WHO DISCUSSION PAPER FOR THE REGIONAL EXPERT CONSULTATIONS

(Version dated 20 August 2021)

DEVELOPMENT OF AN IMPLEMENTATION ROADMAP 2023–2030 FOR THE GLOBAL

ACTION PLAN FOR THE PREVENTION AND CONTROL OF NCDS 2013–2030

1. This WHO Discussion Paper will serve as an input into regional technical consultations with experts
aimed at providing the WHO Secretariat with advice on the current scientific knowledge, available
evidence, and reviews of regional experience in the prevention and control of NCDs. The advice provided
will enable the WHO Secretariat to finalize its work on the development of Annex 1 of the report of the
WHO Director-General on NCDs to the 150th session of the WHO Executive Board (EB150). Annex 1
will cover the contours of the roadmap for approval by the Member States, as well as the steps that the
Secretariat will take to complete the roadmap before the end of 2022 as a technical product.

Mandate

2. Decision WHA74(10) requested the WHO Director-General to submit “an implementation roadmap
2023–2030 for the global action plan for the prevention and control of noncommunicable diseases 2013–
2030, through the Executive Board at its 150th session, and subsequent consultations with Member States1
and relevant stakeholders, for consideration by the Seventy-fifth World Health Assembly”.

Context

3. WHO’s Global Health Estimates 2020 revealed that deaths from NCDs are on the rise. Globally, 7
of the top 10 causes of death in 2019 were noncommunicable disease, which is an increase from 4 of the
top 10 causes in 2000. These seven causes accounted for 44% of all deaths or 80% of the top 10. However,
all NCDs together accounted for 74% of deaths globally in 2019. The world’s biggest killer is ischaemic
heart disease, responsible for 16% of the world’s total deaths. Addressing the increasing burden of NCD
morbidity and mortality needs to reflect in the primary health care (PHC) and universal health coverage
(UHC) agendas and should be central to the achievement of the WHO’s Thirteenth General Programme of
Work (GPW13) Triple Billion targets.2

4. WHO’s World Health Statistics 2020 revealed that, compared with the advances against
communicable diseases, progress in preventing and controlling premature death from NCDs has been
inadequate. An estimated 15 million people worldwide died of NCDs between the ages of 30 and 70 years,
defined as premature death. The probability (risk) of premature death from any one of the four main NCDs
decreased by 18% globally between 2000 and 2016. The most rapid decline was seen for chronic respiratory
diseases (40% lower), followed by cardiovascular diseases and cancer (both 19% lower). Diabetes,
however, showed a 5% increase in risk of premature mortality during the same period.

5. Despite the rapid progress made between 2000 and 2010 in reducing the risk of premature death from
any one of the four main NCDs, the momentum of change has dwindled during 2010–2016, with annual
reductions in premature mortality rates slowing for the main NCDs. In high-income countries, even though
the premature death rate for diabetes decreased from 2000 to 2010, it increased in 2010–2016. In low- and
middle-income countries, the premature death rate due to diabetes increased across both periods.

6. In February 2021, most countries reported disruptions in services related to mental health services
(45%) and noncommunicable diseases (37%). These disruptions relate to preventive services such as
cancer screening, as well as to treatment services, such as cancer treatment, hypertension management, and
rehabilitation services. Preliminary estimates suggest the total number of global deaths attributable to
COVID-19 in 2020 due to these disruptions to be at least 3 million, with similar estimates expected for

1 And, where applicable, regional economic integration organizations.

2 https://apps.who.int/iris/bitstream/handle/10665/324775/WHO-PRP-18.1-eng.pdf

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2021.1,1 Preliminary studies seem to indicate that the majority of these deaths were due co-morbidities
with NCDs.

7. At least half of the world’s population still do not have full coverage of essential health services for
NCDs, and over 800 million people spend at least 10 per cent of their household budgets to pay for health.1 .
Many countries struggling to find the right balance between progressively covering additional people with
nationally-determined sets of integrated quality health services at all levels of care for prevention, diagnosis,
treatment and care in a timely manner, with a view to covering all people by 2030, and trade-offs between
siloed approaches to health systems strengthening, health security and vertical disease programme planning,
budgeting, implementation and evaluation, and strengthening PHC as the cornerstone of a sustainable health
system for UHC. This is leading to setbacks in health outcomes for NCDs and efforts to achieve UHC with
the impacts being disproportionately borne by millions of people living with or at risk of NCDs, in particular
those living in poverty, those in the most productive years of their life, older people, those with disabilities,
migrants and those who have been forcibly displaced.

8. The implementation roadmap 2023–2030 for the prevention and control of NCDs will be linked to
the 2030 SDG agenda focused on recovery from the COVID-19 pandemic. The roadmap will bring clearly
articulated and measurable added value, and enable results at scale, to support countries survive and thrive
in the next frontier for the prevention and control of NCDs, in response to new developments.

a. Political commitments since 2013. The adoption of commitments at the United Nations General
Assembly (UNGA) on the prevention and control of NCDs in 2014, 2015, 2018 and 20192; the provision
of guidance by the World Health Assembly (WHA) since the endorsement of the WHO global action
plan for the prevention and control of noncommunicable diseases 2013–2020 (NCD GAP) in 2013;3
and the decision WHA72(11) in 2019 to extend the period of the action plan to 20304 in order to ensure
its alignment with the 2030 Agenda for Sustainable Development.

b. Shifts in epidemiological patterns. Progress in preventing and treating communicable diseases

(especially those that tend to kill younger people) has seen them decline relative to noncommunicable
diseases and injuries. This progress has led to an ageing global population – a trend that will continue
as more people live longer. More than 15 million of all deaths attributed to NCDs occur between the
ages of 30 and 69 years. Of these "premature" deaths, 85% are estimated to occur in low- and middle-
income countries.

c. Every country can achieve the global NCD targets. The world is not on track to achieve objectives
of the NCD GAP and SDG target 3.4 on NCDs. Despite the global attention paid to NCDs over the
past two decades, progress toward reducing the burden of NCDs has been slow. In 2020, only 31
Member States were on track to achieve a 33% reduction in risk of premature mortality from NCDs by
2030 against a 2015 baseline (SDG target 3.4.1). Progress towards the 9 voluntary global targets set
for 2025 against a 2010 baseline is also not on track. Furthermore, with the exception of tobacco use,
there has not been a significant change in the trends for NCD risk factors across the WHO regions over
the past decade5. However, pathway analyses show that every country still has options for achieving
global NCD targets addressing prevention and treatment.6

d. Increasing number of complex emergencies causing the death of people living with NCDs:
Noting that the increasing number of complex emergencies is hindering the achievement of universal
health coverage, Member States committed to strengthen the design and implementation of policies,
including for resilient health systems and health services and infrastructure to treat people living with
1 World Health Organization (WHO), “Universal health coverage (UHC)”, 24 January 2019, available at www.who.int/en/news-
room/ fact-sheets/detail/universal-health-coverage-(uhc).
2 See h https://undocs.org/en/A/RES/74/2
3 Resolution WHA66.10
4 Decision WHA72(11)
5 World Health Statistics 2020 Visual summary. https://www.who.int/data/gho/whs-2020-visual-summary
6 NCD Countdown Collaborators. NCD Countdown 2030: pathways to achieving Sustainable Development Goal target 3.4.

Lancet. 396:918-934, 2020.

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 non-communicable diseases and prevent and control their risk factors in humanitarian emergencies,
including before, during and after natural disasters, with a particular focus on countries most
vulnerable to the impact of climate change and extreme weather events1;

e. Recommendations available from the mid-point evaluation to guide corrective measures: In line
with paragraph 60 of the NCD GAP, the 2020 mid-point evaluation2 identified major limitations to
implementation and made recommendations. The roadmap will also serve as a response to this
evaluation, “taking corrective measures where actions have not been effective, and to reorient parts of
the plan, as appropriate.”

f. Recovery from the COVID-19 pandemic. At least half of the world’s population do not have full
coverage of essential health services for the prevention and control of NCDs. The COVID-19 pandemic
has affirmed the importance of basic public health, and strong health systems and emergency
preparedness, as well as the resilience of populations to emergence of a new virus or pandemic. These
considerations lend ever greater urgency to the quest for including the prevention and control of NCDs
in UHC. With UHC in place, countries could more effectively and efficiently address the three ways
in which the current health system crisis is directly and indirectly worsening health outcomes for NCDs:
(1) the first is due to a lack of long-term pandemic preparedness and response that recognizes that people
living with or at risk of NCDs are more susceptible to the risk of developing severe COVID-19
symptoms and are among the most affected by the pandemic; (2) the second is due to the inability of
health systems to provide essential health services that meet the health-care needs of people living with
or at risk or NCD, and (3) the third is linked to its socioeconomic impact. There is now a timely
opportunity for COVID-19 to be a new lens through which to see NCDs when seeking to build back
better in the recovery from the pandemic, particularly with regard to integration and alignment with
PHC as the cornerstone for a sustainable health system for UHC.

Purpose of the implementation roadmap

9. The heterogeneity in the epidemiological NCD risk factor and mortality risk profiles, as well as local
socio-cultural and political contexts, suggests that countries might need to take divergent domestic routes
towards achieving the extended NCD GAP targets and SDG target 3.4.1 by 2030. This can be achieved by
accelerating different combinations of interventions for diseases and risk factors specific to the in-country
context.

10. The purpose of the implementation roadmap is, therefore, to encourage Member States to take, in
2023, measures to accelerate progress where actions have not been effective domestically, and to reorient
and accelerate parts of their domestic action plans, as appropriate, with a view to place themselves, in 2023,
on a sustainable path to achieve the 8 voluntary extended global targets and SDG target 3.4.1 by 2030.

11. The global NCD implementation roadmap will serve as an overarching guide for countries, WHO
and other UN System Organizations, and non-State actors to support the acceleration of ongoing national
NCD responses, including through the multisectoral action plans for the period 2023 to 2030 to achieve the
targets set out in paragraph 8, taking into account the new developments set out in paragraph 4.

Scope of the implementation roadmap

12. The roadmap will be a technical product that draws together all WHO recommended interventions
and technical packages for NCD prevention, management, and control.

13. The extended NCD GAP 2013–2030 with the 6 specific objectives will remain as the framework for
countries’ NCD response plans. Nine voluntary global targets were initially set to be achieved by 2025
against a 2010 baseline. In addition, there are 25 indicators within the NCD Global Monitoring Framework

1 in line with A/RES/73/2

2 https://apps.who.int/gb/ebwha/pdf_files/WHA74/A74_10Add1-en.pdf

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(GMF)1, a further nine action plan implementation progress indicators, and 10 commitment fulfilment
progress indicators, established by the WHO Secretariat in response to requests from the WHA. The
roadmap will also align and contribute to the WHO GPW 13, PHC and UHC frameworks.

14. The NCD premature mortality target 1 in the NCD GAP will be extended to a one third reduction in
risk of dying from an NCD between the ages of 30 and 70 (from 2015 levels), and aligned with the SDG
target 3.4 on NCDs for 2030.4 All other NCD GAP targets, will continue to be measured against the agreed
2010 baseline, and represent an extension based on the average annual reduction for five additional years
from 2025 to 2030, reflecting the consideration that the original targets were estimated based on the
historical performance of the top ranked 10th percentile of countries over a 10 year period, with an
allowance of five additional years for countries to scale up their monitoring systems. Where specific targets
have been updated through newer mandates, these new values will be adopted. All indicators remain
consistent with the exception of the indicator for the target on prevention of heart attack and stroke, which
is updated to reflect new CVD risk protection charts that were developed more recently (Table 1). Appendix
1 has more details on the updated NCD GMF and targets.

Table 1. NCD Global Monitoring framework extended to 2030

Domain Outcome Target 2025 Indicator Extension to 2030

Mortality Premature A 25% relative Unconditional probability Target extended to a one third
mortality from reduction in the of dying between ages of relative reduction in the overall
noncommunicable overall mortality 30 and 70 from mortality from cardiovascular
disease from cardiovascular cardiovascular diseases, diseases, cancer, diabetes, or
diseases, cancer, cancer, diabetes or chronic respiratory diseases.
diabetes, or chronic chronic This target is adapted as per the
respiratory diseases respiratory diseases SDG target on NCDs and with
2015 as the baseline and an
extrapolation of the 25% relative
reduction to 2030 making it 33.3%.
Behavioural Harmful use of At least 10% Total (recorded and Target extended to a 20% relative
risk factors alcohol relative reduction in unrecorded) alcohol per reduction in harmful use of
the harmful use of capita (aged 15+ years alcohol. The proposed revision of
alcohol, as old) consumption within the target is under the draft action
appropriate, within a calendar year in litres plan on alcohol that will be
the national context of pure alcohol, as considered by EB 150 and
appropriate, within the WHA75.
national context
Physical inactivity A 10% relative Age-standardized Target extended to a 15% relative
reduction in prevalence of reduction in prevalence of
prevalence of insufficiently physically insufficient physical activity as
insufficient physical active persons aged 18+ part of the Global Action Plan on
activity years (defined as less Physical Activity adopted by MS at
than 150 minutes of WHA May 2018.
moderate-intensity
activity per week, or
equivalent)
Salt/sodium intake A 30% relative Age-standardized mean Target extended to a 40% relative
reduction in mean population intake of salt reduction in mean population
population intake of (sodium chloride) per day intake of salt/sodium
salt/sodium in grams in persons aged
18+ years
Tobacco use A 30% relative Age-standardized Target extended to a 40% relative
reduction in prevalence of current reduction in prevalence of
prevalence of tobacco use among current tobacco use
current tobacco use persons aged 18+ years
Biological Raised blood A 25% relative Age-standardized Target extended to a 33% relative
risk factors pressure reduction in the prevalence of raised reduction in the prevalence of
prevalence of raised blood pressure among raised blood pressure
blood pressure or persons aged 18+ years
(defined as systolic blood

1Noncommunicable Diseases Global Monitoring Framework: Indicator Definitions and Specifications.

https://www.who.int/publications/i/item/ncd-gmf-indicator-definitions-and-specifications

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 contain the pressure ≥140 mmHg
prevalence of raised and/or diastolic blood
blood pressure, pressure ≥90 mmHg) and
according to mean systolic blood
national pressure
circumstances
Diabetes and obesity Halt the rise in Age-standardized Halt the rise in diabetes and
diabetes & obesity prevalence of raised obesity (No change)
blood glucose/diabetes
among persons aged 18+
years (defined as fasting
plasma glucose
concentration ≥ 7.0
mmol/l (126 mg/dl) or on
medication for raised
blood glucose)

Age-standardized
prevalence of overweight
and obesity in persons
aged 18+ years (defined
as body mass index ≥ 25
kg/m² for overweight and
body mass index ≥ 30
kg/m² for obesity)

National Drug therapy to At least 50% of Proportion of eligible No change for this coverage target
systems prevent heart attacks eligible people persons (defined as aged however the indicator is updated to
response and strokes receive drug therapy 40 years and older with a reflect new CVD risk projection
and counselling 10-year cardiovascular charts: Proportion of eligible
(including risk ≥30%, including persons (defined as aged 40 years
glycaemic control) those with existing and older with a 10-year
to prevent heart cardiovascular disease) cardiovascular risk ≥20%,
attacks and strokes receiving drug therapy including those with existing
and counselling cardiovascular disease) receiving
(including glycaemic drug therapy and counselling
control) to prevent heart (including glycaemic control) to
attacks and strokes prevent heart attacks and strokes
Essential NCD An 80% availability Availability and No change for this coverage target.
medicines of the affordability of quality,
and basic affordable basic safe and efficacious
technologies to treat technologies and essential
major essential medicines, noncommunicable
noncommunicable including generics disease medicines,
diseases required to treat including generics, and
major NCDs in both basic technologies in
public and private both public and private
facilities facilities

15. Updated data on progress toward meeting the extended targets of the NCD GAP and NCD-related
SDG targets at the global, regional, and country levels will be provided to Member States through a
“NCD dashboard” available on WHO’s website.

16. Prioritization of the most appropriate interventions for countries will be enabled through
development of a web-based tool for identifying the most cost-effective and impactful interventions
specific to the local context.

17. The objectives of the NCD GAP, which were developed within the context of the so-called “4 x 4
NCD agenda,” will be aligned with new commitments1 to reduce air pollution and to promote mental health

1
A/RES/73/2. UN General Assembly 73rd Session. Political declaration of the third high-level meeting of the General Assembly
on the prevention and control of non-communicable diseases.
https://www.un.org/ga/search/view_doc.asp?symbol=A/73/L.2&Lang=E

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and well-being, thus recognizing the expansion of the NCD framework into the so-called “5 x 5 NCD
agenda.”

18. Multisectoral action will be strengthened through adaptation of the seven accelerator themes of the
Global Action Plan for Healthy Lives and Wellbeing for All.1

Contours of the NCD implementation roadmap

Strategic Direction 1: To understand the drivers and trajectories of NCD burden across countries
and epidemiological regions

Evaluating progress in NCD targets in indicators

19. Progress on risk factors control has been heterogeneous across WHO regions and the epidemiological
trends are complex.2Although some declines in risk of premature mortality from NCDs has been achieved,
there has been no overall significant change in the NCD risk factors across the WHO regions over the past
decade.3

20. The seeming discordance between progress toward the mortality indicators and control of NCD risk
factors, combined with the disparities in outcomes between HICs and LMICs, suggests that acceleration
towards meeting all of the 9 voluntary extended targets requires a different approach, and that countries
should prioritize implementation of the interventions that are most appropriate to their specific local and
regional contexts.

21. Prospects for economic development during and beyond the COVID-19 pandemic are heterogenous
across countries and explicit prioritization and implementation of the most cost-effective and impactful
NCD interventions specific to the local context will accelerate progress towards target 3.4.

Identifying barriers to implementing cost-effective interventions across the NCD voluntary targets

22. The mid-point evaluation of NCD GAP carried out in 20204 reports that progress on action plan
indicators has been heterogeneous, with a strong association between progress and increasing country
income group. Countries should systematically examine their progress in introducing evidence-based
national guidelines, protocols and standards for the management of NCDs, including policies for NCD
research and inclusion and consideration for vulnerable groups.

23. Several challenges to implementation of interventions for NCDs were identified in the UNHLM
report on NCDs in 2018. However, not all barriers identified on a global scale are relevant in all settings
and countries should seek to prioritise and address those specific to their local context.

24. The economic effects of the COVID-19 pandemic on NCDs are likely to be substantial but these have
not yet developed fully. The pandemic poses further challenges for creating and maintaining healthy
environments and people living with NCDs are at greater risk of severe illness and death due to COVID-
19. The implementation roadmap will leverage multisectoral actions to “build back better”, by integrating
NCDs interventions into efforts to rebuild resilient health systems, particularly through strengthening PHC
and UHC.
25.

1 Global Action Plan for Healthy Lives and Well-being for All. https://www.who.int/initiatives/sdg3-global-action-plan
2 Noncommunicable diseases country profiles 2018. https://www.who.int/publications/i/item/ncd-country-profiles-2018
3 World Health Statistics 2020 Visual summary. https://www.who.int/data/gho/whs-2020-visual-summary.
4 https://apps.who.int/gb/ebwha/pdf_files/WHA74/A74_10Add1-en.pdf .

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 Strategic Direction 2: Scale-up the implementation of most impactful and feasible interventions
in the national context

2.1 ENGAGE

26. Given the relatively short time remaining to achieve the NCD targets, a more aggressive approach to
NCD control will be needed for many Member States. Countries have to engage with the various actors
responsible for NCD prevention and control, especially in the context of the barriers identified. This will
entail an assessment of progress made coupled with identification of key partnerships for prioritization and
strategies to build on.

27. The Political Declaration of the third high-level meeting of the General Assembly on the prevention and control
of non-communicable diseases in 2018, includes commitments to scale up national NCD responses, and, as
Heads of State and Government, provide strategic leadership for the prevention and control of NCDs by
promoting greater policy coherence and coordination through whole -of-government and health-in-all-
policies approaches and by engaging stakeholders in an appropriate, coordinated, comprehensive and
integrated, bold whole-of-society action and response1.2

28. The Global Coordination Mechanism on the Prevention and Control of NCDs is developing a new
work plan 2022-2025, in consultation with Member States and non-State actors, in a way that is integrated
with the Organization’s work on NCDs.

29. Research and innovation are critical to change the trajectory of NCD prevention and control and will
be facilitated through working with academic partners and research institutions at global, regional and
national levels.

30. UNIATF provides a mechanism for coordination of UN activities and other intergovernmental
organizations to support national responses to the NCD-related SDGs and the NCD GAP. UNIATF provides
support for stronger governance for NCDs at the country level, across governments and the UN system3.

31. Meaningful engagement of people with lived experience of NCDs in the co-creation, co-design,
implementation and accountability will help to deliver the interventions in a people-centred manner.4

32. Countries should maximize the role of private sector in full alignment of FENSA5 and devise clear
rules and rigorous approaches for engagement, which prevent, identify, and manage real or potential
conflicts of interest and ensure that such engagements directly support the specific objectives of national
NCD responses.

../..

1 Paragraph 17 of A/RES/73/2
2Political declaration of the 3rd High-Level Meeting of the General Assembly on the Prevention and Control of Non-
Communicable Diseases : resolution / adopted by the General Assembly
https://digitallibrary.un.org/record/1648984?ln=en#record-files-collapse-header
3 https://www.who.int/groups/un-inter-agency-task-force-on-NCDs.
4 Nothing for Us Without Us. https://apps.who.int/iris/bitstream/handle/10665/340737/9789240023321-

eng.pdf?sequence=1&isAllowed=y.
5 https://www.who.int/about/collaborations/non-state-actors/A69_R10-FENSA-en.pdf

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2.2 ACCELERATE

Web-tool to identify setting priorities for NCD interventions in a country-specific context

33. A recent analysis from the NCD Countdown 2030 collaboration,1 demonstrates that there are multiple
options for each country to achieve the SDG 3.4 target on NCDs, a premise that can be broadly extended to
achieving the extended NCD GAP objectives.

34. A key challenge across most countries is to choose among interventions and mobilise resources to
accelerate the implementation of the most impactful set of interventions.

35. To support countries with prioritising and scaling of interventions, a web-tool will be developed in
2022. The webtool will use evidence on the cost-effectiveness of interventions to identify their impact in
the period up to the SDG target of 2030 and beyond. A visual representation of the scale to which the
intervention can be implemented and the corresponding impact on premature mortality will help countries
to identify a small set of key accelerators tailored to their specific epidemiological situation.2

Accelerate the implementation of NCD ‘Best Buys’ and other recommended interventions

36. WHO ‘Best-Buys’3 are interventions demonstrated in studies to be the most cost-effective and
feasible for implementation, with an average cost-effectiveness ratio of ≤ I$100/DALY averted in low- and
lower middle-income countries. Interventions with an average cost effectiveness ratio > I$ 100 are also
important and may be considered as per the country context. The WHO best buys will be updated as part of
the mandate to WHO from the WHA and will be made available by 2022.

37. In the case of tobacco control, there is a legally binding instrument, the WHO FCTC, that presents a
comprehensive set of measures that its Parties are obliged to implement.

38. WHO with the support of partners has developed special initiatives and technical packages, for
prevention and disease control including rehabilitation, to enable countries to implement evidence-based
interventions. The packages include tools to support local adaptation and implementation. Detailed
descriptions of the available packages and initiatives are available on the website.4

Include NCDS in Primary Health Care for equitable access

39. Seven out of the 10 deaths globally are from NCDs, but NCD prevention and control is the weakest
link in PHC in many countries. The Operational Framework for Primary Health Care5 provides a detailed
guidance for countries to strengthen primary health care systems through intersectoral actions, empowered
people and communities. Countries can accelerate NCD control by placing it as an integral component of
PHC.

Ensure that Universal health coverage and benefit packages includes NCDs

40. Making sure that the most vulnerable groups are given extra priority is the hallmark of fair
distribution. Fair distribution and equity are closely related to the right to health. Every country in the world
has ratified at least one treaty that specifies obligations regarding the right to health. Under international
law, states have an obligation to adopt appropriate measures to realize the right to health or the right to
healthcare on a non-discriminatory basis. Countries have obligations to allocate sufficient resources to
ensure the right to health. In other words, progressive realization of UHC can contribute to progressive

1 NCD Countdown Collaborators. NCD Countdown 2030: pathways to achieving Sustainable Development Goal target 3.4.
Lancet. 396:918-934, 2020.
2 A prototype of the tool will be available in the weblink.
3 https://www.who.int/ncds/management/WHO_Appendix_BestBuys.pdf
4 https://www.who.int/teams/noncommunicable-diseases/governance
5 Operational Framework for Primary Health Care. https://www.who.int/publications/i/item/9789240017832

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realization of the right to health. Current measurement of the UHC coverage index does not reflect NCDs
adequately and will be addressed.

41. Financial risk protection is important, especially in low- and middle-income settings since disease
may cause substantial loss of income or because out-of-pocket expenditure for health services may
impoverish people. Considering the positive value of financial risk protection is particularly relevant for
NCD priority setting because prevention and treatment often implies long-term costs for the patient and
their household.

42. The WHO UHC compendium provides a set of interventions including for NCDs that can be used to
develop national UHC benefit packages.1 UHC is not comprehensive and universal until essential NCD
packages are included.
Sustainable financing

43. Sustainable financing is required for countries to support population-level interventions and to reduce
unmet need for services and financial hardship arising from out-of-pocket payments. Establishment and
progressive strengthening of systems to mobilize and pool adequate resources for health is needed. For low-
income countries where development assistance is significant, it also involves improving the effectiveness
of external funding support. Out-of-pocket expenditure can be reduced only when NCDs are well covered
under financial protection schemes.

44. Countries have committed to implement fiscal measures, as appropriate, aiming at minimizing the
impact of the main risk factors for NCDs2. Countries should, therefore, include health taxes in their revenue
programs and link these to NCD action plans. Within the recommended packages for reducing the use of
tobacco and reducing the harmful use of alcohol, raising taxes on tobacco and alcohol are amongst the most
effective and cost-effective measures, respectively.

45. The UN Multi-Partner Trust Fund to Catalyse Country Action for NCDs and Mental Health, which
was established in 2021 by WHO, UNICEF and UNDP, will be an enabler for implementing the roadmap.

Build back better with innovation and digital solutions

46. Meeting the objectives and targets of the GAP NCD and the SDG-related NCD targets in a post-
COVID-19 world requires a concerted response and integration of the NCD agenda into existing global and
national efforts to rebuild resilient health systems.

47. New technologies, including digital interventions, can be leveraged to scale up screening, early
diagnosis and self-care for people living with NCDs.

48. Innovation is critical to developing and adapting interventions so that they are tailored for
implementation in a context-specific manner. For example, adaptation of technologies and other
interventions with known impact in HICs might be required for cost-effective, culturally acceptable
implementation in LMICs.

49. Most health facilities in LMICS are already stretched beyond their capacity. Service delivery models
will need to be reviewed and repurposed to ensure that basic diagnostics, technology and medicines, along
with a trained workforce in adequate numbers, are available to deliver the interventions for NCDs.

1 UHC Compendium. https://www.who.int/universal-health-coverage/compendium

2
In line with paragraph 21 of A/RES/73/2

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2.3 ALIGN

50. The Global Action Plan for Healthy Lives and Well-being for All1 brings together stakeholders to
ensure strengthening of multisectoral action to accelerate reductions in the global NCD burden. As countries
are advancing multiple SDG targets, this alignment will help to integrate prevention and management of
NCDs within the broader Sustainable Development Agenda.

51. The NCD implementation roadmap will align with the WHO Triple Billion targets according to the
GPW13.

52. The NCD implementation roadmap will recognize that mental disorders and other mental health
conditions contribute to the global NCD burden. The objectives of the Mental Health Action Plan 2013-
2020 have been extended to 2030 and efforts to meet the objectives therein aligns with the expansion of the
4 x 4 NCD framework to the 5 x 5 framework (encompassing mental health and air pollution), as well as
synergizing with the SDG 3.4.2 indicator.2

Strategic Direction 3: Ensure timely and reliable data on NCD risk factors, diseases and
mortality for informed decision making and accountability

3.1 ACCOUNT

53. Monitoring progress is essential to both understanding the implementation and delivery gaps and
achieving the targets, and data and surveillance for the prevention and control of NCDs should be
strengthened. In line with the extension of the NCD GAP to 2030, the NCD GMF targets will also be
extended to 2030. Other components include monitoring of the agreed NCD Progress Monitoring Indicators
and Process monitoring indicators associated with the NCD GAP and related commitments. Appendix 1
provides more details on the monitoring of NCD prevention and control.3

54. Investing in monitoring is essential to have reliable and timely data at national and subnational levels
to prioritize interventions, assess the implementation and to learn the impact. Periodic NCD risk factor
surveys, country capacity assessments, diseases registries as appropriate and reliable vital registration is
critical for NCD prevention and control.

55. WHO will update NCD monitoring and reporting through a web portal to bring together data from
different sources and render it comparable to allow tracking of global, regional and cross-country progress.

56. WHO will work towards reflecting NCD related indicators in health systems performance and access
to healthcare metrics.

57. NCD measures should be included as integral components of the national and subnational health
information systems aligned with the WHO SCORE package.

Potential risks and mitigation measures

58. The impact of the COVID-19 pandemic on health systems and national resources will continue to be
a challenge in many countries in the near, mid, and long term. Prior to the pandemic, most countries had
under-invested in NCD prevention and control, which has persistently manifested as poor progress in
achievement of the NCD-related indicators in the NCD GAP. In many communities, services relating to

1 Stronger Collaboration, Better Health. https://www.who.int/publications/i/item/WHO-DGO-GAP-19-1

2 https://apps.who.int/gb/ebwha/pdf_files/EB144-REC1/B144_REC1-en.pdf#page=19
3 Appendix 1. WHO NCD Accountability Framework, including Global Monitoring Framework for NCD prevention and control

(2021 update) in alignment with the extension of the NCD Global Action Plan to 2030.

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NCDs have been scaled back, at least temporarily, to allow health systems to respond to the pandemic. The
pandemic can also be used as an opportunity to embrace stronger multisectoral action, as well as new models
of service delivery for NCDs including through PHC and UHC and scaled up digital solutions and
innovations.

59. Inequity in prevention and access to health care is a major concern and will need additional targets
on treatment coverage and control of NCDs to guide countries to measure this reliably and take actions to
ensure UHC. Lessons from the HIV/AIDS area is illustrative.

60. The global NCD narrative is fragmented, and the synergy expected between prevention and control
is often lost due to structural organisation, priorities set based on projects and lack of policy coherence.
Country context and readiness should be placed at the centre to ensure that the acceleration is possible to
meet the national targets.

61. The effects of climate change and its impact NCDs are established. However, there are shared
opportunities for multisectoral engagement to tackle climate change that will have mutually beneficial
effects for NCDs.1

62. Declines in ODA for NCDs risks the establishment of sustainable financing, particularly in LMICs.
Domestic resources can be mobilised through strengthening national health care financing, including health
insurance. Win-win solutions such as taxes for unhealthy products can reduce the risks for NCDs and
enhance domestic resources.

RECOMMENDED ACTIONS

63. The recommended actions for Member States to be taken in 2022 include:

a. Assess the current status of domestic NCD GAP implementation against the nine voluntary NCD global
extended NCD targets and the SDG target on NCDs, identify high-impact interventions, and identify
barriers to their implementation and opportunities for acceleration;

b. Strengthen national monitoring and surveillance systems for NCDs and their risk factors for reliable
and timely data.

64. The recommended actions for international partners to be taken in 2022 include:

a. Assist and support WHO in the development and implementation of the roadmap 2013-2030.

65. The actions for the Secretariat to be taken in 2022 include:

a) Complete the work on the development global implementation roadmap and publish the roadmap (as
a technical product -WHO Public Health Good) before the end of 2022;

1) Develop an NCD dashboard, before the end of 2022, to provide a visual summary of all indicators
and to facilitate international comparison of progress;

2) Propose updates to the Appendix 3 of WHO’s global action plan for the prevention and control of
NCDs 2013-20302, in consultation with Member States, UN organizations and non-State actors,
ensuring that the action plan remains based on scientific evidence for the achievement of
commitments for the prevention and control of NCDs, including SDG target 3.4.1, for
consideration by Member States at the World Health Assembly in 2023, through the EB;

1 NCDs & Climate Change: Shared Opportunities for Action.

https://ncdalliance.org/sites/default/files/resource_files/NCDs_%26_ClimateChange_EN.pdf.
2
https://www.who.int/ncds/management/WHO_Appendix_BestBuys.pdf

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 3) Propose updates to the new WHO Impact Framework that will assess the results of the Thirteenth
General Programme of Work, 2019–2023 in its entirety, and its impact on global health, ensuring
that the Framework will track the impact on NCDs, which make up 7 of the world’s top-10 causes
of death;

4) Scale up efforts to strengthen health information systems that include NCDs, and collect quality,
timely and reliable data, including vital statistics, on NCDs, as required to monitor progress in the
universal and inclusive achievement of the global NCD targets;

5) Ensure that the operational framework on strengthening primary health care, will support
countries to meet the healthcare needs of people living with NCDs.

6) Develop a simulation tool, before the end of 2022, using interventions for NCDs which are
updated with the latest evidence and aligned to PHC and UHC frameworks to support countries to
identify priorities based on their national context;

7) To align the various global initiatives, provide integrated country support as per the national
context, and develop a new partnership model in order to support countries in priority setting,
mobilizing resources, building effective national programmes and strengthening health systems so
that they can meet the growing challenges posed by NCDs;

8) Support the health workforce needs of delivering NCD prevention and management. Additional
human resource requirements related to the delivery of NCD prevention, treatment and care
should be reflected in the development and implementation of evidence- and needs-based,
comprehensive and costed health workforce development plans.

9) Support countries to foster research and innovations in implementation of NCD service delivery,
prevention and management.

10) Scale up strategic communication and partnerships to increase demand for NCDs

ACTION BY THE EXECUTIVE BOARD

66. The Board is invited to adopt the recommended actions for Member States, international partners
and the WHO Secretariat (paragraphs 51, 52 and 53), and recommend their endorsement to the World
Health Assembly.

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 APPENDIX 1

WHO NCD ACCOUNTABILITY FRAMEWORK, INCLUDING GLOBAL MONITORING

FRAMEWORK FOR NCD PREVENTION AND CONTROL (2021 UPDATE) IN ALIGNMENT
WITH THE EXTENSION OF THE NCD GLOBAL ACTION PLAN TO 2030

What is the Global Monitoring Framework (GMF) and the Global NCD Targets?

1. In May 2013, the 66th World Health Assembly adopted the comprehensive Global Monitoring
Framework (GMF) for the prevention and control of noncommunicable diseases. The GMF outlined a set
of indicators capable of application across regions and country settings to monitor trends and assess progress
made in the implementation of national strategies and plans on noncommunicable diseases. Member States
have agreed 25 indicators across three areas which focus on the key outcomes, risk factor exposures and
national systems response needed to prevent and control NCDs. Nine areas were selected from the 25
indicators in the Global Monitoring Framework to be targets : one mortality target (previously agreed at
the WHA in May 2012); six risk factor targets (harmful use of alcohol, physical inactivity, dietary sodium
intake, tobacco use, raised blood pressure, and diabetes and obesity), and two national systems targets
(drug therapy to prevent heart attacks and strokes, and essential NCD medicines and technologies to
treat major NCDs). The targets are ambitious, but attainable, and when achieved will represent major
progress in NCD and risk factors reductions. The global NCD targets are intended to focus global attention
on NCDs and would represent a major contribution to NCD prevention and control. In calculating these
targets, the historical performance of the top ranked 10th percentile of countries was assessed to help set
the level of achievement considered possible. Targets were set for 2025, with a baseline of 2010.

2030 Agenda for Sustainable Development, including SDG target 3.4 on NCDs

2. In September 2015 world leaders adopted a set of 17 Sustainable Development Goals (SDGs), with
associated targets, including one for NCDs. The NCD Target (SDG 3.4.1) is: By 2030, reduce by one third
premature mortality from non-communicable diseases through prevention and treatment and promote
mental health and well-being. This target of 33.3% reduction in the probability of dying from the 4 main
NCDs was aligned to the NCD mortality target within the GMF, with 2015 as the common baseline set for
all SDGs.

Extension of NCD Global Action Plan (NCD GAP) for the Prevention and Control 2013-2020 to
2030 by the WHA

3. The NCD GAP was extended to 2030 by the World Health Assembly in May 2019. Considering the
relatively low progress in the achievement of the 9 NCD targets, the WHA has requested WHO to develop
an implementation roadmap to support the implementation of the extended NCD GAP in countries.

Extension of the WHO NCD GMF 2025 to 2030

4. In line with the extension of the NCD GAP to 2030, the NCD GMF targets are also extended to 2030.
The extension is not applied uniformly as there were developments related to specific targets, including the
SDG target, after the GMF was established. However, it is important to have this clarified as the extended
GMF and associated targets form a major component of the monitoring towards achievement of the
accelerated implementation of the NCD GAP. Other components include monitoring of the agreed NCD
Progress Monitoring Indicators and Process monitoring indicators associated with the NCD GAP and
related commitments. Mid-term evaluation of the NCD GAP has made a specific recommendation on
objective 6 on the NCD GAP on monitoring. WHO Secretariat to brief Member States on what monitoring
and reporting implications there are of extending the NCD-GAP to 2030, including what will be reported
in 2025 and what in 2030.

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5. This paper presents the scope of the 9 NCD GMF targets extended to 2030 and additional
considerations in monitoring the implementation of NCD GAP to 2030. All targets, with the exception of
the mortality target as per SDG baselines, continue to be measured against the agreed 2010 baseline, and
represent an extension based on the average annual reduction for five additional years from 2025 to 2030,
reflecting the consideration that the original targets were estimated based on the historical performance of
the top ranked 10th percentile of countries over a 10 year period, with an allowance of five additional years
for countries to scale up their monitoring systems. Where specific targets have been updated through newer
mandates, these new values are adopted. All indicators remain consistent with the exception of the indicator
for the target on prevention of heart attack and stroke, which is updated to reflect new CVD risk protection
charts which were developed more recently. See: WHO Hearts Technical Package, Risk-based CVD
management module: https://apps.who.int/iris/bitstream/handle/10665/333221/9789240001367-eng.pdf.
All targets will be measured by a simple linear trend.

NCD GMF 9 global targets and their extension to 2030

6. The set of nine voluntary global targets extended for achievement by 2030 for the prevention and
control of noncommunicable diseases would be as follows:

Domain Outcome Target 2025 Indicator Extension to 2030

Mortality Premature A 25% relative reduction Unconditional probability of Target extended to a one
mortality from in the dying between ages of 30 and third relative reduction
noncommunicable overall mortality from 70 from cardiovascular in the overall mortality
disease cardiovascular diseases, diseases, cancer, diabetes or from cardiovascular
cancer, diabetes, or chronic chronic diseases, cancer,
respiratory diseases respiratory diseases diabetes, or chronic
respiratory diseases.
This target is adapted as
per the SDG target on
NCDs and with 2015 as
the baseline and an
extrapolation of the 25%
relative reduction to
2030 making it 33.3%.
Behavioural Harmful use of At least 10% relative Total (recorded and Target extended to a
risk factors alcohol reduction in the harmful unrecorded) alcohol per capita 20% relative reduction
use of alcohol, as (aged 15+ years old) in harmful use of
appropriate, within the consumption within a calendar alcohol. The proposed
national context year in litres of pure alcohol, revision of the target is
as appropriate, within the under the draft action
national context plan on alcohol that will
be considered by EB 150
and WHA75.
Physical inactivity A 10% relative reduction Age-standardized prevalence Target extended to a
in of insufficiently physically 15% relative reduction
prevalence of insufficient active persons aged 18+ years in prevalence of
physical activity (defined as less than 150 insufficient physical
minutes of moderate-intensity activity as part of the
activity per week, or Global Action Plan on
equivalent) Physical Activity
adopted by MS at WHA
May 2018.
Salt/sodium intake A 30% relative reduction Age-standardized mean Target extended to a
in mean population intake population intake of salt 40% relative reduction
of salt/sodium (sodium chloride) per day in in mean population
grams in persons aged 18+ intake of salt/sodium
years
Tobacco use A 30% relative reduction Age-standardized prevalence Target extended to a
in of current tobacco use among 40% relative reduction
prevalence of current persons aged 18+ years in prevalence of current
tobacco use tobacco use

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 Domain Outcome Target 2025 Indicator Extension to 2030

Biological Raised blood A 25% relative Age-standardized prevalence of Target extended to a

risk factors pressure reduction in the raised blood pressure among 33% relative reduction
prevalence of raised persons aged 18+ years (defined as in the prevalence of
blood pressure or systolic blood pressure ≥140 raised blood pressure
contain the prevalence mmHg and/or diastolic blood
of raised pressure ≥90 mmHg) and mean
blood pressure, systolic blood pressure
according to national
circumstances
Diabetes and Halt the rise in Age-standardized prevalence of Halt the rise in diabetes
obesity diabetes & obesity raised blood glucose/diabetes and obesity (No change)
among persons aged 18+ years
(defined as fasting plasma glucose
concentration ≥ 7.0 mmol/l (126
mg/dl) or on medication for raised
blood glucose)

Age-standardized prevalence of
overweight and obesity in persons
aged 18+ years (defined as body
mass index ≥ 25 kg/m² for
overweight and body mass index ≥
30 kg/m² for obesity)

National Drug therapy to At least 50% of Proportion of eligible persons No change for this
systems prevent heart eligible people receive (defined as aged 40 years and older coverage target however
response attacks and strokes drug therapy and with a 10-year cardiovascular risk the indicator is updated
counselling ≥30%, including those with to reflect new CVD risk
(including glycaemic existing cardiovascular disease) projection charts:
control) to prevent receiving drug therapy and Proportion of eligible
heart attacks and counselling (including glycaemic persons (defined as aged
strokes control) to prevent heart attacks 40 years and older with a
and strokes 10-year cardiovascular
risk ≥20%, including
those with existing
cardiovascular disease)
receiving drug therapy
and counselling
(including glycaemic
control) to prevent heart
attacks and strokes
Essential NCD An 80% availability of Availability and affordability of No change for this
medicines the quality, safe and efficacious coverage target.
and basic affordable basic essential noncommunicable disease
technologies to technologies and medicines, including generics, and
treat major essential medicines, basic technologies in both public
noncommunicable including generics and private facilities
diseases required to treat major
NCDs in both
public and private
facilities

Additional monitoring components

7. WHA 73.2 Elimination of cervical cancer. To eliminate cervical cancer, all countries must reach and
maintain an incidence rate of below four per 100 000 women. Achieving that goal rests on three key pillars
and their corresponding targets: Vaccination: 90% of girls fully vaccinated with the HPV vaccine by the
age of 15; Screening: 70% of women screened using a high-performance test by the age of 35, and again
by the age of 45; Treatment: 90% of women with pre-cancer treated and 90% of women with invasive
cancer managed. Each country should meet the 90-70-90 targets by 2030 to get on the path to eliminate
cervical cancer within the next century1.
1 https://apps.who.int/gb/ebwha/pdf_files/WHA73/A73_R2-en.pdf

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8. The WHO Global Childhood Cancer Initiative has set a target, to achieve at least 60% survival for
childhood cancer globally and reduce suffering for all by 20301.

9. WHO is also developing treatment coverage targets for diabetes as part of the Global Diabetes
Compact and for breast cancer as part of the Global breast cancer initiative.

10. As part of the overall accountability framework for NCDs, in May 2014 the WHA adopted a set of
nine NCD GAP indicators to inform reporting on progress made in its implementation. These process
monitoring indicators cover the six objectives of the NCD gap and were considered feasible for use in all
countries and complementary and consistent with the 25 outcome indicators in the GMF. They are collected
through the WHO Country Capacity Survey undertaken every 2 years2. The nine Process Monitoring
Indicators will remain as part of the accountability architecture for the extended NCD GAP. These are:

• Number of countries with at least one operational multisectoral national policy, strategy or action
plan that integrates several noncommunicable diseases and shared risk factors in conformity with
the global/regional noncommunicable disease action plans
• Number of countries that have operational noncommunicable disease
unit(s)/branch(es)/department(s) within the Ministry of Health, or equivalent
• Number of countries with an operational policy, strategy or action plan, to reduce the harmful use of alcohol,
as appropriate, within the national context
• Number of countries with an operational policy, strategy or action plan to reduce physical inactivity and/or
promote physical activity
• Number of countries with an operational policy, strategy or action plan, in line with the WHO Framework
Convention on Tobacco Control, to reduce the burden of tobacco use (AGREED)
• Number of countries with an operational policy, strategy or action plan to reduce unhealthy diet and/or
promote healthy diets
• Number of countries that have evidence-based national guidelines/protocols/standards for the management
of major NCDs through a primary care approach, recognized/approved by government or competent
authorities
• Number of countries that have an operational national policy and plan on NCD-related research including
community-based research and evaluation of the impact of interventions and policies
• Number of countries with noncommunicable disease surveillance and monitoring systems in place to enable
reporting against the nine voluntary global NCD targets

11. In May 2015, WHO published a Technical Note outlining a further component of the NCD
accountability framework, detailing a set of ten NCD progress monitoring indicators to be used to report
on progress achieved in the implementation of national commitments arising from the UN High Level
Meetings on NCDs held in 2011 and 2014. These were updated in September 2017 to ensure consistency
with the revised set of WHO ‘best-buys’ and other recommended interventions for the prevention and
control of noncommunicable diseases which were endorsed by the World Health Assembly in May 2017.
The ten progress monitoring indicators intended to show the progress achieved in countries are as follows:

1) Member State has set time-bound national targets based on WHO guidance
2) Member State has a functioning system for generating reliable cause-specific mortality data on a routine
basis
3) Member State has a STEPS survey or a comprehensive health examination survey every 5 years
4) Member State has an operational multisectoral national strategy/action plan that integrates the NCDs and
their shared risk factors

5) Member State has implemented the following five demand-reduction measures of the WHO FCTC at the
highest level of achievement:
a) Reduce affordability by increasing excise taxes and prices on tobacco products
1 https://www.who.int/docs/default-source/documents/health-topics/cancer/who-childhood-cancer-overview-booklet.pdf
2 https://www.who.int/teams/ncds/surveillance/monitoring-capacity/ncdccs

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 b) Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public places and public
transport
c) Implement plain/standardized packaging and/or large graphic health warnings on all tobacco packages
d) Enact and enforce comprehensive bans on tobacco advertising, promotion and
sponsorship
e) Implement effective mass media campaigns that educate the public about the harms of
smoking/tobacco use and second-hand smoke
6) Member State has implemented, as appropriate according to national circumstances, the following three
measures to reduce the harmful use of alcohol as per the WHO Global Strategy to Reduce the Harmful Use
of Alcohol:
a) Enact and enforce restrictions on the physical availability of retailed alcohol (via reduced hours of sale)
b) Enact and enforce bans or comprehensive restrictions on exposure to alcohol advertising (across
multiple types of media)
c) Increase excise taxes on alcoholic beverages
7) Member State has implemented the following four measures to reduce unhealthy diets:
d) Adopt national policies to reduce population salt/sodium consumption
e) Adopt national policies that limit saturated fatty acids and virtually eliminate industrially produced
trans fatty acids in the food supply
f) WHO set of recommendations on marketing of foods and non-alcoholic beverages to children
g) Legislation/regulations fully implementing the International Code of Marketing of Breast-milk
Substitutes
8) Member State has implemented at least one recent national public awareness and motivational
communication for physical activity, including mass media campaigns for physical activity behavioural
change
9) Member State has evidence-based national guidelines/protocols/standards for the management of major
NCDs through a primary care approach, recognized/approved by government or competent authorities
10) Member State has provision of drug therapy, including glycaemic control, and counselling for eligible
persons at high risk to prevent heart attacks and strokes, with emphasis on the primary care level

===

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1WHO & UNSDG. UNSDG Task Team Meeting – Strengthening Health Systems. Health Response: Risks and how to make
health systems more resilient for future pandemics, July 2021. WHO & UNSDG. Geneva, 2021.

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