The analysis in the paper is limited by explicit information available in the public domain and may not be able to capture all the complex consultations or discussions that may be ongoing in the countries more recently. Hence the results should be interpreted in light of this limitation.
The evolving response to NCDs in LMICs shows several positive trends. These include increasing institutional recognition of NCDs, a move from disease-based programs to integrated NCD programs, and an increasing inclusion of NCDs in sector-wide health plans. These developments reflect the increasing recognition of the high burden of NCDs, and an explicit acknowledgment of the need for multisectoral actions with the creation of high-level coordination mechanisms. The analysis also suggests substantial influence of supranational initiatives and processes on in-country governance structures and policy development processes, which offers both opportunities and challenges.
Notwithstanding the above positive trends, the analysis highlights some areas of concern. Each of these areas of concern and potential strategies to address them are described below.
Institutional arrangements for responding to NCDs
The current directions in development of NCD-specific institutional structures in LMICs with their increasing direct role in planning, management and implementation may lead to segmented service delivery systems for NCDs, especially with increase in NCD-specific external funding, as experienced in the past with scaling-up of programs for immunization, malaria, Tuberculosis, HIV/AIDS.
Two key strategies are recommended to pre-empt this undesirable outcome. The first strategy would be clear separation of the ‘technical’ and the ‘operational and programme management’ functions between NCD-specific units and sector-wide organizational units (e.g. health policy & planning units, human resource development units, drug and logistics units), respectively. The NCD-specific structures are justified to build much needed technical capacity for NCDs in MOH and to provide institutional identity and visibility, especially when similar structures exist within the MOH for other public health problems perceived to be important. However, it will be critical that these NCD-specific units are developed only as technical advisory bodies with strengthening of their capacity in analyzing up-to-date technical information, development of clinical guidelines, advising on suitability of different proposed interventions and research. In addition, NCD-specific units should focus on strategizing, guiding, coordinating policies and activities across different stakeholders within and beyond MOH. However, these units should not act as direct implementing bodies for NCD plans and management and delivery of NCD-related services which should be rather left to sector-wide organizational structures.
Second, the resources to strengthen institutional capacity to respond to NCDs should not be solely targeted to NCD-specific units, but more importantly to sector-wide organizational units to build their capacity in effectively incorporating NCD-specific requirements in human resources development, health financing, medical supply and logistic and information systems.
Visibility and articulation of NCDs in sector-wide health policies and plans
Three major concerns were identified in the increasingly complex NCD policy landscape in LMICs.
First, out analysis suggest that the sector-wide health plans were not entirely informed by critical analysis of local disease burden and health needs. Often local evidence, even when acknowledged in situation analysis, was ignored in favour of global priorities and goals. Hence, NCD-specific units should be fully engaged in the sector-wide health policy and planning process to ensure inclusion of NCDs related activities as appropriate to their epidemiology, morbidity/mortality burden in the sector-wide health plans.
Second, our analysis shows weak alignment (Tables
and ) among sector-wide and NCD-specific policies/ plans suggesting relatively autonomous development at different times by different constituents with unclear linkages. Ideally, the NCD-specific plans should offer a higher-level technical detail expanding on the directions given in the sector-wide plans within the sector-wide operational limits in infrastructure, human and financial resources. NCD-specific plans should be developed with participation and endorsement of all the stakeholders within health and non-health sectors with NCD units playing only a coordinating role. The sector-wide national planning bodies should ensure that NCD-specific plans are within the resources offered by health sector.
Third, NCD specific plans with no information on financial and implementation feasibility and no realistic quantifiable targets, as have been observed in some of the countries examined, may become simply technical papers or 'laundry lists' of desirable activities with limited reference value and no follow-up at the government level [36
Effectiveness of multisectoral coordination
Although the need for multisectoral coordination is acknowledged by most LMICs, the resources needed to organize and manage such coordination mechanisms appear to be inadequate. The inter-ministerial bodies—the most common mechanism reported—seem to be relatively fragile structures in most LMICs with limited effectiveness in influencing the policies, programs and resources allocation in different sectors [36
]. In some countries, such as Mongolia, these structures are already being reported as inactive [35
]. The implementation of 'Health in All Policies' has remained a challenge even in developed countries [39
], with few non-health ministries taking action on their own to reduce deaths from cancers or hypertension. This implies that MOH will have the added responsibility for proactive negotiations and coordinating efforts to build stronger multisectoral partnerships. Also, it will be more efficient to set-up these coordination mechanisms for multiple issues that require inter-sectoral coordination, rather than for specific issues (e.g. tobacco) as observed in some countries. Finally, as international initiatives, partners and assistance for NCDs may increase in the near future, countries have to be in the driver's seat for creating coordination mechanisms that harmonize efforts of different partners and agencies. Preferably these will be part of an overall existing health sector coordination mechanism, rather than creating specific multiple coordination mechanisms to fulfil requirements of specific donors.
To summarize, attention to evolving governance structures and policy development processes for NCDs is vital. It will aid pre-emptive and corrective action at an early stage for the effective, efficient, and sustainable scaling-up of response to NCDs within a health systems context.