Elsevier

Public Health

Volume 144, March 2017, Pages 4-12
Public Health

Review Paper
Legal priorities for prevention of non-communicable diseases: innovations from WHO's Eastern Mediterranean region

https://doi.org/10.1016/j.puhe.2016.11.001Get rights and content

Highlights

  • Law can be a cost-effective and affordable tool to reduce non-communicable disease (NCD) risk factors.

  • Legal interventions must be adapted for local legal, social and economic contexts.

  • Good governance, especially multisectoral collaboration, supports effective NCD prevention.

  • Enabling factors for NCD laws include regulatory capacity and robust public and civil society support.

Abstract

Objectives

Non-communicable diseases (NCDs) are the leading cause of death globally and in the World Health Organization's (WHO) Eastern Mediterranean region (EMR). This paper reports on a research collaboration between the WHO's Eastern Mediterranean Office (EMRO) and the O'Neill Institute for National and Global Health Law at Georgetown University that aims to identify (1) regionally relevant, cost-effective and affordable legal interventions to prevent NCDs, and (2) methods to strengthen implementation and enforcement.

Study design

Comparative analysis of >200 international, regional and domestic interventions addressing key NCD risk factors, including tobacco, alcohol, diet and physical inactivity.

Methods

Researchers searched legal and policy databases including the WHO Nutrition, Obesity and Physical Activity Database and drew upon academic commentary and 'grey' literature. Measures included evidence of impact; evidence of cost-effectiveness; and monitoring and enforcement mechanisms.

Results

Researchers identified many examples of legal interventions effectively reducing NCD risk factors. Key enabling factors for effective NCD-related laws include regulatory capacity; governance mechanisms promoting multisectoral collaboration and accountability; and tailoring interventions to local legal, economic and social contexts.

Conclusions

In the EMR, and globally, law can be a cost-effective and affordable means of curbing underlying drivers of the NCD pandemic, such as rampant junk food marketing. Building upon this research, together with international and regional experts, EMRO has identified 10 priority interventions in the areas of tobacco control, unhealthy diets and NCD governance. The EMRO/O'Neill Institute partnership will develop guidance tools and capacity building initiatives to support Member States to harness the power of law to achieve population health improvements.

Section snippets

NCDs: a high regional burden

Four diseases cause 1.7 of the 2.2 million NCD deaths in the EMR each year: cardiovascular disease, cancer, chronic lung disease and diabetes. These four key NCDs share modifiable risk factors: tobacco use, unhealthy diets, physical inactivity and the harmful use of alcohol. EMR countries have among the highest rates of modifiable risk factors globally. Beyond the alarming mortality and morbidity attributable to tobacco use,8 unhealthy diets and physical inactivity5 are major contributors to

Underlying drivers of NCD risk factors

While modifiable risks are the most visible cause of NCDs, underlying environmental and social factors drive unhealthy behaviours (see Fig. 1). Globalization, trade liberalization and cross-border marketing and advertising fuel the NCD pandemic.12 These factors increase the availability and affordability of foods high in saturated fats, salt and sugars, and low in polyunsaturated fats, fibre, fruits and vegetables. Lack of public transport options and opportunities for physical activity, the

Systematic evaluation of legal strategies: WHO best buys, national and local experiences and scientific evidence

Following the UNGA's global leadership on NCDs, the Eastern Mediterranean Regional Committee adopted the Regional Framework for Action on NCDs.19 Accompanying resolutions urged Member States to counter commercial practices promoting unhealthy products20 and to strengthen national health systems.21 In support of these initiatives, the EMRO/O'Neill Institute partnership catalogued relevant international instruments, such as the FCTC and its guidelines,22 WHO's MPOWER measures23 and the Global

A dashboard of legal and governance priorities for prevention of NCDs

Drawing upon this research and a series of technical consultations, EMRO and the O'Neill Institute, in collaboration with regional and international experts, identified 10 priority legal and governance interventions (see Fig. 2) selected on the basis of:

  • 1.

    Relevance: the intervention's capacity to reduce the prevalence of one or more NCD risk factors of concern in the EMR;

  • 2.

    Effectiveness: evidence that the intervention will effectively reduce prevalence of NCD risk factors;b

Multisectoral collaboration, accountability and transparency

Good governance is essential for effective development and implementation of NCD laws. Governance for health is the government's capacity to design and implement health policy objectives, including a regulatory framework governing the exercise of authority in public sector management and regulating the behaviour of a wide range of non-government actors.25 Many EMR Member States have weak governance and limited civil society participation, which are further compounded by ongoing geopolitical

Tobacco control laws: strengthening legal standards and enforcement

While many EMR Member States have adopted tobacco control laws, legal standards often fall short of global best practice. The EMR region, for example, has the second lowest average excise tax per pack of cigarettes and non-cigarette forms of tobacco are often minimally taxed, if at all.38 In addition to weak requirements, existing tobacco control laws are often not effectively enforced. For example, existing smoke-free laws have not significantly lowered environmental tobacco smoke in 11 EMR

Promoting healthier diets: a novel use of public health law

The final four priority interventions target the alarming rates of diet-related NCDs in the EMR. The number of people with diabetes, for example, has risen seven fold in recent decades, from 6 million in 1980 to 42 million people in 2014.1 EMRO and the O'Neill Institute recommend that Member States enact legislation to eliminate artificial trans fat from the food supply (Fig. 5), reduce the salt content in processed foods, restrict the marketing of foods high in saturated fats, salt and added

The way forward: building regulatory capacity and an enabling environment for law reform

Public health laws achieve their objectives only when there is sufficient regulatory capacity for monitoring, quality control and enforcement. The EMRO/O'Neill Institute partnership is developing detailed guides on the content of recommended laws as well as strategies to overcome challenges throughout the law-making process, including structuring laws to ensure consistency with international trade rules and implementation and enforcement strategies. Recognizing the power of law to effect

Harnessing the law's power to promote health, economic growth and development

Legal interventions to prevent and control NCDs are relatively recent. Laws relating to diet and physical activity, moreover, often face public and political opposition due to concerns about paternalism and the ‘Nanny State’.47 Yet, the law need not coerce but rather can help create environments in which health is the easier choice. The evidence clearly demonstrates that individuals will smoke less and eat healthier diets in societies that are well regulated. In the EMR and globally, law can be

Author contributions

AA and LOG conceived the research and supervised the project, which is implemented by HAT and SAR. LOG, AA, SAR and HAT conceived, prepared, edited and approved the manuscript.

Ethical approval

Not required.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Competing interests

None declared.

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