1. 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

4. 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.

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

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

7. Comprehensive Global Monitoring Framework
Risk Factors

8. 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

9. 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

10. 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

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

12. 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

13. 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

14. 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

15. 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?

16. 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

17. 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

18. Thank you 18

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

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

21. 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

22. 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

23. 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.

24. 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.

25. 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.

26. 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

27. 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

28. 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 years.
*(Personal Digital Assistant)

29. 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

31. 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

32. 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

33. 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).

34. 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

36. 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.

37. 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.

38. 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.

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

40. Compiling and storing NCD data

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

42. 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

43. NCD Country Profiles

44. Questions?