in leveraging a broad approach to achieving guidance, follow-up and treatment services is a key SDG Target 3.8 on Universal Health Coverage. factor in this context. A number of global health It is important to ensure that combating non- initiatives have focused on implementation of such communicable diseases is included in further programmes. There are also epidemiological and follow-up. economic arguments for expanding access to the prevention and treatment of diabetes.

THE GOVERNMENT WILL: • Help ensure that diagnosis and simple treatment for high blood pressure form part of primary health care. 30 THE GOVERNMENT WILL: THE GOVERNMENT WILL: • Continue its support of WHO’s normative work • Intensify efforts in digital health as part of the in this area, including implementing the Global implementation of the White Paper on digital Action Plan for the Prevention and Control of transformation and development policyvii. We Noncommunicable Diseases. will continue to help improve the quality of • Strengthen WHO’s work on including preventive health data and health data registers at country and health promotion work to reduce the level, and develop digital health information prevalence of non-communicable diseases as systems in low-income countries, in cooperation part of the Global Action Plan for achieving with partners including the University of Oslo the health-related SDGs (Global Action Plan for and the Norwegian Institute of Public Health. Healthy Lives and Well-being for All). • Increase collection of data on mental health, by, among other things, mapping prevalence and problems to ensure expedient measures. Health information, digitalisation and research • Contribute to the global knowledge base on Understanding the salient health challenges and combating non-communicable diseases through whether health care services improve health is relevant research programmes and institutions. important for determining priorities and making • Improve knowledge about the impact of air decisions on how scarce resources are to be pollution and climate change on health. deployed. Without good health data, managing health care services sensibly is demanding. Without open access to health data, public debate will not be based on facts. Without the capacity to analyse and Other areas use data, health data will not be used expediently to stimulate effective prioritisation and management. Health initiatives in humanitarian efforts Norway’s expertise in health information and The treatment of non-communicable diseases digital health is widely recognised, and Norway creates special challenges in humanitarian crises, has supported work in these areas for several where health care services are undermined and years. Norway plans to intensify its focus on digital access to treatment is impeded. However, in light health in connection with the Government’s White of the overall increase in NCDs, humanitarian and Paper on digital transformation and development emergency response actors must be prepared to policy. This may include providing support for the respond. implementation of WHO’s own digital strategy. Norway’s humanitarian strategy (2019-2023) states Disseminating health and nutritional information that ‘support for lifesaving basic health services is via mobile phones will make it possible to increase an important element of Norway’s humanitarian people’s knowledge and change their attitudes and efforts’, and that ‘Norway’s humanitarian and behaviour. Sending targeted and engaging content development efforts have many of the same via text messages, sound and/or video files may priorities, such as (…) prevention of pandemics and positively affect health behaviour linked to choosing non-communicable diseases’. The strategy also healthy food, physical activity and using health care includes efforts to make humanitarian operations services. Apps also make it possible to prevent and more environmentally friendly. monitor diseases at the individual level. Ensuring continuity in treatment of non- Norwegian health aid shall be as knowledge- communicable diseases should therefore be based as possible. This means, among other a priority, including for people suffering from things, that the measures must be documented conditions such as diabetes, asthma and rheumatic as being effective, so that they work as intended, conditions. Steps should be taken to facilitate including under different conditions. The measures breastfeeding in crisis situations, e.g. through recommended by WHO will form an important establishment of safe spaces in refugee camps. basis for the strategy. Research on combating non- communicable diseases in partner countries will Most refugee camps currently use diesel or heavy enable Norway to contribute to the development of oil generators, which are very polluting and new knowledge that benefits public health.

31 expensive. Norway already supports actors working on ensuring access to more efficient and clean THE GOVERNMENT WILL: cookstoves and fuel in certain refugee camps. It is • Work to improve access to medical equipment also important that the food rations distributed in and medication in areas hit by crises and the camps are healthy and nutritious and do not conflict to prevent/treat non-communicable contain empty calories. diseases. Ensure healthy and nutritious food rations and facilitate breastfeeding in refugee Education camps (safe spaces). Educating young people about health and risk • Intensify efforts to facilitate clean cooking in factors is an important means of increasing their refugee camps. knowledge and making them better equipped • Intensify efforts to prevent non-communicable to make good decisions about their own health. diseases in a lifecycle perspective through Norway will work to ensure that curricula relating to existing programmes and activities under the health impacts of smoking, alcohol, unhealthy Norway’s education initiative in development diets, air pollution and a low level of physical activity policy, including through promotion of are included in educational programmes in partner school health services as platforms for early countries, as well as to promote school health prevention. services as a platform for early prevention. • Support WHO’s work on preventing disabilities in people with diabetes. This will form part of the initiative focusing on people with disabilities. 32 Foto: Getty Images 33 Foto: Shutterstock Implementation of the strategy Many of the people who will die from a heart attack, stroke or cancer in 2030 are today’s young and middle-aged adults. They are starting their journey towards an untimely death now, unless bolder measures are taken across governments and involving the whole of society (WHO Independent High-Level Commission on NCDs). Development aid funds Today, Norwegian health-related development aid Improved coordination of NCD efforts that may be primarily goes to combating communicable diseases; scattered across existing platforms and initiatives to mother and child health; and to initiatives on will also be important. There is unused potential for sexual and reproductive health and rights. Just integrating measures combating non-communicable over 1 per cent of current health aid is allocated diseases into the global health programmes initiatives that focus on reducing the prevalence that Norway already supports. We should, for of non-communicable diseases. It is Norway’s example, encourage the Global Financing Facility ambition to play a leading role in combating non- (GFF) to increase its support for initiatives on communicable diseases in low-income countries non-communicable diseases that affect their core through development cooperation. This will require groups. Furthermore, some of the funding allocated an increase in the allocations to this field from the to GAVI, The Vaccine Alliance and the Global Fund aid budget, in line with the priority focus areas in goes to strengthening health care systems with this strategy. In addition, allocations to other related emphasis on primary health care services, and this areas may contribute to achieving the goals of the support can also support integrated service delivery strategy (education; food security and nutrition; to prevent non-communicable diseases. climate change; environment and clean energy; people with disabilities; humanitarian efforts). Finally, Norway has advocated intensifying efforts and improving coordination among the The implementation of the strategy requires funding organisations that work in the health field through for normative work, for capacity-building and for the the Global Action Plan for Healthy Lives and Well-being implementation of global action plans and strategies, for All, and whose goal is to more effectively achieve primarily through WHO as a global leader in the the health-related SDGs. This should be followed field. Funds may also go to other key multilateral up to ensure that these efforts also contribute to organisations and partners that are active in the combating non-communicable diseases. priority focus areas in order to achieve the strategy’s goals. Efforts in partner countries through Norway’s foreign service missions as well as civil society may also be supported.

35 Political efforts Potential channels and partners Several of the tasks in the strategy will require The main channel for Norwegian aid to combat non- efforts at the political level. The World Health communicable diseases in low-income countries Assembly is a key arena in which Norway will will be multilateral organisations. WHO will be an continue to advocate intensifying the global important partner, both because WHO’s knowledge commitment to combating non-communicable and recommendations on effective measures diseases. The strategy also sets out more specific will form the basis for the initiative, and because initiatives in which political and diplomatic efforts through its regional and country offices, WHO will be vital. They will be important, for example, in is already actively engaged in assisting member efforts to achieve global commitments and effective states. The Global Coordination Mechanism on measures to prevent harmful air quality. the Prevention and Control of Noncommunicable Diseases (GCM) will be an important platform, in Efforts to combat non-communicable diseases order to enhance the coordination of activities at should also be included in negotiations in national, regional and global level. It will also be different areas and incorporated into existing necessary to strengthen cooperation with other and forthcoming political documents, including multilateral organisations and conventions. relevant white papers (e,g, the White Paper on digital transformation and development policy); Norway will strengthen its cooperation with non- strategies (strategy on renewable energy in state actors in the field, especially civil society developing countries); action plans (action plan on organisations in low-income countries, but also sustainable food systems); and other programmes with Norwegian and international civil society and focus areas (Tax for Development, climate organisations. Civil society already is a driving change adaptation, vulnerable groups, people with force in combating non-communicable diseases disabilities). and implementing international commitments. Cooperation with philanthropic foundations may Other important organisations in the field of also make an important contribution to the global development should be encouraged to intensify work on non-communicable diseases. their efforts in relation to non-communicable diseases as relevant. We should advocate that A cautious approach must be taken to involving organisations such as the UN Development commercial actors, particularly those who may Programme (UNDP), the World Bank, the UN produce products and foodstuffs harmful to health. Children’s Fund (UNICEF), the UN Food and Experience shows that conflicts of interest can Agriculture Organization (FAO), the UN Environment quickly arise, and that it is difficult to get the private Programme (UNEP), the UN Educational, sector on board to help achieve public health policy Scientific and Cultural Organization (UNESCO), goals. This may be a particular problem in low- the World Trade Organization (WTO) and the UN income countries where market regulation is poor Conference on Trade and Development (UNCTAD) and commercial actors wield significant political strengthen their efforts in the field to contribute to power. development, avert poverty and achieve the SDGs that are fundamental to their work. The Framework of Engagement with Non-State Actorsxvi, will form the basis for all measures and projects involving WHO. Other global health actors and civil society may have their own rules for engaging with the private sector.

Norway will in no event support measures or projects that directly involve actors from the private sector in work on national policy design. 36 The private sector can nonetheless play a constructive role in the work on implementing policies already adopted. The 2018 UN Political Declaration of the High-Level Meeting on non- communicable diseases invites the private sector to increase the contribution it makes to implementing national measures to prevent, control and treat non-communicable diseases. This could include contributing to a safe and healthy working environment, and the cessation of advertising and sale of alcohol to minors. Another area mentioned is that children should not be exposed to advertising of food with a high content of salt, sugar, trans fat and saturated fat, and that information about nutrients in food must be provided in accordance with international guidelines. Follow-up A results framework will be prepared in 2020 containing an overview of the goals for the different focus areas. The plan is to review the status of the Strategy, with emphasis on goal attainment, midway and towards the end of the strategy period (2024). 37 References i. WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases, 2013–2020. https://apps.who.int/iris/bitstream/handle/10665/94384/9789241506236_eng.pdf?sequence=1 ii. WHO Framework Convention on Tobacco Control (FCTC): https://www.who.int/fctc/en/ iii. SAFER – WHO’s initiative on alcohol control: https://www.who.int/substance_abuse/safer/en/ iv. WHO Fact sheet on healthy diet: https://www.who.int/news-room/fact-sheets/detail/healthy-diet v. The BreatheLife campaign on air pollution, led by the Climate and Clean Air Coalition, WHO, the UN Environment Programme and the World Bank: www.BreatheLife2030.com vi. Mental Health Action Plan 2013-2020. World Health Organization: https://www.who.int/mental_health/action_plan_2013/en/ vii. White Paper on Digital Transformation and Norwegian Development Policy. https://www.regjeringen.no/en/dokumenter/meldst11_summary/id2699502/ viii. World Health Statistics 2018: Monitoring Health for the SDGs. World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/272596/9789241565585-eng.pdf?ua=1 ix. The Global Burden of Disease Study 2018. The Lancet. https://www.thelancet.com/gbd x. Health and the environment: addressing the health impact of air pollution, World Health Assembly 2015. https://www.who.int/airpollution/ambient/policy-governance/en/ xi. UN Environment Assembly (UNEA) resolution 3/8. Preventing and reducing air pollution to improve air quality globally. https://www.ccacoalition.org/en/resources/preventing-and-reducing-air-pollution-improve-air-quality-globally-resolution-adopted-2017 xii. WHO AMR Global Action Plan on Antimicrobial Resistance, 2015. https://www.who.int/antimicrobial-resistance/publications/global-action-plan/en/ xiii. WHO’s Global Strategy to Reduce the Harmful Use of Alcohol. https://www.who.int/substance_abuse/activities/globalstrategy/en/index1.html xiv. Food, People and the Environment. The Government’s action plan on sustainable food systems in the context of Norwegian foreign and development policy https://www.regjeringen.no/en/dokumenter/sustainablefood_actionplan/id2661208/ xv. Task Force on Fiscal Policy for Health (2019). Health Taxes to Save Lives: Employing Effective Excise Taxes on Tobacco, Alcohol, and Sugary Beverages. Bloomberg Philanthropies. https://www.bloomberg.org/program/public-health/who-global-ambassador/task-force-fiscal-policy-health/ xvi. WHO Framework of Engagement with Non-State Actors (FENSA), resolution WHA 69.10. http://apps.who.int/gb/ebwha/pdf_files/wha69/a69_r10-en.pdf

38 Photo front page: Getty Images Published by: Norwegian Ministry of Foreign Affairs and Norwegian Ministry of Health and Care Services Additional copies may be ordered from: Norwegian Government Security and Service Organisation www.publikasjoner.dep.no Telephone: + 47 22 24 00 00 Publications are also available on: www.government.no L JØ ME R K E T T RY KK SA Publication number: E-991 E MI K Design: Konsis Grafisk AS Print: Norwegian Government Security and Service Organisation 03/2020– Impression 200 20 46 4 1 De 04 p M edia