National plans for response, recovery and preparedness should be designed around their community’s most pressing needs.

In the UN General Assembly 2020 resolution on COVID-19, governments committed to “further strengthen efforts to address NCDs as part of Universal Health Coverage (UHC), recognising that people living with NCDs and those exposed to major risk factors are at a higher risk of developing severe COVID-19 symptoms and are among the most impacted by the pandemic”.[11] To date however, only 16 countries have reported that NCD management in essential health services is included in national COVID-19 response and recovery plans.

Responding to the community’s most urgent health needs requires resuming and seizing the opportunity to improve on NCD and mental health services – including prevention, screening, diagnosis, treatment, rehabilitation and palliative care – as a matter of urgency, in order to minimise further preventable suffering. Severe disruptions to NCD care, including screening and diagnosis, are significantly increasing the death toll during the pandemic. The disruptions are creating huge backlogs in numbers of people waiting for care, across all NCDs and mental health conditions.

Special consideration is required for marginalised groups and the most deprived populations, where risk factors for communicable diseases and NCDs are compounded. This includes 68 million people worldwide currently living in humanitarian settings, displaced by conflicts and natural disasters, such as communities acutely impacted by climate change. This is accompanied by rising demand for NCD care and mental health services and is projected to keep increasing. The needs of people living with NCDs in these settings requires international support for an improved response in primary health care within national health systems, including access to community health workers, diagnosis, treatment and medicines for chronic NCDs, as well as safe living conditions, nutritious food and good sanitation.

Inspiring Examples

Bahrain is recognised for linking action on NCDs into the national recovery plans, thanks to the engagement of the Director for NCDs at the Ministry of Health in their national COVID-19 response committee.

In Ghana, the President used several televised national addresses on COVID-19 to raise awareness of NCDs and major risk factors

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In order to understand people’s needs, community engagement must be enshrined in national response and recovery plans and in the development and outcomes of the pandemic treaty, requiring decision-makers to include those at highest risk.[12]

This includes people living with chronic conditions, including NCDs, disabilities, HIV, TB and ‘long COVID’. Decision makers must also consciously reach out to groups too often left behind: Older people, racial and ethnic minorities, Indigenous communities, people living in urban slums, rural or remote communities, small island developing states, and LGBTQ+ and other marginalised groups. Women are being particularly hard hit by the economic impacts of the pandemic and millions of children and youth are living with NCDs (for example, over 4.5 million children and youth are living with diabetes[13]). They must also be given special consideration in community engagement.

The Independent Panel on Pandemic Preparedness and Response found that the most successful national responses to COVID-19 have been those which engaged with local communities to build resilient health systems, and to inform service delivery, decision-making and governance to meet communities’ needs.[14] Governments committed at the UN High-Level Meeting on UHC in 2019 to establish social participation mechanisms for health decision-making.[15] However, engagement of communities and civil society is still insufficient. Recent trends in many countries to shrink civil society space provide fertile ground for mistrust, which threatens public health.

Engaging diverse groups across the community will increase buy-in to policy responses and decrease health inequalities within countries, and should be a cornerstone of recovery. The pandemic has demonstrated the vital importance of public trust. Lack of trust undermines policy responses and increases inequalities, by reducing adherence to public health guidance, hindering uptake of vaccinations, and dissuading people from seeking timely health care. Participation from across the community in decision-making is an essential foundation to embed trust, combat misinformation, and close the perceived distance between public authorities, health systems and the public.

During the COVID-19 pandemic, many civil society organisations (CSOs) and health professional associations have stepped in to offer support to people living with NCDs where public services were not available, including home delivery of medicines, transporting people to hospital appointments, and offering advice and support. This should be supported by sustainable resources to work alongside governments in formulating and implementing response and recovery plans based on their experience.

Inspiring Examples

NCD civil society and patient representatives in the Philippines, including Cancer Warriors Philippines, are represented on the national advisory council on medicines, and have been involved in emergency meetings on the COVID-19 response.

In India, Blue Circle Foundation (member of Healthy India Alliance) mobilised volunteers to ensure that people living with diabetes were supported; for example, via dedicated helplines to seek advice, or to have essential medication delivered directly to their homes.

When health systems succeed we thrive; when they fail we pay with our lives. All health systems should prioritise the valuable inclusion of persons with lived experience with communicable and noncommunicable diseases in all health policy development and implementation, including the COVID-19 response and Universal Health Coverage.”

Our Views, Our Voices Global Advisory
Committee member, Kenya

GLOBAL CHARTER

The Global Charter on Meaningful Involvement of People Living with NCDs provides fundamental principles and common strategies for placing people living with NCDs and communities at the centre of the NCD response. Policymakers are encouraged to endorse the Global Charter, recognising that the voices of people living with NCDs, with communities and a strong civil society are an imperative to achieving health and development goals – at global, regional, national and local levels.

International financing for the COVID-19 response was mobilised too late and remains too little to provide the “dangerously underfunded” global public goods identified by the Independent Panel for Pandemic Preparedness and Response and the G20 High-Level Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response.[16]The same could be said for NCDs, which remain the biggest causes of premature death and disability worldwide, but currently attract less than 2% of global health financing.[17]

The NCD Alliance supports the recommendations of the panels on global mobilisation of necessary financing to protect against pandemics, but emphasises that investments for the pandemic response must not create another disease-specific silo. A siloed approach risks further exacerbating inequality and inefficiency. Longstanding silos in global health, with funding and health workers restricted to certain disease responses or specific population groups, do not sufficiently recognise the cross-cutting benefits of investments in primary healthcare and NCD prevention. The pandemic brings home the overdue lesson that the same people affected by or at risk of infectious diseases also have broader health needs, including NCDs and mental health.

Heads of Government, Ministries of Finance and international institutions should examine the investment case for making NCDs central to planning, considering the value of healthy, resilient and productive populations as an indispensable asset and of averted future health costs of both NCDs and infectious diseases. This investment case should guide domestic resource allocation, fiscal policies, development assistance, and specific international solidarity mechanisms such as the Health Systems Connector within the ACTAccelerator (Access to COVID-19 Tools), coordinated by Global Fund, World Bank and WHO.[18]

In light of the experience of the syndemic of NCDs and COVID-19, governments and international donors should accord a significantly higher value to the investment case for public health and NCD policies. The WHO set of recommended NCD interventions should be further strengthened and expanded, reflecting the value of improved security and resilience, and reduced inequalities in the cost-benefit analysis. Expansion to include policy recommendations to reduce air pollution and improve mental health is overdue and should be accelerated in light of the severe impacts of the pandemic on community mental health and in regions with poor air quality. The investment case for NCD prevention policies (including within other global health priorities such as maternal and child health, and people living with and at risk of HIV, TB or malaria) should also take into account wider health co-benefits and prevention of complications and co-morbidities, which dramatically increase the cost of healthcare and vulnerability to infectious diseases.[19]

Inspiring examples:

Bhutan is developing a national multisectoral action plan on NCDs, recognising the link between COVID-19 deaths and NCDs, and including consideration of fiscal measures on key risk factors for cardiovascular disease and diabetes.

Philippines has continued to increase the share of taxes raised from tobacco products during the COVID-19 pandemic, with a share being earmarked to bolster capacity for UHC to reach the poorest communities.

India’s budget for the fiscal year that begins 1 April 2021 more than doubles national healthcare and wellbeing spending to 2.2 trillion rupees (US $30.1 billion). It is allocated to develop capacity for primary, secondary and tertiary care, strengthen the National Center for Disease Control, and improve sanitation and air quality.

We welcome the commitment to increase domestic financing and development assistance in achieving Universal Health Coverage. UHC is really far off because it doesn’t reach all people. There is a gap between commitment and action, until this gap between commitment made and action is closed, the world will continue to bear the burden of disabilities and deaths from NCDs.”

Our Views, Our Voices Global Advisory
Committee member, Nigeria

Health systems should be reimagined in light of the pandemic… and better serve the purpose of preparing for and responding to anticipated (and unanticipated) future hazards and risks, and to produce healthier and more resilient societies. …Reconceptualising health systems means shifting future investments into these functions to strengthen health systems and prevent further fragmentation of competing parallel investments in health security and health promotion.”[20]

Alliance for Health Policy and Systems Research

© Nina Robinson/Getty

COVID-19 has demonstrated once again, following observations during the SARS and MERS epidemics, that people living with NCDs are at higher risk and people living with multiple NCDs are the most vulnerable during health crises.

For example, systematic reviews and meta-analysis have demonstrated that people living with obesity linked to cardiovascular and metabolic conditions including hypertension and diabetes, have up to seven times higher risk of severe disease, hospitalisation and death from viral infections including COVID-19 and influenza.[21][22] Similarly, tobacco users are at higher risk of a number of NCDs, including cancer, cardiovascular disease and lung disease, and are found to be at higher risk of severe outcomes from COVID-19. People with gum disease also have more severe outcomes from COVID-19 and have up to nine times higher risk for death, four times higher risk for intensive care unit admission and five times higher risk for assisted ventilation.[23]

To date, the International Health Regulations, WHO’s Health Emergencies pillar, and the Global Health Security Index have not considered the extent to which NCD prevalence exposes populations and economies to unnecessary risk. When aiming to strengthen health systems, governments have tended to focus either on a health security approach or a UHC one, but these should not be considered as mutually exclusive alternatives.[24] Policymakers missed the opportunity to manage and mitigate the vulnerability to epidemics by acting on common risk factors, including NCDs, by providing UHC. While the World Bank and WHO have recognised population health as an economic asset in the concept of human capital, this has not gained widespread traction to shift the political mindset.

As around half of NCDs are preventable via action on common risk factors (tobacco and alcohol use, air pollution, physical inactivity and consumption of unhealthy and ultra-processed food and drinks), governments, international institutions and preparedness rankings must recognise communities that are highly exposed to these risks, which increase vulnerability to future epidemics.

It is therefore imperative to include NCD indicators in surveillance and periodic universal peer reviews of national pandemic preparedness and response capacities. Scoping is underway on how to integrate NCDs into updates of the Global Health Security Index and should also be incorporated into international assessments of preparedness being discussed in the context of a potential pandemic treaty. For example, the data reported to WHO under the NCD global monitoring framework can be used for this purpose. Where not already the case, NCD prevalence and risk factor data should be included in health management information systems to inform decisions on health systems strengthening and NCD prevention policies.

Inspiring examples:

In recognition of the connection between obesity prevalence and population risk of COVID-19, new policy action on obesity has been announced in the United Kingdom. In the UK, it has been found that over a third of COVID-19 hospitalisations can be attributed to lack of physical activity and excess bodyweight.[25]

The pandemic has accelerated recognition that imbalances in power and concentration of wealth continue to unduly influence decision-making. Putting short-term economic interests ahead of public health has cost lives and livelihoods.

The inequitable access to COVID-19 vaccines, both between countries and between communities, shows that stronger international governance mechanisms are needed for fairer pandemic responses. In addition, environmental destruction and pollution continue unabated, which put the world at risk of further avoidable health security threats, including climate change, biodiversity collapse, transmission of zoonotic diseases and antimicrobial resistance. Each of these could trigger humanitarian and economic crises at an unprecedented scale. The development of a pandemic treaty offers an opportunity for improved governance to address health threats and mobilise both national and international resources for global public goods. The world must not return to businessas- usual, but reset with health as the bottom line.

There are broader structural questions to address in relation to governance and planetary health. Case studies from all continents have demonstrated that health-harming industries – including ultra-processed food and drink, alcohol, tobacco, and polluters – have exploited the pandemic to gain unhealthy influence over consumers and decision-makers.[26] The pandemic demonstrates the urgency of redressing these power imbalances and an opportunity for dialogue with the public about better protecting their interests and responding to their health concerns.

The political influence of industries and companies whose practices and products are harmful to health must be closely monitored and strictly limited. Governments must be empowered by better governance to reverse the regulatory ‘race to the bottom’ and put public health first, to close cross border tax loopholes, levy taxes on health-harming commodities and phase out health-harmful subsidies, including those which incentivise production and promotion of tobacco, alcohol, ultra-processed foods and drinks, and fossil fuels. The resulting revenues and savings should be used to build back fairer – for health protection and health promoting commodities and public services.

Inspiring examples:

The pandemic has catalysed solutions in the field of planetary health:

Proposed in the context of the pandemic, the European Union will adopt a legislative package to deliver on climate targets and become the first carbon neutral continent, noting “This decade is a make-or-break moment for delivering on our commitments under the Paris Agreement, in the interest of the health, wellbeing and prosperity of all.[27] The European Union institutions operate a Transparency Register to monitor and publish lobbying activities.[28]

In the Pacific Islands efforts are being intensified to bring back traditional eating habits and reduce the consumption of unhealthy imported products. The government in Fiji for example began distributing seeds to residents during lockdown to ensure a secure supply of healthy food, in a country where only 16% of the population is aged more than 55 years due to premature deaths primarily caused by NCDs.

In Namibia, Zambia, South Africa and Sierra Leone, people living in urban slums are receiving support for local gardening and permaculture projects to promote nutritious food security and bolder livelihoods.[29]

In Bogota, Paris and London, mayors are investing to increase the network of safe bicycle lanes to keep people active and reduce crowding on public transport. As a healthy side effect, this addresses two of the five major NCD risk factors – air pollution and lack of exercise.

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