Non-Communicable Diseases – the Silent Killer: Diagnosis, Risks and Management Evaluation

By Bronte Greer

Bronte attended the 2015 World Bank and International Monetary Fund (IMF) Annual Meetings in Peru. 

Abstract

By 2030 three quarters of global deaths will be attributed to noncommunicable diseases (NCDs).[1] These diseases not only have significant impact on countries social construct but are expected to cause the global economy an economic output loss of $47 trillion over two decades.[2] The World Health Organization (WHO) has identified five main NCDs, these are (1) Cancer, (2) Diabetes, (3) Cardiovascular Disease, (4) Chronic Respiratory Disease and (5) Mental Illness. Further, WHO and other global institutions such as the World Bank and United Nations have further identified that the there are four main behavioural and environmental factors that significantly increase the risk of NCDs. These are (1) tobacco use, (2) abusive alcohol consumption, (3) physical inactivity and (4) poor diet. Previously, NCDs were seen as diseases of influence, but trends globally demonstrate that these diseases are having a severe impact on low-middle income countries. Whilst discussion has increased and recognition of their severity has been understood, frameworks have failed to understand cultural factors and country capabilities. These omissions have ultimately impacted success in decreasing NCDs. This paper has analysed how previous frameworks such as the Millennium Development Goals have attempted but arguably failed in addressing NCDs.  Further, analysis has been conducted to gage if success of reducing and managing NCDs through the proposed Sustainable Development Goals is likely in their present state. This paper has a role in extrapolating the importance and role both the World Bank and Australia have in securing sustainable change in how NCDs are prevent and managed. Combatting the increase in NCDs requires practical and community-based steps such as increased training for nurses’ support in implementing proven frameworks and initiating a collaborative partnership with global institutions. However it is realised that foreign aid budgets are limited, it is therefore recommended that the Australian initiate and evaluate foreign aid programs and direct more funds towards NCDs.

Recommendations 

Action One: Australia review foreign aid funding directed towards HIV and AIDs, redirect a portion of funds towards NCD prevention activities.

Action Two: Establish East Asia, Pacific and Australia nurses training program (EAPA). This program will enable nurses from low-middle income countries within the East-Asian and Pacific region to receive training and develop skills in Australia to be utilised in their communities.    

Action Three: Support implementation of appropriate ‘best-buys’ through human resources support, evaluation of infrastructure and assistance with restructuring of departments if applicable.

Action Four: Provide seed money when appropriate to support establishment of databases. Collaborate with World Bank to establish consistent and financial sustainable data collection frameworks initially in the Pacific and further establish in East Asia region.

Introduction 

Noncommunicable diseases are not only a threat to individuals who suffer from them but also a threat to the development of low-middle income nations. Although there has been increased international recognition, global action has been slow and inconsiderate of country nuances. This paper aims to gain a deeper understanding of the driving forcers behind the significant increase in NCDs in the East Asian and Pacific region. Further, it aims to gage whether real change is possible. Through analysing past and proposed frameworks such as the Millennium Development Goals (MDG) and Sustainable Development Goals (SDG) the paper aims to learn lessons from their successes and failures to ensure greater progress. Further, as NCDs require global action and discussion, institutions such as the World Bank and indeed governments like Australia need to be leaders in financing and supporting the needs of vulnerable countries. However, this support requires acknowledgement of respective countries own capacity and capability. NCDs are a topic that is only going to grow in importance, policy and aid action have the potential to minimise the long-term financial and social impact of NCDs.

Noncommunicable Diseases 

Non-communicable diseases (NCDs) are projected to account for 75% of deaths globally by 2030. Unlike communicable diseases, NCDs are non-infectious and non-transmissible, many requiring long-term treatment and management[3].  

Cardiovascular Disease

Cardiovascular disease, in particular coronary heart disease (CHDs) in developing countries is projected to align with developed nations and be the leading cause of mortality.[4] In 2012, cardiovascular disease was responsible for over 17 million deaths or 30% of mortality.[5] The prevalence of CVDs has increased at a remarkable rate, from 1990 to 2020 it has been estimated that the rate of CVDs will have increased by 120% and 137% for women and men respectively in LMICs.[6] A concern for health practitioners and future health budgets is the increase in youth developing CHDs[7].  

Diabetes

There are three main categories of diabetes, Type One diabetes, Type Two diabetes and Gestational diabetes.[8] Of the populous with diabetes, 90% were diagnosed with type two, and 90% of those were related to obesity levels.[9] ‘People with diabetes require at least two to three times the health-care resources compared to people who do not have diabetes, and diabetes care account for up to 15% of national health budgets[10] [11].

Cancer

Cancer can be caused by internal factors such as inherited mutations; however, the risk is heightened by external factors such as tobacco. The rate of cancer has been increasing in line with population growth. Risk of a cancer diagnosis is expected to increase in low-middle income countries (LMICs) due to epidemiological developments[12].

Chronic Respiratory Disease

The main diseases of chronic respiratory disease are asthma, respiratory infections (pneumonia), bronchitis and tuberculosis. The extent of chronic respiratory disease tends to be underestimated, as many sufferers in LMICs tend not to present or be diagnosed until it is clinically apparent and advanced[13]. However, it was estimated that over three million deaths were attributed to chronic respiratory disease in 2005 but the true figure might far exceed this[14].

Mental Illness

Mental illness includes but is not exclusive to schizophrenia, bipolar, anxiety and depression.[15] The World Health Organisation estimated that four hundred million people suffer from depression, sixty million suffer from bipolar and twenty-one million people suffer from schizophrenia.[16] However, a significant challenge in many developing nations is that governments are rebutting the validity of the illness.[17] The lack of social acceptance has inhibited the true number of deaths caused by mental illness in developing nations to be understood. However, looking at developed nations, it can be seen that the level of expenditure on mental health has more than doubled within a five-year period and this trend is anticipated to continue.[18]

Risk Factors

The World Health Organisation defines four main risk factors to being diagnosed with NCDs, which are (1) tobacco use, (2) alcohol consumption, (3) physical inactivity and (4) poor diet[19]. Governments in high-income countries (HICs) such as Australia have taken action through regulation and education. In contrast LMICs do not have the financial means and face cultural issues, inhibiting progress[20]. It has been estimated that of the total NCD attributed deaths, 80% of occurred in low-middle income countries (LMICs)[21].

Due to the long-term nature and behavioural factors associated with NCDs a significant challenge to governments is comorbidity. Individuals who suffer from a primary NCD are likely to be diagnosed with at least another NCD or communicable disease, escalating the primary disease. Based on this, it is essential that governments, NGOs and community groups not take a silo approach when analysing and implementing strategies.[22]

Tobacco

The rate of smoking has significantly declined in developed nations yet the reverse is occurring in LMICs. Tobacco is the most significant risk factor that is linked between all major NCDs, and is responsible for one in six NCD deaths globally[23]. In the Pacific region, some countries experienced a male smoking population of up to 73%[24]. Yet, this trend is not exclusive to the Pacific islands, with 72.3% and 69.5% of male populations in Indonesia and East Timor respectively engaged in smoking[25]. The disproportionally high levels of tobacco use in these regions are attributed to a number of factors. One of the strongest is the strong cultural norm, in many Pacific Island nations; tobacco is a form of demonstrating friendship and respect[26]. A particularly concerning trend is the increased use and acceptance of tobacco in the youth demographic in both Pacific and East Asian nations.

Alcohol Consumption

Globally, alcohol abuse has been linked with various cancers, hypertension, strokes and organ failure[27]. Unlike other risk factors, alcohol consumption and abuse is extremely complex, influenced by religion, trauma, ethnicity and availability.[28] Comparatively, East Asia and the Pacific region still have relatively low levels of alcohol consumption and abuse. However, the relationship with alcohol is changing as the availability of alcohol products increases. A prime example is the significant increase of alcohol in Thailand, traditionally in a country with a devout Buddhist population alcohol consumption by over 3000% or thirty two fold over a forty-year period.[29] This shift in attitude and availability has altered, leading to the creation of new unprecedented challenges for coming governments[30].

Physical Inactivity and Poor Diet

Physical activity decreases the risk of fractures, maintaining control of weight and strengthening of core muscles[31]. However, globally there has been a decrease in physical movement in conjunction with less nutritious diets[32]. High consumption levels of salt and sugar with less physical activity have been linked with increased risk of cardiovascular disease, diabetes and respiratory disease[33]. The rate of obesity, a consequence of poor diet and physical inactivity, is a key concern in the Pacific region. It has been estimated that over half of the Pacific Islander populations are classified as obese, with significant increases in average body weight, particularly in youth[34].  Similarly, the rate of obesity and diseases triggered by changes in diet has significantly increased in East Asia. For example, the rate of diabetes in China increased from less than one per cent to nearly ten per cent over from 1980 to 2008 China is now on the path to becoming the largest diabetic country.[35] More concerning however, is that those from an Asian heritage are developing type two diabetes at lower levels of obesity.[36] Pacific Island populations face similar biological challenges with genes that encourage storage of fat, escalating the risk of obesity and diabetes[37].

Implications

NCDs are a burden in terms of economic loss and health budget expenditure. From a financial perspective, it has been estimated that in the next two decades, NCDs will cause a global economic output loss of US$47 trillion[38]. Further, the rate of premature deaths and disability adjusted life years (DALYs), which impact productivity, has been estimated to cause 40% - 50% of total DALYs, approximately 668 million DALYs [39] [40]. A large figure but when applied to a specific country the impact can be understood. In 2010 alone, Indonesia was estimated to have foregone US$61.9 billion in economic output, which was 2.1% of GDP in 2010, and 1.78% in today’s terms[41] [42]. Further, it has been estimated that Indonesia will experience US4.47 trillion in economic loss from 2012-2030.[43] Comparably, China is expected to lose US$558 billion in national income over a ten-year period due to preventable NCDs[44].  

Yet, relative to the financial burden and premature deaths, NCDs receive relatively little attention and funding.[45]  ‘In 2010, the International development assistance for health dedicated for each DALY lost to HIV/AIDs was US$69.38, $16.27 per DALY lost to malaria, and $5.42 per DALY lost to poor maternal, newborn, and child health – but only $0.09 per DALY lost to NCDs[46]’ This is despite the fact that death and disability attributed to NCDs was 300% greater than the decrease in the burden of infectious disease over a twenty year period[47].  Additionally, it was found that in forty-nine LMICs, NCDs caused 1.6 times more premature deaths than malaria, tuberculosis, and HIV/AIDs combined[48]. The lack of financial support aggravates the burden on individuals and families.

A barrier to economic development and addressing NCDs on a domestic level is the financial barrier and personal cost. It was estimated that 100 million people were forced back into poverty due to out of pocket (OOP) expenses and associated NCD costs[49]. One of the most significant financial burdens and inhibiters to increased quality of life is out of pocket expenditure on essential treatment. Households in LMICs spend approximately 40% of income on treating NCDs but this percentage is increased with each additional NCD.[50] The level of OOP expenditure is not only foregone expenditure in other areas of the economy but also increases distress patterns for those LMIC households[51].  An area that has significant potential to address the severity and long-term management of NCDs is establishing a mechanism to provide a more affordable healthcare system.

Another factor that acts as a barrier in addressing the root of NCDs is the apprehensiveness of individuals and families in seeking assistance due to social perspectives and lack of education[52]. The true cost of NCD is not truly known, as many individuals particularly those who suffer from mental illness resist seeking medical care due to the associated stigma[53] [54]. Additionally, the results of stigma and lack of understanding have contributed to conditions remaining undiagnosed and inadequate treatment. This further contributes to ongoing social costs[55]. The issue of stigma and the associated pressure and shame on some families worsens the general societal acceptance and the ability to effectively treat individuals[56]. The issue of stigma and shame have been a particular challenge in developing East Asian nations, which in the worst circumstances suffers value as a human is ignored and human rights issues arise[57]. If frameworks are to be successful, understanding of social norms and perspectives towards not only mental health but also disease and disability is required. 

 There is a growing financial argument for governments to re-evaluate resources towards addressing NCDs and focus on prevention, rather than cure.  For example, it was estimated the average dialysis treatment in Samoa was over AUD$38,000 which is twelve times Samoa’s gross national income per capita. In a number of circumstances patients are transferred to New Zealand for treatment further contributing to costs[58]. If resources are directed towards reducing salt intake, tobacco usage and encouraging physical exercise the risk of being diagnosed with kidney failure is significantly reduced and prevents the need for dialysis[59]. Similarly, Vanuatu faces a continual moral and financial dilemma, only 1.3% of the nations total population are able to receive insulin treatment before the entire pharmaceutical budget is exhausted.[60] This is particularly concerning as approximately 21% of adults (20-79) are diagnosed with a form of diabetes[61] [62]. Directing resources towards risk factors the risk of diabetes can be minimised through increased physical exercise, appropriate diet and decreased rates of tobacco consumption.[63]

Existing Policies


Millennium Development Goals

The Millennium Development Goals (MDGs) were constructed to act like a report card, based on eight objectives, aiming to lift the standard of health globally[64]. Despite these objectives there was little focus on areas that were driving the risks of NCDs, particularly in the most vulnerable nations. This is despite the fact that NCDs in LMICs contribute to more deaths and disability adjusted life years in comparison to HIV and aids[65].

Goal 1: Eradicate Extreme Hunger and Poverty

Goal 2: Achieve Universal Primary Education

Goal 3: Promote Gender Equality and Empower Women

Goal 4: Reduce Child Mortality

Goal 5: Improve Maternal Health

Goal 6: Combat HIV/AIDs, Malaria and other diseases

Goal 7: Ensure Environmental Sustainability

Goal 8: Develop a Global Partnership for Development

The MDGs have made significant progress in areas such as child mortality and poverty reduction. For example, ‘The number of people now living in extreme poverty has declined by more than half, falling from 1.9 billion in 1990 to 836 million in 2015’ and ‘…mortality rate of children under-five was cut by more than half since 1990.’[66] However, the success of MDGs was highly variable across countries and inhibited by factors such as unequal access to resources between rural and urban populations[67] [68].

On the surface, MDGs goals aim for universal appeal and implementation. However, it has faced the risk of over simplification extreme generalisation of subsections[69]. The commitment by institutions such as the World Bank, International Monetary Fund and federal governments represent a unified commitment but ‘…the continuance of the MDGs in some form beyond 2015 is implicit not only in the nature and scale of the normative commitment, but also in the gap between the ideal and the practical targets that have been set and agreed.’[70] 

On a microeconomic scale the unique country level factors have inhibited nations from achieving MDGs. Lomazzi et al. (2013) conducted a cross-sectional country study analysing health professionals’ opinion of the sustainability and success of MGDs. Due to insufficient resources, poor communication and lack of understanding of cultural factors success in achieving goals was limited.[71]

It has been postulated that the Sustainable Development Goals (SDGs) will have greater success, learning from the challenges from MGDs as they are more targeted.

Goal 1: No Poverty

Goal 2: Zero Hunger

Goal 3: Good Health and Well-Being

Goal 4: Quality Education

Goal 5: Gender Equality

Goal 6: Clean Water and Sanitation

Goal 7: Affordable and Clean Energy

Goal 8: Decent Work and Economic Growth

Goal 9: Industry, Innovation and Infrastructure

Goal 10: Reduced Inequalities

Goal 11: Sustainable Cities and Communities

Goal 12: Responsible Consumption and Production

Goal 13: Climate Action

Goal 14: Life Below Water

Goal 15: Life on Land

Goal 16: Peace, Justice and Strong Institutions

Goal 17: Partnerships for the Goals

Sustainable Development Goals

The SGDs have six core areas: (1) dignity, (2) prosperity, (3) justice, (4) partnership, (5) planet and (6) people. Ban Ki-moon stated during an event in New York in 2015 that the SDGs is the beginning of a global ‘paradigm shift’[72]. Although SDGs are aiming to create a paradigm shift, questions are arising about the ability of countries to achieve all the goals.  

The Sustainable Development Goals are to be a framework to global development for the next fifteen years. The new framework has set seventeen objectives with 169 targets[73]. Evidently, the scope of the SDGs is more extensive compared to MDGs but it has been argued that the goals and indeed the targets are overly ambitious.[74]

However, positive steps have been implemented to address NCDs long-term burden. Goal 3 ‘Good Health and Wellbeing’, subsection 3.4 states ‘By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well being[75].’ Establishing targets to prevent NCDs as well as providing better treatment is a step forward. However, the proposed targets favour more developed nations and wealthier groups[76].  For example, preventative actions such as food labelling and information campaigns have limited impact or benefit for those in lower-socio economic backgrounds due to factors such as illiteracy and accessibility[77].

Moreover, preventative action is unlikely to occur instantaneously. This is particularly poignant in terms of cultural norms that inhibit the effectiveness of preventative campaigns[78]. An example of this is the use and consumption of tobacco products in the Pacific Island region. Tobacco is widely used and integrated into society. Many tobacco products are accepted and indeed socially expected in many Pacific regions such as Papua New Guinea[79]. Preventive measures, if to be effective need to be targeted towards discouraging youth in engage with cigarettes and tobacco products, however the effectiveness of these actions may not be seen until after the completion of the SDGs.

Similarly in the case of target 3b ‘Support the research and development of vaccines and medicines for the communicable and non-communicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines…’[80] Immediately, this target lacks consideration of the capabilities of developing countries to provide and administer essential medicines and vaccines which is highly contextual.

SDGs are receiving increased criticism on several points. Firstly, SDGs are vulnerable unless monitoring and governance challenges are addressed[81] [82]. The lack of governance and monitoring systems was proven to be a challenge in the MGDs. This is exacerbated the omission of clear accountability mechanisms[83] [84]. For example, in target 3.4 it aims at preventing NCDs as well as promoting healthy wellbeing[85]. However, this target fails to explicitly specify exact preventative measures and who is responsible for the management of (1) prevention activities, (2) promotion of health and wellbeing and (3) reduction in premature mortality rates. Whilst these gaps remain success is unlikely, a result of over simplification.[86] [87] If Goal three is analysed there are a number of targets that are exceedingly oversimplified. For example, target 3.6 ‘By 2020, halve the number of global deaths and injuries from road traffic accidents’[88], the challenge of mortality and injuries from road traffic accidents is highly complex. Target 3.6 does not account for road infrastructure, cultural perceptions of acceptable driving, drink driving and driving experience. Balance has to be achieved between providing an accountable and in-depth framework with universal implementation for SGDs to have a real impact greater definition and accountability is needed. 

It is recognised that both individual governments and global institutions are facing a number of challenges such as climate change, financial austerity and delicate international relations. NCDs are another challenge that governments and institutions such as the World Bank now have to face. Developing targets within SDGs, particularly target 3.4 is a step in the right direction. However, additional support and action within these goals that are contextual to individual countries is required[89]. A barrier to the success of MDGs and potentially SDGs is the integral requirement in acknowledging that countries need (1) appropriate tools to implement and monitor, (2) high level of governance and (3) increased accountability. The Australian Government highlighted in their 2012 submission to World Health Organisation on non-communicable Diseases global monitoring framework that ‘Australia encourages the WHO to seek out the views of developing countries to ensure that by the end of 2012 there is global consensus around the feasibility of the monitoring framework.[90]

Best Buys

The ‘Best Buys’ approach is an evidence-based approach to addressing NCDs that considers risk factors and diseases and appropriate interventions. This approach focuses on cost-effective, evidence-based interventions with the aim of preventing an increase in trends. The table below are the ‘best-buys’ as outlined by WHO.

Risk factor/disease

  • Intervention

Tobacco use

  • Tax increases

  • Smoke-free indoor workplaces and public places

  • Health information and warnings

  • Bans on tobacco advertising, promotion and sponsorship

Harmful alcohol use

  • Tax increases

  • Restricted access to retailed alcohol

  • Bans on alcohol advertising

Unhealthy diet and physical inactivity

  • Reduced salt intake in food

  • Replacement of trans fat with polyunsaturated fat

  • Public awareness through mass media on diet and physical activity

Cardiovascular disease

  • Counselling and multi-drug therapy for people with a high risk of developing heart attacks and strokes (including those with established CVD)
  • Treatment of heart attacks with aspirin

Cancer

  • Hepatitis B immunization to prevent liver cancer
  • Screening and treatment of pre-cancerous lesions to prevent cervical cancer

This approach makes an effort to contextualise the problems and the challenges faced across continents. A further strength of the ‘best buys’ framework is the ability to support current policies that individual governments have already established. The financial framework accounts for five factors, which are, ‘the size of the population; the extent of the burden of disease; the proportion of the population that would be covered by the strategies; the resources required; and the unit cost (for e.g. salaries and medicines).[91]’ Compared to other frameworks it was estimated that collectively each ‘best buy’ intervention would cost no more than US$0.50 per person[92].

Another strength of the ‘best buys’ framework is the economic support. Estimates project the implementation of the ‘best buys’ framework across all LMICs would cost US$170 billion to 2025, a small portion of current expenditure on healthcare[93]. Further, if the cardio vascular and diabetes interventions were implemented, (costing US$8 billion per year) would achieve a 10% reduction in premature mortality (due to ischemic heart disease) in LMICs. This outcome caused a decrease in economic loss of output by US$25 billion per year.[94] Further, if interventions were implemented a reduction of three million premature deaths could be reached[95].

Governments have shown a reasonable level of success in integrating cultural factors with ‘best-buy’ and existing policies. After implementation of tobacco measures Turkey saw a 13.4% decline in smoking. Similarly, Hungary experienced a 27% decrease in sales, a year after implementation of tobacco measures.[96] Once again implementation and governance are proving to be barriers to the successful implementation of the ‘best buys’ framework.

Further, global monitoring and data collection infrastructure is still required for the approach to be effective. The effectiveness of this strategy is still being analysed however, it is proving that in comparison to other frameworks ‘best buys’ has greater ability to be implemented whilst respecting and integrating with cultural and political factors[97].

Tonga

In 2012, the 42nd Pacific Islands Forum communiqué classified the NCD situation in the Pacific region as a crisis[98]. The Australian foreign aid program has a broad focus yet there is paucity in the financial strategy in curbing the risk of comorbidity and the risk factors driving the growth trend. A country that is taking proactive action in addressing NCDs locally and receiving support from the Australian aid program is Tonga. Australia has directed funding towards three main areas (1) health centre improvements, (2) increasing services and standards and (3) training of specialised non-communicable disease nurses[99][100]. Tonga was the first Pacific country to have a strategic plan focusing on NCDs in addition to their own NCD Strategic Plan and integrated key targets into their own MDGs. A strength of Tonga’s approach in addressing NCDs is the cross-sectoral and diverse initiatives. The Government has established policies to encourage a reduction in risk adverse behaviour. It has also in conjunction with the Australia engaged community participation funding sport activities such as PatKau Mai Tonga: Netipolo and interaction with respected community groups[101].

Philippines

The Philippine Government implemented ‘National Policy on Strengthening the Prevention and Control of Chronic Lifestyle Related Non Communicable Diseases’ in 2011. The national framework has taken a number of initiatives to discourage tobacco use and increase a healthy lifestyle. Regulatory provisions include smoke-free public spaces (Republic Act 9211-Tobacco Regulation Act of 2003; Administrative Order No 0010 of 2009: Rules and Regulations Promoting a 100% Smoke-free Environment), increase in tax on tobacco (Republic Act 10315 Sin Tax Law of 2012) as well as health warnings (Administrative Order No. 56 of 2001: Guidelines on Labelling and Advertising (DOH)[102]. Whilst, the Philippine government has taken a number of health promotion programs such as iFly the country still faces significant challenges in managing epidemiological trends and societies behaviours.  

World Bank’s Role

The World Bank has been a strong pillar in gaining an understanding and tracking the development and impact of NCDs. The institution has widened the discussion around NCDs and engaged in a number of research projects such as THE ECONOMIC COSTS OF NON‐COMMUNICABLE DISEASES IN THE PACIFIC ISLANDS: A Rapid Stocktake of the situation in Samoa, Tonga and Vanuatu (2012) and the NCD Roadmap Report (2014). Further, the World Bank’s Human Development Network (HDN) an arm of the World Bank, has initiated projects in vulnerable nations to address NCDs. The HDN has established and funded 143 projects that relate to NCDs. Of concern only twenty-one of these programs have been directed at the Pacific and East Asian region. Which has a far greater LMIC population.[103]

The World Bank has been taking a number of steps to assist in the global NCD challenge. Through projects such as Samoa Health Sector Management Program Support Project and Additional Financing for the Second Health Sector Support Project both financial and administrative support is being dedicated towards prevention and management of NCDs[104]. However, these projects have been structured and directed towards achieving MDGs rather than making sustainable changes.

In response to the relevance of the World Bank being questioned, restructuring, consolidation and collaboration have taken place. However, through the eyes of governments and individuals it has not been enough. A strength of the World Bank is their ability to collect and collate data. These skills and capabilities will be highly valuable in developing countries and their health sectors.  Already the World Bank has conducted a number of in-depth papers investigating the current situation of NCDs in developing nations and the projected burden on societies and governments. To assist in gaining and maintaining importance in strategic regions, the World Bank need to offer this type of support to local authorities and health bodies. Providing this type of assistance and investment, the World Bank is not only providing insight as to the effectiveness of programs such as ‘best buys’ and SDGs but gauges whether investment by financial contributors such as Australia are being given to the required areas.    

Australia’s Role

For Australia to maximise foreign aid expenditure and have a noticeable impact a holistic approach is required[105]. A strong focus of Australia’s foreign aid support has been directed towards higher profile diseases and issues that relate to MDGs and epidemics[106]. Re-evaluation of foreign aid and analysis of bilateral agreements is required for Australia to be an active and leading voice in the NCD paradigm shift.

At present, Australia has the capacity to minimise the severity of NCDs by combating comorbidity through implementing targeted policies. Small steps through financial and skills support has been conducted. For example Australia committed AU$49 million towards Sports Development programs within the Pacific Island region and over AU$20 million towards funding NCD prevention and health programs in the Pacific region[107] [108].

However, there is a significant gap in Australia’s East Asian funding in addressing risk factors of NCDs. It does have to be acknowledged that the Australia’s long-term commitment to many East Asian nations has potential to be reduced as these nations become more self-sufficient. However, this will not be the case for Pacific Island nations[109] [110]. Despite these factors, there is paucity across the East Asian and Pacific regions in supporting governments in building administrative infrastructure to ensure implementation of the programs are achievable and sustainable. It is here that Australia can become a strong regional player and ensure that foreign aid is effective – addressing risk factors such as tobacco use, supporting primary health care services and build administrative capabilities to enable accurate collection of data.

Finally, in existing funding agreements evaluation needs to be undertaken to ensure that projects are not unintentionally encouraging an environment for the risk factors such as physical inactivity to again grow.

Recommendations

Action One: Over the medium term, it is highly recommend that Australia evaluate funding directed towards HIV and AIDs, particularly in the Pacific region. It is recommend that restructuring of foreign aid towards prevention and management of NCDs and supporting NCD programs is conducted. Programs targeted to NCDs may have a wider effect in increasing low-middle income countries quality of life.  This restructuring will be a country by case scenario. As Australia needs to be judicious in foreign aid and support cost-effective programs that have a higher likelihood of success and enable Australia to realise a social return on investment. 

Action Two: Building on the success of Tonga, cross border training programs are strongly recommended. Nurses from in need regions such as Papua New Guinea, Indonesia and Solomon Islands should be eligible to receive specific training from Australian institutions.   Whilst it is acknowledged that training and facilities in Australia are highly advanced, gaining the knowledge and networks to diagnose, treat and monitor patients will be critical. There is appropriate to the level of conditions where the nurses will be deployed.

Action Three: It is recommended that Australia provide human resources and technical skills to support initial ‘best buys’ implementation in willing nations.  Human resources support includes but is not exclusive to analysis of sustainable taxation collection systems and training for appropriate staff to monitor and enforce tobacco and alcohol use policies.    

Action Four: Long-term strategies that facilitate the collection reliable data is a matter of urgency. It recommended that both resources be allocated to purchase basic equipment such as weight scales as well as data collection equipment and programs such excel programs for rural regions. Initial support should be provided to staff to enable them to train individuals utilise these tools in clinic themselves. These data collection frameworks require initial advisory from Australian support services and training to local staff in clinics.

Limitations

The data presented has been sourced from global institutions and peer reviewed literature. However, due to the short and questionable collection methods within LMICs certainty regarding pure accuracy cannot be assured. Secondly, data may be skewed according to the policy positions of particular institutions and parties, whilst all efforts have been undertaken to ensure unbiased and objective information subtle biases may have influenced secondary data. Finally, in many LMIC the availability of data was limited and due to the short history of many LMIC databases a proper baseline could not be established.

Conclusion

NCDs are a global challenge that is neither curable nor short-term. They are threatening economic development but more importantly quality of life. Whilst there is an increased recognition of the impact and suggestions as to how to address NCDs, many frameworks have not fully considered individual cultural, infrastructure and financial factors of individual countries.  For the NCD challenge to be managed and for the SDGs to have the possibility of success a focus and support needs to be directed towards establishing basic foundations such as data collection tools, infrastructure to support implementation and an increase in skilled nurses. The World Bank can demonstrate its relevance on the world stage through its capacity to assist countries both on a state and local level in collecting, managing and interpreting data. Further, Australia can also assist in managing NCDs through providing funding and expertise to areas that decrease risk factors and equally support local community empowerment.  Whilst NCDs cannot be eradicated it has the ability to be managed and steps can be taken to lead to an overall increase in quality of life and in turn support economic development.

Full Footnotes and Bibliography can be found here or by copying the following URL into your browser: http://bit.ly/Bronte-Greer-2015