Health officials from several countries are meeting this week in Geneva at the annual Executive Board Meeting of the World Health Organization (WHO) to set the agenda for the 2023 World Health Assembly, WHO’s highest decision-making body. Global health advocates are watching the proceedings closely for several key issues, such as how WHO will finance itself and global plans for future pandemics. There is, however, one crucial but obscurely titled item that must not be neglected: updates to “Appendix 3 of the Global Action Plan for The Prevention and Control of NCDs 2013‒2030.”
The document offers countries an updated menu of cost-effective policy solutions to address noncommunicable diseases (NCDs), our most prolific modern killer, and will serve as an official statement of government policy priorities which can significantly impact the trajectory of NCDs. But classifying it as an “appendix” relegates its contents to a footnote or supplementary information, creating a risk that countries may miss its significance, or allow corporations to interfere with its implementation.
Noncommunicable diseases such as heart disease, stroke, cancer, diabetes, and chronic lung disease are not only debilitating on their own; as demonstrated by the COVID-19 pandemic, those with NCDs also fare more poorly when contracting infectious diseases. With under-resourced health systems struggling to keep up with cascading crises, countries need efficient solutions that will yield a big bang for their buck. “Appendix 3” offers just that, but the producers of unhealthy commodities that contribute to NCDs, including tobacco, alcohol, and ultra-processed foods, have a direct stake in maintaining their markets and will attempt to dilute WHO’s recommended policies. Recall how aggressively Coca-Cola lobbied to remove taxes on sodas and sugary drinks—a best buy to combat unhealthy diets—in previous versions of this document.
It’s imperative that trusted parties, from civil society groups to individual researchers, scrutinize proposed revisions on their merits, offer feedback ahead of the Assembly, and prevent efforts by self-interested commercial entities to undercut the proposed solutions. Global health advocates must protect the scientific legitimacy of Appendix 3 from corporate political interference.
That is why we recommend the following updates to the current draft of Appendix 3:
- Conflict-of-interest policies must be listed as recommended policy solutions, not simply philosophical goals. Corporate influence has clearly been identified as a reason for poor implementation of NCD policies. A global study of 194 countries identified corporate influence as one of the main reasons for the poor implementation of WHO’s recommended cost-effective solutions in Appendix 3. The most recent Gallup poll released by WHO and Bloomberg Philanthropies on public perception of NCDs bears this out further. Most people support policies like taxes on unhealthy commodities, particularly if the money will support public programs. They want labels on unhealthy foods and restrictions on ads that entice their kids. Therefore, removing conflicts of interest—like the aforementioned lobbying from Coca-Cola and other mega-corporations—must be included as a core intervention, and not merely stated as an aspirational goal. Tobacco control may be a good place to start, given that conflicts of interest are listed as clear and unequivocal policy interventions in its global treaty, the Framework Convention on Tobacco Control.
- WHO guidance for cost-effective solutions to NCDs could be more comprehensive and inclusive of all known risk factors. Appendix 3 acknowledges that a broader set of NCD risk factors must be acted upon, noting that cost-effective solutions for air pollution, road safety and traffic injuries, and mental and oral health, are complementary. Yet, there is no mention of integrating these complementary processes within a single document. Multiple parallel processes are needlessly confusing to time-strapped policymakers. This is a missed opportunity for creating a simple and comprehensive guide for policymakers.
- In a related vein, WHO’s guidance should promote a more integrated approach to the prevention and control of NCDs. The different NCD risk factors often share a common underlying relationship. Improvements in one area can foster improvements in others. For instance, best-buy solutions that improve diets, particularly by reducing the consumption of ultra-processed products, can not only address obesity but also improve malnutrition in all its forms. Moreover, since food production is associated with 80% of land-use conversion and biodiversity loss, as well as 20-30% of greenhouse gas emissions, reductions in consumption of ultra-processed foods—the worst of the unhealthy dietary options—can reap environmental gains. These “double-duty” actions and co-benefits, concepts promoted by WHO, could be better signaled in Appendix 3.
Much in the current draft merits adoption, particularly the following recommendations:
- The focus on preventing NCDs by reducing unhealthy behaviors must be maintained. The cost-effectiveness of prevention rather than cure is signaled in an expanded set of cost-effective interventions to limit unhealthy behaviors that cause NCDs, whether this involves tobacco and alcohol use or unhealthy diets and physical inactivity. The current draft of Appendix 3 also helpfully lists the technical policy packages associated with these behavioral risk factors—such as the MPOWER package for tobacco control and SAFER for alcohol—that can yield immediate gains.
- Policy solutions that shape consumer environments and nudge healthy choices are crucial. Appendix 3 recognizes the important role that environments play in shaping healthy behaviors, and aptly recommends policy solutions that help make healthy choices the default. These include clear warning labels, marketing restrictions, and limited retail environments (particularly schools) for unhealthy products like tobacco, alcohol and ultra-processed foods. Appendix 3 also rightly recognizes the importance of health literacy, including via strategic media campaigns, to promote healthier social norms and empowered consumers.
- Fiscal policy solutions, such as taxes on harmful products, offer multiple vital benefits. Most importantly, they reduce people’s consumption of unhealthy products while also providing a source of revenue to cash-strapped governments. Hence, fiscal policies such as robust taxation on unhealthy goods are strongly recommended. These are also the policies that are most often under threat from corporate political interference that seek to protect their profits over the health of consumers.
WHO’s updated guidance for NCDs is a great start. By helping governments determine where to place their efforts, Appendix 3 is a valuable document worthy of time and revision. But like any living document, it is open to interference. Global advocates must serve their accountability function, and WHO leadership must welcome this committed activism and collaboration by producing a document with real potential for impact.