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NONCOMMUNICABLE DISEASES
PROGRESS MONITOR 2017

NONCOMMUNICABLE DISEASES
PROGRESS MONITOR 2017

Noncommunicable Diseases Progress Monitor, 2017
ISBN 978-92-4-151302-9
© World Health Organization 2017

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CONTENTS
4 Acknowledgements
5 Foreword
7 Introduction
10 Explanatory notes
10 Progress monitoring indicators
11 Demographics
11 Mortality
13 References
15 Country profiles
211 Appendix 1: Indicator Definitions and Specifications
3
ACKNOWLEDGEMENTS
This report was prepared by Leanne Riley, Hebe Gouda and Melanie Cowan from
the Surveillance and Population-Based Prevention Unit, Department for Prevention of
Noncommunicable Diseases, World Health Organization (WHO).
Contributions to the report were made by the following colleagues in WHO

Headquarters and Regional Offices: Naveen Agarwal, Douglas Bettcher, Lubna
Bhatti, Fiona Bull, Roberta Caixeta, Marie Clem Carlos, Alison Commar, Carolina
Chavez Cortez, Kaia Engesveen, Heba Fouad, Alexandra Fleischmann, Larry
Grummer-Strawn, Regina Guthold, Warrick Junsuk Kim, Anna Kurmanova, Enrique
Loyola Elizondo, Doris Ma Fat, Colin Mathers, Jayasuriya Navaratne, Leo Nederveen,
Nivo Ramanandraibe, Manju Rani, Dag Rekve, Stefan Savin, Kerstin Schotte, Bela
Shah, Kate Sheffer, Hai-Rim Shin, Wendy Snowdon, Chandralall Sookram, Gretchen
Stevens, Menno Van Hilten, Cherian Varghese, and Temo Waquanivalu.
Sincere thanks to all WHO Member States for their assistance in reporting data to
WHO which allowed compilation of these indicators.
4
FOREWORD
Premature death from noncommunicable diseases (NCDs) continues to be one of the
major development challenges in the 21st century. NCDs kill 15 million women and
men between the ages of 30 and 70 each year, and leave no country untouched.
This burden is rising disproportionately among low-income and lower-middle-income

countries, where almost half of premature NCD deaths occur. Within countries, these
deaths disproportionally affect the poorest and those furthest behind. The NCD
epidemic is driven by poverty, globalization of marketing and trade of health-harming
products, rapid urbanization, and population growth.
This Progress Monitor is based on the latest data tracked against 10 progress indicators
to chart progress in developing national responses. It describes achievements and
challenges faced by all countries in fulfilling promises made since the first United
Nations High-level Meeting on NCDs in 2011.
Most premature NCD deaths can be prevented or delayed by implementing a set of so

called “best buys” and other interventions to prevent and control these conditions, primarily
cardiovascular and chronic respiratory diseases, cancer and diabetes. These measures
were endorsed by the 70th World Health Assembly and are available to all countries.
World leaders committed in the Agenda for Sustainable Development to reduce

premature NCD deaths by one third by 2030 and promote mental health and
wellbeing (Sustainable Development Goal target 3.4).
Since the 2011 High-level Meeting, governments have made many political
commitments to prevent and control NCDs. Progress, however, has been insufficient
and highly uneven. Unless political leaders accelerate commitments to take national
action at the third UN High-level Meeting in 2018, the current rate of decline in
premature death from NCDs will not meet the SDG target, leading to significant GDP
losses and impoverishing millions of people through long-term healthcare costs.
To promote accountability to the world’s citizens, WHO defined the 10 national progress
indicators that it will use to develop a report in November 2017 for the UN General
Assembly. Member States will review this report in January 2018, which will set the tone
for negotiations on the outcome document for the third High-level Meeting.
5
This report shows we are on the path to tangible progress in countries, and that the
roadmap contained in the 2011 Political Declaration can promote collective action
for faster results. However, it also reveals progress has been impeded in many
countries and that bolder political action is needed to address constraints, including
the mobilization of domestic and external resources and safeguarding communities
from interference by powerful economic operators.
This Progress Monitor urges Member States to ensure that the steps needed for all
people, especially the poorest, to live in a world free of the avoidable burden of NCDs
are reiterated at the 2018 High-level Meeting.
The UN, as a global beacon of solidarity, must also show it can shape such a world. In so
doing, it must keep listening to and involving the peoples of the world. It must build a future
that ensures globalization becomes a positive force for present and future generations.
Dr Tedros Adhanom Ghebreyesus

Director-General
World Health Organization
6
INTRODUCTION
Noncommunicable diseases (NCDs), such as cardiovascular diseases, cancer,
diabetes and chronic respiratory diseases, are the leading global cause of death and
are responsible for 70% of deaths worldwide. These NCDs share key modifiable
behavioural risk factors like tobacco use, unhealthy diet, lack of physical activity,
and the harmful use of alcohol, which in turn lead to overweight and obesity, raised
blood pressure, and raised cholesterol, and ultimately disease. They continue to be an
important public health challenge in all countries, including low- and middle-income
countries where more than three quarters of NCD deaths occur.
Effectively tackling NCDs and their key risk factors requires a detailed understanding
of the current status and progress being made at the country level. Feasible and cost-
effective interventions exist to reduce the burden and impact of NCDs now and in
the future. Tracking national implementation of a key set of tracer actions linked to
these interventions allows for global benchmarking and monitoring of progress being
made against NCDs. It also serves to highlight challenges and areas requiring further
attention.
In May 2015 the World Health Organization published a Technical Note (1) on how
WHO will report in 2017 to the United Nations General Assembly on the progress
achieved in the implementation of national commitments included in the 2011 UN
Political Declaration and the 2014 UN Outcome Document on NCDs. The Technical
Note was 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 Technical Note outlines a set of ten progress monitoring indicators
intended to show the progress achieved in countries in the implementation of selected
national commitments included in the 2014 Outcome Document. The ten NCD progress
monitoring indicators are as follows:
7
Consider setting national NCD targets for 2025:
1 Member State has set time-bound national targets based on WHO

guidance
2
1 Member State has a functioning system for generating reliable
cause-specific mortality data on a routine basis
3
1 Member State has a STEPS survey or a comprehensive health
examination survey every 5 years
Consider developing national multisectoral policies and plans to achieve the

national targets by 2025:
4 Member State has an operational multisectoral national strategy/

action plan that integrates the major NCDs and their shared risk factors
Reduce risk factors for NCDs, building on guidance set out in the WHO Global
NCD Action Plan:
5
1 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
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
8
6
1 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
1 Member State has implemented the following four measures to
reduce unhealthy diets:
a Adopt national policies to reduce population salt/sodium consumption
b Adopt national policies that limit saturated fatty acids and virtually eliminate
industrially produced trans fatty acids in the food supply
c WHO set of recommendations on marketing of foods and non-alcoholic

beverages to children
d Legislation /regulations fully implementing the International Code

of Marketing of Breast-milk Substitutes
8
1 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.
Strengthen health systems to address NCDs through people-centred primary

health care and universal health coverage, building on guidance set out in WHO
Global NCD Action Plan:
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
9
EXPLANATORY NOTES
This report presents information for each country related to their achievement of the NCD
progress monitoring indicators. The profiles also include information on the population,
percentage and number of deaths from NCDs, and the risk of premature death from
the four main NCDs (cardiovascular diseases, cancer, diabetes or chronic respiratory
diseases) – the indicator used to monitor the Sustainable Development Goal target 3.4
on NCDs. The data presented in the country pages are derived from several sources,
each of which is explained in the following notes.
Progress monitoring indicators

Details of the progress monitoring indicators, including detailed definitions,
specifications, data sources and assessment criteria are included in Appendix 1.
For each indicator the following symbols denote the level of achievement: = fully
achieved, = partially achieved, = not achieved, “NA” = not applicable to country
due to national situation, “DK” = country responded “don’t know” to that question in
the survey, and “NR” = no response or missing data.
Assessment of indicators 1, 3, 4, 7a, 7b, 7c, 8, 9 and 10 were taken from Member
State responses to the 2017 NCD Country Capacity Survey (NCD CCS). The 2017
NCD CCS questionnaire was completed through an online web-based platform by
the NCD focal points or designated colleagues within the Ministry of Health (MOH)
or a national institute or agency in all WHO Member States (194 countries) between
February and June 2017. The questions were developed in a manner intended to
obtain objective information about adequacy of capacity and countries were required
to provide supporting documentation to enable review by WHO in order to validate
the responses. Where discrepancies were noted between the country response and
the documents provided for validation, a clarification request was returned to the
country for their consideration and an updating of their response.
Assessment of indicators 7a, 7b and 7c were additionally reviewed against responses

obtained by WHO in the 2nd Global Nutrition Policy Review and supporting
documentation contained in the WHO Global database on the Implementation of
Nutrition Action (GINA).
Assessment of indicator 2 related to the system for generating mortality data was
based on data collected by WHO and stored in the WHO mortality database through
a routine annual call for data.
10
Assessment of indicator 5 was based on data collected from Member States in 2016
for the production of the WHO Report on the Global Tobacco Epidemic. The WHO
assessment was shared with national authorities for review and approval.
Indicator 6 achievement status was based on the responses of country focal points,
officially nominated by the Ministry of Health, to the 2016 Global Survey on Alcohol
and Health conducted by WHO. Responses were reviewed and validated by WHO,
and subsequently endorsed by the Member States.
Indicator 7d achievement status was based on the analysis by WHO, UNICEF, and
IBFAN/ICDC of copies of all national legislation and regulations on the International
Code of Marketing of Breast-milk Substitutes for the production of the report on
Marketing of breast-milk substitutes: National implementation of the international code
Status Report 2016.
Demographics
The 2015 population estimates from the most recent United Nations Population Division
World Population Prospects (2) are reported in each profile.
Mortality
Percentage of deaths from NCDs and total number of NCD deaths are reported for
2015 for all countries with a population greater than 90,000. These data were drawn
from the 2015 all-cause mortality rates estimated from revised life tables, published
in World Health Statistics 2017 (3). Total number of deaths by age and sex were
estimated for each country by applying these death rates to the estimated resident
populations prepared by the United Nations Population Division in its 2015 revision
(2). Vital registration systems which record deaths with sufficient completeness and
quality of cause of death information were used as the preferred data source. Detailed
information on methods for mortality and causes of death estimates were published
previously (4).
The risk of premature death from target NCDs presented in the profiles is the probability
of dying between ages 30 and 70 years from the four main NCDs and was estimated
for 2015 using age-specific death rates (in 5-year age groups, e.g. 30-34… 65-69,
for those between 30 and 70) of the combined four main NCD categories, for each
Member State (4). Using the life table method, the risk of death between the exact ages
of 30 and 70, from any of the four causes and in the absence of other causes of death,
11
was calculated using the equation below. The ICD codes used are: Cardiovascular
disease: I00-I99, ‪Cancer: C00-C97, Diabetes: E10-E14, ‪and Chronic respiratory
disease: J30-J98.‬‬
Five-year death rates were then translated into the probability of death for each NCD
using the following formula:
The unconditional probability of death, for the 30-70 age range, was calculated last:
12
REFERENCES
1. http://www.who.int/nmh/events/2015/technical-note-en.pdf?ua=1, accessed
4 September 2017.
2. World Population Prospects: The 2017 Revision, Key Findings and Advance
Tables. New York, United Nations Population Division, 2017.
3. World Health Statistics 2017: monitoring health for the SDGs, Sustainable
Development Goals. Geneva, World Health Organization, 2017.
4. WHO methods and data sources for country-level causes of death 2000-2015.
Geneva, World Health Organization, 2017.
13
14
COUNTRY
PROFILES
15
AFGHANISTAN
33 736 000 42% 110 000 31%
Total population Percentage of deaths Total number of NCD Risk of premature death
from NCDs deaths from target NCDs
National NCD targets ○

Mortality data ○
Risk factor surveys ◐
National integrated NCD policy/strategy/action plan ●
Tobacco demand-reduction measures:
increased excise taxes and prices ○
smoke-free policies ●
large graphic health warnings/plain packaging ◐
bans on advertising, promotion and sponsorship ●
mass media campaigns ○
Harmful use of alcohol reduction measures:
restrictions on physical availability ●

advertising bans or comprehensive restrictions ●
increased excise taxes ●
Unhealthy diet reduction measures:
salt/sodium policies ◐
saturated fatty acids and trans-fats policies ●
marketing to children restrictions ●
marketing of breast-milk substitutes restrictions ●
Public education and awareness campaign on physical activity DK
Guidelines for management of cancer, CVD, diabetes and CRD ○

Drug therapy/counselling to prevent heart attacks and strokes ○
● = fully achieved ◐ = partially achieved ○ = not achieved
DK = don't know
World Health Organization - Noncommunicable Diseases Progress Monitor 2017
16
ALBANIA
2 923 000 92% 20 000 15%
National NCD targets ◐

Mortality data ◐
increased excise taxes and prices ◐
mass media campaigns ◐
restrictions on physical availability ◐

advertising bans or comprehensive restrictions ○
increased excise taxes ◐
salt/sodium policies ○
saturated fatty acids and trans-fats policies ○
marketing to children restrictions ○
Public education and awareness campaign on physical activity ○
Guidelines for management of cancer, CVD, diabetes and CRD ◐
Drug therapy/counselling to prevent heart attacks and strokes ◐
17
ALGERIA
39 872 000 74% 144 000 15%
National NCD targets ●

Mortality data ○
National integrated NCD policy/strategy/action plan ◐
smoke-free policies ◐
large graphic health warnings/plain packaging
bans on advertising, promotion and sponsorship
○
◐
mass media campaigns NR

salt/sodium policies ●
marketing of breast-milk substitutes restrictions ◐
Public education and awareness campaign on physical activity ●

Drug therapy/counselling to prevent heart attacks and strokes DK
DK = don't know NR = No Response
18
ANDORRA
78 000 - - -
from NCDs† deaths† from target NCDs†

Mortality data ◐
National integrated NCD policy/strategy/action plan ○
large graphic health warnings/plain packaging ○
bans on advertising, promotion and sponsorship ○

marketing of breast-milk substitutes restrictions NR

DK = don't know NR = No Response † = see Explanatory Notes
19
ANGOLA
27 859 000 27% 93 000 25%

Mortality data ○
increased excise taxes and prices NR

increased excise taxes ○
marketing of breast-milk substitutes restrictions ○
Public education and awareness campaign on physical activity NR
Guidelines for management of cancer, CVD, diabetes and CRD DK

◐ = partially achieved ○ = not achieved
20
ANTIGUA AND BARBUDA
100 000 80% 400 16%

Mortality data ●
Risk factor surveys ○
smoke-free policies ○

21
ARGENTINA
43 418 000 81% 268 000 17%

Mortality data ●
increased excise taxes and prices ●
●
◐
restrictions on physical availability ○

advertising bans or comprehensive restrictions ◐

22
ARMENIA
2 917 000 93% 27 000 23%

Mortality data ●
Risk factor surveys ●
large graphic health warnings/plain packaging ●
mass media campaigns
○
NR

NR = No Response
23
AUSTRALIA
23 800 000 90% 136 000 9%

Mortality data ●
●
◐
mass media campaigns ●

Guidelines for management of cancer, CVD, diabetes and CRD ●
DK = don't know
24
AUSTRIA
8 679 000 92% 72 000 11%

Mortality data ●
●
◐


Drug therapy/counselling to prevent heart attacks and strokes ●
25
AZERBAIJAN
9 617 000 86% 57 000 24%

Mortality data ◐
bans on advertising, promotion and sponsorship ◐


26
BAHAMAS
387 000 74% 1 000 17%

Mortality data ●

saturated fatty acids and trans-fats policies DK
DK = don't know
27
BAHRAIN
1 372 000 85% 2 000 16%

Mortality data ◐
restrictions on physical availability NR

advertising bans or comprehensive restrictions NR
increased excise taxes NR

28
BANGLADESH
161 000 000 67% 580 000 22%

Mortality data ○
●
◐

marketing to children restrictions DK

DK = don't know
29
BARBADOS
284 000 83% 2 000 16%

Mortality data ◐

30
BELARUS
9 486 000 89% 114 000 29%

Mortality data ●
●
◐

NR = No Response
31
BELGIUM
11 288 000 86% 94 000 12%

Mortality data ●
●
◐


32
BELIZE
359 000 66% 1 000 22%

Mortality data ●
○
NR

NR = No Response
33
BENIN
10 576 000 37% 36 000 22%

Mortality data ○

NR = No Response
34
BHUTAN
787 000 68% 3 000 23%

Mortality data ○
increased excise taxes and prices NA
○
◐

NA = not applicable
35
BOLIVIA (PLURINATIONAL STATE OF)
10 725 000 62% 44 000 16%

Mortality data ◐
●
◐

NR = No Response
36
BOSNIA AND HERZEGOVINA
3 536 000 94% 37 000 18%
National NCD targets DK
Mortality data ◐
○
◐

salt/sodium policies DK

37
BOTSWANA
2 209 000 42% 6 000 19%

Mortality data ○
○
◐

38
BRAZIL
206 000 000 73% 928 000 17%

Mortality data ●

39
BRUNEI DARUSSALAM
418 000 80% 1 000 13%

Mortality data ●
increased excise taxes and prices NA
●
◐

DK = don't know NA = not applicable
40
BULGARIA
7 177 000 95% 101 000 24%

Mortality data ●
●
◐


41
BURKINA FASO
18 111 000 33% 51 000 23%

Mortality data ○
●
◐


42
BURUNDI
10 199 000 31% 32 000 22%

Mortality data ○
○
NR


NR = No Response
43
CABO VERDE
533 000 68% 1 000 16%

Mortality data ◐
○
◐

44
CAMBODIA
15 518 000 61% 57 000 23%

Mortality data ○
●
◐


45
CAMEROON
22 835 000 34% 83 000 22%

Mortality data ○

46
CANADA
35 950 000 88% 219 000 10%

Mortality data ●
●
◐


47
CENTRAL AFRICAN REPUBLIC
4 546 000 30% 19 000 24%

Mortality data ○
○
NR


NR = No Response
48
CHAD
14 009 000 25% 45 000 23%

Mortality data ○
●
NR

NR = No Response
49
CHILE
17 763 000 84% 87 000 11%

Mortality data ●
●
◐


50
CHINA
1 405 000 000 89% 8 792 000 18%

Mortality data ◐


51
COLOMBIA
48 229 000 73% 178 000 15%

Mortality data ●


DK = don't know
52
COMOROS
777 000 41% 2 000 23%

Mortality data ○


53
CONGO
4 996 000 37% 12 000 18%

Mortality data ○

DK = don't know
54
COOK ISLANDS
17 000 - - -

Mortality data ◐

NR = No Response † = see Explanatory Notes
55
COSTA RICA
4 808 000 83% 19 000 11%

Mortality data ●
●
◐

56
CÔTE D'IVOIRE
23 108 000 36% 102 000 28%

Mortality data ○


57
CROATIA
4 236 000 93% 50 000 17%

Mortality data ●



DK = don't know
58
CUBA
11 461 000 84% 78 000 16%

Mortality data ●
○
NR


NR = No Response
59
CYPRUS
1 161 000 91% 7 000 11%

Mortality data ◐


DK = don't know
60
CZECHIA
10 604 000 90% 99 000 16%

Mortality data ●
●
◐


61
DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA
25 244 000 81% 188 000 26%


Mortality data ○


62
DEMOCRATIC REPUBLIC OF THE CONGO
76 197 000 30% 218 000 20%


Mortality data ○



DK = don't know
63
DENMARK
5 689 000 90% 44 000 12%

Mortality data ●
●
◐


64
DJIBOUTI
927 000 43% 3 000 19%

Mortality data ○
●
NR


NR = No Response
65
DOMINICA
73 000 - - -

Mortality data ●
○
NR

66
DOMINICAN REPUBLIC
10 528 000 69% 42 000 19%

Mortality data ◐

67
ECUADOR
16 144 000 71% 59 000 13%

Mortality data ◐
●
◐


68
EGYPT
93 778 000 83% 476 000 24%

Mortality data ◐
●
◐


69
EL SALVADOR
6 312 000 71% 28 000 14%

Mortality data ◐
●
◐


70
EQUATORIAL GUINEA
1 175 000 39% 3 000 25%

Mortality data ○
○
NR



71
ERITREA
4 847 000 42% 13 000 25%

Mortality data ○
●
NR

NR = No Response
72
ESTONIA
1 315 000 93% 13 000 17%

Mortality data ●
●
◐


73
ETHIOPIA
99 873 000 39% 284 000 19%

Mortality data ○

74
FIJI
892 000 84% 5 000 31%

Mortality data ●
●
◐

NR = No Response
75
FINLAND
5 482 000 93% 48 000 10%

Mortality data ●
●
◐


NR = No Response
76
FRANCE
64 457 000 87% 487 000 11%
Mortality data ●
●
◐


● = fully achieved ◐ = partially achieved
77
GABON
1 930 000 45% 6 000 16%

Mortality data ○

78
GAMBIA
1 978 000 33% 5 000 20%

Mortality data ○

Drug therapy/counselling to prevent heart attacks and strokes NR
NR = No Response
79
GEORGIA
3 952 000 93% 46 000 22%

Mortality data ◐

80
GERMANY
81 708 000 91% 800 000 12%

Mortality data ●
●
◐


81
GHANA
27 583 000 44% 101 000 21%

Mortality data ○

82
GREECE
11 218 000 94% 113 000 12%

Mortality data ●
●
◐


DK = don't know
83
GRENADA
107 000 81% 700 25%

Mortality data ●

84
GUATEMALA
16 252 000 57% 49 000 15%

Mortality data ●

85
GUINEA
12 092 000 31% 38 000 20%

Mortality data ○


86
GUINEA-BISSAU
1 771 000 30% 5 000 19%

Mortality data ○


DK = don't know
87
GUYANA
769 000 67% 4 000 28%

Mortality data ●

88
HAITI
10 711 000 56% 51 000 24%

Mortality data ○

● = fully achieved ○ = not achieved
NR = No Response
89
HONDURAS
8 961 000 60% 21 000 14%

Mortality data ◐


90
HUNGARY
9 784 000 94% 116 000 23%

Mortality data ●
●
◐


91
ICELAND
330 000 90% 1 000 8%

Mortality data ●


DK = don't know
92
INDIA
1 309 000 000 61% 5 817 000 23%

Mortality data ◐
●
◐

93
INDONESIA
258 000 000 73% 1 340 000 27%

Mortality data ○


94
IRAN (ISLAMIC REPUBLIC OF)
79 360 000 81% 291 000 15%

Mortality data ◐


95
IRAQ
36 116 000 54% 104 000 22%

Mortality data ◐


96
IRELAND
4 700 000 90% 27 000 10%

Mortality data ●
●
◐


97
ISRAEL
8 065 000 86% 36 000 9%

Mortality data ●


98
ITALY
59 504 000 92% 573 000 9%

Mortality data ●
●
◐


99
JAMAICA
2 872 000 79% 15 000 15%

Mortality data ◐
○
NR

NR = No Response
100
JAPAN
128 000 000 82% 1 072 000 9%

Mortality data ●

DK = don't know
101
JORDAN
9 159 000 78% 22 000 20%

Mortality data ◐


102
KAZAKHSTAN
17 750 000 82% 123 000 29%

Mortality data ●
●
◐


DK = don't know
103
KENYA
47 236 000 33% 106 000 18%

Mortality data ○

104
KIRIBATI
112 000 65% 500 28%

Mortality data ◐

DK = don't know
105
KUWAIT
3 936 000 77% 7 000 18%

Mortality data ◐

NR = No Response
106
KYRGYZSTAN
5 865 000 82% 30 000 24%

Mortality data ●
●
◐


NR = No Response
107
LAO PEOPLE'S DEMOCRATIC REPUBLIC
6 664 000 55% 25 000 26%


Mortality data ○
●
◐


NR = No Response
108
LATVIA
1 993 000 92% 26 000 23%

Mortality data ●
●
◐


109
LEBANON
5 851 000 89% 32 000 18%

Mortality data ○

110
LESOTHO
2 175 000 29% 7 000 24%

Mortality data ○
○
NR

NR = No Response
111
LIBERIA
4 500 000 31% 11 000 17%

Mortality data ○
○
NR

Guidelines for management of cancer, CVD, diabetes and CRD NR

NR = No Response
112
LIBYA
6 235 000 76% 24 000 20%

Mortality data ○


DK = don't know
113
LITHUANIA
2 932 000 90% 38 000 20%

Mortality data ●
●
◐


114
LUXEMBOURG
567 000 88% 3 000 10%

Mortality data ●


DK = don't know
115
MADAGASCAR
24 234 000 43% 68 000 24%

Mortality data ○

saturated fatty acids and trans-fats policies NR
marketing to children restrictions NR

NR = No Response
116
MALAWI
17 574 000 31% 48 000 20%
Mortality data ○
○
NR


117
MALAYSIA
30 723 000 71% 107 000 17%

Mortality data ◐
●
◐

118
MALDIVES
418 000 78% 900 12%

Mortality data ◐

119
MALI
17 468 000 30% 54 000 24%

Mortality data ○


DK = don't know
120
MALTA
428 000 90% 3 000 10%

Mortality data ●
●
◐


NR = No Response
121
MARSHALL ISLANDS
53 000 - - -

Mortality data ○

† = see Explanatory Notes
122
MAURITANIA
4 182 000 37% 11 000 18%

Mortality data ○
○
NR

NR = No Response
123
MAURITIUS
1 259 000 87% 8 000 23%

Mortality data ●

124
MEXICO
126 000 000 79% 492 000 15%

Mortality data ●
○
NR


125
MICRONESIA (FEDERATED STATES OF)
104 000 74% 500 26%

Mortality data ○


NR = No Response
126
MONACO
38 000 - - -

Mortality data ◐
○
NR


127
MONGOLIA
2 977 000 78% 15 000 30%

Mortality data ◐


128
MONTENEGRO
628 000 95% 6 000 22%

Mortality data ◐



129
MOROCCO
34 803 000 78% 151 000 17%

Mortality data ◐
○
◐

130
MOZAMBIQUE
28 011 000 32% 90 000 23%

Mortality data ○
○
◐

131
MYANMAR
52 404 000 68% 297 000 24%

Mortality data ○


132
NAMIBIA
2 426 000 40% 6 000 19%

Mortality data ○
●
◐

133
NAURU
11 000 - - -

Mortality data ○


134
NEPAL
28 656 000 65% 121 000 22%

Mortality data ○

NR = No Response
135
NETHERLANDS
16 938 000 89% 130 000 11%

Mortality data ●
●
◐


136
NEW ZEALAND
4 615 000 90% 27 000 10%

Mortality data ●
●
◐

137
NICARAGUA
6 082 000 76% 22 000 16%

Mortality data ◐
National integrated NCD policy/strategy/action plan DK



DK = don't know
138
NIGER
19 897 000 26% 46 000 18%

Mortality data ○


139
NIGERIA
181 000 000 26% 570 000 21%

Mortality data ○
●
NR


140
NIUE
2 000 - - -

Mortality data ○
○
NR


141
NORWAY
5 200 000 87% 35 000 10%

Mortality data ●


142
OMAN
4 200 000 70% 8 000 18%

Mortality data ◐


143
PAKISTAN
189 000 000 57% 774 000 25%

Mortality data ○

144
PALAU
21 000 - - -

Mortality data ○
○
◐

salt/sodium policies NR
saturated fatty acids and trans-fats policies NR
marketing to children restrictions NR

145
PANAMA
3 969 000 74% 14 000 14%

Mortality data ●

146
PAPUA NEW GUINEA
7 920 000 56% 32 000 36%

Mortality data ○
○
◐


NR = No Response
147
PARAGUAY
6 639 000 73% 26 000 18%

Mortality data ◐


148
PERU
31 377 000 67% 113 000 13%

Mortality data ◐

149
PHILIPPINES
102 000 000 68% 457 000 29%

Mortality data ◐
●
◐

150
POLAND
38 265 000 90% 350 000 18%

Mortality data ●
●
◐



DK = don't know
151
PORTUGAL
10 418 000 86% 90 000 11%

Mortality data ●
●
◐


152
QATAR
2 482 000 66% 2 000 14%

Mortality data ◐
●
NR


NR = No Response
153
REPUBLIC OF KOREA
50 594 000 79% 220 000 8%

Mortality data ●


154
REPUBLIC OF MOLDOVA
4 066 000 91% 39 000 23%

Mortality data ●


155
ROMANIA
19 877 000 93% 241 000 21%

Mortality data ●
●
◐


156
RUSSIAN FEDERATION
144 000 000 86% 1 719 000 29%

Mortality data ◐


157
RWANDA
11 630 000 45% 31 000 20%

Mortality data ○
○
NR


NR = No Response
158
SAINT KITTS AND NEVIS
54 000 - - -

Mortality data ●

† = see Explanatory Notes
159
SAINT LUCIA
177 000 82% 1 000 20%

Mortality data ●

160
SAINT VINCENT AND THE GRENADINES
109 000 79% 700 24%


Mortality data ●
○
NR

NR = No Response
161
SAMOA
194 000 81% 800 22%

Mortality data ○
●
◐

NR = No Response
162
SAN MARINO
33 000 - - -

Mortality data ●
○
◐


DK = don't know NR = No Response † = see Explanatory Notes
163
SAO TOME AND PRINCIPE
196 000 48% 600 18%

Mortality data ○
○
◐

NR = No Response
164
SAUDI ARABIA
31 557 000 72% 76 000 16%

Mortality data ◐


165
SENEGAL
14 977 000 41% 37 000 18%

Mortality data ○


166
SERBIA
8 851 000 94% 99 000 20%

Mortality data ●


167
SEYCHELLES
94 000 79% 600 22%

Mortality data ●
●
◐


168
SIERRA LEONE
7 237 000 31% 27 000 30%

Mortality data ○

169
SINGAPORE
5 535 000 75% 20 000 10%

Mortality data ●
●
◐

DK = don't know
170
SLOVAKIA
5 439 000 89% 45 000 18%

Mortality data ●
●
◐


DK = don't know
171
SLOVENIA
2 075 000 88% 17 000 13%

Mortality data ●


172
SOLOMON ISLANDS
587 000 68% 2 000 26%

Mortality data ○
●
◐


NR = No Response
173
SOMALIA
13 908 000 22% 29 000 20%

Mortality data ○

174
SOUTH AFRICA
55 291 000 48% 260 000 26%

Mortality data ◐
○
◐

DK = don't know
175
SOUTH SUDAN
11 882 000 28% 35 000 20%

Mortality data ○

176
SPAIN
46 398 000 92% 363 000 10%

Mortality data ●


177
SRI LANKA
20 714 000 80% 113 000 18%

Mortality data ◐
●
◐

178
SUDAN
38 648 000 50% 150 000 26%

Mortality data ○
○
◐


179
SURINAME
553 000 75% 2 000 21%

Mortality data ◐

180
SWAZILAND
1 319 000 38% 4 000 25%

Mortality data ○

NR = No Response
181
SWEDEN
9 764 000 89% 80 000 9%

Mortality data ●
●
◐


182
SWITZERLAND
8 320 000 90% 58 000 9%

Mortality data ●


183
SYRIAN ARAB REPUBLIC
18 735 000 48% 68 000 24%

Mortality data ◐
○
◐


184
TAJIKISTAN
8 549 000 64% 29 000 26%

Mortality data ◐
○
◐


185
THAILAND
68 658 000 71% 393 000 16%

Mortality data ◐
●
◐

186
THE FORMER YUGOSLAV REPUBLIC OF MACEDONIA
2 079 000 95% 19 000 22%


Mortality data ●


187
TIMOR-LESTE
1 241 000 47% 3 000 21%

Mortality data ○

188
TOGO
7 417 000 37% 23 000 22%

Mortality data ○

189
TONGA
106 000 81% 500 24%

Mortality data ○


NR = No Response
190
TRINIDAD AND TOBAGO
1 360 000 83% 10 000 26%

Mortality data ◐



DK = don't know
191
TUNISIA
11 274 000 85% 62 000 17%

Mortality data ◐


NR = No Response
192
TURKEY
78 271 000 88% 392 000 17%

Mortality data ●


193
TURKMENISTAN
5 565 000 79% 31 000 35%

Mortality data ●
●
◐


NR = No Response
194
TUVALU
11 000 - - -

Mortality data ○

195
UGANDA
40 145 000 35% 100 000 22%

Mortality data ○

196
UKRAINE
44 658 000 90% 605 000 29%

Mortality data ●
●
◐


197
UNITED ARAB EMIRATES
9 154 000 76% 11 000 17%

Mortality data ◐


NR = No Response
198
UNITED KINGDOM
65 397 000 90% 513 000 11%

Mortality data ●
●
◐


199
UNITED REPUBLIC OF TANZANIA
53 880 000 34% 142 000 18%

Mortality data ○
○
◐

NR = No Response
200
UNITED STATES OF AMERICA
320 000 000 88% 2 343 000 14%

Mortality data ●
increased excise taxes and prices† ○

DK = don't know † = data not approved by national authorities
201
URUGUAY
3 432 000 84% 27 000 17%

Mortality data ●


DK = don't know
202
UZBEKISTAN
30 976 000 78% 148 000 27%

Mortality data ●


203
VANUATU
265 000 73% 900 22%

Mortality data ○

204
VENEZUELA (BOLIVARIAN REPUBLIC OF)
31 155 000 69% 119 000 18%


Mortality data ●

205
VIET NAM
93 572 000 76% 411 000 17%

Mortality data ○
●
◐

206
YEMEN
26 916 000 61% 97 000 31%

Mortality data ○

DK = don't know
207
ZAMBIA
16 101 000 29% 37 000 17%

Mortality data ○


208
ZIMBABWE
15 777 000 30% 40 000 18%

Mortality data ○


209
210
APPENDIX 1
INDICATOR DEFINITIONS
AND SPECIFICATIONS
211
Member State has set time-bound national targets
Indicator 1
based on WHO guidance
Definition Country has set national NCD targets. The NCD-related targets should be
time-bound and based on the 9 voluntary global targets and the WHO
Global Monitoring Framework.
Data collection WHO NCD Country Capacity Survey tool – The NCD CCS is completed
tool and by a team at the country level to ensure a comprehensive response is
achievement compiled.
criteria
This indicator is considered fully achieved if a country responds “Yes”
to the question “Are there a set of time-bound national targets for
NCDs based on the 9 voluntary global targets from the WHO Global
Monitoring Framework for NCDs?”, and provides the needed supporting
documentation. Targets must be time-bound, based on the 9 global
targets, and need to address NCD mortality, as well as key risk factors in
the country and/or health systems.
This indicator is considered partially achieved if the country responds “Yes”
to the question “Are there a set of time-bound national targets for NCDs
based on the 9 voluntary global targets from the WHO Global Monitoring
Framework for NCDs ?”, but the targets do not cover two of the three
areas addressed in the 9 global targets (including mortality) or they are not
time-bound.
Data validation Countries are asked to submit a copy of their targets when submitting their
process response to the NCD CCS. WHO will confirm that document provided
is indeed a set of national NCD targets, addressing NCD mortality, as
well as key risk factors in the country, and/or health systems, based on
the 9 global targets, and that these targets are time-bound (e.g. include
such language as “by 2025”). Where discrepancies are noted, these are
referred back to the country for clarification and modification.
Expected Every 2 years
frequency of data
collection
Links to tool http://www.who.int/ncds/surveillance/ncd-capacity/en/
212
Member State has a functioning system for generating
Indicator 2
reliable cause-specific mortality data on a routine basis
Definition Country has a vital registration system that captures deaths and the causes
of death routinely. The International Form of Medical Certificate of the
Cause of Death is completed by certifiers. The International Classification
of Diseases (ICD) is used to code the causes of death. The data compiled
are made available to policy-makers and researchers.
Data collection The WHO collects mortality data, including cause of death, from civil
tool and registration systems in the WHO mortality database through a routine
achievement annual call for data. Data are considered to generate reliable cause-
criteria specific mortality data on a routine basis if:
• Data from the five most recent reporting years are, on average, at least
70% usable. Usability is calculated as
(Completeness (%))*(1- Proportion Garbage)1.
• At least five years of cause-of-death data have been reported to the
WHO in the last 10 years.
• The most recent year of data reported to the WHO is no more than five
years old.
This indicator is considered fully achieved if the country meets all of the
above criteria.
This indicator is considered partially achieved if the country does not meet
all of the above criteria but has submitted some vital registration data to
WHO.
Data validation Data submitted are verified and inconsistencies are referred back to
process countries to resolve.
Expected Yearly
frequency of data
collection
Links to tool http://www.who.int/healthinfo/tool_cod_2010.pdf
1 For further details, see page 5 of the following document: http://www.who.int/healthinfo/global_burden_disease/GlobalCOD_

method_2000_2015.pdf
213
Member State has a STEPS survey or a comprehensive
Indicator 3
health examination survey every 5 years
Definition Country has completed a STEPS survey or another risk factor survey which
includes physical measurements and biochemical assessments covering
the key behavioural and metabolic risk factors for NCDs. Country must
indicate that survey frequency is at least every 5 years.
criteria
This indicator is considered fully achieved if the country responds “Yes”
to each of the following for adults: “Have surveys of risk factors (may
be a single RF or multiple) been conducted in your country for all of the
following:” “Harmful alcohol use” (optional for the 10 Member States
where there is a total ban on alcohol), “Physical inactivity”, “Tobacco
use”, “Raised blood glucose/diabetes”, “Raised blood pressure/
hypertension”, “Overweight and obesity”, and “Salt / Sodium intake”.
For risk factors “Raised blood glucose/diabetes”, “Raised blood
pressure/hypertension”, and “Overweight and obesity”, the data must be
measured, not self-reported. Additionally, for each risk factor, the country
must indicate that the last survey was conducted in the past 5 years (i.e.
2012or later for the 2017 CCS survey responses) and must respond “Every
1 to 2 years” or “Every 3 to 5 years” to the subquestion “How often is the
survey conducted?”. The country must also provide the needed supporting
documentation.
This indicator is considered partially achieved if the country responds that
at least 3, but not all, of the above risk factors are covered, or the surveys
were conducted more than 5 years ago but less than 10 years ago.
Data validation Countries are asked to submit a copy of their survey report(s) when
process submitting their response to the NCD CCS. Where discrepancies are
noted, these are referred back to the country for clarification and
modification. Data are also checked against the STEPS tracking system
which records details of STEPS surveys undertaken by countries.
frequency of data
collection
214
Member State has an operational multisectoral
Indicator 4 national strategy/action plan that integrates the
major NCDs and their shared risk factors
Definition Country has a multisectoral, national integrated NCD and risk

factor policy/strategy/action plan that addresses the 4 main NCDs
(cardiovascular diseases, diabetes, cancer, chronic respiratory diseases)
and their main risk factors (tobacco use, unhealthy diet, physical inactivity,
harmful use of alcohol).
“Multisectoral” refers to engagement with one or more government sectors
outside of health. “Operational” refers to a policy, strategy or action plan
which is being used and implemented in the country, and has resources
and funding available to implement it.
Data collection WHO NCD Country Capacity Survey tool – The NCD CCS is completed by
tool and a team at the country level to ensure a comprehensive response is compiled.
achievement
criteria This indicator is considered fully achieved if the country responds “Yes” to
the questions “Does your country have a national NCD policy, strategy
or action plan which integrates several NCDs and their risk factors?” and
to the subquestion “ Is it multisectoral?”. Countries also have to respond
“operational” to the subquestion “Indicate its stage” and “Yes” to all of the
subquestions pertaining to the 4 main risk factors and 4 main NCDs: “Does
it address one or more of the following major risk factors?” “Harmful use
of alcohol” (optional for the 10 Member States where there is a total ban
on alcohol), “Unhealthy diet”, “Physical inactivity”, “tobacco” (all 4 must
have “Yes”) and “Does it combine early detection, treatment and care for:”
“Cancer”, “Cardiovascular diseases”, “ Chronic respiratory diseases” and
“Diabetes” (all 4 must have “Yes”). Country must also provide the needed
supporting documentation.
This indicator is considered partially achieved if the country responds “Yes”
to the questions “Does your country have a national NCD policy, strategy
or action plan which integrates several NCDs and their risk factors?” and
to the subquestion “ Is it multisectoral?”. Countries also have to respond
“operational” to the subquestion “Indicate its stage” and “Yes” to at least two
of the 4 main risk factors and at least two of the 4 main NCDs.
Data validation Countries are asked to submit a copy of their policy/strategy/action plan
process when submitting their response to the NCD CCS. Where discrepancies are
noted, these are referred back to the country for clarification and modification.
frequency of data
collection
215
Member State has implemented measures to reduce
Indicator 5a affordability by increasing excise taxes and prices
on tobacco products
Definition Country has total taxes set at a level that accounts for more than 75% of the
retail price of tobacco products.
Data collection Data collected from governments for the production of the WHO Report
tool and on the Global Tobacco Epidemic.
achievement
criteria Total taxes (including excise tax, value added/sales tax, import
duties (where applicable) and any other taxes levied) are calculated
as a proportion of the price of the tobacco product. Currently, this is
calculated in relation to the most sold brand of cigarettes.
This indicator is considered fully achieved if the country has total taxes
more than 75% of the price of the most sold brand of cigarettes.
This indicator is considered partially achieved if the country has total
taxes from 51% up to 75% of the retail price of the most sold brand of
cigarettes.
Data validation WHO assessment is shared with national authorities for review and approval.
process
frequency of data
collection
Links to tool http://www.who.int/tobacco/global_report/
http://www.who.int/tobacco/global_report/2017/technical_note_I.pdf?ua=1
216
Member State has implemented measures to eliminate
Indicator 5b exposure to second-hand tobacco smoke in all indoor
workplaces, public places and public transport
Definition Country has all public places completely smoke-free (or at least
90% of the population covered by complete subnational smoke-free
legislation).“Completely” means that smoking is not permitted, with no
exemptions allowed, except in residences and indoor places that serve
as equivalents to long-term residential facilities, such as prisons and long-
term health and social care facilities such as psychiatric units and nursing
homes. Ventilation and any form of designated smoking rooms and/or
areas do not protect from the harms of second-hand tobacco smoke, and
the only laws that provide protection are those that result in the complete
absence of smoking in all public places.
Data collection Legal instruments are analysed for the production of the WHO Report on
tool and the Global Tobacco Epidemic.
achievement
criteria Legislation is assessed to determine whether smoke-free laws provided for
a complete indoor smoke-free environment at all times, in all the facilities
of each of the following eight places: health care facilities; educational
facilities other than universities; universities; government facilities; indoor
offices and workplaces not considered in any other category; restaurants
or facilities that serve mostly food; cafés, pubs and bars or facilities that
serve mostly beverages; public transport.
This indicator is considered fully achieved if all public places in the country
are completely smoke-free (or at least 90% of the population covered by
complete subnational smoke-free legislation).
This indicator is considered partially achieved if three to seven public
places are completely smoke-free, or the law allows designated smoking
rooms with strict technical requirements in five or more places.
Data validation WHO assessment is shared with national authorities for review and
process approval.
frequency of data
collection
217
Member State has implemented plain/standardized
Indicator 5c packaging and/or large graphic health warnings on
all tobacco packages
Definition Country mandates plain/standardized packaging and/or large

graphic warnings with all appropriate characteristics. Appropriate
characteristics for large graphic warnings include:
• specific health warnings mandated;
• appearing on individual packages as well as on any outside
packaging and labelling used in retail sale;
• describing specific harmful effects of tobacco use on health;
• are large, clear, visible and legible (e.g. specific colours and font
style and sizes are mandated);
• rotating health warnings and/or messages;
• pictures or pictograms;
• written in (all) the principal language(s) of the country.
Appropriate characteristics for plain/standardized packaging include:
• restrictions or prohibitions on the use of logos, colours, brand images
or promotional information on packaging other than brand names
and product names displayed in a standard colour and font style;
• standardized shape, size and materials of tobacco packaging;
• no advertising or promotion inside or attached to the package or
tobacco product.
Data collection Legislation is assessed to determine the size of the warnings (the front and
tool and back of the cigarette pack are averaged to calculate the percentage of the
achievement total pack surface area covered by warnings) and warning characteristics.
criteria This indicator is considered fully achieved if the country has plain/
standardized packaging and/or large graphic health warnings which
are defined as covering on average at least 50% of the front and back of
the package with all appropriate characteristics as detailed above.
This indicator is considered partially achieved if there are medium-size
warnings, which are defined as covering on average between 30 and 49% of
the front and back of package, with some or all appropriate characteristics, or
large warnings that are missing some appropriate characteristics.
process approval.
frequency of data
collection
218
Member State has enacted and enforced
Indicator 5d comprehensive bans on tobacco advertising,
promotion and sponsorship
Definition Country has a ban on all forms of direct and indirect advertising. Direct
advertising bans include: national television and radio; local magazines
and newspapers; billboards and outdoor advertising; point of sale.
Indirect advertising bans include: free distribution of tobacco products in
the mail or through other means; promotional discounts; non-tobacco
products identified with tobacco brand names (brand stretching); brand
names of non-tobacco products used for tobacco products (brand
sharing); appearance of tobacco brands (product placement) or tobacco
products in television and/or films; and sponsorship (contributions and/
or publicity of contributions).
Data collection Legislation is assessed to determine whether the law completely bans
tool and all forms of direct and indirect tobacco advertising, promotion and
achievement sponsorship.
criteria
This indicator is considered fully achieved if the country has a ban on all
forms of direct and indirect advertising.
This indicator is considered partially achieved if the country has a ban on
national TV, radio and print media, but not on all other forms of direct and/
or indirect advertising.
process approval.
frequency of data
collection
219
Member State has implemented effective mass media
Indicator 5e campaigns that educate the public about the harms of
smoking/tobacco use and second hand smoke
Definition Country has implemented a national anti-tobacco mass media campaign

designed to support tobacco control, of at least 3 weeks duration with all
appropriate characteristics. Appropriate characteristics include:
• campaign was part of a comprehensive tobacco control programme;
• before the campaign, research was undertaken or reviewed to gain a
thorough understanding of the target audience;
• campaign communications materials were pre-tested with the target
audience and refined in line with campaign objectives;
• air time (radio, television) and/or placement (billboards, print
advertising, etc.) was obtained by purchasing or securing it using either
the organization’s own internal resources or an external media planner
or agency (this information indicates whether the campaign adopted
a thorough media planning and buying process to effectively and
efficiently reach its target audience);
• the implementing agency worked with journalists to gain publicity or
news coverage for the campaign;
• process evaluation was undertaken to assess how effectively the
campaign had been implemented;
• an outcome evaluation process was implemented to assess campaign
impact; and
• the campaign was aired on television and/or radio.
Data collection Eligible campaigns are assessed according to the appropriate
tool and characteristics to determine whether it signifies the use of a comprehensive
achievement communication approach.
criteria
This indicator is considered fully achieved if the country has a campaign
conducted with at least seven appropriate characteristics including airing
on television and/or radio.
This indicator is considered partially achieved if the country has a
campaign conducted with one to six of the appropriate characteristics.
process approval.
frequency of data
collection
220
Member State has enacted and enforced restrictions
Indicator 6a on the physical availability of retailed alcohol (via
reduced hours of sale)
Definition Country has a licensing system or monopoly on retail sales of beer, wine,
spirits.
Country has restrictions for on-/off-premise sales of beer, wine, spirits
regarding hours, days and locations of sales.
Country has legal age limits for being sold and served alcoholic
beverages.
Data collection Data is collected through the WHO Global Survey on Alcohol and Health.
tool and
achievement This indicator is considered fully achieved if:
criteria • a licensing system or monopoly exists on retail sales of beer, wine and
spirits;
• restrictions exist for on- and off-premise sales of beer, wine, and spirits
regarding hours and locations of sales and restrictions exist for off-
premise sales of beer, wine, and spirits regarding days of sales; and
• legal age limits for being sold and served alcoholic beverages are 18
years or above for beer, wine, and spirits.
This indicator is considered partially achieved if there are any, but not all,
positive responses to the three indicators above.
Data validation Focal points, officially nominated by the Ministry of Health, respond to
process the Global Survey on Alcohol and Health. Responses are reviewed and
validated by WHO, and subsequently endorsed by the Member States.
Expected Every 3-4 years
frequency of data
collection
Links to tool http://www.who.int/entity/substance_abuse/activities/survey_alcohol_
health_2016.pdf?ua=1
221
Member State has enacted and enforced bans or
Indicator 6b comprehensive restrictions on exposure to alcohol
advertising (across multiple types of media)
Definition Country has regulatory or co-regulatory frameworks for alcohol

advertising through different channels (public service/national TV,
commercial/private TV, national radio, local radio, print media,
billboards, points of sale, cinema, internet, social media).
Country has a detection system for infringements on marketing restrictions.
tool and
criteria • restrictions exist on alcohol advertising for beer, wine, and spirits
through all channels ; and
• detection system exists for infringements on marketing restrictions.
This indicator is considered partially achieved if there are restrictions on
at least public service/national TV, national radio and billboards but no
detection system exists for infringements.
frequency of data
collection
222
Member State has increased excise taxes on
Indicator 6c
alcoholic beverages
Definition Country has excise tax on beer, wine, spirits.

Country adjusts level of taxation for inflation for alcoholic beverages.
tool and
criteria • excise tax on all alcoholic beverages (beer, wine, and spirits) is
implemented;
• there are no tax incentives or rebates for production of other alcoholic
beverages; and
• adjustment of level of taxation for inflation for beer, wine, and spirits is
implemented.
This indicator is considered partially achieved if there is excise tax on
alcoholic beverages as specified above.
frequency of data
collection
223
Member State has adopted national policies
Indicator 7a
to reduce population salt/sodium consumption
Definition Country has implemented national policies to reduce population

salt/sodium consumption, including reformulation of food products;
establishment of a supportive environment in public institutions to enable
lower sodium options to be provided; behaviour change communication
and mass media campaigns; and front-of-pack labelling.
criteria
to the question “Is your country implementing any policies to reduce
population salt consumption?” and to the subquestions “Are these targeted
at: product reformulation by industry across the food supply; regulation
of salt content of food; public awareness programme; nutrition labeling
? (must have “Yes” to product reformulation by industry across the food
supply and/or regulation of salt content of food, and “Yes” to public
awareness programme and nutrition labeling”). Country must also provide
the needed supporting documentation.
This indicator is considered partially achieved if the country responds
“Yes” to the question “Is your country implementing any policies to
reduce population salt consumption?”, and “Yes” to at least one of
the four subquestions “Are these targeted at: product reformulation by
industry across the food supply; regulation of salt content of food; public
awareness programme; nutrition labeling?”.
Data validation Countries are asked to submit a copy of their policy(ies) when submitting
process their response to the NCD CCS. Responses are cross-validated with
data obtained through the Global Nutrition Policy Review and the WHO
Global database on the Implementation of Nutrition Action (GINA).
Where discrepancies are noted, these are referred back to the country
for clarification and modification.
frequency of data
collection
224
Member State adopted national policies that
limit saturated fatty acids and virtually eliminate
Indicator 7b
industrially produced trans fatty acids in the food
supply
Definition Country has implemented a policy(ies) to limit saturated fatty acids and
virtually eliminate industrially produced trans-fats in the food supply.
criteria
This indicator is considered fully achieved if the country responds “Yes” to
the question “Is your country implementing any national policies that limit
saturated fatty acids and virtually eliminate industrially produced trans-fats
(i.e. partially hydrogenated vegetable oils) in the food supply?”, and
provides the needed supporting documentation.
Data validation Countries are asked to submit a copy of their policy(ies) when
process submitting their response to the NCD CCS. Responses are cross-
validated with data obtained through the Global Nutrition Policy
Review and the WHO Global database on the Implementation of
Nutrition Action (GINA). Where discrepancies are noted, these are
frequency of data
collection
225
Member State has implemented the WHO set of
Indicator 7c recommendations on marketing of foods and non-
alcoholic beverages to children
Definition Country has implemented a policy(ies) to reduce the impact on children

of marketing of foods and non-alcoholic beverages high in saturated fats,
trans-fatty acids, free sugars, or salt.
criteria
to the question “Is your country implementing any policies to reduce the
impact on children of marketing of foods and non-alcoholic beverages
high in saturated fats, trans-fatty acids, free sugars, or salt?”, and provides
the needed supporting documentation.
Data validation Countries are asked to submit a copy of their policy(ies) when
process submitting their response to the NCD CCS. Responses are cross-
validated with data obtained through the Global Nutrition Policy
Review and the WHO Global database on the Implementation of
Nutrition Action (GINA). Where discrepancies are noted, these are
frequency of data
collection
226
Member State has legislation/regulations fully
Indicator 7d implementing the International Code of Marketing of
Breast-milk Substitutes
Definition Country has implemented legislation/regulations that fully implement the

International Code of Marketing of Breast-milk Substitutes.
Data collection Copies of legislation and regulations on the International Code of
tool and Marketing of Breast-milk Substitutes are compiled by WHO every two
achievement years. In 2015/16, countries were asked to submit copies. Additionally,
criteria copies of legislation were obtained from UNICEF and IBFAN/ICDC and
legal databases (Lexis/Nexis and FAO-LEX), EUR-LEX, national gazettes
and internet search engines.
This indicator is considered fully achieved if the country is assessed as
having national legal measures categorized as “full provisions in law”,
whereby countries have enacted legislation or adopted regulations,
decrees or other legally binding measures encompassing all or nearly all
provisions of the Code and subsequent WHA resolutions.
This indicator is considered partially achieved if the country is assessed as
having national legal measures categorized as “many provisions in law”
or “few provisions in law”, whereby countries have enacted legislation
or adopted regulations, decrees or other legally binding measures
encompassing many or few provisions of the Code and subsequent WHA
resolutions.
Data validation WHO, UNICEF, and IBFAN/ICDC analyse all legislation and
process regulations to determine which provisions of the Code were covered.
All three organizations agree upon the categorization based on the
provisions included.
frequency of data
collection
Links to tool http://www.who.int/nutrition/publications/infantfeeding/code_
report2016/en/
227
Member State has implemented at least one
recent national public awareness programme and
Indicator 8 motivational communication for physical activity,
including mass media campaigns for physical activity
behavioural change
Definition Country has implemented at least one recent (within the past 5 years)
national public awareness programme on physical activity.
criteria
This indicator is considered fully achieved if the country responds “Yes” to
the following question: “Has your country implemented any national public
awareness programme on physical activity within the past 5 years?”, and
provides the needed supporting documentation.
Data validation Countries are asked to submit a copy of any documentation of the
process programme and/or a link to the programme website when submitting
their response to the NCD CCS. Where discrepancies are noted, these
are referred back to the country for clarification and modification.
frequency of data
collection
228
Member State has evidence-based national guidelines/
protocols/standards for the management of major
Indicator 9
NCDs through a primary care approach, recognized/
approved by government or competent authorities
Definition Government approved evidence-based national guidelines/protocols/

standards for the management (diagnosis and treatment) of the four
main NCDs – cardiovascular diseases, diabetes, cancer and chronic
respiratory diseases.
criteria
This indicator is based on the number of countries who indicate that national
guidelines/protocols/standards exist for all four NCDs (cardiovascular
diseases, diabetes, cancer and chronic respiratory diseases).
This indicator is considered fully achieved if national guidelines/protocols/
standards exist for all four NCDs (cardiovascular diseases, diabetes,
cancer and chronic respiratory diseases), and the country provides the
needed supporting documentation.
This indicator is considered partially achieved if the country has
guidelines/protocols/standards for at least two of the four NCDs
(cardiovascular diseases, diabetes, cancer and chronic respiratory
diseases), but not for all four.
Data validation Countries are asked to submit a copy of the guidelines/protocols/
process standards when submitting their response to the NCD CCS. Where
discrepancies are noted, these are referred back to the country for
clarification and modification.
frequency of data
collection
229
Member State has provision of drug therapy,
including glycaemic control, and counselling for
Indicator 10
eligible persons at high risk to prevent heart attacks
and strokes, with emphasis on the primary care level
Definition Country has provision of drug therapy (including glycaemic control for
diabetes mellitus and control of hypertension using a total risk approach),
and counselling to individuals who have had a heart attack or stroke
and to persons with high risk (≥ 30%, or ≥20%) of a fatal and non-fatal
cardiovascular event in the next 10 years.
criteria
This indicator is based on the number of countries who respond “more than
50%” to the question “What proportion of primary health care facilities are
offering cardiovascular risk stratification for the management of patients at
high risk for heart attack and stroke?”. Additionally, countries must have
said all the following drugs were “generally available” in the primary care
facilities of the public health sector: insulin, aspirin, metformin, thiazide
diuretics, ACE inhibitors, CC blockers, statins, and sulphonylurea(s).
This indicator is considered fully achieved if the country reports that more
than 50% of primary health care facilities are offering cardiovascular risk
stratification for the management of patients at high risk for heart attack
and stroke and that all drugs listed above were generally available in the
primary care facilities of the public health sector.
This indicator is considered partially achieved if the country reports
that between 25% to 50% of primary health care facilities are offering
cardiovascular risk stratification for the management of patients at high
risk for heart attack and stroke and that all of the drugs listed above were
generally available in the primary care facilities of the public health sector.
Data validation NCD focal points, officially nominated by the Ministry of Health,
process provide the official response to WHO through the NCD Country
Capacity Survey tool.
frequency of data
collection
230
231
ISBN 978 92 4 151302 9
The n e w e ng l a n d j o u r na l of m e dic i n e
review article
global health
Noncommunicable Diseases
David J. Hunter, M.B., B.S., M.P.H., Sc.D., and K. Srinath Reddy, M.D., D.M.
T
From the Departments of Epidemiology he United Nations has held only two meetings of heads of state
and Nutrition, Harvard School of Public on a health-related issue. The first, in 2001, was on human immunodeficiency
Health, Boston (D.J.H.); the Public Health
Foundation of India, New Delhi (K.S.R.); virus infection and the acquired immunodeficiency syndrome. The second, in
and the World Heart Federation, Geneva September 2011, was on noncommunicable diseases. Although noncommunicable
(K.S.R.). Address reprint requests to Dr. diseases were ignored during the framing of the Millennium Development Goals in
Hunter at the Departments of Epidemiolo-
gy and Nutrition, Harvard School of Public 2000, their leading and growing contribution to preventable deaths and disability
Health, 677 Huntington Ave., Boston, MA across the globe has compelled policymakers to pay attention and initiate action.
02115, or at [email protected]. The United Nations and the World Health Organization (WHO) have called for a
N Engl J Med 2013;369:1336-43. 25% reduction by 2025 in mortality from noncommunicable diseases among persons
DOI: 10.1056/NEJMra1109345 between 30 and 70 years of age, in comparison with mortality in 2010, adopting
Copyright © 2013 Massachusetts Medical Society.
the slogan “25 by 25.” 1,2 We review the burden of noncommunicable diseases and
issues in prevention, detection, and treatment that must be addressed in order to
meet this goal.
Dise a se a nd Ec onomic Bur dens
Disease Burden
Noncommunicable diseases have been a difficult group to define. Even the term
“noncommunicable diseases” is a misnomer, because it includes some diseases —
notably, cancers of the liver, stomach, and cervix — that are at least partly caused
by infectious organisms, and it usually excludes mental illnesses, despite their large
contribution to long-term disability. However, four common behavioral risk factors
(tobacco use, excessive alcohol consumption, poor diet, and lack of physical activity)
are associated with four disease clusters (cardiovascular diseases, cancers, chronic
pulmonary diseases, and diabetes) that account for about 80% of deaths from non-
communicable diseases.3 According to WHO estimates, noncommunicable diseases
contributed to 36 million deaths globally in 2008, accounting for 63% of 57 mil-
lion total deaths (Fig. 1).4 The Global Burden of Diseases, Injuries, and Risk Fac-
tors Study 2010 (GBD 2010) estimated that mortality due to noncommunicable
diseases (with the use of a somewhat different definition of noncommunicable dis-
eases than that used by the WHO) increased from 57% of total mortality in 1990 to
65% in 2010.3,5 About 80% of deaths related to noncommunicable diseases occur
in low- and middle-income countries, which also have a high proportion of deaths
in middle age; such countries account for 90% of the 9 million noncommunicable
disease–related deaths that occur before 60 years of age (Fig. 2).6 This staggering
toll of noncommunicable diseases and premature mortality in low- and middle-
income countries sometimes surprises those who suppose that mortality in these
An interactive countries is still dominated by maternal and child deaths and deaths due to infec-
graphic showing tious diseases.
the global burden Cardiovascular diseases account for the largest fraction of deaths related to non-
of noncommu-
nicable diseases
communicable diseases, followed by cancer, chronic obstructive pulmonary disease
over time is avail- (COPD), and diabetes (Fig. 3A and interactive graphic, available with the full text of
able at NEJM.org this article at NEJM.org).7 Proportional mortality from noncommunicable diseases is
1336 n engl j med 369;14 nejm.org october 3, 2013
The New England Journal of Medicine

Downloaded from nejm.org on March 28, 2024. For personal use only.
No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved.
global health
higher in high-income countries than in low- and

middle-income countries, because high-income 70 Male Female
countries have a lower burden of maternal and 60
child deaths and deaths due to infectious dis-
Percent of Total Deaths

eases. However, the absolute number of deaths 50
due to noncommunicable diseases is higher in 40

the low- and middle-income countries owing to
30
their larger populations. Age-standardized rates of
death due to noncommunicable diseases are also 20
higher in these countries than in the high-income
10
countries.8
The GBD 2010 also calculated disability-adjusted 0
Communicable Noncommunicable Injuries
life-years (DALYs), which are the sum of years of Diseases and Diseases
life lost from premature death and years lived with Maternal,
Perinatal, and
disability, and estimated that 54% of DALYs world- Nutritional Conditions
wide in 2010 were due to noncommunicable dis-
eases, an increase from 43% in 1990.7 Between Figure 1. Global Deaths According to Cause and Sex, 2008.
1990 and 2010, DALYs due to cardiovascular dis- Adapted from the World Health Organization (WHO).4
eases, cancer, and diabetes mellitus increased by
22.6%, 27.3%, and 69.0%, respectively, whereas
DALYs due to COPD decreased by 2.0% (Fig. 3B). cumulative output loss of $47 trillion between
In addition, a large share of the burden of disabil- 2011 and 2030 because of noncommunicable dis-
ity is due to other noncommunicable diseases, eases and mental illness, about $30 trillion of
such as asthma, digestive diseases, neurologic dis- which will be attributable to cardiovascular dis-
orders, mental and behavioral disorders, kidney eases, cancers, chronic pulmonary diseases, and
diseases, gynecologic disorders, hemoglobinopa- diabetes.10 Noncommunicable diseases are also a
thies, musculoskeletal disorders, congenital anom- major cause of catastrophic health expenditure
alies, and skin, sense-organ, and oral disorders. among the uninsured.11
Whereas these diseases were associated with only
19.6% of deaths in 2010, they accounted for 54.8% Prevalence of Risk Factors
of DALYs.7 For some of these diseases, the primary Tobacco use, excessive alcohol consumption,
risk factors are similar to those for cardiovascular poor diet, and lack of physical activity contribute
disease, cancer, COPD, and diabetes, but for many to the development of noncommunicable diseas-
the risk factors are specific and unique — a re- es. Measurable phenotypes such as high blood
minder that not all aspects of control of noncom- pressure, hypercholesterolemia, and obesity me-
municable diseases are addressed by strategies diate much of the relationship between these risk
targeted to the four major groups of noncommu- factors and the incidence of noncommunicable
nicable diseases. disease. As summarized in the review by Ezzati
The WHO projects that noncommunicable and Riboli,12 global trends in the prevalence of
diseases will account for an increasing absolute these behavioral risk factors and intermediate
number and proportion of worldwide deaths, phenotypes portend substantial increases in
rising to about 70% of deaths in 2030.9 The in- most of the noncommunicable diseases world-
crease in the absolute numbers of deaths is pri- wide, with the patterns of change in incidence
marily due to the increase in the size and age of varying between and within regions, depending
the world population. on the level of economic development, the pace
of the demographic transition from high birth
Economic Effects and death rates to low birth and death rates, and
The economic consequences of noncommunica- the prevalence of risk factors.12,13
ble diseases are huge, because of the combined Ethnic variations in susceptibility to disease
burden of health care costs and lost economic have also been described, such as an increased
productivity due to illness and premature deaths. risk of stroke in East Asian populations and an
A study commissioned by the World Economic increased risk of coronary heart disease in South
Forum concluded that the world will sustain a Asians.14,15 Risk factors vary across regions. For
n engl j med 369;14 nejm.org october 3, 2013 1337

since the 1950s, rates of death from cerebrovas-

100 Male Female Both sexes cular disease decreasing by 78% since the 1950s,
Percent of Deaths from Noncommunicable
90 and rates of death from cancer down by 17%

80 since 1980.18 Similar reductions in the rate of
70 death from cardiovascular diseases and, among
60 men, the rate of death from lung cancer have
Diseases
50 been seen in many high-income countries.13 The

40 sobering news is that despite these falls in the
30 age-adjusted rates, the decline in the absolute
20 number of deaths per year is much less substan-
10 tial because of the growth and aging of the pop-
0 ulation. Thus, even if countries with growing
Low- Lower-Middle- Upper-Middle- High-
Income Income Income Income and aging populations can engineer decreases in
Countries Countries Countries Countries mortality, they will need to prepare for substan-
tial numbers of cases of noncommunicable dis-
Figure 2. Proportion of Deaths from Noncommunicable Diseases among
eases. Worldwide, the GBD 2010 estimates of
Persons Younger than 60 Years of Age, According to Income Group of Countries.
age- and sex-specific rates of deaths and DALYs
Adapted from the WHO.6
due to noncommunicable diseases, as compared
with rates in 1990, also show a substantial reduc-
example, in South Asia, indoor air pollution due tion in incidence rates, but these reductions are
to burnt wood or biomass fuel at home is a ma- more than canceled out by increasing population
jor cause of COPD, and oral cancer is most often size and population aging.3,7
caused by chewed tobacco. Modeling suggests that risk-factor reduction
explains approximately 44 to 76% of the decline
The “Unfinished Agenda” in mortality from coronary heart disease in the
and Noncommunicable Diseases United States and other high-income countries,
The term “unfinished agenda” is often used to and improvements in treatments and access to
refer to the health problems of less developed treatments explain 23 to 47%.19 During the 20th
countries before the onset of the health transi- century, mortality from cervical cancer decreased
tion — that is, mainly infectious diseases, mal- dramatically in high-income countries, mainly
nutrition, and other diseases of poverty. In a because organized cervical screening led to early
cruel twist, some of the causes of noncommuni- detection and treatment.20 Lung-cancer rates are
cable diseases in these countries are due not to dropping as a result of declines in the prevalence
the behavioral risk factors listed above but rather of smoking. Thus, trends in high-income coun-
to these “unfinished” problems. Heart disease tries suggest that the size of the epidemic of
due to rheumatic fever, for instance, is still a noncommunicable diseases is not predetermined,
common cause of early-onset heart disease in and the challenge for low- and middle-income
low- and middle-income countries,16 and the countries is to intervene sufficiently early to
Barker hypothesis proposes that exposure to in- mitigate the epidemic.
adequate maternal nutrition in utero and during
the first years of life increases the risk of non- S t r ategie s for Pr e v en t ion
communicable diseases in adulthood.17 a nd C on t rol
To be comprehensive, a program for the preven-

T r ends in High-Inc ome
C oun t r ie s tion and control of noncommunicable diseases
must integrate policies designed to foster a soci-
The rates of death due to noncommunicable dis- etal environment in which people are encouraged
eases have peaked in some high-income coun- to make and maintain healthy living choices,
tries, particularly with respect to cardiovascular promote health literacy so that people can protect
diseases and some cancers, such as lung cancer. and improve their health, and provide health ser-
Figure 4 shows the 60-year trends in the United vices focused on early detection and cost-effective
States, with age-adjusted rates of death from car- management of noncommunicable diseases and
diovascular diseases decreasing by about 70% their risk factors (Table 1).

global health
Population-based interventions include policy

measures such as increasing taxation of tobacco A Global Deaths
and alcohol, reducing salt and saturated fat and 18 1990 2010
eliminating trans fats in processed foods, and 16

creating smoke-free and exercise-friendly public 14
spaces. Among the risk factors identified as 12
No. (millions)
major causes of noncommunicable diseases,13 10
dietary risk factors and physical inactivity are 8
partially determined by individual preferences 6
but are substantially influenced by the manufac- 4
turing and marketing practices of the food in- 2
dustry and by the built and social environments 0
that permit or impede physical activity. Evidence
er
PD
s
di lar
as
te
er
nc
u
be
se
CO
th
is rapidly accumulating that the consumption of
sc
Ca
O
ia
va
D
io
sugared beverages is an important cause of
rd
Ca
childhood obesity, and in randomized trials, the
substitution of lower-calorie beverages is associ- B Global DALYs
ated with weight loss.21,22 Mass-media messaging 800 1990 2010
as well as health promotion in specific settings

(schools, workplaces, and community centers) 600
may be used to provide health education. Pre-
No. (millions)
ventive interventions include risk-factor assess-

400
ment and treatment with behavioral interven-
tions and medication for persons at high risk.
Although multidrug therapy for persons with 200
established cardiovascular disease is required
for secondary prevention, there is also a need to 0
treat persons at high absolute risk for a first
e
er
PD
s
di lar
as
te
er
nc
u
be
se
CO
th
serious cardiovascular event. Some evidence-based
sc
Ca
O
ia
va
D
io
therapies, such as the administration of generic

rd
Ca
antihypertensive agents and statins, are low-cost

by the standards of high-income countries but Figure 3. Global Deaths and Global Disability-Adjusted
are prescribed in low- and middle-income coun- Life-Years (DALYs) Due to Noncommunicable Diseases
in 1990 and 2010.
tries for only a small fraction of patients who are
DALYs are the sum of years of life lost from premature
candidates for such treatment according to evi-
death and years lived with disability. COPD denotes
dence-based guidelines, even though high blood chronic obstructive pulmonary disease. Adapted from
pressure is the leading cause of deaths and Murray et al.7
DALYs.13 Similarly, there is underutilization of
therapies for secondary prevention of recurrent
events — for example, after a myocardial infarc- implemented within and between nations.26,27
tion or cerebrovascular event. The development Public-interest litigation and changes in national
of combination pills (one form of which is called laws such as the U.S. Tobacco Control Act28 to
the “polypill”) has now entered the clinical-trial provide greater government regulation of the
phase and holds promise for a simplified regi- tobacco industry are needed. Increasing obesity
men at even lower cost.23,24 rates presage an increase in mortality from a
Tobacco is the second largest cause of deaths wide variety of cancers29; thus, obesity preven-
and DALYs worldwide, and tobacco control tion is a priority for cancer prevention, as well as
could prevent about a third of all deaths from for the prevention of cardiovascular disease and
cancer in the United States25 and could also diabetes. In countries with infant vaccination
rapidly reduce deaths from cardiovascular and against hepatitis B virus, chronic-carrier rates
chronic pulmonary diseases. The WHO Frame- and rates of liver cancer have declined sharply.30
work Convention on Tobacco Control provides The recent development of human papillomavi-
proven tobacco-control strategies that need to be rus vaccines for cervical-cancer prevention offers

1200
Diabetes
Chronic lower
Age-Adjusted Rate of Death per 100,000 Population

1000 respiratory diseases
Malignant neoplasms
Cerebrovascular
diseases
800 Diseases of the heart
600
400
200
0
1950 1960 1970 1980 1990 2000 2010
Figure 4. Declines in Rates of Death from Major Noncommunicable Diseases in the United States, 1950 to 2010.
Adapted from the National Center for Health Statistics, Centers for Disease Control and Prevention.18
a new opportunity to control the fourth leading clinical facilities, and adequate supplies of drugs.
cause of cancer deaths in women worldwide.31 Bloom et al.10 conclude, “Interventions in this
Many cancers are highly treatable, if detected area will undeniably be costly. But inaction is
early, and the provision of evidence-based screen- likely to be far more costly.”
ing and treatment regimens in low- and middle-
income countries is an important component of Ch a l l enge s t o He a lth S ys tems
cancer control that requires larger investments
in human and capital resources.32 The global epidemic of noncommunicable dis-
Many of these interventions have been identi- eases poses challenges to the health systems of
fied as cost-effective by the WHO.33 A series of all countries, though the problems vary. High-
“best buys,” determined on the basis of cost- income countries are confronted by the rising
effectiveness and the feasibility of implementa- costs of technology-intensive health care for ag-
tion, have been suggested. For risk-factor reducing populations. The health systems of low- and
tion, these include tobacco and alcohol taxes, middle-income countries must address the si-
advertising bans and warnings, reductions in multaneous challenges of multiple infectious
salt and trans fat intakes, promotion of physical diseases, undernutrition, and ongoing substan-
activity, and hepatitis B vaccination. Health care dard maternal and child health, which vie with
“best buy” interventions include counseling re- noncommunicable diseases for scarce financial
garding risk-factor reduction and multidrug ther- and human resources. These problems are com-
apy for persons at high risk for cardiovascular pounded by weak disease and risk-factor surveil-
disease or diabetes, aspirin therapy for those with lance systems and lack of access to affordable
a history of acute myocardial infarction, and drugs and laboratory and diagnostic tests.
cervical-cancer screening and treatment. These In low- and middle-income countries, finan-
interventions require a complex series of legisla- cial protection from the costs of treatment for
tive actions, public-awareness campaigns, and noncommunicable diseases, in the form of pub-
public health interventions, as well as adequate lic financing or insurance, is limited. The health
numbers of clinical personnel, at least basic care infrastructure is also limited, with inade-

global health
Table 1. Opportunities for Prevention, Detection, and Treatment of Noncommunicable Diseases in Low- and Middle-Income Countries.
Level of
Approach Prevention Detection Treatment
Government Anti-tobacco policy; policies that promote re- Promotion of awareness of noncommu- Policies that ensure access to af-
duction in salt intake; regulation and label- nicable diseases, their signs and fordable essential medicines
ing of processed foods and high-sugar bev- symptoms, and the need for early
erages; planning for safe, healthy environ- detection
ments that promote physical activity and
limit the transition to a sedentary lifestyle;
policies designed to mitigate the harmful
effects of alcoholic beverages
Health care Intersectoral planning for health promotion; Surveillance to determine the preva- Facilities and equipment for
system training of health personnel, including task lence of risk factors and noncom- affordable treatments; recog-
shifting for detection and treatment of municable diseases; facilities and nition of the need for both
noncommunicable diseases (e.g., blood- equipment for low-cost detection of short-term and long-term
pressure and glycemic control provided by intermediate risk factors (e.g., high treatment of noncommuni-
nurses or ancillary health workers) blood pressure) cable diseases
Clinicians Counseling of patients in risk-factor reduction; Evaluation of intermediate risk factors, Evidence-based treatment with
treatment of tobacco addiction coupled with lifestyle and drug inter- affordable essential medi-
ventions to lower risk-factor profiles; cines; procedural or surgical
appropriate screening (e.g., detec- interventions, if appropriate
tion of human papillomavirus)
quate facilities for advanced care and shortages pocket health care expenditures, resulting in mil-
of trained medical specialists, nurses, and allied lions of people being pushed into poverty. Coun-
health workers. Paradoxically, some low- and tries such as Thailand and India are resorting to
middle-income countries have highly advanced compulsory licensing to domestically produce
tertiary clinical care facilities in major cities, the more expensive cardiovascular or anticancer
staffed by very skilled professionals. However, drugs. Lack of reform of national and interna-
even in such countries, the diagnosis and treat- tional regulations on opiate production and ex-
ment of noncommunicable diseases are usually port means that many patients with cancer are
very deficient at the primary and secondary deprived of low-cost drugs such as morphine that
care levels. In general, the health systems are could provide pain relief.37
configured to provide episodic care for acute At the same time, the reduced cost of care for
illness and have not yet made the adaptations many procedures, such as cardiac or cancer sur-
required to provide continuous care for chronic gery, in developing countries is opening up
illness. markets in medical tourism. Even as low- and
Access to essential drugs is not ensured in middle-income countries can gain from access
many countries, with inadequate supplies of to technical expertise in high-income countries,
cardiovascular drugs, anticancer agents, insulin the latter can learn from the highly cost-efficient
and oral hypoglycemic agents, and bronchodila- and high-throughput models of surgery devel-
tors.34 An analysis of WHO data from 36 coun- oped in some low- and middle-income countries38
tries showed that the availability of cardiovas- and new, lower-cost technologies developed un-
cular drugs was poor (26.3% of public-sector der the rubric of “frugal innovation.”39
facilities and 57.3% of private-sector facilities In primary health care, there is a need to train
had such drugs),35 and a survey of 6 countries and deploy nonphysician health care workers,
by the WHO showed that the monthly cost of ranging from community health workers to
treatment with a single antihypertensive medi- skilled nurses, while enhancing the ability of
cation exceeded several days’ wages in many primary care physicians to provide appropriate
countries.36 When multiple drugs are used, the care based on standard guidelines. The ability of
cost becomes unaffordable, and this problem is nonphysician health workers to effectively detect
further compounded when more than one family and manage diabetes and high blood pressure
member needs treatment.36 In low- and middle- has been shown in countries such as South Af-
income countries, drug therapy for cardiovascular rica40 and Iran.41 The WHO Cardiovascular Risk
disease is a major contributor to high out-of- Management Package has been shown to be use-

ful for scaling up the management of cardiovas- communicable diseases were omitted from the
cular diseases in primary health care settings in Millennium Development Goals in 2000, a consen-
which physicians are not available.42 sus is emerging among the various United Nations
Cell phone–based “mHealth” tools have been agencies and other international organizations that
successfully used by frontline health care workers a life-course perspective must be adopted, with an
for remote data collection, remote monitoring, emphasis on noncommunicable diseases as part of
and diagnostic and treatment support in several the health goal to be included in the set of post-
developing countries.43 Further extending these 2015 Sustainable Development Goals. Whether the
applications with regard to noncommunicable goal itself will be defined as “Gaining Health and
diseases could also be promising, as shown in Well-Being at All Stages of Life” or “Maximizing
formative research on diabetes care in developed Healthy Life Expectancy” or “Universal Health
nations.44 Information and communication tech- Coverage”46 (which are leading contenders at pres-
nology can enable nonphysician health care pro- ent), it is clear that the prevention and control of
viders to play an effective role in the diagnosis noncommunicable diseases will be acknowledged
and management of noncommunicable diseases. as an integral part of the sustainable-development
Progress toward the goal of a 25% reduction agenda. However, it remains to be seen whether
in the rate of premature death from noncom- the plan of action will address the many upstream
municable diseases by 2025 will require both determinants of noncommunicable diseases, go-
country-specific actions and global coopera- ing beyond the needed clinical services.47
tion.45 Country-specific actions require strong
political leadership and the development of na- C onclusions
tional action plans that mobilize a multisectoral
response (e.g., multiple levels of government, the Noncommunicable diseases will be the predomi-
private sector, and nongovernmental organiza- nant global public health challenge of the 21st
tions) and provide mechanisms to monitor prog- century. Prevention of premature deaths due to
ress and ensure accountability from the multiple noncommunicable diseases and reduction of re-
sectors involved. Brazil, for instance, passed a lated health care costs will be the main goals of
new anti-tobacco law, signed agreements with health policy. Improving the detection and treat-
the food industry to reduce salt consumption ment of noncommunicable diseases and prevent-
and eliminate trans fats from processed foods, ing complications and catastrophic events will
and improved access to cardiovascular drugs.45 be the major goals of clinical medicine. A mul-
Global cooperation is needed, given the global- tilevel approach that integrates policy actions,
ization of tobacco exportation and agribusiness regulations, health education, and efficient health
and multinational ownership of major food and systems to achieve these goals will be the mis-
soft-drink manufacturers. sion of public health. All countries can benefit
The importance of addressing noncommunica- by sharing experience and pooling expertise for
ble diseases at the global level has also become a the prevention and control of noncommunica-
major element of the ongoing discussion concern- ble diseases.
ing the post-2015 development goals, which is be- Disclosure forms provided by the authors are available with
ing steered by the United Nations. Whereas non- the full text of this article at NEJM.org.
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NONCOMMUNICABLE DISEASES

PROGRESS MONITOR 2017

PROGRESS MONITOR 2017

© World Health Organization 2017

211 Appendix 1: Indicator Definitions and Specifications

Contributions to the report were made by the following colleagues in WHO

This burden is rising disproportionately among low-income and lower-middle-income

Most premature NCD deaths can be prevented or delayed by implementing a set of so

World leaders committed in the Agenda for Sustainable Development to reduce

Dr Tedros Adhanom Ghebreyesus

1 Member State has set time-bound national targets based on WHO

Consider developing national multisectoral policies and plans to achieve the

4 Member State has an operational multisectoral national strategy/

a Reduce affordability by increasing excise taxes and prices on tobacco products

b Eliminate exposure to second-hand tobacco smoke in all indoor workplaces,

c Implement plain/standardized packaging and/or large graphic health

d Enact and enforce comprehensive bans on tobacco advertising, promotion and

b Enact and enforce bans or comprehensive restrictions on exposure to alcohol

c Increase excise taxes on alcoholic beverages

a Adopt national policies to reduce population salt/sodium consumption

c WHO set of recommendations on marketing of foods and non-alcoholic

d Legislation /regulations fully implementing the International Code

Strengthen health systems to address NCDs through people-centred primary

9 Member State has evidence-based national guidelines/protocols/

10 Member State has provision of drug therapy, including glycaemic

Progress monitoring indicators

Assessment of indicators 7a, 7b and 7c were additionally reviewed against responses

National NCD targets ○

restrictions on physical availability ●

Guidelines for management of cancer, CVD, diabetes and CRD ○

World Health Organization - Noncommunicable Diseases Progress Monitor 2017

National NCD targets ◐

restrictions on physical availability ◐

● = fully achieved ◐ = partially achieved ○ = not achieved

World Health Organization - Noncommunicable Diseases Progress Monitor 2017

National NCD targets ●

Harmful use of alcohol reduction measures:

restrictions on physical availability ◐

Public education and awareness campaign on physical activity ●

● = fully achieved ◐ = partially achieved ○ = not achieved

DK = don't know NR = No Response

World Health Organization - Noncommunicable Diseases Progress Monitor 2017

National NCD targets ○

restrictions on physical availability ◐

Public education and awareness campaign on physical activity ●

● = fully achieved ◐ = partially achieved ○ = not achieved

DK = don't know NR = No Response † = see Explanatory Notes

World Health Organization - Noncommunicable Diseases Progress Monitor 2017

National NCD targets ○

restrictions on physical availability ◐

Guidelines for management of cancer, CVD, diabetes and CRD DK

Drug therapy/counselling to prevent heart attacks and strokes ○

DK = don't know NR = No Response

World Health Organization - Noncommunicable Diseases Progress Monitor 2017

National NCD targets ○

restrictions on physical availability ◐

World Health Organization - Noncommunicable Diseases Progress Monitor 2017

National NCD targets ●