Non-communicable disease policy implementation from 2014 to 2021: a repeated cross-sectional analysis of global policy data for 194 countries

Background: Non-communicable diseases (NCDs) are the world's leading cause of death and disability. Global implementation of WHO-recommended NCD policies has been increasing with time, but in 2019 fewer than half of these policies had been implemented globally. In 2022, WHO released updated data on NCD policy implementation, on the basis of surveys conducted in 2021 during the COVID-19 pandemic. We sought to examine whether the trajectory of global policy implementation changed during this period. Methods: In this repeated cross-sectional analysis, we used data from the 2015, 2017, 2020, and 2022 WHO progress monitors to calculate NCD policy implementation scores for all 194 WHO member states. We used Welch's ANOVA and Games-Howell post-hoc pairwise testing to examine changes in mean implementation scores for 19 WHO-recommended NCD policies, with assessment at the global, geographical, geopolitical, and country-income levels. We collated sales data on tobacco, alcohol, and junk foods to examine the association between changes in sales and the predicted probability of implementation of policies targeting these products. We also calculated the Corporate Financial Influence Index (CFII) for each country, which was used to assess the association between corporate influence and policy implementation. We used logistic regression to assess the relationship between product sales and the probability of implementing related policies. The relationship between CFII and policy implementation was assessed with Pearson's correlation analysis and random-effects multivariate regression. Findings: Across the 194 countries, in the years preceding publication of each progress monitor, mean total policy implementation score (out of a potential 18·0) was 7·0 (SD 3·5) in 2014, 8·2 (3·5) in 2016, 8·6 (3·6) in 2019, and 8·6 (3·6) in 2021. Only the differences in mean implementation score between 2014 and the other three report years were deemed statistically significant (pairwise p<0·05). Thus the steady improvement in mean global NCD policy implementation stalled in 2021 at 47·8%. However, from 2019 to 2021, we identified shifts in individual policies: global mean implementation scores increased for policies on tobacco, clinical guidelines, salt, and child food marketing, and decreased for policies on alcohol, breastmilk substitute marketing, physical activity mass media campaigns, risk factor surveys, and national NCD plans and targets. Six of the seven policies with the lowest levels of implementation (global mean score <0·4 out of a potential 1·0) in both 2019 and 2021 were related to tobacco, alcohol, and unhealthy food. From 2020 onwards, we identified weak or no associations between sales of tobacco, alcohol, and junk foods and the predicted probability of implementing policies related to each commodity. Country-level CFII was significantly associated with total policy implementation score (Pearson's r –0·49, 95% CI –0·59 to –0·36), and this finding was supported in multivariate modelling for all policies combined and for all commercial policies except alcohol policies. Interpretation: NCD policy implementation has stagnated. Progress in the implementation of some policies is matched by decreased implementation of others, particularly those related to unhealthy commodities. To prevent NCDs and their consequences, and attain the Sustainable Development Goals, the rate of NCD policy adoption must be substantially and urgently increased before the next NCD progress monitor and UN high-level meeting on NCDs in 2024. Funding: None

Global health education in Swedish medical schools.

Global health education is increasingly acknowledged as an opportunity for medical schools to prepare future practitioners for the broad health challenges of our time. The purpose of this study was to describe the evolution of global health education in Swedish medical schools and to assess students' perceived needs for such education

Assessing the association between Corporate Financial Influence and implementation of policies to tackle commercial determinants of non-communicable diseases: A cross-sectional analysis of 172 countries.

OBJECTIVE: Non-communicable diseases (NCDs) are the leading cause of global death and disability. Tobacco, alcohol, and unhealthy foods are major contributing risk factors. WHO Member States have unanimously endorsed a set of 12 policies designed to constrain the sale of these commodities, however, there are myriad case studies of commercial entities seeking to undermine effective legislation in order to protect their profits. We set out to quantify the association between corporate financial influence and implementation of commercial policies. METHODS: We generated policy implementation scores for all 194 WHO Member States using data from the 2015, 2017, and 2020 WHO NCD Progress Monitor Reports. We used publicly available data to create a novel Corporate Financial Influence Index (CFII) that quantifies the opportunity for corporations to use their financial resources to directly influence policymaking in each country. We reported policy implementation trends over time and used random effects multivariate regression to test the association between policy implementation and CFII for each country, while controlling for broad set of economic, cultural, historical, geographic, and demographic factors. FINDINGS: Implementation of the 12 WHO-backed commercial policies has risen over time, but remains low at approximately 40%. Progress is reversing for alcohol policies. CFII explains around a fifth of the variance in global implementation. For every 10% rise in CFII, implementation falls by approximately 2% (95%CI 0.90 to 3.5, p < 0.001). CONCLUSION: Our quantitative global analysis suggests that financial corporate influence is negatively associated with implementation of policies that seek to restrict the marketing, sale, and consumption of unhealthy (but profitable) commodities. In the context of anemic international progress tackling NCDs, greater attention should be paid to managing regulatory opportunities for overt and covert corporate financial influence as a core plank of the global NCD response

Study protocol: assessing the association between corporate financial influence and implementation of policies to tackle commercial determinants of non-communicable diseases: a cross-sectional analysis of 172 countries.

INTRODUCTION: There are many case studies of corporations that have worked to undermine health policy implementation. It is unclear whether countries that are more exposed to corporate financial influence are systematically less likely to implement robust health policies that target firms' financial interests. We aim to assess the association between corporate financial influence and implementation of WHO-recommended policies to constrain sales, marketing and consumption of tobacco, alcohol and unhealthy foods. METHODS AND ANALYSIS: We will perform a cross-sectional analysis of 172 WHO Member States using national datasets from 2015, 2017 and 2020. We will use random effects generalised least squares regression to test the association between implementation status of 12 WHO-recommended tobacco, alcohol and diet policies, and corporate financial influence, a metric that combines disclosure of campaign donations, public campaign finance, corporate campaign donations, legislature corrupt activities, disclosure by politicians and executive oversight. We will control for GDP per capita, population aged >65 years (%), urbanisation (%), level of democracy, continent, ethno-linguistic fractionalisation, legal origin, UN-defined 'Small Island Developing States' and Muslim population (%) (to capture alcohol policy differences). We will include year dummies to address the possibility of a spurious relationship between the outcome variable and the independent variables of interests. For example, there may be an upward global trend in policy implementation that coincides with an upward global trend in the regulation of lobbying and campaign finance. ETHICS AND DISSEMINATION: As this study uses publicly available data, ethics approval is not required. The authors have no conflicts of interest to declare. Findings will be submitted to a peer-reviewed journal for publication in the academic literature. All data, code and syntax will be made publicly available on GitHub

Implementation of non-communicable disease policies from 2015 to 2020: a geopolitical analysis of 194 countries.

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of morbidity and mortality globally. We aimed to analyse trends in implementation of WHO-recommended population-level policies and associations with national geopolitical characteristics. METHODS: We calculated cross-sectional NCD policy implementation scores for all 194 WHO member states from the 2015, 2017, and 2020 WHO progress monitor reports, and examined changes over time as well as average implementation by geographical and geopolitical region and income level. We developed a framework of indicators of national characteristics hypothesised to influence policy implementation, including democracy, corporate permeation (an indicator of corporate influence), NCD burden, and risk factor prevalence. We used multivariate regression models to test our hypotheses. FINDINGS: On average, countries had fully implemented a third (32·8%, SD 18·2) of the 19 policies in 2020. Using aggregate policy scores, which include partially implemented policies, mean implementation had increased from 39·0% (SD 19·3) in 2015 to 45·9% (19·2) in 2017 and 47·0% (19·8) in 2020. Implementation was lowest for policies relating to alcohol, tobacco, and unhealthy foods, and had reversed for a third of all policies. Low-income and less democratic countries had the lowest policy implementation. Our model explained 64·8% of variance in implementation scores. For every unit increase in corporate permeation, implementation decreased by 5·0% (95% CI -8·0 to -1·9, p=0·0017), and for every 1% increase in NCD mortality burden, implementation increased by 0·9% (0·2 to 1·6, p=0·014). Democracy was positively associated with policy implementation, but only in countries with low corporate permeation. INTERPRETATION: Implementation of NCD policies is uneven, but broadly improving over time. Urgent action is needed to boost implementation of policies targeting corporate vectors of NCDs, and to support countries facing high corporate permeation. FUNDING: The National Institutes for Health Research, the Swedish Research Council, the Fulbright Commission, and the Swedish Society of Medicine

Barriers and Opportunities for WHO “Best Buys” Non-communicable Disease Policy Adoption and Implementation From a Political Economy Perspective: A Complexity Systematic Review

Background: Improving the adoption and implementation of policies to curb non-communicable diseases (NCDs) is a major challenge for better global health. The adoption and implementation of such policies remain deficient in various contexts, with limited insights into the facilitating and inhibiting factors. These policies have traditionally been treated as technical solutions, neglecting the critical influence of political economy dynamics. Moreover, the complex nature of these interventions is often not adequately incorporated into evidence for policy-makers. This study aims to systematically review and evaluate the factors affecting NCD policy adoption and implementation.Methods: We conducted a complex systematic review of articles discussing the adoption and implementation of WHO’s “best buys” NCD policies. We identified political economy factors and constructed a causal loop diagram (CLD) program theory to elucidate the interplay between factors influencing NCD policy adoption and implementation. A total of 157 papers met the inclusion criteria.Results: Our CLD highlights a central feedback loop encompassing three vital variables: (1) the ability to define, (re)shape and pass appropriate policy into law; (2) the ability to implement the policy (linked to the enforceability of the policy and to addressing NCD local burden); and (3) ability to monitor progress, evaluate and correct the course. Insufficient context-specific data impedes the formulation and enactment of suitable policies, particularly in areas facing multiple disease burdens. Multisectoral collaboration plays a pivotal role in both policy adoption and implementation. Effective monitoring and accountability systems significantly impact policy implementation. The commercial determinants of health (CDoH) serve as a major barrier to defining, adopting, and implementing tobacco, alcohol, and diet-related policies.Conclusion: To advance global efforts, we recommend focusing on the development of robust accountability, monitoring, and evaluation systems, ensuring transparency in private sector engagement, supporting context-specific data collection, and effectively managing the CDoH. A system thinking approach can enhance the implementation of complex public health interventions

Determining universal processes related to best outcome in emergency abdominal surgery:a multicentre, international, prospective cohort study

Introduction: Emergency abdominal surgery outcomes represent an internationally important marker of healthcare quality and capacity. In this study, a novel approach to investigating global surgical outcomes is proposed, involving collaborative methodology using ‘snapshot’ clinical data collection over a 2-week period. The primary aim is to identify internationally relevant, modifiable surgical practices (in terms of modifiable process, equipment and clinical management) associated with best care for emergency abdominal surgery. Methods and analysis: This is a multicentre, international, prospective cohort study. Any hospital in the world performing acute surgery can participate, and any patient undergoing emergency intraperitoneal surgery is eligible to enter the study. Centres will collect observational data on patients for a 14-day period during a 5-month window and required data points will be limited to ensure practicality for collaborators collecting data. The primary outcome measure is the 24 h perioperative mortality, with 30-day perioperative mortality as a secondary outcome measure. During registration, participants will undertake a survey of available resources and capacity based on the WHO Tool for Situational Analysis. Ethics and dissemination: The study will not affect clinical care and has therefore been classified as an audit by the South East Scotland Research Ethics Service in Edinburgh, Scotland. Baseline outcome measurement in relation to emergency abdominal surgery has not yet been undertaken at an international level and will provide a useful indicator of surgical capacity and the modifiable factors that influence this. This novel methodological approach will facilitate delivery of a multicentre study at a global level, in addition to building international audit and research capacity

Global surgery, obstetric, and anaesthesia indicator definitions and reporting: An Utstein consensus report

Background Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define—for the first time—the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally. Methods and findings The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries—who only made up 21% of the total attendees. Conclusions To track global progress towards timely access to quality SAO care, these indicators—at the basic level—should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies.publishedVersio

Measuring global surgery, obstetrics and anaesthesia from health systems to patients

BackgroundWorldwide, an estimated 5 billion people lack access to safe, affordable surgical care when needed. This leads to millions of avertable deaths and unnecessary morbidity each year. To change this situation, urgent action is needed at many levels, but indicators and data have been lacking to guide improvement.AimsThe aim of this thesis was to describe and evaluate measurement of surgical public health. Organised according to the Lancet Commission on Global Surgery indicator framework, the thesis specifically aimed to: I. quantify global access to emergency obstetric care; II. describe the global distribution of specialist surgeons, anaesthesiologists and obstetricians; III. measure the rate and mortality of Caesarean sections in Sierra Leone, the country with the world’s highest maternal mortality; IV. to propose a new study design for collecting data on surgical outcomes; V. calculate the cost-effectiveness of surgical care, as exemplified by Ponseti club foot repair, and; VI. critically review the global data collection efforts of the six Lancet global surgery indicators.MethodsTo address these aims, a range of methodologies were employed: I. Available reports of national and sub-national data on the met need for emergency obstetric care were collected, reviewed and analysed; II. National data on the number and distribution of the specialist surgical workforce were collected; III. The rate and outcomes of Caesarean sections in Sierra Leone were analysed based on data from facilities and from the national Maternal Death Surveillance and Response system; IV. A protocol for collecting data on perioperative mortality of emergency abdominal surgery was developed; V. Cost effectiveness analysis was carried out for club foot repair; VI. Data on the six indicators proposed by the Lancet Commission on Global Surgery in 2015 were collected, and indicators analysed and critically reviewed.ResultsThe global met need for emergency obstetric care was 45% [interquartile range 28–57%], and the met need was significantly correlated with the proportion of births attended by skilled birth attendants. There were an estimated two million specialist surgeons, obstetricians and anaesthesiologists, of which only 20% serve the poorest half of the world. In 2016, the Sierra Leonean Caesarean section rate was 2.9% of all deliveries, with a perioperative mortality rate of 1.5%. A multicentre, international, prospective cohort study protocol for the measurement of perioperative mortality of emergency abdominal surgery was published. Clubfoot repair by the Ponseti method was highly cost-effective at 22 USD per averted Disability Adjusted Life Year. The six indicators proposed by The Lancet Commission on Global Surgery have been implemented to varying degrees, with definitional challenges as well as lack of commitment and structures for data collection.SignificanceMeasuring global surgery, obstetrics and anaesthesia – from health systems to patients explores methods of measuring surgical care in the context of a growing recognition of the need to increase access to safe, affordable surgical care around the globe. This research has provided baseline data on several indicators, some of which have been adopted by the WHO and the World Bank. Furthermore, it has critically reviewed the six indicators proposed for global implementation, and made suggestions for further improvement. Good quality indicators are paramount for guiding further efforts in global surgery, obstetrics and anaesthesia, with potential impact for surgical patients, families and societies today and in the future