How the UN high level meeting misses the mark for NCD prevention and management in Africa and the needed amendments to fix that.
On 27th September 2018, Heads of State and Government and representatives of States and Governments, will gather at the United Nation’s headquarter in New York, to talk about the roadblocks in the pathway of implementing activities for the prevention and control of NCDs. This is imperative as to-date NCDs account for over seven times as many deaths as infectious diseases (NCD Alliance, 2018).
The key stipulations in UNGA HLM3 NCDs:
The document takes a holistic view in recognizing the socio-economic, environmental and mental health aspect to prevent and control NCDs. The UNGA HLM3 NCDs categorises cardiovascular disease, diabetes, cancer and chronic respiratory diseases as four main NCDs and identified excessive/harmful usage of tobacco and alcohol, unhealthy diets and physical inactivity as the primary risk factors to act upon. The document addresses the fact that increase in burden of NCDs has huge economic burden in developing countries and threatens the economy and further increases the inequality in these countries. It considers mental health conditions and addresses the comorbidity between mental disorders and major noncommunicable diseases. It calls upon the support from civil society and private sector to work together in preventing and controlling NCDs. Incorporation of communications technologies to accelerate action towards reducing burden of NCDs is also included in the paper. Reducing childhood obesity, promotion of healthy diets and physical activity have all been incorporated in this document. Tobacco has been an important topic of the paper, discussing about implementation of tobacco control measures without any tobacco industry interference. Promotion of intake of fruits and vegetables and establishing affordable health systems for all to combat NCDs and associated mental diseases, have been well highlighted. Private sector engagement: policy formulation in regulating advertisements targeted towards children; ensuring affordability and accessibility of healthy food; establishing good corporate practices and healthy and tobacco-free workplaces; accessibility and affordability of medicines; low sodium consumption; - are some very important points mentioned in the paper. Lastly, mechanisms to bring together efforts of other United Nations agencies, development banks, regional and international organizations to further enhance actions towards prevention and control of NCDs and exploring new finances have also been emphasised (UNGA, 2018).
Where the UN hits the mark on NCD prevention and management in Africa:
The PP8 of UNGA HLM3 NCDs, correctly points out and recognises the comorbidity of mental health and non-communicable diseases. OP15 further discusses about establishing a combined health system to address mental diseases and NCDs. OP19 talks about promotion of mental health and wellbeing. In the entire document prevention and control of NCDs and promotion mental health and well-being are spoken in single breath. In African continent, mental health issues are key factors leading to increase in burden of NCDs. From public health policy viewpoint, we feel this is integral and the document has made justice to the issue of mental health associated with NCDs (UNGA, 2018).
What is immensely hopeful about the document that it has addressed and good amount of weightage to excessive usage of tobacco. They discussed about firmly implementing tobacco control measures and have clearly mentioned to keep aside the tobacco industry interference. An integrated approach has been formulated-the document mentions educating people about harmful impacts of first and second hand smoking through formal education and mass media campaigning and establishment of tobacco free workplaces. It has emphasised on behavioural changes towards usage of tobacco. This, we strongly feel, would be a great stride towards elimination of excessive usage of tobacco and minimizing its harmful impacts (UNGA, 2018).
In order to save the coming generations from the growing epidemic, UNGA HLM3 NCDs, greatly emphasises on NCD issues of children. Promoting healthy diet and physical activity for children, as the document pinpoints, could greatly reduce the risk of NCDs in adulthood. They have particularly highlighted about channelling efforts towards addressing specific health needs of children in regard to NCDs and strong interventions to reduce childhood obesity. They have asked for private sector support in restricting advertisements, targeted towards children that promote sugary and processed foods. Obesity rates among African children are on a rise and as public health policy experts, we feel, this would be impactful enough as the document has an integrated plan (UNGA, 2018).
Where the UN misses the mark on NCD prevention and management in Africa:
UNGA HLM3 NCDs: Zero draft outcome document, has categorised cardiovascular disease, diabetes, cancer and chronic respiratory diseases as four main NCDs and identified excessive/harmful usage of tobacco and alcohol, unhealthy diets and physical inactivity as the primary risk factors to act upon. (UNGA, 2018). However, obesity is the triggering factor of NCDs especially cardiovascular disease and diabetes. Obesity should have been categorised as one of the main NCDs too. As we know, a healthy adult body mass index (BMI) should range from 18.5 to 24.9. In central Kenya, 47.1% of women are obese with a mean BMI of 25.3kg/m2 (Mboya, 2018). Two out of every five Egyptians (39%) are obese, followed by Ghana at 22%. Egypt and Ghana also experienced a significant increase in obesity over the past 25 years — from 34% to 39% in Egypt and 8% to 22% in Ghana. The increase in obesity doubled in Kenya, Benin, Niger, Rwanda, Ivory Coast and Uganda, while Zambia, Burkina Faso, Mali, Malawi and Tanzania experienced a three-fold increase (Amugsi, 2018). In South Africa, 68% of women are obese. Study unfolds that the number of young South Africans suffering from obesity doubled in the last six years, while it had taken the United States 13 years for this to happen (Adams, 2018). These cases of obesity will eventually lead to diabetes and cardiovascular disease. Therefore, the overwhelming statistics of obesity implies that obesity should be categorised as one of the main non-communicable diseases. Although there is a mention of childhood obesity in the document, this is not enough. And including obesity as one of the main NCDs will help in creating meaningful changes in the prevention and control of NCDs.
In South Africa, fruits and vegetables are expensive, people prefer cheaper carbohydrate-rich foods, leading to increasing the burden of NCDs in the region. The report of a non-governmental organisation, the Pietermaritzburg Agency for Community Social Action (Pacsa), highlights the biggest issue to be lack of affordability. It says, while the median wage for black South Africans is USD209 a month, a monthly food basket that is nutritionally complete costs USD297 (Adams, 2018). OP10 of the document makes commitment to implement policies to promote healthy diets and lifestyles; OP18b seeks support of the private sector to produce healthy foods which are affordable and accessible. What is missing and which is why this sounds incomplete is how to attain this affordability and accessibility. PP11 declares about bringing together civil society and private sector and working together to combat NCDs; OP1 commits to implement policies so that government and all stakeholders, inclusive of private sector and civil society, work towards an integrated whole-of-society approach in decreasing the burden of NCDs; OP17 says it looks into avenues where private sectors’ objectives culminates with the objectives of SDG 3,4; OP18 details out the private sector engagement activities - policy formulation in regulating advertisements targeted towards children; ensuring affordability and accessibility of healthy food; establishing good corporate practices and healthy and tobacco-free workplaces; accessibility and affordability of medicines; low sodium consumption; In all these statements there is no mention of how to attain affordability and accessibility of healthy food. According to Adams (2018), the underlying cause behind lack of affordability is monopoly in production and selling of produce. The statements do not mention de-monopolisation of the agriculture industry, starting from manufacturers to retailers. De-monopolisation can be attained by giving contracts to small to large manufacturers, farmers and retailers to produce healthy food and later awarded (incentivization) whoever is able to provide the lowest price. This is how price of fresh produce will come down and people of every class will be able to afford fresh fruits and vegetables. In order for manufacturers, farmers and retailers to provide low price, some initial interventions are required. This can be achieved through providing them training and tax rebate (incentivization) in the initial phases and then eventually making them independent. This is how affordability and accessibility of healthy food will be attained. The statements in UNGA HLM3 NCDs should talk clearly about the engagement of private sector in demonopolizing the agriculture industry and attaining sustainable, affordable and accessible agriculture industry through issuance of contracts and providing incentives and training at the initial phases and thereby attaining affordability and accessibility of healthy food.
The path forward
UNGA HLM3 NCDs: Zero draft outcome document is surely very encouraging and shows us light in our fight against NCD prevention and control. Emphasizing on the comorbidity between mental health and non-communicable diseases was a great stride forward. Discussion on firmly implementing tobacco control measures was significant. Putting bigger weightage on NCD related issues of children and to promote healthy lifestyles was imperative. On the other hand, how to attain affordability and accessibility of healthy food was missing i.e. private sector engagement should be such that de-monopolisation of agriculture industry is attained through issuance of contracts, incentivizing and training the manufacturers, farmers and retailers and hence attaining affordability and accessibility of healthy food. Lastly, it is imperative that obesity (a primary initiator of other NCDs) is named as one of the main NCDs just like cardiovascular disease, diabetes, cancer and chronic respiratory disease.
Detailed recommendations for overall prevention and control of NCDs in Africa can be found here in Engage Africa Foundation’s policy brief papers.
Adams, N. (2018) ‘How the Lack of Affordable Vegetables is Creating a Billion-Dollar Obesity Epidemic in South Africa’, Inter Press Service News Agency, 10 August. Available at: http://www.ipsnews.net/2018/08/lack-affordable-vegetables-creating-billion-dollar-obesity-epidemic-south-africa/ (Accessed: 12 August 2018).
Amugsi, D. (2018) ‘Scientists have seen a shocking rise in obesity levels in urban Africa over the past 25 years’, Quartz Africa, 3 February. Available at: https://qz.com/africa/1194268/obesity-is-rising-rapidly-in-africa-say-scientists/ (Accessed: 13 August 2018).
Mboya, E. (2018) ‘Study ties Kenya obesity increase to supermarket food’, Business Daily, 7 August. Available at: https://www.businessdailyafrica.com/datahub/Study-ties-Kenya-obesity-supermarket-food/3815418-4702688-8e7alm/index.html (Accessed: 12 August 2018).
NCD Alliance (2018) Draft Political Declaration for UN High-Level Meeting on NCDs lacks strength and ambition required to avoid a preventable global health crisis [Media Release]. 8 August. Available at: https://ncdalliance.org/news-events/news/draft-political-declaration-for-un-high-level-meeting-on-ncds-lacks-strength-and-ambition-required-to-avoid-a-preventable-global-health-crisis (Accessed: 11 August 2018).
United Nations General Assembly (UNGA) (2018) UNGA HLM3 NCDs: Zero draft outcome document. Available at: https://www.un.org/pga/72/wp-content/uploads/sites/51/2018/06/NCD-8-June.pdf (Accessed: 12 August 2018).