Implementing the global monitoring framework at country level Leanne Riley Team Leader Surveillance Surveillance and Population-based Prevention Department for the Prevention of NCDs 1

In selecting indicators and targets, the following criteria were considered: High epidemiological and public health relevance Coherence with major strategies Priorities of the Global Strategy for the Prevention and Control of NCDs and its Action Plan, as well the Political Declaration. WHO framework for health systems priorities to monitor exposures, outcomes, and health systems response Evidence driven targets and indicators Availability of evidence-based effective and feasible public health interventions Evidence of achievability at the country level Existence of unambiguous data collection instruments and potential to set a baseline and monitor changes over time.

Reporting on indicators WHA68 2015 WHA73 2020 WHA78 2025 Reporting on indicators 2010 baseline

Comprehensive Global Monitoring Framework Cancer incidence, by type of cancer per 100 000 population Unconditional probability of dying between ages 30 and 70 years from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases. Mortality & Morbidity

Comprehensive Global Monitoring Framework Risk Factors

Comprehensive Global Monitoring Framework Age-standardized prevalence of insufficiently physically active persons aged 18+ years defined as less than 150 minutes of moderate-intensity activity per week, or equivalent Prevalence of insufficiently physically active adolescents defined as less than 60 minutes of moderate to vigorous intensity activity daily. Age –standardized mean proportion of total energy intake from saturated fatty acids in person aged 18+ years Risk Factors

Comprehensive Global Monitoring Framework Age-standardized prevalence of current tobacco use among persons aged 18+ years Prevalence of current tobacco use among adolescents Risk Factors

Comprehensive Global Monitoring Framework Age-standardized prevalence of overweight and obesity in persons aged 18+ years Age-standardized prevalence of raised blood pressure among persons aged 18+ years and mean systolic blood pressure. Risk Factors

Comprehensive Global Monitoring Framework Age-standardized prevalence of raised total cholesterol among persons aged 18+ years and mean total cholesterol. Risk Factors

Comprehensive Global Monitoring Framework National Systems response Vaccination coverage against hepatitis B virus monitored by number of third doses of Hep-B vaccine (HepB3) administered to infants National Systems response

Comprehensive Global Monitoring Framework National Systems response Access to palliative care assessed by morphine-equivalent consumption of strong opioid analgesics (excluding methadone) per death from cancer Adoption of national policies that limit saturated fatty acids and virtually eliminate partially hydrogenated vegetable oils (PHVO) in the food supply, as appropriate within the national context and national programmes Availability, as appropriate, if cost-effective and affordable, of HPV vaccines, according to national programmes and policies 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. National Systems response

Relationship between global and national targets National targets should be consistent with the global targets Targets may be adapted nationally, based on the country's situation Adaptations would reflect what might be achievable in a specific country based on their performance, current exposure and what actions can be achieved National adapted targets may be more or less ambitious than the global target

Issues to consider Are the targets and indicators in the GMF all suitable in your country? Are there additional targets and indicators needed for your country? Does your country have the systems in place to track these global indicators and report on global targets? And systems which track any new proposed ones? What is the current level of exposure/mortality/service provision in your country? Are the reductions or coverage proposed for global targets appropriate for your country or should they be more or less?

Indicators and data sources Vital Reg with COD Cancer Registry Risk factor survey National capacity/service assessment Mortality from main NCDs Cancer incidence by type Harmful use of alcohol (3) Low fruit and veg intake Physical inactivity in adults Physical inactivity in adolescents Salt intake Saturated fat intake Tobacco use in adults Tobacco use in adolescents Raised blood glucose/diabetes Raised blood pressure Overweight and obesity in adults Overweight and obesity in adolescents Raised total cholesterol

Indicators and data sources, cont. Vital Reg with COD Cancer Registry Risk factor survey National capacity/service assessment Cervical cancer screening Drug therapy and counseling Essential NCD meds and technologies Hepatitis B vaccine HPV vaccine Marketing to children Access to palliative care Policies to limit saturated fats and eliminate PHVOs

Thank you 18

Surveillance of NCDs: Instruments and Data Sources Leanne Riley Team Leader Surveillance Surveillance and Population-based Prevention Prevention of NCDs Department 19

Surveillance definition On-going, systematic collection, analysis, interpretation and dissemination of data essential for health promotion and disease prevention (CDC MMWR 2004)

Why is surveillance important? Sizes the problem Informs interventions Content of advocacy information Basis for evaluating impact of policy/practice Helps prioritise resources allocation Stimulates research

NCD Surveillance tools at WHO NCD global monitoring framework, indicators and targets NCD Country Capacity Survey (CCS) STEPS (adults) GSHS (adolescents) Service availability and readiness assessment (SARA) Comparable estimates for key risk factors Compiling and storing NCD data

Monitoring Framework for NCD surveillance Exposures Behavioural risk factors: tobacco use, physical inactivity, harmful use of alcohol and unhealthy diet Metabolic risk factors: raised blood pressure, overweight/obesity, raised blood glucose, and raised cholesterol. Social determinants: education, material well being, access to health care Outcomes Mortality: NCD specific mortality Morbidity: cancer incidence and type Health System Response Interventions and health system capacity: infrastructure, policies and plans, access to key health care interventions and treatments, partnerships.

NCD Country Capacity Survey To gather information about individual country capacity to respond to NCD prevention and control. Assessment focused on current strengths and weaknesses related to: NCD infrastructure, policy response, surveillance and health systems response and partnerships and health promotion. 4th wave of surveillance currently underway in 2013 – previous surveys in 2000, 2005, and 2010. Generally a high response rate from Member States. Periodic monitoring of national progress would assist countries in identifying gaps in prevention and control efforts and assist with future planning.

STEPS- adult risk factor surveillance Objectives Empower Member States to gather information on chronic disease risk factors for use in planning health programmes and interventions. Provide standardized questionnaire that allows for comparisons, but is flexible to meet Member States' needs. Build capacity in Member States in all aspects of national survey implementation; in particular, develop skills in sample design, data collection and data analysis.

Questionnaire Overview Different levels of risk factor assessment: STEP 1 – questionnaire STEP 2 – physical measurements STEP 3 – blood samples Three modules per Step: Core Expanded Optional

Questionnaire Overview, cont. Behavioural Risk Factors Tobacco use Harmful alcohol consumption Unhealthy diet (low fruit and vegetable consumption) Physical inactivity Biological Risk Factors Overweight and obesity Raised blood pressure Raised blood glucose Abnormal blood lipids Optional Modules on Health Care, Injury and Violence, Mental Health (suicide) Oral Health, Salt intake, Sexual Health, and Tobacco policy

STEPS Methodology Targets a nationally representative sample of adults aged 18 – 69. STEP 1 (questionnaire) and STEP 2 (physical measures) are conducted in the household by trained interviewers. STEP 3 (biochemical measures) is typically clinic or health centre-based. Pocket PCs (PDAs*) are used for data collection: "eSTEPS" Repeat survey should be done every 3 - 5 years. *(Personal Digital Assistant)

Current Status of STEPS # planning* # in field / data entry or analysis work # reporting completed** Total # active # trained but inactive # with 1 or more repeats** AFRO 10 2 37 47 (4) 4 AMRO 9 7 8 26 (2) 3 EMRO 15 18 (1) EURO 6 1 (0) SEARO WPRO 21 129 *includes planning for repeat surveys **includes "STEPSlike" surveys

Global School Based Student Health Survey (GSHS) Overview & Objectives System for surveillance of behavioural risk factors and protective factors in school-aged children Help countries develop priorities, establish programmes, and advocate for resources Establish trends in the prevalence of health behaviors and protective factors by country Allow countries and international agencies to make comparisons across countries

GSHS: Methods Self-administered questionnaire and generic answer sheet Targets grades with students aged 13 – 17 years Completed by students during one classroom period Anonymous and confidential 10 Question Modules are available, from which countries can select a minimum of 6: Alcohol, diet, drugs, hygiene, mental health, physical activity, protective factors, sexual behaviours, tobacco, violence & injury

GSHS: Current Implementation Status Worldwide, 106 countries across all six WHO regions have been trained and 96 have finished GSHS data collection (including 17 countries with repeat surveys).

GSHS: Current Implementation # trained and planning # 1 survey completed # with 1 or more repeats Total # active AFRO 4 14 3 21 AMRO 22 7 33 EMRO 11 6 17 EURO 2 SEARO WPRO 1 96

Service Availability and Readiness Assessment (SARA) A health facility assessment tool designed to assess and monitor service availability and readiness of the health sector and generate evidence to support planning and managing a health system. Designed as a systematic survey to generate a set of tracer indicators of service availability and readiness, including: availability of key human and infrastructure resources; availability of basic equipment, basic amenities, essential medicines, and diagnostic capacities; and readiness of health facilities to provide basic health-care interventions relating to family planning, child health services, basic and comprehensive emergency obstetric care, HIV, TB, malaria, and non-communicable diseases.

Comparable estimates for selected NCD Risk Factors GBD 2008 update, includes many NCD risk factors Metabolic risk factors – BMI, Blood pressure, Blood Glucose, Cholesterol Country consultation conducted on all comparable risk factor estimates between September and December 2010 and again during July 2011. Included in the NCD Global Status Report (April 2011), and NCD Country Profiles (September 2011). Lancet papers released in April 2011, showing 30 year trends in metabolic risk factors. Also included in Country profiles. Being updated to provide 2010 baseline data for GMF and targets.

Comparable estimates – overweight/obesity/mean BMI Lancet paper released in April 2011, showing 30 year trends in overweight and obesity. In 2008, 35% adults overweight globally (34% men and 35% women). 10% men and 14% women obese in 2008. Worldwide obesity has more than doubled since 1980. In 2008, 1.5 billion adults, 20 and older, were overweight. Of these over 200 million men and nearly 300 million women were obese. Country specific estimates available and included in the GSR and country profiles.

Age-standardized prevalence of overweight in adults aged 20+ years by WHO Region and World Bank income group, comparable country estimates, 2008

Compiling and storing NCD data

Prevalence of overweight (BMI 25+), 2008, ages 20+, age adj

Prevalence of raised blood pressure*, 2008, ages 25+, age std *defined as less systolic BP 140+ and/or diastolic BP 90+ or on medication for raised BP

NCD Country Profiles

Questions?