RECOMMENDATIONS ON HOW TO STRENGTHEN THE DESIGN AND IMPLEMENTATION OF POLICIES, INCLUDING THOSE FOR RESILIENT HEALTH SYSTEMS AND HEALTH SERVICES AND INFRASTRUCTURE, TO TREAT PEOPLE LIVING WITH NONCOMMUNICABLE DISEASES AND TO PREVENT AND CONTROL THEIR RISK FACTORS IN HUMANITARIAN EMERGENCIES
1. Paragraphs 31, 46 and 48 of the NCD-GAP call for ensuring the continuity of essential NCD services, including the availability of life-saving technologies and essential medicines, in humanitarian emergencies. Also, in paragraph 40 of United Nations General Assembly resolution 73/2 (2018), Member States reaffirmed their commitment to “strengthen the design and implementation of policies, including for resilient health systems and health services and infrastructure to treat people living with NCDs and prevent and control their risk factors in humanitarian emergencies, including before, during and after natural disasters, with a particular focus on countries most vulnerable to the impact of climate change and extreme weather events”.
2. To provide initial guidance to Member States, the Secretariat submitted Annex 9 of document EB148/7 (2021), which describes the process the Secretariat is following to support Member States in their commitment to strengthen policies to treat people living with NCDs and prevent and control their risk factors in humanitarian emergencies.
3. Building on this initial guidance, this annex suggests recommendations for Member States, international partners and WHO to ensure essential service provision for people living with NCDs in humanitarian emergencies by investing in and building longer-term NCD emergency preparedness and responses during the COVID-19 pandemic and beyond, as part of “build back better” through a multisectoral all-hazards approach.
CHALLENGES AND OPPORTUNITIES
THE COVID-19 PANDEMIC: A PERSISTING DEADLY INTERPLAY WITH THE NCD EPIDEMIC
4. In December 2020, the United Nations General Assembly adopted resolution 75/130, “noting with concern that non-communicable diseases, notably cardiovascular diseases, cancers, diabetes, chronic respiratory diseases, as well as mental disorders, other mental health conditions and neurological disorders, are the leading causes of premature death and disability globally, including in low- and middle-income countries, and that people living with non-communicable diseases are more susceptible to the risk of developing severe COVID-19 symptoms and are among the most affected by the pandemic, and recognizing that necessary prevention and control efforts are hampered by, inter alia, lack of universal access to quality, safe, effective, affordable essential health services, medicines, diagnostics and health technologies, as well as a global shortage of qualified health workers”.
5. Lack of functioning civil registration and vital statistics systems as well as different processes to test and report COVID-19 deaths make it difficult to account for accurate, complete and timely data on causes of deaths and comorbidities, including from COVID-19 among people living with or at risk of NCDs.
6. The virus and the pandemic affect people living with or at risk of NCDs through different pathways, including:
(a) a higher susceptibility to COVID-19 infection and higher severity and case fatality rates among people with NCDs;
(b) delays in diagnosis of NCDs, resulting in more advanced disease stages;
(c) delayed, incomplete or interrupted therapy of NCDs; and
(d) increases in behavioural risk factors for NCDs, such as physical inactivity, increased harmful use of alcohol, tobacco use and unhealthy diets.
7. COVID-19 has disproportionately impacted people living with or at risk of NCDs, including economically disadvantaged groups such as migrant workers, older adults, as well as forcibly displaced and refugee populations in humanitarian contexts. Therefore, the pandemic magnified and further drew attention to persistent inequalities in both health outcomes and health determinants, including NCD risk factors, social determinants and access to health services, both within and across countries. Working long-term and recognizing how COVID-19 and NCDs are syndemically interlocked conditions may be the first step towards developing the nuanced approaches that are needed to more comprehensively protect society’s vulnerable populations.
8. Disruptions of essential NCD health services due to COVID-19 have been widespread due to the shortage of medicines, staff, diagnostics and public transport services among other constraints. The rapid assessment survey of the impact of the COVID-19 pandemic on NCD resources and services, conducted by WHO’s NCD Department in May 2020 and to which 163 Member States (84%) responded, reported widespread complete or partial disruptions to a range of NCD services across countries. Some 59% of countries reported that access to outpatient essential NCD services were restricted to some degree, while 35% reported that inpatient NCD services were open for emergencies only. About half of countries reported complete or partial disruptions to hypertension management services (53%) or to diabetes and diabetic complication management services (49%). In terms of disruption of activities, 77% of countries reported some disruption to ministry of health NCD activities planned for 2020, such as screening programmes, awareness campaigns, population-based surveys (STEPS) or training courses and implementation of WHO technical packages such as WHO/PEN and WHO/HEARTS.
9. The COVID-19 pandemic increased also rehabilitation needs in those who were affected by the virus with an anticipated secondary surge in needs as the pandemic settles, due to the disruption of routine health and rehabilitation services, as well as the potential long-term impacts and sequelae among people living with NCDs and other people infected by the virus.
10. The subsequent two rounds of WHO-wide surveys assessing the continuity of essential health services during the COVID-19 pandemic (pulse surveys) revealed less severe but persistent disruption of services, including for NCDs. Complementing these surveys, WHO’s NCD Department invited countries to complete a COVID-19-related module as part of the periodic assessment of national capacity for NCD prevention and control, between May and September 2021. This assessment confirmed enduring disruption, with 70% of Member States reporting some disruption to NCD-related services more than one year into the pandemic. At least half of countries reported disruptions for diabetes and hypertension management services, cancer screening and treatment services as well as asthma services. Cancer screening services were most likely to be severely disrupted, with more than 10% of Member States still reporting a high level of disruption.
11. The lack of understanding and attention given to the interplay between the virus and NCDs in the early stages of the COVID-19 pandemic hampered the inclusion of NCDs in country strategic preparedness and response plans (CSPRPs). A review of 87 plans and 121 documents through an NCD lens, which was conducted by WHO in October 2020, revealed that only 33 countries included NCDs as part of the essential health services to be maintained during the pandemic, only 16 countries included the management of NCDs and only 3 countries had a specific budget line for NCDs. Deeply concerned about this blind spot, the United Nations General Assembly, in resolution 74/306 (2020), called upon Member States “to further strengthen efforts to address noncommunicable diseases as part of universal health coverage, recognizing that people living with noncommunicable diseases are at a higher risk of developing severe COVID-19 symptoms and are among the most impacted by the pandemic”. Similarly, in resolution 75/130 (2020), entitled “Global health and foreign policy: strengthening health system resilience through affordable health care for all”, adopted in December 2020, the General Assembly noted with concern the severe impact COVID-19 on people living with NCDs, stressing the importance of monitoring the indirect impacts of the COVID-19 pandemic on integrated service delivery as well as maintaining the essential part of health care delivery and global supply chains, including for NCDs, and called for governments to reaffirm their commitments made under the political declaration of the third high-level meeting of the General Assembly on the prevention and control of noncommunicable diseases to accelerate the implementation of national NCDs responses as part of the 2030 Agenda.
12. To support countries in mitigating the disruption of essential health services, WHO released in March 2020 and subsequently updated an operational guidance on maintaining essential services during the outbreak, outlining basic principles and practical recommendations that support decision-making to ensure the continuity of selected essential health services, highlighting key actions that countries should consider, including for NCDs. Another guidance was issued in January 2021 to support countries in analysing and using routine data to monitor the effects of COVID-19 on essential health services.
13. WHO’s NCD Department contributed to this normative work through the development of scientific briefs summarizing the latest evidence for the susceptibility and/or negative impact on outcomes for COVID-19 from the presence of specific NCDs, as well as the development of modelling studies with policy scenarios to model possible service delivery model changes, the economic parameters associated with these and the mid-term and long-term health impacts, including on meeting SDG target 3.4. The work was complemented by numerous case studies documenting how countries mitigated the disruptions to NCD-related services, including through innovative digital health solutions (such as the use of mobile health technologies to support people living with NCDs or the use of telemedicine to ensure continuity of care).
14. As the world engages in a new phase of the pandemic, rolling out COVID-19 vaccines in the attempt to control the pandemic, the review of the situation of NCDs during the pandemic has demonstrated that NCD preparedness and response must be part of any pandemic response and preparedness at global, regional and national levels. Recovery and building back better needs to go together with action to address NCDs. The prevention, screening, early diagnosis and treatment of hypertension, diabetes, cancer and other NCDs cannot be postponed because the NCD epidemic is not on hold. Addressing NCDs and COVID-19 simultaneously and at sufficient scale requires a response stronger than any seen before to safeguard lives and livelihoods. Furthermore, the lessons learned from the COVID-19 pandemic offer opportunities for strengthening emergency preparedness and responses beyond pandemic ones.
15. Beyond the COVID-19 pandemic, WHO was, as at 8 December 2021, aware of and responding to 73 active emergencies graded according to the WHO Emergency Response Framework.