Responding to the Challenge of NCDs: The World Bank Responding to the Challenge of Non-communicable Diseases The World Bank 1. The rising burden of NCDs poses a United Nations high-level meetings have threat to health and development highlighted the need for UN agencies, including WB, to scale up their work on NCDs as part of the NCDs are a growing concern in all countries. 2030 Agenda for Sustainable Development. NCDs are projected to rise in low- and middle- income countries (LMICs) by 2030 in line NCDs contribute to ill health, poverty and inequities and slow the development of countries. with changing lifestyles, ageing populations, Every year 15 million people die before age 70 urbanization and other factors. Many from NCDs, with 86% of these premature deaths countries face a double burden of disease occurring in low- and middle-income countries. with an unfinished communicable disease burden and a rising NCD epidemic. Likewise, Major progress on NCDs is possible. Premature deaths from NCDs are largely caused by some LMICs face both a high prevalence of modifiable behavioural risk factors, such as childhood stunting and the growing problem unhealthy diet, tobacco use, physical inactivity of obesity (the number of obese children and and harmful use of alcohol. Environmental risks adolescents has grown more than tenfold (e.g. air pollution) and constrained access to over the past 40 years). basic services also contribute significantly to NCDs. NCDs result in increased health care spending Addressing NCDs requires coordinated action and significant economic losses due to the from all UN agencies within a broader whole-of- often complex, costly and/or chronic nature of society response. care, as well as to lost productivity. Between 2011 and 2025, NCDs are projected to cost LMICs more than US$7 trillion.1 Households bear the brunt of health care spending on NCDs and have limited financial protection in most LMICs. Considering the impoverishing effect of many NCDs, it will not be possible to attain the equity and financial protection goals of the UHC agenda if NCDs are not addressed. 1 Bloom, D. E., Chisholm, D., Jané-Llopis, E., Prettner, K., Stein, A., & Feigl, A. (2011). From burden to “best buys”: reducing the economic impact of non-communicable diseases in low-and middle-income countries (No. 7511). Available at: https:// www.who.int/nmh/publications/best_buys_summary.pdf. NCDs are defined as cardiovascular disease, cancers, diabetes and chronic respiratory diseases. 1 Responding to the Challenge of NCDs: The World Bank Regardless of their income levels, countries Urgent action is needed to accelerate should not neglect the NCD burden given its progress in health service coverage and implications for human capital development. financial protection, and to address the Since NCDs are a major cause of broader socioeconomic determinants of premature death, disability and foregone NCDs. wages, investments in the prevention and treatment of these conditions will improve adult health and economic growth. Investing in cost-effective NCD interventions in poorer countries will generate US$350 billion in economic benefits and save 8.2 million lives by 2030. This is a return of US$7 per person for every dollar invested.2 Financing of NCDs remains inadequate and out of line with the growing burden in LMICs. About 80% of the NCD burden is in LMICs, and NCDs overall represent over two thirds of the global disease burden; financing for NCDs is however concentrated in high- income countries and overseas development assistance for NCDs accounts for less than 3% of total assistance for health.3 NCD prevention requires a multisectoral, whole-of-government, whole-of-society approach which focuses on reducing population exposure to environmental and behavioural risk factors while increasing affordable access to basic services. Integrated care models which are patient-centered and leverage investments in infectious diseases and maternal, newborn and child health will be critical to managing both the rising burden of disease and spiralling costs. Despite several high-level NCD events since 2011, progress remains slow. The third UN High-Level Meeting on NCDs in September 2018 aimed to intensify political support in the context of the SDG agenda with a focus on “reducing premature mortality from NCDs by one third by 2030”, in line with SDG target 3.4. 2 WHO GCM/NCD Working Group on the Inclusion of NCDs in Other Programmatic Areas (2018). Final Report: Working Group on the Inclusion of NCDs in Other Programmatic Areas. Retrieved from https://www.who.int/global-coordination- mechanism/activities/working-groups/3-1-report.PDF?ua=1 3 Health Finance Institute. Addressing the economic burden of underinvestment in NCDs. Available at: http://healthfinanceinstitute.org/ 2 Responding to the Challenge of NCDs: The World Bank 2. The World Bank has a role to Investment lending is effective for scaling play in supporting countries in up domestic action on the prevention and control of NCDs preventing and controlling NCDs The World Bank’s health sector strategy The Bank has a diversified portfolio of supports countries to accelerate progress investment operations in health systems towards UHC. Its three main pillars include: (a) and health services in support of NCDs, expanding financial protection so that no one totaling about US$1.5 billion (2019): this is tipped into poverty because of catastrophic represents about 12% of the Bank’s overall health spending; (b) increasing coverage of health, nutrition and population (HNP) quality health services for the poorest 40% lending. Projects include: (a) strengthening of the population; and (c) fostering a healthy early detection and screening for NCDs; society, including investments that reduce (b) promoting NCD risk reduction; and (c) risk factors for NCDs. The prevention and revamping health systems and facilitating control of NCDs cut across the three pillars. transformational reforms to shift attention from costly secondary care to primary The World Bank responds to client demand health care. Over a half of all NCD health to prevent and control NCDs by providing investments are on integrated projects with financial support, policy advice and technical both disease prevention and chronic disease assistance to strengthen the health system management activities. Other projects use response and address key risk factors for communicable disease investments to NCDs. support NCD prevention and treatment. The World Bank has produced analytic work The Bank portfolio also includes roughly to understand the nature and magnitude of US$0.2 billion of non-health investment the NCD problem, identify risk factors and operations that directly or indirectly propose mitigation measures. It has also contribute to NCD prevention. Examples conducted expenditure analyses to determine include: (a) promoting environmental health; the efficiency of public spending and identify (b) expanding the use of safe and efficient strategies to expand domestic resource cookstoves; (c) enhancing awareness mobilization (including through taxation of and knowledge; (d) promoting fiscal and health-harming products) in order to increase regulatory reforms; and (e) reducing the risk those available for primary health care (PHC). of road injuries. The World Bank plays an important knowledge-sharing role by producing a wide range of knowledge products and sharing experiences and lessons across countries. The Bank has brokered various partnerships to leverage technical and financial support, working in close collaboration with technical agencies, the private sector and UN agencies. 3 Responding to the Challenge of NCDs: The World Bank Examples of World Bank-funded NCD Towards Population-Based Screening and Interventions Community-Level Outreach for NCDs in India. Tamil Nadu is India’s sixth most populous state and is dealing with a double burden Protecting Vulnerable People against NCDs in of communicable and non-communicable Argentina. NCDs generate a heavy health and diseases. Cardiovascular disease, diabetes, economic burden. The US$350 million project and cancer are the leading causes of death (2015–2020) in Argentina aims to improve for people aged above 40. The World Bank has the readiness of public health facilities provided a US$287 million loan to strengthen to deliver higher quality NCD services for management of NCDs, with a focus on health vulnerable population groups and expand promotion and NCD prevention, population- the scope of selected services, as well as to based screening of NCDs among the protect vulnerable population groups against eligible population, treatment and follow- prevalent NCD risk factors. up, and improvement of NCD monitoring and evaluation. The project aims to support Regional Programme of Cancer Registries a move from opportunistic screening to in East Africa. In 2012, sub-Saharan Africa population-based screening. had about 850,000 new cancer cases and 600,000 deaths. The World Bank is supporting Establishment of Health Lifestyle Centres Burundi, Kenya, Rwanda, Tanzania and (HLCs) for NCD Screening and Referral in Uganda to strengthen their capacity for Sri Lanka and Turkey. The World Bank has collecting, analysing and sharing data on supported the establishment of Healthy Life cancers. Access to timely information on Centres at the PHC level for the detection the rising cancer disease burden is critical to and management of patients with a high develop financial protection mechanisms to NCD risk. In Sri Lanka this is being done by ensure that households are not impoverished strengthening PHC capacity, population by catastrophic health spending, provide screening and better treatment and follow-up. quality services in a timely manner in order to facilitate early detection and treatment, and Performance-Based Financing for NCDs in address risk factors associated with cancers. Tajikistan. Ischaemic heart disease is one of the leading causes of death in Tajikistan. The Leveraging Investments in Infectious Diseases World Bank is supporting the government’s to combat NCDs in Egypt. The World Bank performance-based financing scheme to supported a combined national hepatitis improve the coverage and quality of basic C and NCD risk factor (hypertension, high primary health services in rural health facilities blood sugar and body mass index) screening in 10 districts. Under this supply-side project, campaign, with high-level political support the Ministry of Health contracts rural health from the President. Individuals with hepatitis centers to enhance both the quantity and C and/or at risk of NCDs were enrolled in quality of NCD services, providing coverage structured treatment programmes. To date, in about 450 health facilities to approximately 49.8 million adults aged of 18 or over have 15 percent of the country’s total population. been screened. This innovative initiative demonstrates the potential for leveraging existing infectious disease platforms to address NCDs. 4 Responding to the Challenge of NCDs: The World Bank Analytic work and knowledge management: Impact of NCDs on Human Capital (2019). The WB Linking evidence to operations is collaborating with several partners to produce a report that describes how human capital and productivity can be enhanced by tackling NCDs, The Bank undertakes a wide range of with recommendations for action. This work is country, regional and global studies to better part of the World Bank’s Human Capital Project understand and address the risk factors to improve human capital at the country level through investing in health and education. associated with NCDs, as well as to provide an analytic underpinning for investment Obesity: A Ticking Time Bomb – What can the lending and inform public policy. Examples World Bank do to Defuse It? (2019). This report are given in the box. highlights the growing epidemic of obesity in both low- and high-income countries, and its health and economic costs. The report lays out the drivers of The World Bank Group’s Global Tobacco obesity, lessons learned from obesity-prevention Control Programme supports knowledge efforts across the globe, and the policy and exchange among selected countries on the investment tools that the World Bank can deploy economics of tobacco control. Experts in across different sectors to address obesity. health, governance and macroeconomic and How to Improve the Use of Fiscal Policy to Address financial management, poverty and equity, the NCD Crisis: Lesson Learned from Tonga agriculture and trade engage actively in this (2019). Tonga has a very high burden of NCDs. programme, which is a win-win for both public This study generates policy-relevant findings and health and domestic resource mobilization.4 insights on the implementation of taxation policy on tobacco, alcohol, food and behaviours, pricing, government revenues and the country’s response The programme assists countries to design to the rising NCD burden. tobacco tax policy reforms and increase tobacco tax rates in order to: The Challenge of NCDs and Road Traffic Injuries in sub-Saharan Africa (2013). This (a) achieve public health goals by increasing is a comprehensive review of the literature with input from policy-makers, researchers prices, reducing smoking, and preventing and practitioners. It describes how resource- initiation among youth; constrained governments can prevent and control (b) raise domestic resources for investments NCDs and increase road safety. that benefit the entire population; and (c) enhance equity by reducing the health The Challenge of NCDs and Road Traffic Injuries in sub-Saharan Africa (2013). This risks associated with tobacco-attributable is a comprehensive review of the literature diseases and the risk of impoverishment due with input from policy-makers, researchers to high out-of-pocket expenditure among the and practitioners. It describes how resource- lowest income population groups. constrained governments can prevent and control NCDs and increase road safety. Achievements include providing support for tobacco tax policy reforms in several countries and the launch of the World Bank Group report “Tobacco Tax Reform: At the Crossroads of Health and Development”. 4 The World Bank. Global Tobacco control. https://www.worldbank.org/en/topic/ tobacco 5 Responding to the Challenge of NCDs: The World Bank 3. Partnerships are critical for the World Bank in mobilizing an effective response to NCDs The Bank has been an active member of several key partnerships and/or leader in key initiatives (e.g. tobacco control and mental health) to prevent and control NCDs. Examples include: • Access Accelerated. The Bank brokered this partnership with the private sector to leverage funding for pilot projects that aim to support early screening, detection and initial treatment for NCDs in countries such as Kenya and El Salvador. • Union for International Cancer Control (UICC) — City Cancer Challenge. The Bank participated in the UICC-led City Cancer Challenge initiative which supports cities to design, plan and implement cancer treatment solutions to reduce cancer mortality by 2025. • World Bank Umbrella Facility for Gender Equality (UFGE). The UFGE is a multidonor trust fund that aims to strengthen awareness, knowledge and capacity for gender-informed policy-making; it also explores new approaches to improve human capital, such as through the control of NCDs. Photo credits: © World Bank via Flickr The United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases was established in 2013 by the Secretary General and placed under the leadership of WHO to coordinate the activities of the UN System to support the realization of the commitments made by Heads of State and Government in the 2011 Political Declaration on NCDs. Joint activities included in the work plan of the Task Force are additive to various, more comprehensive efforts conducted by the UN agencies to prevent and control NCDs. These joint activities offer important opportunities to address cross-cutting issues and to advance capacity and learning in countries. This brief was developed by the World Bank as part of a set of United Nations system agency briefs under the Task Force 6