(From the ISHN Member information service)  It is always nice to find someone that agrees with you. It is also disconcerting to find that they made the point before you. Our analysis of the WHO 2013-20 action plan on NCD noted that it, and the health ministries around the world, were retreating from a population, health promotion approach to a narrow, medical strategy. Our ongoing review of journals found a similar, earlier argument in the 2014 issue of Global health Action. The author, writing in a series on the medicalization of global health, comments on the "medicalization of NCD efforts". She says "The 2011 UN Summit, WHO 25×25 targets, and support of major medical and advocacy organisations have propelled prominence of NCDs on the global health agenda. NCDs are by definition ‘diseases’ so already medicalized. But their social drivers and impacts are acknowledged, which demand a broad, whole-of-society approach. However, while both individual- and population-level targets are identified in the current NCD action plans, most recommended strategies tend towards the individualistic approach and do not address root causes of the NCD problem. These so-called population strategies risk being reduced to expectations of individual and behavioural change, which may have limited success and impact and deflect attention away from government policies or regulation of industry. Industry involvement in NCD agenda-setting props up a medicalized approach to NCDs: food and drink companies favour focus on individual choice and responsibility, and pharmaceutical and device companies favour calls for expanded access to medicines and treatment coverage. Current NCD framing creates expanded roles for physicians, healthcare workers, medicines and medical monitoring. The challenge and opportunity lie in defining priorities and developing strategies that go beyond a narrow medicalized framing of the NCD problem and its solutions". Read more>>

(From the ISHN Member information service)  The WHO released its 2013-2020 Action Plan on Non-Communicable Disease (NCD) prevention in January 2015. This commentary looks into the document from the perspective of the latest knowledge we have on school health promotion. 

The action plan states "The action plan provides a road map and a menu of policy options for all Member States and other stakeholders, to take coordinated and coherent action, at all levels, local to global, to attain the nine voluntary global targets, including that of a 25% relative reduction in premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 2025. 6. The main focus of this action plan is on four types of noncommunicable disease—cardiovascular diseases, cancer, chronic respiratory diseases and diabetes—which make the largest contribution to morbidity and mortality due to noncommunicable diseases, and on four shared behavioural risk factors—tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. It recognizes that the conditions in which people live and work and their lifestyles influence their health and quality of life" It is in this last sentence where the action plan fails. quite badly. In this analysis, we look more closely at the words in the document and then discuss one aspect drawing from the recent evidence and experience in school health promotion. 

The vision described on page 12 of the document is revealing. it begins with the goal " A world free of the avoidable burden of noncommunicable diseases". Nowhere does the document contain the WHO vision of health, which, as we know, is "more than the absence of disease". The vision contains several nice concepts, including human rights, equity, national multi-sectorial action, life-course approach, empowerment, and managing potential conflicts of interest with food companies and others. But the implicit nature of the document becomes clearer when we note that the words population health, public health u or health promotion are not used. As well, the agenda becomes clearer when we note that of the five functions of public health (protection, promotion, prevention, services and surveillance) only universal health services is mentioned. The WHO intent in this document is clearly to galvanize action in countries in a disease prevention strategy. The first objective of the action plan (p. 5) is to "raise the priority accorded to the prevention and control of NCD's".  This action plan really is about disease, and building the case for for access to universal health care. In our view, the document is part of and reflects a world wide trend for the health sector to retreat back to a medical model and move away from the principles of the Ottawa and ensuing charters related to health promotion and social development.  

We will come back to the vision statement about evidence-based strategies later in this analysis.  

As proponents of school health promotion and settings-based work, we were hopeful when we read on page 5 of the objective stating " to reduce modifiable risk factors for noncommunicable diseases and underlying social determinants through creation of health-promoting
environments." If there is any chance that WHO and the health ministries in countries are to secure the cooperation of other sectors in the Health in All Policies (HiAP) initiatives, then the health sector will need to "go to where those sectors do their work, ie in the settings where people live, learn, work and play. However, when we got to pages 29-37, we found no mention of healthy cities/communities, schools, workplaces, hospitals, universities and other settings. We found only recommended actions such as legislation on second-hand smoke, warnings on cigarette packages, controls on food marketing, promotion of physical activity guidelines and limitations on alcohol sales. These are all good things but they are also all "prescriptions" (medical pun intended) for behaviour change. This medical model has long been discredited in the research on behaviour change and, more recently, even more so on our growing understanding of ecological and systems-based approaches. 

The document does suggest that the WHO Secretariat should provide technical assistance to countries through settings such as schools, cities, recreation etc but the investment (or re-investment) by countries in these settings-based strategies as the means to deliver the NCD prevention strategy is clearly not included as part of the recommended action by countries. Further, when we know that the current total investment of the global WHO office for working with all of these settings is one staff person, we must question the feasibility of the intent to provide such technical assistance.  

In closing, we will pick out one aspect of the action plan that further illustrates how the WHO action plan is actually more of a medically-inspired, bureaucratic creation rather than being based on research evidence and professional experience in the real world. On page  33, we find recommendations that suggest countries should promote "active transportation" and "Improved provision of quality physical education in educational settings (from infant years to tertiary level) including opportunities for physical activity before, during and after the formal school day." If you are a reader of this blog you will recall that we have been tracking the research and reports on physical activity, particularly in regards to its connection to obesity/overweight. Based on several research reviews and articles, we now know that increased physical activity alone, has little effect on body weight. We also know that increased PE time does little to increase actual moderate/vigorous activity unless PE classes are transformed. We know that extensive school-based obesity prevention programs have not reduced obesity levels. We know that we can squeeze out more minutes of activity for some students through active recess, after-school and in-class activities but these efforts do not always engage the naturally less active or uncoordinated students. We know that walking and biking to schools is the best way to accumulate activity minutes. But we also know that structural barriers (perceived safety, parent work schedules, existing neighbourhood designs all prevent significant change in transportation patterns. 


We also know that these economic and social barriers to active transportation to school may actually illustrate the more fundamental, deeper analysis that is missing throughout the WHO action plan.  For example, a recent analysis of active school transportation in California notes that poor children are the ones most walking to school and they are also the ones that are more obese and overweight. As well, these poor children, who now comprise over one-half of the school children in the United States, actually have more urgent and important health problems. If we retreat to a medical, prescriptive model, one that ignores what we have learned about behaviour and ecological influences in the past two decades, then all of the words in documents like the NCD plan will be much less useful in the real world. 

(From the ISHN Member information service)  The WHO fact sheet describing the response of health ministries to prevent and control NCDs indicates the collective, global intentions and strategies. The ideas and actions not mentioned on the page and in the action plan are as important as the ones that are highlighted. WHO summarizes the actions needed as follows:
" To lessen the impact of NCDs on individuals and society, a comprehensive approach is needed that requires all sectors, including health, finance, foreign affairs, education, agriculture, planning and others, to work together to reduce the risks associated with NCDs, as well as promote the interventions to prevent and control them. An important way to reduce NCDs is to focus on lessening the risk factors associated with these diseases. Low-cost solutions exist to reduce the common modifiable risk factors (mainly tobacco use, unhealthy diet and physical inactivity, and the harmful use of alcohol) and map the epidemic of NCDs and their risk factors. Other ways to reduce NCDs are high impact essential NCD interventions that can be delivered through a primary health-care approach to strengthen early detection and timely treatment. Evidence shows that such interventions are excellent economic investments because. The greatest impact can be achieved by creating healthy public policies that promote NCD prevention and control and reorienting health systems. Lower-income countries generally have lower capacity for prevention and control. Countries with inadequate health insurance coverage are unlikely to provide universal access to essential NCD interventions". Our initial comments: (1) The WHO is clearly medical, focused on health services rather than health promotion. (2) The absence of disease is the goal rather than overall health. (3) Other sectors are expected to be partners but a settings-based approach, essential to these partnerships, is neglected and forgotten. Read more>>

(From the ISHN Member information service)  The release of the WHO status report/global action plan this week represents the efforts of health ministries to address a cluster of physical health diseases. The key facts are not new: "(1) NCD's kill 38 million people each year. (2) Almost 3/4 of deaths (28 million) occur in low- and middle-income countries.(3) Sixteen million deaths occur before the age of 70; 82% of these "premature" deaths occur in low/middle-income countries. (4) Cardiovascular diseases account for most deaths, (17.5 million), followed by cancers (8.2 million), respiratory diseases (4 million), and diabetes (1.5 million). These 4 groups of diseases account for 82% of all NCD deaths. Tobacco use, physical inactivity, unhealthy diet and the harmful use of alcohol increase the risk of NCDs. Tobacco accounts for around 6 million deaths every year and is projected to increase to 8 million by 2030. About 3.2 million deaths annually can be attributed to insufficient physical activity. More than half of the 3.3 million annual deaths from harmful drinking are from NCDs In 2010, 1.7 million annual deaths from cardiovascular causes have been attributed to excess salt/s. To lessen the impact of NCDs on individuals and society, a comprehensive approach is needed that requires all sectors, including health, finance, foreign affairs, education, agriculture, planning and others, to work together to reduce the risks associated with NCDs, as well as promote the interventions to prevent and control them.odium intake.More than 190 countries agreed in 2011 to reduce the avoidable NCD burden in a Global action plan. This plan aims to reduce the number of premature deaths from NCDs by 25% by 2025. In 2015, countries will begin to set national targets and measure progress on the 2010 baselines. The UN General Assembly will convene a third high-level meeting on NCDs in 2018 to take stock of national progress. Read more>>