Progress and challenges in NCD prevention and control in the South-East Asia Region

The Action plan for the prevention and control of noncommunicable diseases in South-East Asia, 2013–2020 adopted the NCD 2025 targets and the 10 NCD progress monitoring indicators. Updated information is available from the global mortality database to track NCD premature mortality, and the NCD country capacity survey carried out in 2021 provides the status of the national response (11).

In the South-East Asia Region, the probability of dying from cardiovascular diseases (CVDs), cancers, diabetes and chronic respiratory diseases between the ages of 30 and 70 years declined from 23.4% in 2010 to 21.6% in 2019, the decline being slightly greater in males than in females (Fig. 2). At the current rate of decline, the region is not on track to achieve the 2025 NCD and the 2030 SDG 3.4 targets. The ongoing COVID-19 pandemic may have impacted trends and indicates the clear need for an acceleration of NCD prevention and control.

Fig. 2. Trends in probability of premature mortality due to NCDs in the South-East Asia Region (2000–2019)

Fig. 3 presents the status of NCD progress monitoring for countries in the South-East Asia Region based on data collected in 2021 (11). Progress is monitored within the objectives of the Action plan for the prevention and control of noncommunicable diseases in South-East Asia, 2013–2020 (9).

Countries in the Region have prioritized prevention and control of NCDs and, in 2021, 10 of the 11 countries had set time-bound national targets and had an operational multisectoral national strategy or action plan.

Tobacco use, harmful use of alcohol, unhealthy diet, physical inactivity and air pollution are the five risk factors common to NCDs. While most countries have made some progress in policy development for the five risk factors included in the regional action plan, progress is uneven across risk factors and between countries. There is still a substantial policy gap between the current level and the best achievable level; this needs to be closed as soon as possible in order to control the risk factors and achieve the targets by 2030.

In 2021, six countries had implemented standardized packaging and/ or graphic health warnings on all tobacco packages, while only two countries had enforced comprehensive bans on tobacco advertising, promotion and sponsorship. Similarly, according to MPOWER (12), all countries had initiated tobacco reduction measures, although some were only partially achieved. The information collected, however, does not constitute a thorough and complete legal analysis of each country’s legislation, and information may be incomplete about Member States where subnational governments play an active role in tobacco control.

The policy commitment from countries to address obesity is strong; the Strategic action plan to reduce the double burden of malnutrition in the South-East Asia Region 2016–2025 (13) was endorsed at the 69th session of the WHO Regional Committee for South-East Asia Region (14). The mid-term assessment of the plan showed progress in strengthening policy and legislative frameworks to address the food environment as well as surveillance, but significant resource constraints exist.

Reduction of salt consumption at the population level is a cost-effective “best buy” intervention. Ten countries have set national salt/sodium reduction targets aligned to the Global action plan for the prevention and control of noncommunicable diseases 2013–2020 (15), and have identified baseline population mean salt/sodium intake. However, progress on reducing salt/sodium consumption is slow. Three countries have implemented front-of-pack labelling to empower consumers to make healthier choices. Four countries have implemented settings based actions to reduce salt, and two countries have initiated actions to reformulate foods. The major source of salt/sodium in the region is through discretionary salt, and six countries have implemented national public education and awareness campaigns.

In 2021, one country had partially achieved adoption of national policies that limit saturated fatty acids to eliminate industrially produced trans fatty acids (TFA). However, best practice policies to eliminate trans fatty acids had been legislated in two more countries by 2022, and three other countries were making progress towards elimination of trans fatty acids.

As reported in 2019, almost half the countries in the Region had imposed bans on advertisements and restrictions on the physical availability of alcohol, according to SAFER – an action package prioritizing five high-impact interventions outlined in the Global strategy to reduce harmful use of alcohol (16). Overall, the SAFER composite score varied from 31.3 to 68.3 for countries in the Region (17). This shows substantial policy space to further strengthen policies to prevent alcohol-related morbidity and mortality in the Region.

The roadmap for implementing the global action plan on physical activity in the WHO South-East Asia Region supports countries on initiatives to address physical inactivity (18). Six countries have taken up national communication campaigns to promote physical activity. Activities in schools and workplaces are also progressing in different parts of the Region, often through the health-promoting schools and the healthy cities platforms, which support comprehensive actions for risk factor reduction.

About 63% of households in the Region still rely on solid fuels, which leads to unacceptable levels of household air pollution. More than 92% of the cities in the Region recorded PM2.5 levels much higher than WHO air-quality guideline levels. As of 2021, 11 cities across four countries had joined the BreatheLife Network, which is promoting and sharing clean air solutions that will have significant impact on people living in these cities, now and in the future (19). Fuel subsidies and other programmes have helped to double the rate of access to clean cooking in two countries.

Progress has been made in most Member States in strengthening health systems for NCDs. Evidence-based national guidelines for the management of major NCDs through a primary care approach were reported from seven countries in the 2022 NCD progress monitor, while three reported a partially implemented approach. Coverage of drug therapy and counselling for eligible persons at high risk was reported by only three countries. Most of the progress was made by improving the availability of needed diagnostics and medicines in primary health care facilities in the public sector (20).

Among the four NCDs, diabetes is showing an increasing trend, and the premature mortality attributable to diabetes mellitus is also on the increase. There are major gaps in the detection, diagnosis and management of the disease which need urgent attention. Gestational diabetes mellitus (GDM) needs more attention, as GDM has increased risk for future diabetes in women. The offspring of women with GDM are also at higher risk of developing cardiometabolic diseases such as heart attack, stroke, diabetes mellitus, insulin resistance and nonalcoholic fatty liver disease. Hypertension control has been taken up recently in some countries and has demonstrated that it is possible to improve the care cascade (21).

CVD, including stroke, is still the main contributor to premature NCD mortality. In addition to preventing the occurrence of heart attack and stroke, adequate infrastructure, capacity and financial protection models are needed to provide acute care and to prevent mortality.

Cancer as a cause of death is on the increase, and lung, breast, oral, cervix and colorectal cancers are of concern. Tobacco smoking and chewing needs more work to reduce tobacco-related cancers. WHO global initiatives on cervical, breast and childhood cancers are being taken up in the Region. Human papillomavirus (HPV) vaccination can help to reduce the incidence of cervical cancer, along with screening and management.

Palliative care is a critical area and efforts are ongoing in all countries, but more work is needed to expand the coverage of palliative care to everyone who needs it.

Member States have made progress in improving monitoring and surveillance for NCDs, with most countries in the Region having conducted at least one population-based survey in the past five years. Progress in developing systems for reliable cause-specific mortality data is still very slow due to inadequate practices for medical certification of “cause of death” for institutional deaths, and a very high proportion of deaths taking place at home.

A review of multisectoral policies and actions in South-East Asia Region in 2018 observed the different approaches used in the Member States (22). The following challenges were identified for effective NCD governance and multisectoral response – diverse sectoral priorities, lack of subnational coordination, limited human resources, unclear expectations to and from collaborators, financial constraints, political challenges and industry interference. The Region has made progress, and a summary SWOT analysis indicates that there are some challenges, but there are more opportunities and strengths to advance the work on NCD prevention and control (Fig. 4).

SWOT analysis

Fig. 4. SWOT analysis of NCD prevention and management in the South-East Asia Region