FCV Health Knowledge Notes Non-Communicable Diseases in Fragile, Conflict, and Violence (FCV) Situations Five key questions to be answered SUMMARY The global burden of disease has shifted from that of communicable to non-communicable diseases in many countries. This note highlights the need for investment, as well as best practices in designing, implementing and evaluating a project that includes an NCD focus or component within an FCV setting. WHY invest in NCDs Q1 in FCV situations? conflict situations, as seen in Yemen, Mali and Non-Communicable Diseases (NCDs) such as cancer, many Pacific Island countries. cardiovascular diseases, diabetes, chronic respiratory diseases, and cerebrovascular diseases account for Total annual economic losses to LMICs from four major over 70 percent of deaths, annually, around the world. NCDs are estimated to be approximately 4 percent of Low- and middle-income countries (LMICs) these countries’ current annual output, resulting in disproportionately suffer from NCDs in comparison to high- further poverty implications on already financially burdened income countries (HICs), with 85 percent of premature countries. However, investing in NCD interventions has a deaths occurring in LMICs. good return on investment (ROI=3 for ischemic heart disease and stroke reduction). Successful interventions in LMICs and FCV countries against NCD-related risk factors (tobacco and alcohol The economic burden of NCDs is particularly use, salt intake, obesity, elevated blood pressure and high pronounced in the FCV countries of the East Asia and blood glucose) can lead to substantial changes in reducing Pacific region where the average total years lost due to the probability of NCD-related death. death and disability (DALYs) for diabetes is 5444 per 100,000 and the economic loss due to NCD mortality NCDs and risk factors incur high economic burden to across 11 Pacific Island countries is estimated to be countries, account for a high proportion of health between 8.5 percent and 14.3 percent of GDP. expenditure, and correlate with a higher risk of household catastrophic medical expenditure. The economic impact of NCDs is also high in FCV countries in the Middle East and North Africa regions NCDs also have high indirect costs and adversely affect where the average DALYs for ischemic heart disease is employment chances and working hours in both fragile and 4,999 per 100,000. 1 estimated that 60 to 80 percent of deaths in most countries Q2 WHO has NCDs in in this region are caused by the four leading NCDs. FCV situations? Sub-Saharan Africa is facing a double burden of disease as the changing disease epidemiology in the region will People in conflict and post-conflict settings are often result in NCDs being the most common cause of death by more vulnerable to NCDs because of an increase in 2030. negative coping mechanisms, which are often NCD risk factors, such as smoking and alcohol consumption. This is compounded by healthcare systems that are weakened as WHAT interventions a result of the conflict. Furthermore, NCD management, particularly in conflict settings, is often disrupted, as Q3 could be considered healthcare facilities are damaged and even targeted in when addressing NCDs these situations. Additionally, an increasing amount of conflict situations are occurring in middle income countries, in FCV contexts? such as Libya and Syria, where historically, NCD prevalence was often higher than lower income countries. While some guidelines have been developed for implementing NCD interventions, serious gaps exist with Individuals in emergency situations, which extends to particular reference to addressing the FCV and refugee circumstances beyond conflict, such as natural disasters context. and famine, are two to three times more likely to experience stroke and heart attack. Because of the movement of NCD patients that often takes place in the FCV context, mobile service delivery with Migrants and refugees also have an increased the use of community health workers has emerged as vulnerability to experiencing NCDs due the disruption of an intervention used for Syrian refugee populations in regular treatment and medical care during travel, in Lebanon with the potential for scale up in other refugee and forced displacement settings. addition to other factors. Due to changing disease epidemiology, many FCV BOX 1.1 WHO’s guidelines for providing countries now have higher NCD mortality rates than that NCD interventions of communicable, maternal, perinatal and nutrition related • “Package of Essential Noncommunicable (PEN) conditions. Countries like Haiti, Myanmar, Solomon Islands, Iraq and Lebanon are examples of this Disease Interventions for Primary Health Care in epidemiological shift. Low-Resource Settings” is a set of protocols, medicines and equipment for NCDs management, FCV countries in the Middle East and North Africa with focus on integration into primary health care. (MENA) region have particularly high NCD rates. The • “Best Buys” provides cost effective interventions, by percentage of total deaths in this region due to NCDs, risk factor or disease, which cost less than USD 1.00 ranges from 43 percent in Djibouti to 89 percent in in low-income countries. Lebanon. • “Noncommunicable diseases in emergencies” FCV countries in the East Asia Pacific (EAP) region also which provides minimum standards and priorities suffer disproportionately from high rates of NCDs. It is related to NCDs in emergency situations. 2 It is important to note that treatment for different Empirical evidence shows “price” and “non-price” populations may differ. For example, treatment for Syrian interventions can reduce risk factors for NCDs (Figure 1.1). refugees may be more expensive than that of populations The “price” approach includes taxation and subsidies, while in Sub-Saharan Africa since the Syrian population is older “non-price” mechanisms are based on legislation, and tends to suffer from more chronic disease. substitute provision and behavioral change (for example, information and education campaigns). Among “non-price” Further, it is important to consider that not all NCD interventions, legislation (for example, tax) may be more treatments are financially equal. Treatments such as effective to reduce risky behaviors, but behavioral change renal dialysis and cancer treatments are far more interventions may have longer impacts if successful. expensive than treatments for other NCDs. In FCV settings, appropriate interventions may differ The current international guidelines recommend cost depending on the type of crisis (Figure 1.2). Prior to effective interventions that focus on providing care within implementing the interventions, existing health service the limitations of available limited resources. delivery structures, targeted NCDs or risk factors, and population should be assessed. Figure 1.1 Price vs. Non-price approach (de Walque and Pande 2013) Figure 1.2 Level of crisis and type of intervention (Perone et al. 2017) 3 Q4 WHAT has been done at the World Bank? What are the challenges and lessons learned? 32 World Bank projects with an NCD component  21 Health, Nutrition and Population Global Practice operational projects.  5 out 31 Health, Nutrition and Population FCV projects. 43 World Bank reports and papers on NCDs since 2010, including:  Effective Responses to Non-communicable Diseases: Embracing Action Beyond the Health Sector (2011) Montserrat Meiro-Lorenzo, Tonya L. Villafana, Margaret N. Harrit.  The Challenge of Non-Communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa (2013) Patricio V. Marquez, Jill L. Farrington.  Health in All Policies as a Strategic Policy Response to NCDs (2014) Vivian Lin, Catherine Jones, Shiyong Wang, Enis Baris.  Setting the Stage to Address the Dual Challenge of MDGs and NCDs (2014) Anne Maryse Pierre-Louis, Katharina Ferl, Christina Dinh Wadhwani, Neesha Harnam, Montserrat Meiro-Lorenzo.  Cancer Care and Control: South-South Knowledge Exchange (2015) Miriam Schneidman, Joanne Jeffers, Kalina Duncan.  Health and Noncommunicable Diseases: Bending the Noncommunicable Disease Cost Curve in the Pacific (2017) Xiaohui Hou, Ian Anderson, Ethan-John Burton-Mckenzie. BOX 1.2 Voices from the Field  Deaths from NCDs are not always properly categorized and attributed to NCDs. Common Challenges Emerged from Task Team  There is a need on the institutional level to define Leader Interviews what level of service (primary, secondary, tertiary)  Governments in many FCV countries do not prioritize will be supported when addressing NCDs. NCDs because the burden of communicable and nutrition related diseases are often high. Key Lessons Learned  In conflict situations, security is a concern since patients  Build a consensus among all stakeholders prior to are not able to safely travel to providers. Similarly, beginning project (key government ministries, providers are not able to safely travel to work. department partners, organizations, etc.).  Treatment of NCDs often requires specialists, who are  Ensure close monitoring of interventions; often better paid and tend to relocate. Often, there are particularly those related to policy changes. shortages in other health related human resources in  Interventions, such as policy change, in sectors FCV settings. outside of health, are important in addressing the  Low literacy rates and cultural norms may contribute issue. to a lack of understanding of risk factors leading to  The focus should be on primary care for early NCDs. detection versus late stage treatments.  It is difficult to identify immediate, measurable  Working with community health workers can ease results when implementing NCD interventions. the strain on human resources.  Focusing specific components on NCDs is difficult due to  Utilize the country’s existing health resources the broad nature of the topic. instead of developing new platforms, where possible.  Out of pocket expenditures are much higher, because  Make NCD operations simple and basic. of lack of regulations and governance, in addition to pharmaceutical shortages that are present in many FCV  Strategic partnerships (CSOs, NGOs, UN settings. agencies, etc.) are essential to success. 4 Q5 HOW should we evaluate NCD interventions? While evidence on evaluating various NCD interventions exists on a global scale, there is very limited literature on evaluating NCD programs in FCV or humanitarian contexts. Though NCDs are generally not seen as a priority for interventions in these contexts, good evaluation studies are required to demonstrate the outcome and make a case for NCD investment. A systematic review of empirical literature also highlighted several emerging trends in the practices of evaluating NCD programs in FCV contexts. Study Design Dimensions to Measure Measurement Instruments  Study design methods that have  Compliance with protocols and • A set of standardized instruments multiple measurements over guidelines validated in FCV settings time to evaluate the intermediate and long-term effects.  Implementation of interventions of guidelines in specific contexts  Before and after (e.g. RCT, case control)  Intermediate and long-term outcomes  Longitudinal (e.g. cohort, interrupted time series)  Sex and age disaggregated evaluation The FCV Health Knowledge Notes Series highlights operational tips to resolve health issues in FCV situations. These Notes are supported by the Middle East and North Africa Multi Donor Trust Fund and The State and Peacebuilding Fund (SPF). The SPF is a global fund to finance critical development operations and analysis in situations of fragility, conflict, and violence. The SPF is kindly supported by: Australia, Denmark, Germany, the Netherlands, Norway, Sweden, Switzerland, the United Kingdom, as well as IBRD. Authors: Sheila Carrette, Health Consultant, Nutrition and Population Global Practice, World Bank Group Di Dong, Health Economist, Health, Nutrition and Population Global Practice, World Bank Group Takahiro Hasumi, Health Specialist, Health, Nutrition and Population Global Practice, World Bank Group For more information on other HNP topics, go to www.worldbank.org/health 5 Appendix – Current HNP FCV and Forced Displacement Operations with NCD components Project Size Country Project Year of Effectiveness TTL / Key Contact Person (million $) Bosnia & Herzegovina Reducing Health Risk Factors (P160512) 1.41 2017 Ana Holt Health System Strengthening for Better Congo, Democratic Maternal and Child Health Results 346.5 2016 Hadia Nazem Samaha Republic of (P147555) Case Study on Integrated Delivery of GNV Ramana, Kenya Selected Non-Communicable Diseases 2.5 2017 Miriam Schneidman in Kenya (P164301) Dorothee Chen, Kosovo Kosovo Health Project (P147402) 25.5 2015 Lorena Kostallari Emergency Primary Healthcare Lebanon 21.0 2015 Nadwa Rafeh Restoration Project (P152646) Lebanon Health Resilience Project Lebanon 95.8 2017 Nadwa Rafeh (P163476)