“Appendix III” is critical for accelerating progress on NCDs

30th May 2017

Noncommunicable diseases (NCDs) accounted for 70% of global deaths in 2015, with three quarters of these deaths occurring in low and middle income countries (LMICs). NCDs are a silent epidemic of premature and preventable death and disability from diseases such as cancer, diabetes, heart disease, chronic lung disease, and mental and neurological disorders. Their main risk factors – unhealthy diets, alcohol and tobacco use, physical inactivity, and environmental determinants such as air pollution, are transmitted via unhealthy environments. They are directly and indirectly caused by commercial determinantsmisaligned public policies in agriculture, commerce, education, energy, health, finance, trade, and social security, and are exacerbated by social determinants including poverty and inequity.

In 2011, The United Nations General Assembly declared NCDs a global health and development challenge at a UN High-Level Summit. In 2018, world leaders will return to the United Nations to review NCD progress. To date, this progress has been deemed insufficient to meet commitments made by Member States to achieve a 25% reduction in premature mortality from NCDs by 2025.

A menu of effective NCD interventions – WHO’s ‘Appendix III’

In order to guide governments, in particular LMICs with limited resources and high NCD burdens, in the selection of cost-effective and highly impactful policies, the World Health Assembly (WHA) endorsed a document called “Appendix III” as part of the WHO Global NCD Action Plan on NCDs in 2013. Despite its unassuming official name (more commonly referred to as the WHO “Best Buys” for NCDs), Appendix III is the main technical document that countries utilise when developing national NCD plans and policies. It provides decision-makers with a menu of evidence-based policy options and cost-effective interventions. Since 2013, Member States have stipulated that the document should be updated to reflect the evolution of scientific evidence and cost-effectiveness of interventions over time. As a result, the WHA is currently discussing endorsement of the second iteration of Appendix III. This updated version reflects the latest evidence, for example, taxation of sugar-sweetened beverages (SSBs) to prevent overweight and obesity.

The politics of public health policy

Rumours about potential opposition to the endorsement of Appendix III have circulated since the WHO’s Executive Board in January. This past week, they materialised as opposition from the US government, who on Friday at WHA discussions on NCDs stated that the country would only “note”, not “endorse” the document. Meanwhile a number of countries from across WHO regions have come out in strong support of the revised document, in particular LMICs with high NCD burdens such as Sri Lanka who endorsed the updated Appendix III on behalf of the 11 Member States of the WHO South-East Asia region. Official discussions will continue on Monday with more countries to speak. While Appendix III is merely a menu of policy options for countries to choose from, US opposition to its endorsement signals how important Appendix III is for setting trends for evidence-based policymaking. These policy trends protect individuals, families, and society from death and disability, as well as catastrophic health care expenditure and productivity losses. At the same time, they go against powerful economic interests – be it taxes on alcohol, tobacco or sugary drinks; restrictions on marketing of unhealthy commodities; plain-packaging of tobacco products; or front-of-pack labelling to provide consumers with clear and easily accessible nutrition information.

Addressing the externalities of commercial determinants

As the evidence on sugar has evolved over the past years, governments in Latin America, Europe, and Pacific Island countries, as well as city governments across the US, have successfully implemented taxes on sugary drinks as recommended by WHO. Taxes on unhealthy commodities to reduce consumption and generate revenue for health promotion can address the externalities of products that are cheap and extremely profitable but eventually cost consumers and society. Fiscal measures such as “taxes and subsidies to promote healthy diets” were mentioned in the original Appendix III, however, the updated document now specifically highlights SSB taxes as a cost-effective intervention. As exemplified by Mexico’s successful SSB tax, and the strong leadership of countries such as South Africa, currently considering introducing a tax on sugary drinks – SSB taxes are meeting resistance from large multinational companies and domestic stakeholders seeking to protect industry interests.

On Friday, the US expressed their concern over “certain interventions included in the draft Appendix III with limited evidence currently available on their effectiveness in achieving Member States’ public health goals” (referring to the evidence on the cost-effectiveness of SSB taxation) and specifically highlighted “the sovereign rights of nations to determine taxation.”

Semantics and implications of ‘noting’ or ‘endorsing’

Whether countries “note”, “welcome” or “endorse” a technical policy document that is not legally binding is of less importance, its political significance is another matter. In a climate of declining WHO expenditure for NCDs, severe resource and capacity constraints at country level, reported industry interference, and the upcoming 2018 UN High-Level Meeting on NCDs that will take an honest look at the barriers and facilitators of effectively addressing NCDs, the political messaging element of NOT endorsing WHO’s recommended cost-effective interventions for NCDs is highly significant. Those with concerns about the implications of Appendix III have previously been quick to exploit perceived opportunities to weaken the document; after conditional support for the document at the WHO Executive Board in January, industry sources were quick to announce that WHO had vetoed sugar tax endorsement. The WHO immediately refuted this claim.

Advocating for support 

US opposition took many countries that supported the updated Appendix III by surprise. Knowing this, over the past few days, NCD advocates ensured that countries that support the updated Appendix III  were aware of its vulnerability and the importance of explicitly supporting the endorsement of the document. Many of these countries may otherwise not have explicitly referenced their support of the updated document, or may not have been present during NCD discussions given the human resource constraints faced by countries with small delegations covering the extensive WHA agenda.

Endorsement of Appendix III is not secured. It will depend on strong continued support from countries on Monday and the willingness of the US, where the national burden of NCDs closely reflects the devastating global burden, to find consensus and to demonstrate strong political leadership for NCDs. The opposition to interventions such as SSB taxation may also affect the proposed endorsement of the WHO Implementation Plan on Ending Childhood Obesity, which seeks to address the alarming levels of childhood overweight and obesity globally through a comprehensive set of recommendations including SSB taxes and restrictions on marketing of unhealthy food to children.

Every country in the world is affected by the slow motion disaster that is NCDs – we are in this together as a global community to work with each other, to support all countries, and to take effective actions to reverse their devastating trajectory.


Follow-up comment, May 30 2017

After strong dissenting statements on Monday from a large number of Member States responding to US opposition to endorsement of the updated Appendix III of the Global NCD Action Plan, a ‘drafting group’ was convened to find consensus on the proposed WHA resolution on NCDs. A draft decision had been proposed by the US following their intervention on Friday 26 May to suggest that the updated Appendix III should be noted, not endorsed.

The drafting group was called for by Member States such as Norway and Uruguay and attended by a large and diverse set of Member States. Due to strong leadership from countries across WHO regions who would not settle for anything less than endorsement of Appendix III, the US announced that they would disassociate from operative paragraph I (OPI) of the adopted NCD resolution which endorsed Appendix III in Committee B this morning. While this is a rare occurrence at the WHA and means that no consensus was achieved, this development reflects strong Member States’ commitment to evidence-based, cost-effective NCD prevention and control, as well as protection of policy-making from industry interference. The decision of the 70th World Health Assembly to endorse Appendix III is of great significance as countries are preparing themselves for the next UN High-Level Meeting on NCDs in 2018.

The endorsement was particularly welcomed by NCD advocates working at the national level. Luis Manuel Encarnación Cruz, a colleague and coordinator at Mexico Salud-Hable (a broad alliance of over 80 member organizations that work on NCD prevention, treatment and control in Mexico) commented to me after the drafting group had been adjourned that he saw the endorsement of Appendix III as a key step towards meeting international commitments to reduce the prevalence and mortality of NCDs worldwide. In his view, “the best-buys included in Appendix III will allow countries to introduce and/or strengthen national policies to tackle main risk factors of obesity and NCDs, such as effective taxes on sugary drinks” and “non-endorsement of Appendix III would be a step back in the fight against NCDs, allowing economic interests to prevail over public health and development.”

The decision on the updated Appendix III is likely to further influence discussions on the endorsement of the WHO Implementation Plan on Ending Childhood Obesity later today which is expected to also be met with opposition from the US. Once more, strong leadership from the many committed Member States that helped secure endorsement of Appendix III will be needed to endorse the Implementation Plan.

This blog was first posted on May 29, 2017 at PlosBlogs (now archived) 


About the Author

Alena Matzke is NCD Alliance's Advocacy Manager, based in Geneva, and policy lead for nutrition.