The role of social media in preventing and managing non-communicable diseases in low-and-middle income countries: Hope or hype?

Non-communicable diseases (NCDs) pose major challenges for health systems in low-and-middle income countries (LMICs). Social media may be a low-cost, powerful tool to support NCDs prevention and management in LMICs through its ability to reach a large population. However, data on the role of social media for NCD prevention and management in LMICs is scares. This commentary paper explores the role of social media for prevention and management of NCDs and discusses how these may particularly have a role in supporting people in LMICs. We conducted a literature search using PubMed and Google Scholar to identify peer-reviewed articles using social media for NCDs in LMICs. Technology based interventions are increasingly being examined as a means to address healthcare gaps, especially in LMICs. The potential role of social media in NCD prevention and management includes patient health education and information sharing, psychological support, self-management, public health campaigns and health professional's capacity building. Nevertheless, there is little direct data on utilizing social media for NCD prevention and management in LMICs and thus a systematic review was not possible. However, social media may also have risks and challenges, such as conveying incorrect information, lack of data confidentiality, monitoring, and regulation, commercial interests, equity of access, and lack of standards. Regulatory guidelines and standards need to be developed and adhered to help avoid adverse consequences. Further research on effectiveness of social media for NCDs using robust methodologies in different population groups for short/long term impacts in LMICs is recommended.     

Evaluation of community-based interventions for non-communicable diseases: experiences from India and Indonesia

This paper reports the results of formative and outcome evaluation of two ongoing community-based intervention programmes for integrated non-communicable disease (NCD) prevention and control in urban low-income settings of Ballabgarh near New Delhi, India, and in Depok, West Java Province of Indonesia. At both sites, a coalition of community members facilitated by academic institution and the World Health Organization, planned and implemented the intervention since 2004. The intervention consisted of advocacy and mediation with stakeholders, training of volunteers and school teachers, communication campaigns, risk assessment camps and reorientation of health services. The formative evaluation was based on the review of documents, and outcomes were assessed using the standardized surveys for NCD risk factors in 2003-2004 and 2006-2007. The baseline surveys showed that tobacco use, low intake of fruits and vegetable, suboptimal levels of physical activity and obesity were prevalent in both the communities. A frequent change in local administrators and lack of perceived priority for health and NCDs limited their involvement. Pre-existing engagement of community-based organizations and volunteers in health activities facilitated its implementation. The reach of the programme among the population was modest (25-32%). Health system interventions resulted in increased diagnosis and better management of NCDs at health facilities. Early outcome measures showed mixed results of change in different risk factors. The experiences gained are being used in both countries to expand and provide technical support to national efforts. This paper adds to the knowledge base on the feasibility of designing and implementing large-scale community-based interventions for integrated prevention of NCDs through modification of risk factors.     

Applications of Complex Systems Science in Obesity and Noncommunicable Chronic Disease Research

Interest in the application of systems science (SS) to obesity and noncommunicable chronic disease (NCD) research has been growing rapidly over the past decade as the epidemic of obesity and NCDs continues to grow globally. This article summarizes the key messages of the presentations made in the special symposium “Applications of Complex Systems Science in Obesity and Noncommunicable Chronic Disease Research,” held during the ASN Scientific Sessions and Annual Meeting at Experimental Biology 2014. Invited leaders from various fields presented cutting-edge aspects of the applications of SS in public health research, with a focus on obesity and NCDs. In addition, the symposium was capped with a discussion on funding opportunities from the NIH. The speakers described the nature of SS, how it could be applied to biomedical and public health research, lessons from SS to inform obesity and NCD interventions, and the promises, challenges, and recommendations going forward.     

Development and status of health insurance systems in China

Health insurance programs have changed rapidly over time in China. Among rural populations, insurance coverage shifted from nearly universal levels in the 1970s to 7% in 1999; it stands at 94% of counties in 2009. This large increase is the result of a series of health reforms that aim to achieve universal access to healthcare and better risk protection, largely through the rollout of the health insurance programs and the gradual increase in subsidies and benefits over time. In this paper, we present the development of the rural and urban health insurance programs, their modes of financing and operation and the benefits and reimbursement schemes at the end of 2009. We discuss some of the problems with the rural and urban residents' schemes including reliance on local government capacity, reimbursement ceilings and rates, and incentives for unnecessary care and waste in the design of the programs. Recommendations include increasing financial support and deepening the benefits packages. Strategies to control cost and improve quality include developing mixed provider payment mechanisms, implementing essential medicines policies and strengthening the quality of primary-care provision.     

Does health insurance mitigate inequities in non-communicable disease treatment? Evidence from 48 low- and middle-income countries

Non-communicable diseases (NCDs) are the greatest contributor to morbidity and mortality in low- and middle-income countries (LMICs). However, NCD care is limited in LMICs, particularly among the disadvantaged and rural. We explored the role of insurance in mitigating socioeconomic and urban–rural disparities in NCD treatment across 48 LMICs included in the 2002–2004 World Health Survey (WHS). We analyzed data about ever having received treatment for diagnosed high-burden NCDs (any diagnosis, angina, asthma, depression, arthritis, schizophrenia, or diabetes) or having sold or borrowed to pay for healthcare. We fit multivariable regression models of each outcome by the interaction between insurance coverage and household wealth (richest 20% vs. poorest 50%) and urbanicity, respectively. We found that insurance was associated with higher treatment likelihood for NCDs in LMICs, and helped mitigate socioeconomic and regional disparities in treatment likelihood. These influences were particularly strong among women. Insurance also predicted lower likelihood of borrowing or selling to pay for health services among the poorest women. Taken together, insurance coverage may serve as an important policy tool in promoting NCD treatment and in reducing inequities in NCD treatment by household wealth, urbanicity, and sex in LMICs.     

Preferences for benefit packages for community-based health insurance: an exploratory study in Nigeria

Background  

It is important that community-based health insurance (CBHI) schemes are designed in such a way as to ensure the relevance of the benefit packages to potential clients. Hence, this paper provides an understanding of the preferred benefit packages by different economic status groups as well as urban and rural dwellers for CBHI in Southeast Nigeria.     

实现人人享有基本医疗卫生服务的关键问题探讨

探讨了基本医疗卫生服务的内涵,提出了基本人力、基本设施、基本药物、基本技术和基本服务规程等五个要素。另外,还介绍了建立卫生体制的基本共识和经验,并对我国建立基本医疗卫生制度提出了建议：增加公共筹资,控制个人支付比例;利用和发挥公立服务机构的作用;促进各类卫生筹资方式融合;促进财政投入政策和价格政策配合;公共投入优先支持和提供预防服务和基层卫生组织提供的初级诊疗服务;发展公立与私立机构、政府保障与商业健康保险之间的合作互补关系;构建精简统一效能的行政管理体制。     

Ultraprocessed Food: Addictive,Toxic, and Ready for Regulation

Past public health crises (e.g., tobacco, alcohol, opioids, cholera, human immunodeficiency virus (HIV), lead, pollution, venereal disease, even coronavirus (COVID-19) have been met with interventions targeted both at the individual and all of society. While the healthcare community is very aware that the global pandemic of non-communicable diseases (NCDs) has its origins in our Western ultraprocessed food diet, society has been slow to initiate any interventions other than public education, which has been ineffective, in part due to food industry interference. This article provides the rationale for such public health interventions, by compiling the evidence that added sugar, and by proxy the ultraprocessed food category, meets the four criteria set by the public health community as necessary and sufficient for regulation—abuse, toxicity, ubiquity, and externalities (How does your consumption affect me?). To their credit, some countries have recently heeded this science and have instituted sugar taxation policies to help ameliorate NCDs within their borders. This article also supplies scientific counters to food industry talking points, and sample intervention strategies, in order to guide both scientists and policy makers in instituting further appropriate public health measures to quell this pandemic.     

关于实行“三位一体”县域慢病防控策略的思考

当前,我国慢病防治工作面临严峻挑战。为有效遏制慢病高发态势,保护和增进人民群众健康,本文分析了农村地区慢病防控管理方面存在的主要问题,提出了＂三位一体＂的县域慢病防控策略的基本思路,即分别实现＂县、乡、村＂三级医疗卫生机构之间、＂防、医、管＂之间、＂体系、体制、机制＂之间的三位一体。实行＂三位一体＂的县域慢病防控策略,首先,实现＂县、乡、村＂三级医疗卫生机构各负其责、分工合作的慢病防控新模式;其次,要实现慢病预防、诊治和管理的有机结合;最后,要加强县域医疗卫生机构能力建设、慢病管理体制建设和完善县域慢病防控运行机制,全面提高医疗卫生服务体系整体功能。     

Burden of Noncommunicable Diseases and National Strategies to Control Them in Korea

Noncommunicable diseases (NCDs) are the most important causes of premature mortality and disability-adjusted life years in Korea. NCDs are also the main contributor to socioeconomic inequalities in mortality and life expectancy. Reduction of NCDs and NCD inequalities would result in significant improvement in healthy life expectancy and health equity in Korea. Major NCD risk factors such as dietary risks (including salt intake), alcohol consumption, cigarette smoking, and high blood pressure were found to be the leading modifiable risk factors of disability-adjusted life years in Korea, based on the 2010 Global Burden of Disease Study. Several Korean studies have shown that these risk factors play an important role in creating socioeconomic inequalities in NCD mortality and total mortality. Current international discussions on NCD policies in the United Nations and the World Health Organization would provide better opportunities for developing aggressive population-wide policy measures in Korea. Considering the paucity of population-wide policies to control major NCD risk factors in Korea, rigorous population approaches such as taxation and regulation of unhealthy commodities as well as public education and mass campaigns should be further developed in Korea.     

Commentary: setting priorities in NCD prevention and control

Decision making in health requires the use of sound evidence and context-specific information, guided by a priority setting methodology or framework. For noncommunicable disease (NCD) prevention and control, a decision-making methodology has been applied by the World Health Organization to delineate priorities, and options for cost-effective NCD interventions. A set of 14 interventions considered very cost-effective, affordable and feasible for implementation in various resource level settings were identified. Among them, tobacco control through taxation, bans on tobacco advertising, plain packaging, and smoke free public spaces stands out as perhaps the single most important interventions to tackle NCDs.     

An Analysis of the Policy Environment Surrounding Noncommunicable Diseases Risk Factor Surveillance in Kenya

Kenya is a developing country in sub-Saharan Africa, facing a triple disease burden, with an increase in non-communicable diseases (NCDs); uncontained infectious diseases; coupled with significant morbidity and mortality from environmental causes such as droughts and flooding. The limelight has been on infectious diseases, leaving few resources for NCDs. As NCDs start to gain attention, it is becoming apparent that essential information on their epidemiology and risk factor trends—key in evidence-based decision-making—is lacking. As a consequence, policies have long relied on information derived from unreliable data sources such as vital registries and facility-level data, and unrepresentative data from small-scale clinical and academic research. This study analyzed the health policy aspects of NCD risk factor surveillance in Kenya, describing barriers to the successful design and implementation of an NCD risk factor surveillance system, and suggests a strategy best suited for the Kenyan situation. A review of policy documents and publications was augmented by a field-study consisting of interviews of key informants identified as stakeholders. Findings were analyzed using the Walt and Gilson policy analysis triangle. Findings attest that no population baseline NCD burden or risk factor data was available, with a failed WHO STEPs survey in 2005, to be undertaken in 2013. Despite the continued mention of NCD surveillance and the highlighting of its importance in various policy documents, a related strategy is yet to be established. Hurdles ranged from a lack of political attention for NCDs and competing public interests, to the lack of an evidence-based decision making culture and the impact of aid dependency of health programs. Progress in recognition of NCDs was noted and the international community and civil society''s contribution to these achievements documented. While a positive outlook on the future of NCD surveillance were encountered, it is noteworthy that overcoming policy and structural hurdles for continued success is imperative.     

Systems Thinking as a Framework for Analyzing Commercial Determinants of Health

Policy Points:

• Worldwide, more than 70% of all deaths are attributable to noncommunicable diseases (NCDs), nearly half of which are premature and apply to individuals of working age. Although such deaths are largely preventable, effective solutions continue to elude the public health community.
• One reason is the considerable influence of the “commercial determinants of health”: NCDs are the product of a system that includes powerful corporate actors, who are often involved in public health policymaking.
• This article shows how a complex systems perspective may be used to analyze the commercial determinants of NCDs, and it explains how this can help with (1) conceptualizing the problem of NCDs and (2) developing effective policy interventions.

Context

The high burden of noncommunicable diseases (NCDs) is politically salient and eminently preventable. However, effective solutions largely continue to elude the public health community. Two pressing issues heighten this challenge: the first is the public health community's narrow approach to addressing NCDs, and the second is the involvement of corporate actors in policymaking. While NCDs are often conceptualized in terms of individual‐level risk factors, we argue that they should be reframed as products of a complex system. This article explores the value of a systems approach to understanding NCDs as an emergent property of a complex system, with a focus on commercial actors.

Methods

Drawing on Donella Meadows's systems thinking framework, this article examines how a systems perspective may be used to analyze the commercial determinants of NCDs and, specifically, how unhealthy commodity industries influence public health policy.

Findings

Unhealthy commodity industries actively design and shape the NCD policy system, intervene at different levels of the system to gain agency over policy and politics, and legitimize their presence in public health policy decisions.

Conclusions

It should be possible to apply the principles of systems thinking to other complex public health issues, not just NCDs. Such an approach should be tested and refined for other complex public health challenges.     

An evaluation of the effects of general practitioner–supported patient noncommunicable diseases control model in Shanghai,China

Noncommunicable diseases (NCDs) are the leading cause of death worldwide. A litmus test for China's health reform is its ability to effectively deal with NCDs. The general practitioners (GPs)–supported NCD control model was designed to address ways to effectively prevent and control NCDs population‐wide. This study aimed to evaluate the GPs‐supported NCD control model and its effect on China's NCD control. The model was structured with three layers of two‐way relationships between patients, GPs, and specialists. The four technologies included the community‐based NCD self‐management model, the electronic clinical‐pathways–supporting community NCD intervention, the largest regional independent medical information system engaged by the Shanghai Healthcare Cloud, and continuous and successive policy intervention. Under the influence of the model, hypertension awareness, treatment, and control were the highest in Shanghai. By 31 August 2017, 131 453 users declined to use the mobile application while 10 444 completed the type 2 diabetes mellitus (T2DM) risk assessment. By 15 August 2017, 249 000 residents had participated in early detection and screening, leading to the identification of 29 304 (11.8%) being in a prediabetic state and 24 422 (9.8%) being newly diagnosed with T2DM. From 2012 to 2016, 208 537 patients were newly identified with hypertension using Internet‐connected devices and hypertension awareness increased 5.7%. After implementing the self‐management interventions, patients' blood pressure was controlled at around 90% (from 2007 to 2015). This pilot model in Shanghai suggested positive social benefits and appears to have played an important role in advancing NCD control in China.     

High Prevalence of Chronic Non-Communicable Conditions Among Adult Refugees: Implications for Practice and Policy

The global rise in non-communicable disease (NCD) suggests that US-based refugees are increasingly affected by chronic conditions. However, health services have focused on the detection of infectious disease, with relatively limited data on chronic NCDs. Using data from a retrospective medical record review of a refugee health program in the urban Northeast (n = 180), we examined the prevalence of chronic NCDs and NCD risk factors among adult refugees who had recently arrived in the US, with attention to region of origin and family composition. Family composition was included because low-income adults without dependent children are at high risk of becoming uninsured. We found that half of the adult refugees in this sample had at least one chronic NCD (51.1%), and 9.5% had three or more NCDs. Behavioral health diagnoses were most common (15.0%), followed by hypertension (13.3%). Half of adults were overweight or obese (54.6%). Chronic NCDs were somewhat more common among adults from Iraq, but this difference was not significant (56.8 vs. 44.6%). Chronic NCDs were common among adults with and without dependent children (61.4 vs. 44.6%, respectively), and these two groups did not significantly differ in their likelihood of having a chronic NCD after adjustment for age and gender (AOR = 0.78, 95% CI = 0.39, 1.55). This study suggests that chronic NCDs are common among adult refugees in the US, including refugees at high risk for uninsurance. We propose that refugee health services accommodate screening and treatment for chronic NCDs and NCD risk factors, and that insurance outreach and enrollment programs target recently arrived refugees.     

Non-communicable diseases and human rights: Global synergies,gaps and opportunities

The incorporation of human rights in health policy and programmes is known to strengthen responses to health problems and help address disparities created or exacerbated by illness yet this remains underexplored in relation to non-communicable diseases (NCDs). Aiming to understand existing synergies and how they might be further strengthened, we assessed the extent to which human rights are considered in global NCD policies and strategies and the degree of attention given to NCDs by select United Nations human rights mechanisms. Across global NCD policies and strategies, rhetorical assertions regarding human rights appear more often than actionable statements, thus limiting their implementation and impact. Although no human rights treaty explicitly mentions NCDs, some human rights monitoring mechanisms have been paying increasing attention to NCDs. This provides important avenues for promoting the incorporation of human rights norms and standards into NCD responses as well as for accountability. Linking NCDs and human rights at the global level is critical for encouraging national-level action to promote better outcomes relating to both health and human rights. The post-2015 development agenda constitutes a key entry point for highlighting these synergies and strengthening opportunities for health and rights action at global, national and local levels.     

Protecting policy space for public health nutrition in an era of international investment agreements

Philip Morris has recently brought claims against Australia (2011) and Uruguay (2010) under international investment agreements (IIAs). The claims allege that Philip Morris is entitled to compensation following the introduction of innovative tobacco packaging regulations to reduce smoking and prevent noncommunicable diseases (NCDs). Since tobacco control measures are often viewed as a model for public health nutrition measures, the claims raise the question of how investment law governs the latter. This paper begins to answer this question and to explain how governments can proactively protect policy space for public health nutrition in an era of expanding IIAs. The authors first consider the main interventions proposed to reduce diet-related NCDs and their intersection with investment in the food supply chain. They then review the nature of investment regimes and relevant case law and examine ways to maximize policy space for public health nutrition intervention within this legal context. As foreign investment increases across the food-chain and more global recommendations discouraging the consumption of unhealthful products are issued, investment law will increase in importance as part of the legal architecture governing the food supply. The implications of investment law for public health nutrition measures depend on various factors: the measures themselves, the terms of the applicable agreements, the conditions surrounding the foreign investment and the policies governing agricultural support. This analysis suggests that governments should adopt proactive measures – e.g. the clarification of terms and reliance on exceptions – to manage investment and protect their regulatory autonomy with respect to public health nutrition.     

The World Health Organization STEPwise Approach to Noncommunicable Disease Risk-Factor Surveillance: Methods,Challenges, and Opportunities

Objectives. We sought to outline the framework and methods used by the World Health Organization (WHO) STEPwise approach to noncommunicable disease (NCD) surveillance (STEPS), describe the development and current status, and discuss strengths, limitations, and future directions of STEPS surveillance.Methods. STEPS is a WHO-developed, standardized but flexible framework for countries to monitor the main NCD risk factors through questionnaire assessment and physical and biochemical measurements. It is coordinated by national authorities of the implementing country. The STEPS surveys are generally household-based and interviewer-administered, with scientifically selected samples of around 5000 participants.Results. To date, 122 countries across all 6 WHO regions have completed data collection for STEPS or STEPS-aligned surveys.Conclusions. STEPS data are being used to inform NCD policies and track risk-factor trends. Future priorities include strengthening these linkages from data to action on NCDs at the country level, and continuing to develop STEPS’ capacities to enable a regular and continuous cycle of risk-factor surveillance worldwide.The global burden of chronic, noncommunicable diseases (NCDs)—largely heart disease, stroke, cancer, chronic respiratory disease, and diabetes—is increasing rapidly and will have significant social, economic, and health consequences unless urgently addressed. In 2012, the major NCDs accounted for 63% of all deaths, representing 38 million deaths a year. Eighty percent of these deaths are already occurring in low- and middle-income countries.1 Because NCDs are largely preventable, these deaths can be significantly reduced.To address this global health problem, in 2013, the World Health Assembly—the decision-making body of the World Health Organization (WHO)—adopted a Global Monitoring Framework for NCDs with 25 key indicators to track progress in prevention and control of NCDs. The World Health Assembly also agreed on a set of global voluntary targets linked to the Global Monitoring Framework to prevent and control NCDs by 2025, including a target to reduce premature mortality from the 4 main NCDs by 25%, and targets for the main behavioral and metabolic NCD risk factors and 2 health systems targets.2 Furthermore, in 2015, the 2030 Agenda for Sustainable Development recognizes the importance of addressing NCD issues with the inclusion of a similarly ambitious target to reduce the number of premature deaths from NCDs by one third by 2030.3The key to controlling the global epidemic of NCDs and meeting these ambitious but achievable NCD targets is primary prevention based on comprehensive population-wide programs. Effective prevention of NCDs is possible through identification of the major common risk factors and their prevention and control.4–6A few common and preventable risk factors underlie most NCDs. These NCD risk factors are the leading cause of the death and disability burden in all countries, regardless of their economic development status. The leading behavioral risk factors for NCDs are tobacco use, harmful alcohol consumption, unhealthy diet including high salt and sodium intake, physical inactivity, and overweight and obesity, and the leading physiological risk factors are raised blood pressure, raised blood glucose, and abnormal blood lipids.7,8Recognizing a global need for risk-factor data on these key NCD risk factors, WHO initiated the STEPwise approach to surveillance (STEPS) in 2002. The key goals of STEPS are to guide the establishment of risk-factor surveillance systems in countries by providing a framework and approach; to strengthen the availability of data to help countries inform, monitor, and evaluate their policies and programs; to facilitate the development of population profiles of NCD risk-factor exposures; to enable comparability across populations and across time frames; and to build human and institutional capacity for NCD surveillance.9,10Since its inception, the STEPS approach has advocated that small amounts of good-quality data are more valuable than large amounts of poor-quality data.10 The STEPS approach supports monitoring a few modifiable NCD risk factors that reflect a large part of the future NCD burden and that can indicate the impact of interventions considered to be effective in reducing the leading NCDs. Because STEPS also promotes the collection of data on a number of different risk factors, it has the benefit over single risk factor surveys in that it allows an understanding of how risk factors cluster within a population and offers an opportunity for countries to estimate the small proportion of the population with high overall risk of a cardiovascular event for referral for possible treatment.9,10Our objective was to outline the framework and methods used by STEPS, to describe the development and current status of STEPS, to discuss the strengths and limitations of STEPS surveillance, and to highlight future directions.     

Noncommunicable Diseases and Human Rights: A Promising Synergy

Noncommunicable diseases (NCDs) have finally emerged onto the global health and development agenda. Despite the increasingly important role human rights play in other areas of global health, their contribution to NCD prevention and control remains nascent.The recently adopted Global Action Plan for the Prevention and Control of NCDs 2013–2020 is an important step forward, but the lack of concrete attention to human rights is a missed opportunity.With practical implications for policy development, priority setting, and strategic design, human rights offer a logical, robust set of norms and standards; define the legal obligations of governments; and provide accountability mechanisms that can be used to enhance current approaches to NCD prevention and control. Harnessing the power of human rights can strengthen action for NCDs at the local, national, and global levels.Noncommunicable diseases (NCDs), responsible for more than two thirds of all deaths each year and mostly occurring in low- and middle-income countries, are finally on the global health and development agenda.1 Despite the inclusion of human rights in the guiding principles of the recently adopted World Health Organization (WHO) Global Action Plan for the Prevention and Control of NCDs 2013–2020, the objectives, targets, and indicators of the NCD Global Monitoring Framework attached to this plan, do not take human rights into account.1 Human rights play an increasingly important role in other parts of the global health agenda, but their contribution to NCD prevention and control has yet to be fully recognized.Public health and human rights share a common concern for ensuring the conditions in which people can live healthy lives. Human rights offer a logical, robust set of norms and standards; define the legal obligations of governments; and add accountability mechanisms to traditional public health strategies. These government commitments impose minimum standards on all sectors of development, including health, with practical implications for policy development, priority setting, and strategic design.Public health policies and actions often integrate aspects of human rights in their strategies and practices such as avoidance of cruel, inhuman, or degrading treatment and respect for privacy, although they are often cast in ethical terms. Evidence from mental health,2 HIV/AIDS,3 maternal and child health,4 reproductive health,5 and public health efforts more generally6 have shown that sustained attention to human rights can improve service delivery, focus attention on marginalized populations, mobilize resources, improve laws and policies, and enhance equality, equity, inclusiveness, and accountability.By encouraging participation in health programs and targeting barriers to public health such as discrimination and inequality, incorporation of human rights in public health strategies favorably impacts health awareness, health-seeking behaviors, and health outcomes. Policies that respect human rights help governments fulfill their duties, help medical and public health professionals achieve their goals, and help people realize their rights and live healthier lives.Clarifying how human rights could be included in the NCD response can help guide implementation of WHO’s Global Action Plan. There are 4 areas in which the congruence of public health and human rights can enhance the response to NCDs. First, policies, laws, strategies, and practices in such realms as the environment; the food, tobacco, and pharmaceutical industries; and the educational sector can promote healthy diets and lifestyles by imposing stringent, evidence-based standards. Examples include the US Food and Drug Administration’s regulations on salt content in foods,7 the European Charter on Counteracting Obesity,8 and the adoption and implementation of the Framework Convention on Tobacco Control.9The causes of ill health, along with their determinants and outcomes, can be framed around human rights principles, norms, and standards emphasizing equality, nondiscrimination, a focus on the most vulnerable populations, participation of affected groups, and access to technologies. Such linkages have been made in public reports and documents on diabetes in Canada,10 exposure to carcinogenic products in the workplace in the United Kingdom,11 and prevention of cervical cancer in the United States.12 At the global level, a useful resource for promoting attention to NCDs in human rights reporting mechanisms can be seen in the explicit reference made to NCDs by the Committee on the Rights of the Child, which provides guidance to incorporate children’s right to health into NCD program planning, implementation, monitoring, and evaluation.13Second, as evidenced in a number of areas such as the response to HIV14 and campaigns aimed at reducing NCD morbidity and mortality among aboriginal communities,15 facilities, goods, and services are required at every stage of risk factor and disease management for there to be a meaningful, culturally sensitive response to NCDs that complies with human rights principles. This includes appropriate technologies and essential medicines and vaccines that are available, accessible, acceptable, and of optimal quality.16 Protection of human rights in the identification of predictors of vulnerability to NCDs as well as in their detection and treatment requires focused attention on and support for marginalized populations directly affected by NCDs, including children, people with disabilities, indigenous populations, elderly individuals, and groups that are socially, culturally, or economically excluded from mainstream society.Third, although WHO’s NCD Global Monitoring Framework includes monitoring of national policies relating to, for example, the food industry, it would benefit from equal attention to the degree to which such policies are implemented and whether accountability mechanisms exist to monitor and review progress and, if necessary, ensure remedial action in relation to all relevant actors.17Finally, accountability at the subnational, national, and international levels can be advanced through use of the mechanisms being established specifically to address NCDs but will also benefit from more robust use of the existing United Nations (UN) human rights machinery (e.g., universal periodic reporting to the UN Human Rights Council and UN human rights treaty bodies). The UN’s Committee on Economic, Social and Cultural Rights, for example, requests that countries report on measures taken

to prevent the abuse of alcohol and tobacco [and] to ensure affordable access to essential drugs, as defined by the WHO, including … medicines for chronic diseases.18

The committee then helps ensure accountability in terms of what a country does and does not do to fulfill its human rights obligations in this regard. For example, the committee has requested that a diverse range of countries, including Cameroon, Estonia, and Mauritius, evaluate their strategies to combat NCDs, especially tobacco use, obesity, and diabetes, and subsequently report to the committee on their progress.Other components of the human rights system should be encouraged to focus more explicit attention on NCDs. The special rapporteur on the right to the highest attainable standard of physical and mental health, for example, should produce a report on NCDs, and the UN Human Rights Council should place NCDs on its agenda. A subset of core indicators for the purpose of monitoring the public health and human rights response to NCDs should be developed for common use by these mechanisms. These indicators could include tracking of progress in the fulfillment of human rights objectives among affected populations, for example progress in equality, equity, and nondiscrimination in access to needed goods and services and participation among people living with or affected by NCDs in policies and actions intended for their benefit.If human rights policies are to truly strengthen NCD prevention and control, there must be conscious attention to rights from the grassroots level up to the highest levels of leadership. Furthermore, attention to rights is required across all sectors of program design, monitoring, and evaluation with respect to service delivery, underlying NCD risk factors, and the social, economic, or environmental determinants that may influence risk behaviors.Finally, as has been learned in efforts focusing on HIV and sexual and reproductive health, attention to the aforementioned issues is necessary but not sufficient. Also critical are an enabling legal and policy environment, political will, donor support, and a dynamic and active civil society capable of playing an advocacy role, providing services, and serving a “watchdog” function. Harnessing the power of human rights to prevent and control NCDs can galvanize action toward meaningful change, broaden the number of actors and beneficiaries, and help strengthen the foundations for public health in the future.     

Assessing costs and potential returns of evidence-based programs for seniors

The authors describe the customary tools used by health services researchers to conduct economic evaluations of health interventions. Recognizing the inherent challenges of these tools for utilization in contemporary public health practice, we recommend a practical cost-benefit analysis (PCBA) to allow public health practitioners to assess the economic merits of their existing public health programs. The PCBA estimates what health effects and corresponding medical cost avoidance would be required to support the costs associated with implementing a community-based prevention program. We apply the PCBA to evaluate a statewide evidence-based falls prevention program for seniors in Texas. We estimate a positive return on realized costs due to avoided direct and indirect medical expenses if the program averts 7 falls among 140 participants within the first year. While acknowledging the demonstrated health-related benefits of public health interventions, we provide a practical ex-post economic evaluation methodology to assess return on investment as a more simplistic yet effective alternative for public health practitioners versus contemporary analyses of health services researchers.