Correcting Market and Government Failures in Tackling the Global Growth of Type 2 Diabetes: Application of WHO’s Common Goods for Health Approach

This paper presents the economic rationale for treating Common Goods for Health (CGH) as priorities for public intervention. We use the concept of market failure as a central argument for identifying CGH and apply cost-effectiveness analysis (CEA) as a normative tool to prioritize CGH interventions in public finance decisions. We show that CGH are consistent with traditional lists of public health core functions but cannot be identified separately from non-CGH activities in such lists. We propose a public finance decision tree, adapted from existing health economics tools, to identify CGH activities within the set of cost-effective interventions for the health sector. We test the framework by applying it to the 2018 Disease Control Priority (DCP) list of interventions recommended for public funding and find that less than 10% of cost-effective interventions unconditionally qualify as CGH, while another two-thirds may or may not qualify depending on context and form. We conclude that while CEA can be used as a tool to prioritize CGH, the scarcity of such analyses for CGH interventions may be partly responsible for the lack of priority given to them. We encourage further research to address methodological and resource challenges to assessing the cost-effectiveness of CGH intervention packages, in particular those involving large investments and long-term benefits.

Noncommunicable diseases (NCDs) are the leading cause of mortality and morbidity, and posing significant challenges both in developed and developing countries including Bangladesh. In 2016, of the total 56.9 million global deaths, 71.0%, were due to NCDs. Some 85.0% of premature deaths from NCDs, are in low and middle income countries, where greater burden of undernutrition and infectious diseases exist.1-3 Evidence suggests a higher age specific mortality for NCDs among Bangladeshi population compared to Western populations, which putting burden on healthcare systems. 4 Bangladesh NCD Risk Factors Survey, 2018 showed that among the adult population, the mean salt intake was 16.5 gram per day and the prevalence of dislipidaemia was 28.4 %.5 Sugar consumption also continues to rise, driven by increased intake of beverages, biscuits, sweets and confectionary items. Industrially produced transfat in some food items is also an important issue in the country. Malnutrition is a key risk factor for NCDs. Globally, nearly one in three people has at least one form of malnutrition, and this will reach one in two by 2025, based on current trends.6-8 All forms of malnutrition are caused by unhealthy, poor quality diets. Unhealthy diets that include high sugar, salt and fat intake, malnutrition, and NCDs are closely linked. Not only on the health, malnutrition and diet related NCDs pose a substantial burden on the economy and development. Food systems worldwide face major challenges, such as population growth, globalisation, urbanisation, and climate change. Today’s food systems are broken and do not deliver nutritious, safe, affordable, and sustainable diets; they undermine nutrition in several ways, particularly for vulnerable and marginalised populations. Billions of dollars are spent annually marketing foods high in calories, fats, sugars, and salt, and intake has increased globally, including in low income countries.8 United Nations (UN) is well committed to prevent and control noncommunicable diseases through adopting series of resolutions in its General Assembly. In 2013, Member States of the World Health Organization (WHO) resolved to develop and implement national action plans, in line with the Global Action Plan for the Prevention and Control of Noncommunicable Diseases (2013–2020).9 NCDs are also embedded in sustainable development goal (SDG) target 3.4, that is, to reduce by one-third the premature mortality from noncommunicable diseases by 2030. NCDs are also linked to other SDGs, notably SDG 1 to end poverty. In 2017, the WHO Global Conference on Noncommunicable Diseases reaffirmed noncommunicable diseases as a sustainable development priority in the Montevideo roadmap 2018–2030.10 Bangladesh has also developed the Multisectoral Action Plan for Prevention and Control of Noncommunicable Diseases 2018-2025, with a three-year operational plan.11 Earlier the country has developed National Nutrition Policy, 2015, Second National Plan of Action for Nutrition, 2016-2025, Dietary Guidelines and other policies, strategies and action plan. The country is putting efforts for the prevention and control of malnutrition and NCDs. Furthermore, to prevent and control the diet related noncommunicable diseases across the life cycle nutrition labelling, re-formulation of food standards with limiting high sugar, salt and fat, and banning industrial transfats; restriction of food advertising particularly marketing of unhealthy foods to children, imposing tax on sugar sweetened drinks, junk food etc. Aimed at behavior change communication, mass-media campaigns, nutritional advice and nutrition education on NCDs in general and diet related NCDs in particular are thus recommended.

The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion

Global health 2035: a world converging within a generation

Safeguarding the continued existence of humanity requires building societies that cause minimal disruptions of the essential planetary systems that support life. While major successes have been achieved in improving health in recent decades, threats from the environment may undermine these gains, particularly among vulnerable populations and communities. In this article, we review the rationale for governments to invest in environmental Common Goods for Health (CGH) and identify functions that qualify as such, including interventions to improve air quality, develop sustainable food systems, preserve biodiversity, reduce greenhouse gas emissions, and encourage carbon sinks. Exploratory empirical analyses reveal that public spending on environmental goods does not crowd out public spending on health. Additionally, we find that improved governance is associated with better performance in environmental health outcomes, while the degrees of people’s participation in the political system together with voice and accountability are positively associated with performance in ambient air quality and biodiversity/habitat. We provide a list of functions that should be prioritized by governments across different sectors, and present preliminary costing of environmental CGH. As shown by the costing estimates presented here, these actions need not be especially expensive. Indeed, they are potentially cost-saving. The paper concludes with case examples of national governments that have successfully prioritized and financed environmental CGH. Because societal preferences may vary across time, government leaders seeking to protect the health of future generations must look beyond electoral cycles to enact policies that protect the environment and finance environmental CGH.

Introduction: India is experiencing health transition with a rising burden of noncommunicable diseases (NCDs). There is a need to study risk factors of NCDs among poor and underprivileged section of the society. Methodology: A cross-sectional study was done among adults in an urban slum in Pune using the World Health Organization's STEP wise approach to surveillance (STEPS). Two hundred individuals selected by simple random sampling participated in this study. Information regarding dietary habits, physical activity, and tobacco and alcohol consumption was obtained. Physical measurements of height, weight, waist and hip circumference, and blood pressure were also done. Nominal and numerical variables in different groups were compared by Fisher's exact test and Student's t-test, respectively. Logistic regression was used to determine the association of various factors with high blood pressure. Results: Tobacco and alcohol consumption was observed in 22.5% (95% confidence interval [CI]: 16.9%–28.9%) and 11.5% (95% CI: 7.4%–16.8%) of individuals, which was significantly higher among males. 40.0% (95% CI: 33.2%–47.1%) of participants were doing less than recommended physical activity. 47% (95% CI: 40.0%–54.2%) of individuals were overweight or obese. The prevalence of high blood pressure was found to be 43.9% (95% CI: 36.6%–51.3%). Significant positive correlation was observed among different anthropometric variables. Multivariable logistic regression showed that there was significant positive association of high blood pressure with age (adjusted odds ratio [aOR] = 1.05 [95% CI: 1.02–1.08]) and waist hip ratio (aOR = 1.45 [95% CI: 1.01–2.09]). Conclusions: There is a high prevalence of risk factors for NCDs among residents of urban slum. Behavior change communication is required for adoption of healthy lifestyle and prevents NCDs in urban slums.

Globalization offers great opportunities, but its benefits are at present very unevenly shared. Inequity in health at the population level is affected by global changes in marketing and trade, rapid urbanization and population ageing. The social, economic and physical environments in low- and middle-income countries often afford their populations much lower levels of protection from the risks and consequences of noncommunicable diseases (NCDs).1 Such factors contribute to the 12 million premature deaths and estimated economic losses of US$ 500 billion from NCDs that occur in these countries every year. However, lives and resources can be saved by investing in better prevention, control and treatment measures.2 In 2011, the World Health Organization (WHO) was assigned a leadership and coordination role in supporting national efforts to address noncommunicable diseases by the Political Declaration of the high-level meeting of the General Assembly on the prevention and control of non-communicable diseases.3 Three years later, there is a global road map in place based on nine concrete global targets for 2025, organized around the WHO Global action plan for the prevention and control of NCDs 2013–2020. The global action plan, when implemented collectively by Member States, international partners and WHO, will help to attain a global target of a 25% reduction in premature deaths from NCDs by 2025.4 The United Nations Interagency Task Force on NCDs, which the United Nations Secretary-General established in July 2013 and placed under the leadership of WHO, has started to provide support to national efforts to build solutions to address NCDs. The WHO Global Coordination Mechanism on NCDs, established in May 2014, will facilitate contributions from non-State actors. Progress within countries matters most. Some striking achievements emerge from a survey conducted by WHO in 2013. Of the 172 countries reporting data, 95% have a unit or department in the Ministry of Health responsible for NCDs. Half now have an integrated operational plan with a dedicated budget. The number of countries conducting recent surveys of risk factors jumped from 30% in 2011 to 63% in 2013. In other words, more countries are getting the basics in place. However, in July 2014 at the United Nations General Assembly ministers from across the world found that overall progress is insufficient and highly uneven. The United Nations review saw no lack of commitment, but witnessed a lack of capacity to act, especially in low- and middle-income countries, due to a lack of access to expertise which is only available through international cooperation. To move forward, the outcome document adopted by the United Nations review presents a highly focused agenda for strengthening international cooperation. The outcome document also contains next priorities in clear steps that will guide action until 2018, when the United Nations General Assembly will convene a third high-level meeting on NCDs. These include five commitments from Member States;5 setting national NCD targets for 2025, developing national multisectoral plans and implementing the WHO Global action plan for the prevention and control of NCDs 2013–2020 to reduce risk factors and strengthen health systems. WHO has three major assignments; the first is to prepare a framework for country action aimed at supporting national efforts to improve health through action across sectors on risk factors for NCDs. The second is to develop an approach to register and publish contributions of non-State actors to the achievement of the nine global targets and the third is to submit a progress report to the United Nations General Assembly. The Organisation for Economic Co-operation and Development has been tasked with developing a code to track official development assistance for NCDs. In July 2014, ministers in New York also agreed to give due consideration to addressing NCDs in the elaboration of the post-2015 development agenda, taking into account that NCDs constitute one of the major challenges for development in the twenty first century.6 A proposed target to reduce premature mortality from NCDs by one third by 2030 will be considered by Member States in September 2014 at the United Nations General Assembly. This milestone will provide critical guidance to the September 2015 United Nations Summit, which will adopt the post-2015 agenda. The discussions in July 2014 provided a timely opportunity for rallying political support for bolder measures in the post-2015 era. To build a future in which globalization becomes a positive force for all the world’s peoples, political commitment is needed. Only with such commitment can WHO orchestrate the broad collaboration required to make progress.

ObjectiveTo examine the impact on infant and young child nutrition knowledge and practice of mothers who were neighbors of mothers participating in a nutrition Behavior Change Communication (BCC) intervention in rural Bangladesh.MethodsWe analyzed data from 300 mothers whose neighbor participated in a nutrition BCC intervention and 600 mothers whose neighbor participated in an intervention that did not include BCC. We constructed measures capturing mothers’ knowledge of infant and young child nutrition (IYCN) and measures of food consumption by children 6-24m. The effect on these outcomes of exposure to a neighbor receiving a nutrition BCC intervention was estimated using ordinary least squares and probit regressions. The study was registered with ClinicalTrials.gov (Study ID: NCT02237144).ResultsHaving a neighboring mother participate in a nutrition BCC intervention increased non-participant mothers’ IYCN knowledge by 0.17 SD (translating to 0.3 more correct answers). They were 14.1 percentage points more likely to feed their 6-24m children legumes and nuts; 11.6 percentage points more likely to feed these children vitamin A rich fruits and vegetables; and 10.0 percentage points more likely to feed these children eggs. Children of non-participant mothers who had a neighboring mother participate in a nutrition BCC intervention were 13.8 percentage points more likely to meet World Health Organization (WHO) guidelines for minimum diet diversity, 11.9 percentage points more likely to meet WHO guidelines for minimum acceptable diet, and 10.3 percentage points more likely to meet WHO guidelines for minimum meal frequency for children who continue to be breastfed after age 6m. Children aged 0-6m of non-participant mothers who are neighbors of mothers receiving BCC were 7.1 percentage points less likely to have ever consumed water-based liquids.ConclusionsStudies of nutrition BCC that do not account for information spillovers to non-participants may underestimate its benefits in terms of IYCN knowledge and practice.

This article reflects on the United Nations' recent statement on the prevention and control of noncommunicable disease, the disproportionate burden of these diseases in low- to middle-income countries (with a particular focus on noncommunicable forms of heart disease), and the practical difficulties of tackling such a historically underresourced and complex health problem. ### Perceptions Are Everything Like many of us, I have spent more than a decade of my research career trying to persuade the lay public and, indeed, many health care workers and administrators, that cardiovascular disease (CVD) and its major component heart disease is a major burden to rival that of the common forms of cancer. The American Heart Association's “Go Red for Women” campaign is indicative of our collective fight to address common misperceptions about the risk of heart disease in women and its often fatal consequences.1 Even when presenting compelling evidence of the disproportionate number of men and women who lose their life prematurely (many suddenly and with little warning2) to acute myocardial infarction and chronic heart failure relative to the common malignancies,3 the response is underwhelming. Is this so surprising, given the entrenched branding of cancer sufferers as predominantly young “survivors” in a heroic battle to overcome a life-long disease? The broad misperception of heart disease, of course, is often limited to male-dominated “heart attacks” that leave the “victim” deceased (and therefore unable to tell their battle to survive) or the idea of an instant “cure” thanks to modern-day technology—the external and implantable cardiac defibrillator being the most recognizable of these. There is no “right or wrong” in our efforts to highlight serious public health issues and educate the public and health administrators alike to the enormity of the problem. The terminal malignancy that killed my own father at an early age deserves equal attention to …

World Health Organization.

Dr Brock Chisholm, the first Director-General of the World Health Organization (WHO), was a psychiatrist and shepherded the notion that mental and physical health were intimately linked. He famously stated that “without mental health there can be no true physical health”.1 Half a century later, we have strong evidence elucidating the bidirectional relationship between mental illnesses – specifically depression and anxiety – and physical health outcomes. However, policy continues to lag behind the evidence in this regard, as demonstrated by our global noncommunicable disease response. Over a decade ago, the World Health Assembly adopted a global strategy for the prevention and control of noncommunicable disease. At the time, these were limited to the following four illness types: cardiovascular disease, diabetes, respiratory illness and cancers. Such a categorization would set a precedent for the exclusion of mental illnesses from all future WHO discussions on noncommunicable diseases. It is not surprising then, that in the 2008–2013 action plan for the global strategy for the prevention and control of noncommunicable diseases mental illnesses were relegated to a footnote, with the justification that they do not share risk factors with the other four types of illnesses.2 We take issue with this viewpoint, as mental illnesses are themselves risk factors that affect the incidence and prognosis of diseases traditionally classified as “noncommunicable”. Patients with type II diabetes mellitus, for example, are twice as likely to experience depression as the general population,3 and those patients with diabetes who are depressed have greater difficulty with self-care.4 Patients suffering from mental illness are twice as likely to smoke cigarettes as other people, and in patients with chronic obstructive pulmonary disease mental illness is linked to poorer clinical outcomes.5,6 Up to 50% of cancer patients suffer from a mental illness, especially depression and anxiety,7 and treating symptoms of depression in cancer patients may improve survival time.8 Similarly, in patients who are depressed, the risk of having a heart attack is more than twice as high as in the general population;9 further, depression increases the risk of death in patients with cardiac disease.10 Moreover, treating the symptoms of depression after a heart attack has been shown to lower both mortality and re-hospitalization rates.11 In light of this evidence, how can we possibly address the burgeoning epidemic of noncommunicable diseases without tackling co-morbid mental illnesses? Mental illnesses were declared a regional priority in Africa during the WHO African Region Ministerial Consultation on Noncommunicable Diseases, held in Brazzaville, Congo, in April 2011. Later that month the WHO’s African Member States and India reiterated this priority at the first Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control, held in Moscow, Russia.12 As a result, mental illnesses were featured prominently in the preambles of the Moscow Declaration, as well as in the political declaration issued by the United Nations General Assembly at the high-level meeting on noncommunicable diseases held in New York City in September 2011.13 Despite this progress, however, mental illnesses received no mention at all in the resolution on noncommunicable diseases that WHO’s Member States adopted during the 130th session of WHO’s Executive Board.14 Mental illnesses were also omitted from WHO’s proposed monitoring framework, indicators and voluntary targets for the prevention and control of noncommunicable diseases, which was released in November 2012.15 The 2008–2013 action plan for the global strategy for the prevention and control of noncommunicable diseases will be revised over the coming year, and the WHO’s Executive Board and World Health Assembly are preparing their deliberations for 2013. During this critical time we urge Member States to recognize the importance of co-morbid mental illnesses as amplifiers of the burden of other noncommunicable diseases. To this end, we call on Member States to assess and monitor co-morbid mental illnesses in primary care settings, prioritize the training of professionals in mental health care, and, critically, incorporate mental health interventions within chronic disease programs as part of a vigorous global response to noncommunicable diseases. We now know that addressing mental illnesses in primary care settings will delay progression, improve survival outcomes, and reduce the health care costs of other noncommunicable diseases. The time has now come to do away with the artificial divisions between mental and physical health, as WHO’s first Director-General championed so many decades ago.

To control diabetes epidemic and NCDs, WHO has been promoting its action plans since 2000, but diabetes epidemic is continuing. New action plan for 2013-2020 aim to reduce shared risk factors of NCDs, such as tobacco use, unhealthy (i.e., high fat) diet, physical inactivity and harmful use of alcohol and is strengthening the risk reduction measures, such as taxing on tobacco, alcohol and sugary beverages, banning advertisements of unhealthy foods. However it might fail because it did not consider the contribution of environmental pollution on the pathogenesis of diabetes and NCDs.

The aim of this study was to map existing country policies and initiatives addressing population dietary sodium reduction in the Region of the Americas; to identify policy gaps following what is outlined in the World Health Organization (WHO) “Best Buys” most cost-effective recommendations for the prevention and control of diet-related noncommunicable diseases (NCDs); and to discuss priorities for future work to reduce population salt/sodium intake. We analyzed data from 34 countries in the Region. A review of different databases informed the mapping. Databases included (1) responses from the online Survey on National Initiatives for Salt/Sodium Reduction in the Americas carried out by PAHO in 2016; (2) the databases from the 2017 and 2019 PAHO Country Capacity Surveys for NCDs and Risk Factors; and (3) the repositories of legislation of the PAHO REGULA initiative as of 2018. Research in these databases was complemented by electronic searches on official websites from the ministries of health, education, and agriculture and the library of the national congress in each country. Additionally, when available, government regulatory gazettes were reviewed. National policies that have adopted the most cost-effective interventions for preventing and controlling diet-related NCDs of WHO “Best Buys” included reformulating food products with both voluntary (n=11/34) and mandatory (n=2/34) targets; establishing a supportive environment in public institutions (n=13/34); consumer awareness programs (n=26/34) and behavior-change communication and mass media campaigns (n=(0/34); and implementing front-of-pack labeling (n=5/34). We also found that some countries have implemented regulations that restrict marketing of foods high in salt/sodium to children (n=5/34), or are using nutritional labeling that includes sodium content, either voluntary (n=9/34) or mandatory (n=10/34). However, no country in the Region has implemented taxes on high salt/sodium foods. Based on our review, we concluded that there has been a significant advance in policies to reduce sodium intake in the Region of the Americas in recent years. However, we identified that the level of implementation is quite varied and is challenging to assess. Despite the progress, there remains much work to do on this issue, especially in countries where there is limited or no action yet. Reducing sodium consumption is a cost-effective intervention that can save many lives by preventing and reducing the burden of diet-related NCDs. Therefore, a further call to action is needed for governments to accelerate efforts to meet the 2025 global target of a 30% relative reduction in mean population intake of sodium.

THE principal rationale for public policy intervention lies in the inadequacies of market outcomes. Yet this rationale is really only a necessary, not a sufficient, condition for policy formulation.1 Policy formulation properly requires that the realized inadequacies of market outcomes be compared with the potential inadequacies of nonmarket efforts to ameliorate them. The "anatomy" of market failure provides only limited help in prescribing therapies for government success.2 That markets may fail to produce either economically optimal or socially desirable outcomes has been elaborated in a well-known and voluminous

report, Pre-venting Chronic Diseases: A Vital Investment (1), showsthat non-communicable diseases (NCDs) dominated by di-abetes are causing double the deaths that are caused byinfectious diseases, maternal/perinatal conditions, and mal-nutrition combined. The report states that without action,388 million people globally will die from chronic diseaseslike diabetes and heart disease in the next decade.It is against this background that we are facing a globalthreat from the spectacular rise in the global prevalence oftype 2 diabetes and obesity and their consequences (2). Interms of diabetes, the number of cases has reached pan-demic proportions and will continue to increase sharply.TheInternationalDiabetesInstitutepreparedthedatafortheInternational Diabetes Federation’s Diabetes Atlas 2003report (3), which predicted that the number of people withdiabetes will almost double within just one generation, fromthe present 190 million to 335 million in 2025. The linkagebetween obesity and type 2 diabetes is very strong, in fact,so strong that the term diabesity is being used frequently tobetter describe the current twin epidemic (2).Unfortunately, most nations are poorly prepared to tacklethis twin epidemic effectively. Governments remain largelyunawareof,orarecomplacentabout,theexistingmagnitudeof the NCD challenge. More important is the fact that theyignore the future increases in obesity and diabetes and theirserious complications such as cardiovascular disease(CVD). Failure to act now on the direct costs of healthcareand the indirect costs from loss of productivity and frompremature morbidity and mortality is very likely to cripplethe health budgets of many nations, both developing anddeveloped.With this major international challenge in mind, in May2005, the Monash University-affiliated International Diabe-tes Institute, in conjunction with the Monash UniversityInstitute of Global Movements and the United Kingdom-based Nuffield Trust, held a meeting of 25 leading worldexperts from a number of disciplines at the Nuffield Trustheadquarters in London. The objective of the meeting wasto assess the impact of globalization on health in bothdeveloped and developing countries with respect to NCDssuch as CVD, diabetes, and obesity.The London conference focused on how the world hascome by a chronic disease health calamity that rivals oreven exceeds the emergence or reemergence of devastatingcommunicable diseases including severe acute respiratorysyndrome (SARS), acquired immune deficiency syndrome(AIDS), the Ebola virus, and our old enemy, tuberculosis(4). While governments around the world are busy prepar-ing for an avian influenza pandemic, they ignore the equallyinsidious threat of diabetes and other NCDs!In the brief period of several decades, many developingnations are faced with a double burden of communicablediseases and NCDs, placing enormous pressure for solu-tions on WHO and other international and regional non-governmental agencies. The NCD burden has now becomeone of the major threats to human health in the 21st century(1,4). A report on the London meeting’s discussions andconclusions is published in this issue of