Non-communicable diseases and
health information systems in the
Pacific region
Alan LopezHebe N Gouda, Nicola Hodge,
Carla AbouZahr, Audrey Aumua, Robert
Beaglehole, Colin Bell, Amanda Benson ,
Ruth Bonita, Mark Durand, Charles Gilks,
Damian Hoy, Lene Mikkelesen, Bruce
Neal, Tueila Percival, Rasika Rampatige,
Graham Roberts, Boyd Swinburn and
1
Working Paper Series
Number ?? March 2013 WORKING PAPER
2
About this series
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AusAID or the Australian Government.
Author details
Hebe N Gouda, Nicola Hodge, Audrey Aumua, Charles Gilks, Lene Mikkelesen, Rasika Rampatige
and Alan Lopez
School of Population Health, University of Queensland
Carla AbouZhar
Independent consultant
Robert Beaglehole, Ruth Bonita, Tueila Percival and Boyd Swinburn
University of Auckland, New Zealand
Colin Bell
Western Pacific Regional Office, World Health Organisation
Amanda Benson
Nossal Institute for Global Health, University of Melbourne
Mark Durand
Pacific Island Health Officers Association
Damian Hoy
Secretariat of the Pacific Commission, Noumea
Bruce Neal
George Institute for Global Health and the University of Sydney
Graham Roberts
University of New South Wales
3
The authors would like to thank Neal Pierce for reading and commenting on the paper. Further
thanks for contributions made by Michael Buttsworth, Taralina Gae'e-Atefi, Mark Power, Jillian
Ridley, and Anna Rodney.
© The University of Queensland 2013
Published by the Health Information Systems Knowledge Hub, School of Population Health, The
University of Queensland
Public Health Building, Herston Rd, Herston Qld 4006, Australia
Please contact us for additional copies of this publication, or send us feedback:
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Edited by Econnect Communication
Design by ??
4
Contents
Figures ..................................................................................................................................................... 6
Tables ...................................................................................................................................................... 7
Acronyms and abbreviations .................................................................................................................. 8
Summary ............................................................................................................................................... 10
1.
Background ................................................................................................................................... 12
1.1
Introduction .......................................................................................................................... 12
1.2
Guiding values and principles underlying health information systems in the Pacific .......... 13
1.3
Strengthening health information systems for non-communicable diseases in the Pacific. 14
1.4
Priority interventions and interventions that work .............................................................. 16
2. The WHO global monitoring framework and the Pacific .................................................................. 17
2.1
Data availability..................................................................................................................... 17
2.2
Proposed targets and indicators for the Pacific .................................................................... 24
2.3
Prioritising targets and indicators ......................................................................................... 30
2.4
Trade, regulatory mechanisms and non-communicable diseases........................................ 32
2.5
Data sources.......................................................................................................................... 33
3. Capacity and coordination ................................................................................................................ 38
3.1
Building capacity for civil registration and vital statistics ..................................................... 38
3.2
Generating and managing data ............................................................................................ 38
3.3
Building analytical capacity ................................................................................................... 39
3.4
Building institutional capacity ............................................................................................... 40
3.5
Coordinating efforts .............................................................................................................. 40
4. Regional governance ......................................................................................................................... 42
4.1 The potential role of a regional non-communicable disease monitoring alliance ..................... 42
4.2 Translational research................................................................................................................. 43
5. Conclusion ......................................................................................................................................... 44
References ............................................................................................................................................ 46
5
Figures
Figure 1 Strengthening a health information system to monitor and control non-communicable diseases in
Pacific Island Countries and Territories....................................................................................................... 15
Figure 2 The three pillars of non-communicable disease (NCD) surveillance (Source: WHO) ............................. 25
Figure 3 Prioritisation of indicators and data sources .......................................................................................... 32
Figure 4 Population-based and institution-based data sources (Source: HMN 2008) ......................................... 34
Figure 5 High priority actions to improve and strengthen data sources .............................................................. 37
6
Tables
Table 1 Pacific Island Countries reporting on non-communicable disease (NCD) indicators ............................... 19
Table 2 Year of survey and year of reports for three population surveys in Pacific Island Countries and
Territories .................................................................................................................................................... 24
Table 3 Global monitoring framework targets and indicators for the prevention and control of noncommunicable diseases .............................................................................................................................. 26
7
Acronyms and abbreviations
AusAID
Australian Agency for International Development
BAG
Brisbane Accord Group
CDC
Centre for Disease Control
CNMI
Commonwealth of the Northern Mariana Islands
CRVS
civil registration and vital statistics
CVD
cardiovascular disease
GHPS
Global Health Professionals Survey
GMF
Global Monitoring Framework
GSPS
Global School Personnel Survey
GSHS
Global School-based Student Health Survey
GTSS
Global Tobacco Surveillance System
GYTS
Global Youth Tobacco Survey
HIA
health impact assessments
HISHub
Health Information System Knowledge Hub
HIV/AIDS
human immunodeficiency virus/acquired immunodeficiency syndrome
HMN
Health Metrics Network
HPV
human papillomavirus
ICT
information and communications technology
INDEPTH
International Network for the Demographic Evaluation of Populations and their
Health
IT
information technology
MDGs
Millennium Development Goals
NCD
non-communicable disease
NZAID
New Zealand Aid Programme
PAHO
Pan-American Health Organization
PBCR
population-based cancer registries
PEN
package of essential non-communicable [disease interventions]
PHIN
Pacific Health Information Network
PICTs
Pacific Island Countries and Territories
PNG
Papua New Guinea
SARA
Service Availability and Readiness Assessment
SPC
Secretariat of the Pacific Community
STEPS
STEPwise Approach to Risk Factor Surveillance for NCDs
UNAIDS
Joint United Nations Programme on HIV/AIDS
8
UNESCO
United Nations Educational, Scientific and Cultural Organization
UNICEF
United Nations Children’s Fund
USAID
United States Agency for International Development
WHO
World Health Organization
WPRO
World Health Organization – Pacific Region Office
9
Summary
According to the Ninth Meeting of Ministers of Health for the Pacific Island Countries (WHO WPRO
2011), the Pacific region is in the midst of a non-communicable disease (NCD) epidemic which has
reached crisis point. Urgent and deliberative action is necessary such as cardiovascular disease and
stroke. The World Health Organization has developed the ‘Global action plan for the prevention and
control of non-communicable diseases 2013–2020’ and ‘A comprehensive global monitoring
framework including indicators and a set of voluntary global targets for the prevention and control
of noncommunicable diseases’ (WHO 2012a).
An expert panel was brought together by the Health Information Systems Knowledge Hub to assess
the application of the WHO global monitoring framework to Pacific health information systems. The
panel also considered the implications to health information systems in Pacific Island Countries and
Territories of supporting national and health system responses to the NCD epidemic.
In this working paper, we present the issues highlighted by the expert panel and set out
recommendations for strengthening health information systems in the Pacific region. We endorse a
hierarchical approach to applying the global monitoring framework NCD targets. Countries should
focus efforts on interventions that are known to have large health impacts and that are feasible and
cost-effective. To this end, we identify the parts of health information systems in the Pacific that
require strengthening and capacity building. Strengthening national civil registration and vital
statistics systems is crucial so that reliable mortality-by-cause data can be collected and used.
Integrating NCD surveillance into health information systems is important to provide much- needed
evidence on prevalence and trends in age- and sex-specific risk factors.
Health information systems usually collect and compile data from national health systems, vital
registration systems and population-based surveys. However, the severity of the NCD epidemic
demands that these systems go beyond the traditional sources of information. Health information
systems in the Pacific should incorporate information about trade regulations, national policies and
implementation programs intended to control access, costs and the quality of potentially harmful
products such as processed foods, as well as further limit access to tobacco and alcohol. To do this,
the potential desirable outcomes of this response must be defined and tracked systematically to
show what impact these measures have on individual jurisdictions and allow comparison between
jurisdictions.
In this paper, we also identify areas that should be incorporated into the health information systems
mandate, including investigations into the incremental costs of surveillance activities and core policy
interventions. Clarifying the direct and hidden costs and benefits associated with NCDs and
interventions is likely to help advance the policy agenda surrounding NCDs. This working paper also
recommends a structure for regional NCD governance that can harmonise monitoring, prevention
and control efforts and coordinate capacity-building activities for Pacific Island Countries and
Territories.
10
Key recommendations for Pacific Island Countries and Territories
1. Strengthen, as a matter of urgency, the civil registration systems and vital statistics in Pacific
Island Countries and Territories (PICTs) to provide mortality by cause information which is
essential for monitoring progress on NCDs.
2. Maintain focus on a few high-priority cost-effective interventions that bring the greatest
health benefit to all people and surveillance should reflect these priorities. Targets and
indicators of the global monitoring framework must be prioritised to suit the Pacific issues and
capacities. Targeting tobacco use, unhealthy diets and an approach to treat those at high risk
of cardiovascular diseases are the three top priorities and this should be reflected in
prioritised surveillance actions.
3. Expand on the GMF to include accountability indicators of NCD risk factors. These include
trade agreements and policies to regulate the prices. Access to tobacco, alcohol and unhealthy
foods should be better monitored and PICTs should agree on a prioritised list of these
upstream factors.
4. Integrate the STEPwise approach to risk factor surveillance for NCDs (STEPS) survey and the
Global School-based Student Health Survey (GSHS) into the routine data collection systems.
STEPS should be kept as simple as possible when incorporating modules on salt consumption
and access to treatment to prevent heart attacks and strokes in high-risk groups. The age
range for STEPS sampling should also be extended to 18 years and above to fill the gap
currently left between STEPS and GSHS. This modified survey should be administered every
five years in PICTs. Biological samples for the STEPS survey can be collected on alternate
cycles.
5. Improve capacity in the Pacific, as a matter of urgency, by taking concerted and coordinated
action to deal with human resource shortfalls which are a major impediment to strengthening
health information.
6. Address the urgent need for research on the costs and benefits of interventions and
monitoring different indicators.
7. Develop an external body under country ownership to strengthen surveillance activity in the
Pacific region by: identifying gaps in country capacities, helping coordinate capacity building
efforts, identifying research priorities, and providing technical support for data management,
data analysis and knowledge dissemination.
11
1. Background
1.1 Introduction
Non-communicable diseases (NCDs) are increasingly being recognised as a global issue which
threatens economic development and imposes heavy financial costs on households. The resources
available at national and regional levels are neither in proportion to the burden of NCDs, nor
adequate to address the challenge (The World Bank 2012). Recent estimates taken from the WHO
2009 ‘Western Pacific regional action plan for the prevention and control of noncommunicable
diseases (2014-2020)’ and Lozano et al. (2012) suggest that NCDs are leading causes of death in
Pacific Island Countries and Territories (PICTs) and responsible for over 70 per cent of all deaths
annually. Many of these deaths are preventable and share common risk factors. NCDs such as stroke
and diabetes can result in many years of chronic illness and place a debilitating burden on families
and health systems.
Pacific health leaders have aptly described the NCD situation in the region as a ‘crisis’ and have
issued a regional declaration of health emergency. The high-level meeting of the United Nations in
2011 addressed NCDs and raised them to a position of high priority on the global health agenda. The
political declaration recognised NCDs as a ‘human, social and economic crisis requiring an urgent and
comprehensive response’. The declaration calls for all member states to include NCDs in health
planning processes and development agendas. In May 2012, the World Health Assembly set a goal to
reduce the burden of premature mortality due to NCDs by 25 per cent by the year 2025.
In May 2013, the World Health Assembly endorsed the final version of the World Health
Organization (WHO) ‘Global action plan for the prevention and control of non-communicable
diseases 2013–2020’ and the ‘Comprehensive global monitoring framework, indicators and targets
for the prevention and control of NCDs’ (GMF). This represented consensus among member states
on the purpose, methods, roles and responsibilities towards NCD monitoring, prevention and
control. The GMF includes a set of nine voluntary time-bound targets and 25 indicators to track
progress. It provides an important platform for political support to integrate NCDs into national
health and development planning and monitoring. A regional NCD action plan has also been
prepared. In addition to the indicators outlined in the GMF, it also proposes to monitor country
performance by establishing national multi-sectoral action plans, reporting on the global targets and
integrating NCDs into the United Nations Development Assistance Framework (WHO 2002).
Collecting data to inform health planning and decision-making requires concerted and coordinated
efforts. This poses challenges for many low-resource countries, such as PICTs, which struggle to
develop and maintain health information systems with sufficient capacity to collect and analyse data
and to effectively report on the health of their populations. Health information systems in the Pacific
suffer from critical gaps and weaknesses. This is particularly true for NCDs which can often go
undiagnosed, untreated and/or unreported. Surveys from which NCD data is attainable are often
dated and much of what we know about NCD mortality in the Pacific is based on crude estimates.
In February 2013, the Health Information Systems Knowledge Hub (HISHub) at the University of
Queensland hosted a workshop bringing together an expert panel to discuss the key implications of
the proposed NCD monitoring and control framework on health information systems and their
strengthening in Pacific countries. The workshop reviewed the GMF and proposed priorities for the
framework that aim to maximise the cost-effectiveness of the targets and indicators appropriate for
the Pacific. In addition to this, the panel sought to identify key areas of applied research and regional
governance that could enhance the implementation of the WHO framework and ultimately control
or prevent NCDs.
12
1.2 Guiding values and principles underlying health information systems in
the Pacific
The expert panel defined the guiding values and principles that underlie health information systems
in the Pacific (see Panel 1). The primary values that should support and permeate all work to
strengthen health information systems in the Pacific are equity and country ownership. When
possible, monitoring efforts should incorporate indicators of socio-economic status as a marker for
inequalities in risk factor levels. With appropriate technical guidance, monitoring strategies should
be developed and implemented by countries, and, to the greatest extent possible, integrated into
existing systems.
In addition to these values, at the centre of all NCD monitoring and health information system
strengthening activities in the Pacific should be the following six guiding principles. The approaches
taken must be informed by sound scientific evidence and best possible practice. To be useful in
informing actions indicators should be clear and simple for easy interpretation. The development of
monitoring strategies must consider logistical challenges and resource limitations to ensure that
adopted approaches are feasible and sustainable. Developing sustainable systems of monitoring
requires a concerted approach to integrating systems of data collection and collation and building
local capacity dedicated to HIS and NCDs. Lastly, the approaches taken should be assessed and
prioritised by their relevance to the region and by the impact that they can have on overall
population health. The Pacific is in the midst of an NCD crisis, reaping the greatest impact with the
limited resources at hand is essential.
Panel 1: Values and principles to strengthen health information systems for non-communicable
diseases (NCD) in the Pacific
Values
Equity – Monitoring strategies should be capable of detecting the social and gender-specific
distribution of risk factors, impacts and services.
Pacific ownership – Pacific ownership must be central to the choice of strategy and aim for
sustainable systems of NCD monitoring and control.
Principles
Scientific rigour – Strategies to monitor NCDs in the Pacific must be guided by the best available
evidence and supported by ongoing research to inform future improvements.
Relevance – Strategies adopted to monitor NCDs must take into account the current health
information system capacities and reflect the health priorities for the Pacific Island Countries and
Territories.
Simplicity – Indicators should be easy to collect and easy to understand.
Feasibility – Monitoring strategies must take into account the practical and logistical challenges
on the ground and be realistic and viable.
Sustainability – NCD monitoring will require the collection of comparable data over time.
Implemented strategies must, therefore, be adequately supported so that they can be
maintained over long periods.
Action focused – Indicators should lead to action. Particular focus should be on cost-effective
actions which can have a high impact on improving population health.
13
1.3 Strengthening health information systems for non-communicable
diseases in the Pacific
Health information from PICTs is often incomplete, unreliable or lacking in quality (Finau 1994).
Although most Pacific countries have some form of hospital/health service use data system, data
quality is often poor, and there are no (or limited) computer-based linkages between data sources.
This makes it impossible to effectively link and track patients’ morbidity and mortality as they move
through the healthcare system (Ferguson et al. 2011). Due, in part, to out dated public health acts
and legislation, existing data systems are focused on capturing data related to communicable
diseases, with many countries required to report on infectious, dangerous and notifiable diseases.
Substantial improvement and modification is required to strengthen data-gathering mechanisms for
NCDs, including vital registration, cause-of-death statistics, population-based surveys and facilityinformation systems (Samb et al. 2010).
National health information systems in the Pacific do not give its decision-makers enough
information to determine the magnitude of their NCD problem or to address the needs for NCD
prevention and control. Even though the case study below is not specifically related to NCDs, it
highlights some of the fundamental issues experienced in PICTs.
Case study: An example of how effective decisions are hampered by the quality of
health statistics (Soakai & Wood 2012): Nauru prior to 2009
A request for the total number of births for Nauru produced four different figures from
different sources. Two were from the birth and death registry, one from hospital records
and one from the Nauru Bureau of Statistics. This outcome highlighted the following
issues:
1. There is clear duplication of services in an already overburdened workforce.
2. Multiple sources of information can lead to inconsistencies which undermine the
confidence of decision-makers seeking to use the data.
3. Inconsistencies in the majority of health statistics arise from each stage of the
data collection method, analytical methods and reporting methods.
4. Data is often aggregated at a provincial or country level making it less useful for
regional planning.
5. There is a lack of skilled staff for data collection and no clear standards are set to
guide staff in writing reports.
An effective surveillance framework needs to include information on major risk factors, outcomes
(morbidity and cause-specific mortality), national-systems-response interventions and health system
capacity (Alwan et al. 2010). We use the Health Metrics Network (HMN) Health Information System
Framework to help summarise and illustrate where recommendations made by the expert panel
apply to the components of a health information system (Figure 1). This HMN framework divides
health information systems into three categories (inputs, processes and outputs) and six
components (indicators, data sources, data management, information products, dissemination and
use, and health information system resources). By conceptualising the needs of a strong health
information system, the framework enables countries to effectively evaluate and ultimately improve
their existing systems (WHO 2008).
14




Train policy analysts [Section 3.3]
Share costs of monitoring to ensure country ownership [Section 3.5]
Develop local capacity in public health law and advocacy [Section 3.4]
Develop a ‘tool box’ of sample laws, regulations and policies that can be
quickly adapted/adopted to needs of jurisdictions [Section 3.3]


Coordinate efforts to build capacity to
interpret, use and disseminate evidence
[Section 4]

Health information
system resources
Dissemination and
use

Indicators
Components of a
health information
system
Information products
Data sources
Data management

Develop a coordinated set
of training courses in report
writing and packaging of
evidence for different
audiences [Section 3.3]
Prioritise targets and
indicators [Section 2.1]
Develop upstream indicators
[Section 2.3]





Provide IT support and training [Section 3.2]
Provide training in critical data analysis for civil
registration and vital statistics data [Sections 3.3 and 4]
Use external coordinating body [Section 4]
Figure 1 Strengthening a health information system to monitor and control non-communicable diseases in Pacific Island Countries and Territories

Strengthen civil registration and vital
statistics and repackaging a mini STEPs
survey [Section 2.2]
Integrate data sources for upstream
indicators into health information
system [Section 2.3]
Continually review the status of surveys
to ensure that the data are used to
inform policy [Section 4]
15
1.4 Priority interventions and interventions that work
The WHO has worked with PICTs to develop response packages appropriate to a country’s resource
base and founded on the WHO and World Economic Forum ‘best buys’ approach to preventing and
controlling NCDs (World Economic Forum 2011). The most robust evidence for cost-effective
interventions includes tobacco control as outlined in the Framework Convention on tobacco control,
reducing population-wide salt consumption, harmful alcohol consumption and physical inactivity, as
well as multi-drug treatment of individuals at high risk of heart attack and stroke with cost-effective
and readily available drugs (Robinson & Hort 2011). The expert working group identified the
following intervention areas as the highest priority. If appropriately applied, they will likely achieve
the 25 by 25 goal (Bonita et al. 2013).

Tobacco control
Smoking rates are on the increase in many Pacific countries (Allen & Clarke 2007; WHO
WPRO 2012b). Tobacco control is a highly cost-effective intervention for low- and middleincome countries and can be enforced through a number of mechanisms. These include
increasing taxes on tobacco products; enforcing smoke-free workplaces; packaging and
labelling of tobacco products with health warnings supported by public education; and
banning tobacco advertising, promotion and sponsorship. The paucity of data in the Pacific
on smoking and its consequences makes it difficult to assess the real size of the problem, but
the range of prevalence rates in tobacco use in PICTs suggests that tobacco control
strategies have a proven track record in the region (WHO WPRO 2012a).

Reduced consumption of unhealthy diets
All countries in the region report prevalence of raised blood pressure in over 20 per cent of
the population and adult obesity is thought to be as high as 75 per cent (WHO WPRO
2012a). Food policies to improve diets have been shown to be a viable intervention strategy
both in the Pacific and globally (Thow et al. 2010). Evidence on the benefits of reducing salt
consumption and the effectiveness of interventions to reduce salt consumption is
particularly strong (Bonita et al. 2013). In the Pacific, population-wide approaches to salt
reduction through legislation at the national level have been shown to be cost-effective
(Neal 2006). Strategies to reduce salt consumption levels include regulating food labelling;
reducing salt, sugar and trans-fats content in processed and restaurant food; taxing
processed food with high salt, sugar or trans-fats content; and subsidising healthy local
produce.

Total risk approach
The total risk approach provides counselling and treatment with cost-effective and readily
available drugs for individuals at high risk of heart attack and stroke. At the very minimum,
those who have experienced a heart attack or stroke should be provided with drugs that
lower blood pressure and blood lipids and often also anti-thrombotic agents. Providing these
drugs in generic fixed-dose combination pills should also reduce costs and improve
adherence. If and when resources are available, then similar strategies should be applied to
people identified opportunistically as at high risk of cardiovascular disease (>30% over 10
years) based on their age, sex, blood pressure measurements and other self-reported risks.
Interventions to reduce the consumption of alcohol and to reduce levels of physical inactivity are
also crucial cost-effective approaches to NCD prevention and control and should not be neglected.
Here we have simply identified those areas where PICTS should concentrate their efforts for the
greatest impact on population health.
16
2. The WHO global monitoring framework and the Pacific
2.1
Data availability
As noted, vital registration systems in the Pacific are weak. Although the legislation requiring deaths
to be registered may exist in most PICTs, this does not necessarily translate into practice. However, it
is likely that more data exist than expected, but most of these data have not been properly collated
and therefore not available for analysis (Carter et al. 2012). Annual reports from the Pacific are
typically poor quality, but they do present data on health facilities and health service performance
and are often the sole outlet for facility-based data (Hodge 2012).
Apart from routinely collected data, a series of standardised population-based surveys have been
established in the Pacific over the last decade to identify NCD burden and the prevalence of NCD risk
factors. For instance, five PICTs have to date been supported by the Secretariat of the Pacific
Community (SPC) to conduct local demographic and health surveys which cover a broad range of
subjects related to the health and nutritional status of a sample population and can provide valuable
information on NCDs.
Designed specifically for NCDs, the STEPwise Approach to Risk Factor Surveillance for NCDs (STEPS) is
a standardised population-based survey which is usually administered to 25–64 year olds. STEPS
assesses three levels of risk factor exposure: risk behaviour, physical measurement and blood
samples. The underlying principle of STEPS is to establish a surveillance system that builds local
capacity to collect comparable data on core measures of known risk factors. The STEPS survey is
modular and designed to be flexible and adaptable to the specific needs and capabilities of different
countries. The STEPS survey provides a complete package of tools and guidelines for implementing
the survey and for data analysis, as well as comprehensive templates for writing-up reports and fact
sheets. STEPS and its coverage in PICTs will be further discussed later in this working paper.
The Global Tobacco Surveillance System (GTSS) was initiated in 1999 by the WHO and Centre for
Disease Control (CDC) to assist countries to collect data on youth and adult tobacco use. The GTSS is
made up of three surveys. The Global Youth Tobacco Survey (GYTS) collects information on
adolescent’s knowledge and attitudes towards tobacco. The other two collect data from adults: the
Global School Personnel Survey (GSPS) and the Global Health Professionals Survey (GHPS).
In 2001, the WHO collaborated with the Joint United Nations Programme on HIV/AIDS (UNAIDS), the
United Nations Educational, Scientific and Cultural Organization (UNESCO), and the United Nations
Children’s Fund (UNICEF), and with technical assistance from the CDC, to develop the Global Schoolbased Student Health Survey (GSHS). The GSHS survey collects systematic information, using a
scientific sample selection process and a self-administered questionnaire, from students on risk
behaviours and protective factors. The GSHS is school based and captures students aged 13 to 15
years. Moves are underway to expand this to 17 years.
17
In preparation for the February NCD workshop, we carried out a preliminary literature review to
assess the state of NCD monitoring in PICTs. We analysed six main sources of data for 16 countries1
representing country-driven reporting requirements, external reporting requirements, and reports
from population-based surveys. Sources examined included: STEPS reports, demographic and health
surveillance reports, as well as data that were available from GSPS and GYTS. We also collected
results from annual reports and Millenium Development Goal (MDG) reports. Routine health
information from ministries of health, NCD surveys run by ministries of health, and STEPS surveys
are the usual sources of these data. We compared information in these reports with indicators
required for reporting in the WHO GMF.
1
Cook Islands, Commonwealth of the Northern Mariana Islands (CNMI), Fiji, Federated States of Micronesia,
Kiribati, Nauru, Niue, Palau, Papua New Guinea (PNG), Tonga, Tuvalu, Tokelau, Samoa, Solomon Islands,
Vanuatu
18
Table 1 Pacific Island Countries reporting on non-communicable disease (NCD) indicators
Country
Indicator
Cook
Islands
CNMI
Fiji
FSM
Kiribati
Marshall
Islands
Nauru
Niue
Palau
PNG
Tonga
Tuvalu
Tokelau
Samoa
Solomon
Islands
Vanuatu
Outcomes (mortality and morbidity)
Cancer incidence
by type
Premature
mortality
Risk factors
Alcohol
consumption
Energy intake
from saturated
fatty acids
Consumption of
fruit and
vegetables
Overweight and
obesity
Physical inactivity
Raised blood
glucose
Raised blood
pressure
Raised total
cholesterol
Salt intake
19
Country
Indicator
Cook
Islands
CNMI
Fiji
FSM
Kiribati
Marshall
Islands
Nauru
Niue
Palau
PNG
Tonga
Tuvalu
Tokelau
Samoa
Solomon
Islands
Vanuatu
Current tobacco
smoking
Current tobacco
smoking in
adolescents
National Health Response
Cervical cancer
screening
Drug therapy for
heart attacks and
stroke
NCD medicines
and technology
Access to
palliative care2
Policies on
partially
hydrogenated
vegetable oils 2
Policies on food
marketing2
Vaccination for
HPV and HBV
2
Not currently available from standard health information sources but recommendations of how such information might be collected and organised can be found in
Section 2.4. HPV – human papillomavirus, HBV – hepatitus B virus
20
Country
Indicator
Cook
Islands
CNMI
Fiji
FSM
Kiribati
Marshall
Islands
Nauru
Niue
Palau
PNG
Tonga
Tuvalu
Tokelau
Samoa
Solomon
Islands
Vanuatu
Other NCD indicators
Per cent of
primary
healthcare
services with
PEN*
Admission rate
for NCDs
Amputation rate
for diabetic sepsis
Patients
registered at NCD
clinics
Patients screened
for high risk of
cardiovascular
disease (CVD)
NCD healthcare
expenditure
Adults aged 25+
ever diagnosed
with diabetes,
hypertension,
CVD or rheumatic
heart disease
Adults aged 25+
ever diagnosed
with diabetes or
hypertension by
wealth
21
Country
Indicator
Cook
Islands
CNMI
Fiji
FSM
Kiribati
Marshall
Islands
Nauru
Niue
Palau
PNG
Tonga
Tuvalu
Tokelau
Samoa
Solomon
Islands
Vanuatu
Per cent of
children (<5) who
are overweight
Routine reporting
Annual report
*PEN – package of essential non-communicable [disease interventions]
Population-based surveys
STEPs report
Demographic and Health Survey
Global School Personnel Survey
Global School-based Student Health Survey
Millennium Development Goals reporting
22
As demonstrated in Table 1, reports from population-based surveys are the primary data source for
indicators relating to behavioural risk factors and most countries had data on these. Cook Islands,
Fiji, Kiribati and Samoa were the only countries that regularly report on health outcomes (cancer
incidence and cause of death) in their annual reports; however, three-quarters of countries did not
have this information. No countries had data on indicators relating to health system response in any
of the four sources reviewed.
Where data is available, it is often obtainable from more than one data source. For example, the
prevalence of adult tobacco smoking is collected by STEPS surveys and often also by demographic
and health surveys and by GSPS. This can lead to conflicting values due to different methods and
unnecessary duplication of effort. Opportunities to coordinate these surveys need to be seized to
ensure coherence and compatibility in definitions and methods and that implementation is as
efficient as possible.
Although a number of countries had NCD strategic plans, proposed indicators were heavily focused
on health system inputs and outputs. As of November 2012, no monitoring or evaluation reports had
been developed on implementation of the strategies. Furthermore, there is not much data and
capacity to define and track the upstream determinants of these NCD indicators, such as
government policies and industry actions, is limited. The extent to which settings that need to be
targeted are actually reached by the programs and to which they are able to take the necessary
actions should be monitored and reviewed. This will require concerted leadership and systems of
accountability.
This is not an exhaustive review of the data available from PICTs; however, it is clear from our review
that it will take substantial efforts to integrate NCD indicators and monitoring into routine reporting
in PICTs. Countries such as Papua New Guinea (PNG), Tuvalu, Commonwealth of the Northern
Mariana Islands and Palau have no data available at this time (though PNG’s STEPS report will be
published soon) on NCD risk factors. Only four countries out of the 16 presented here have
accessible data on mortality by cause and cancer mortality. If available, the data are often very old,
and, where STEPS surveys are conducted, the information is often several years old before a report
is published. This significantly reduces the usefulness of the evidence for policy purposes (Table 2).
23
Table 2 Year of survey and year of reports for three population surveys in Pacific Island Countries and Territories (2002 2012)
Country
STEPwise Approach to Risk Factor
Surveillance for NCDs
Demographic and Health Survey
Year of survey
Year of survey
Year of report
Global School-based
Student Health Survey
Year of report
Year of survey
FSM (Pohnpei)
2002
2008
-
-
-
Fiji
2002
2002
-
-
2005
Marshall
Islands
2002
2007
2007
2008
-
Samoa
2002
Pending publication
2009
2010
2007
Cook Islands
2004
2011
-
-
2008
Nauru
2004
2007
2007
2009
-
Tonga
2004
2012
-
-
2010
Tokelau
2005
2007
-
-
-
FSM (Chuuk)
2006
2012
-
-
-
Solomon
islands
2006
2010
2007
2009
2008
Niue
2011
Pending publication
-
-
-
Vanuatu
2011
Pending publication
-
-
2007
Kiribati
2004–2006
2009
2009
2010
-
Papua New
Guinea
2007
Pending publication
2006
2009
2007
Tuvalu
-
-
2007
2009
2005
FSM – Federated States of Micronesia
2.2
Proposed targets and indicators for the Pacific
Given the demonstrated difficulty in collecting and presenting timely data in the PICTs, future plans
for NCD monitoring and control must recognise the challenges and limitations experienced by these
countries. Targets and indicators must therefore be selected based on their feasibility and potential
health impact for populations.
The targets and indicators of the WHO GMF are categorised into one of the three pillars of the NCD
surveillance system: mortality and morbidity outcomes, risk factors (both upstream and
downstream) and national systems responses (Figure 2).
NCD surveillance
system
Outcomes: mortality/morbidity
24
Figure 2 The three pillars of non-communicable disease (NCD) surveillance (Source: WHO)
In Table 3 we present the 9 proposed targets, the 15 indicators associated with them and the 8
additional indicators. We provide some information on current data sources, data sources that could
potentially be pursued and some of the issues and limitations identified associated with the target or
indicator.
In the first instance, some of the targets and indicators proposed will clearly not be feasible for the
Pacific. The infrastructure to collect cancer incidence by type of cancer, for example, simply does not
exist in most PICTs. Likewise, the same could be said of the target of ’80 per cent availability of
affordable basic technologies and essential medicines to prevent heart attacks and strokes’.
Monitoring progress towards an unrealistic target will likely result in wasted time and resources,
where there are none to spare.
25
Table 3 Global monitoring framework targets and indicators for the prevention and control of non-communicable diseases
Target
Mortality and morbidity
1) Reduce premature mortality
from NCDs by 25%
Indicator
Potential data sources
Issues and limitations
1. Unconditional probability of dying
between ages 30 and 70 years from
cardiovascular disease (CVD), cancer,
diabetes or chronic respiratory diseases
 Collected from vital
registration systems or sample
registration systems using verbal
autopsies
 Top 10 causes of mortality (no
ages), absolute number, not using
International Classification of
Disease codes
 Many civil registration and vital statistics systems in
the region are very weak and need strengthening.
2. Cancer incidence by type of cancer per
100 000 population
 Collecting cancer prevalence,
not disaggregated by cancer type,
absolute number
 Most PICTs do not have adequate cancer registries
to collect a reliable estimate of cancer incidence.


Risk factors
Behavioural risk factors
2) At least 10% relative
reduction in overall
consumption of alcohol
(including hazardous and
harmful drinking)
1. Total (recorded and unrecorded) alcohol
per capita (15+ years old) consumption
within a calendar year in litres of pure
alcohol
2. Age-standardised prevalence of heavy
episodic drinking among (adolescents and
adults) as appropriate, within the national
context
3. Alcohol-related morbidity and mortality
among adolescents and adults, as
appropriate within the national context
 Government statistics based on
national sales, data from alcohol
industry, UN statistics, FAO,
expert opinion on unrecorded
alcohol consumption
 eSTEPS data 25 to 64 years,
amount consumed in past 12
months, number of drinks per day
 GSHS can be used to collect
alcohol consumption for
adolescents
 For example: data from
hospital admissions for road
traffic accidents could be useful
 Measurement is difficult. Harmful drinking is often
conducted using alcohol that is not obtained legally.
Also, alcohol consumption by tourists in some areas
may complicate measurements. 
 May need to collect data from the alcohol industry
and the conflicting interests may cause problems.
26
Target
3) 10% relative reduction in
prevalence of insufficient
physical activity
4) 30% reduction in mean
population intake of salt with
aim of achieving
recommended level of less
than five grams per day
5) 30% reduction in prevalence
of current tobacco smoking
Indicator
Potential data sources
Issues and limitations
1. Age-standardised prevalence of
insufficiently active adults aged 18+ years
(defined as less than 150 minutes of
moderate intensity activity per week or
equivalent)
 eSTEPS data 25 to 64 years,
using metabolic energy
 GSHS can be used to collect
physical inactivity for
adolescents.
 The appropriate interventions for Pacific Islands are
not clear and have not been adequately considered.
2. Prevalence of insufficiently physically
active adolescents defined as less than 60
minutes of moderate to vigorous intensity
activity daily
1. Age-standardised mean population
intake of salt (sodium chloride) per day in
grams in adults aged 18+ years
A salt module has been
developed and can be added to
STEPS.
 24-hour urine collection is difficult to achieve. The
potential of spot urine specimens should be
considered.

 eSTEPS data 25 to 64 years,
absolute number and proportion;
considering adding younger age
groups to fill gap between STEPS
and GYTS
 GYTS report on 13 to 15 years,
absolute number and proportion
 This target is probably not ambitious enough and
instead we should be aiming for the lowest levels
currently observed.
 Self-reported in eSTEPS
 eSTEPS data 25 to 64 years,
absolute number and proportion,
raised/diabetes defined as >=6.1
mmol/L can be gathered during
alternate rounds of the survey
 Reporting on prevalence of diabetes – definition of
‘raise blood glucose’ is not included, not agestandardised, mostly absolute numbers, new cases
diagnosed at clinics
1. Age-standardised prevalence of current
tobacco smoking among persons aged 15+
years
2. Prevalence of current tobacco use
among adolescents
Biological risk factors
6) Halt the rise in diabetes and
obesity
1. Age-standardised prevalence of raised
blood glucose/diabetes among adults aged
18+ years (defined as fasting plasma
glucose value >= 7.0mmol/L (126mg.dl) or
on medication for raised blood glucose)
2. Age-standardised prevalence of
overweight and obesity in adults aged 18+
years (defined as body mass index (BMI)
greater than 25kg/m for overweight or
30kg/m for obesity)
 Recommend that the measure be refined as mean
fasting plasma glucose. Indicators of diabetes
prevalence based upon HbA1c may be easier (but
more costly) to obtain especially if done using dried
blood spot techniques.

27
Target
7) 25% relative reduction in
the prevalence of raised blood
pressure or contain the
prevalence of raised blood
pressure according to national
circumstances
Indicator
3. Prevalence of overweight and obesity in
adolescents (defined according to the WHO
Growth Reference: overweight – one
standard deviation BMI for age and sex,
and obese – two standard deviations BMI
for age and sex)
Age-standardised prevalence of raised
blood pressure among adults aged 18+
years (defined as systolic blood pressure >=
140mmHg and/or diastolic blood pressure
>=90mmHg)
Potential data sources
Issues and limitations
School-based health surveys
STEPS data 25 to 64 years,
absolute number and proportion
 Current reporting practices: measuring
hypertension, not raised blood pressure (not defined),
not age standardised, mostly absolute numbers, new
cases diagnosed at clinics

STEPS data 25 to 64 years,
absolute number and proportion,
defines high as >=5.2 mmol/l
(2002 STEPS)
National surveys
 Feasiblity of blood sampling – may be eased by
dried blood spot techniques if these can be validated
Additional indicators
Cholesterol
Age-standardised prevalence of raised total cholesterol among adults aged 18+ years
(defined as total cholesterol >=5.0mmol/L or 190mg/dl
Fat intake
Age-standardised mean proportion of total energy intake from saturated fatty acids
and polyunsaturated fatty acids in adults aged 18+ years
Fruit and vegetable intake
Age-standardised prevalence of adult (aged 18+ years) population consuming less
than five total servings (400g) of fruit and vegetables per day
National systems responses
8) At least 50% of eligible
people receive drug therapy
and counselling (including
glycaemic control) to prevent
heart attacks and strokes
Proportion of eligible persons (defined as
aged 40 years and over with a 10-year
cardiovascular risk greater than or equal to
30% including those with existing CVD)
receiving drug therapy and counselling to
prevent heart attacks and strokes
STEPS data 25 to 64 years,
absolute number and proportion
per category

Treatment module can be added
to eSTEPS
 Will require 24-hour diet recall surveys and food
composition databases to get a good estimate. 24hour recall could be added to STEPS but adds a
significant amount of time to data collection and
detracts from the quick and easy flow of key
information.
 Will require 24-hour diet recall surveys and food
composition databases to get a good estimate. 
 Appropriate CVD Risk Charts would need to be
made available at clinic settings. Some training in the
use of risk charts would be required. Drug regimens
would need to be determined. Drugs would need to
be accessible and affordable.

 Are these targets realistic in PICTs?
28
Target
9) 80% availability of
affordable basic technologies
and essential medicines to
prevent heart attacks and
strokes
Indicator
Potential data sources
Availability and affordability of generic
essential NCD medicine and basic
technologies in both public and private
facilities
WHO/Health Action International
surveys on medicine availability
and pricing from SARA surveys.
Information Management
Systems have some data from
high- income countries.
Issues and limitations
Additional indicators
Palliative care
Access to palliative care assessed by morphine-equivalent consumption of strong
opioid analgesics (excluding methadone) per death from cancer
Cervical cancer
Proportion of women between the ages of 30 and 49 screened for cervical cancer at
least once, or more often, and for lower and higher age groups according to
programs and policies
Trans-fat elimination
Adoption of national policies that virtually eliminate partially hydrogenated vegetable
oils in the food supply and replace with polyunsaturated fatty acids
Marketing foods to children
Policies to reduce the impact on children of marketing of foods high in saturated fats,
trans-fatty acids, free sugars or salt
Vaccination against cancer-causing infections
Vaccination against cancer causing infections: human papillomavirus (HPV) and
hepatitis B virus
FAO
GYTS
PICTs
SARA
UN
WHO
International Narcotics Control
Board reports on consumption of
narcotics, and WHO reports on
estimates of cancer deaths.
A screening module could be
added to the STEPS instrument.
 No major issues but not likely to be a priority in
PICTs.
WHO NCD Country Capacity
Survey
 Trans fat is not required by most food labelling
regulations and monitoring strategies are mostly
absent.
WHO NCD Country Capacity
Survey; country reporting back to
the World Health Assembly
 Political will to implement is the key challenge and
metrics to better understand and address this issue
would be helpful.
Recommended indicators have included:
 number of girls aged 15 in target population who
have received three doses of HPV vaccine/total
number of 15 year old girls in target population *100
 danger of another population survey of a target
group – better to measure through number of
vaccines given as numerator and population aged 15
as the denominator.
Surveys conducted to monitor
national immunisation program
coverage
 The validity of self-reported screening in PICTs has
not been tested.
Food and Agriculture Organization
Global Youth Tobacco Survey
Pacific Island Countries and Territories
Service Availability and Readiness Assessment
United Nations
World Health Organization
29
2.3
Prioritising targets and indicators
Targets agreed upon by member states play a crucial role in driving change and provide clear
markers and expectations that can potentially be used to develop systems of accountability. If
countries choose to pursue the cost-effective interventions outlined earlier that are likely to provide
the greatest impact for Pacific populations, the targets and indicators that are monitored should be
selected to reflect local issues and capture the changes expected from their implementation. In this
section we outline and prioritise these key targets and indicators for PICTs (Figure 3). This is not to
suggest that the rest of the targets and indicators are irrelevant. Rather, that countries should
ensure the mechanisms for the prioritised targets and indicators are well established before
investing time and resources in the others.
A few priority targets stand out above the rest, in order of importance: at the population level,
reducing or eliminating tobacco use and reducing population salt consumption to reduce blood
pressure are key. At the individual level, treating people who are at high risk of heart attacks and
stroke will also have a great health impact. Due to the harm these risks are known to inflict upon
populations, the relatively large attributable burden, and the cost-effectiveness of interventions
designed to combat them, low- and middle-income countries like the PICTs should begin by
concentrating their efforts on these three targets. As resources allow, other targets and indicators
should be prioritised accordingly.
Mortality and morbidity outcomes
Priority 1: Mortality by cause is an essential indicator for NCD monitoring. Although cause-specific
mortality may not be very sensitive to changes over time, population-level information on this
indicator can be very useful for detecting inequalities between genders, socio-economic and ethnic
groups. Comprehensive data on mortality by cause can help track inequalities in the population and
help to target services and interventions to help those most in need.
Cancer incidence has been proposed as a measure of morbidity outcomes. Ideally, data for this
indicator would be obtained from cancer registries that collect and classify all new cases of cancer.
Most PICTs, however, do not have functional cancer registries or sophisticated cancer reporting
systems (Moore et al. 2008). For most PICTs, setting cancer incidence as an indicator will not be
feasible or realistic and therefore is not recommended in the short term. The starting point should
be strengthening collection of hospital-based cancer data.
Risk factors
Priority 2: Getting people to stop smoking should be a priority for PICTs. Even where tobacco does
not appear to be the leading cause of death in a country, tobacco is a contributing cause for a large
number of diseases. A number of effective interventions exist to prevent the uptake and to promote
the cessation of smoking. A focus on tobacco control is likely to save costs and have large health
benefits in the long term. In fact, the importance of this risk factor makes the GMF target of ‘30 per
cent relative reduction in tobacco use in persons aged 15+ years’ appear insufficiently ambitious. A
more ambitious goal for PICTs is a Smokefree Pacific by 2025, where less than five per cent of adults
smoke.
Two indicators for this target have been agreed upon:
1. the prevalence of tobacco use among adolescents
2. age-standardised prevalence of current tobacco use among persons aged 18+ years.
The prevalence of tobacco use must be monitored. The WHO STEPS survey provides a convenient
tool to collect the data. Generally, the STEPS survey is given to 25 to 64 year olds. Countries may
choose to extend the lower end of this age range to 18, for example, in order to capture the
30
prevalence of tobacco use among a younger cohort. Tobacco use among adolescents can be
obtained from school surveys like GSHS.
Priority 3: Reducing salt consumption should be the next priority for PICTs. The target set is a ‘30
per cent reduction in mean population intake of salt/sodium’, and moving towards a goal of five
grams per day (WHO 2012b). There are tried, tested and cost-effective approaches that can reduce
salt consumption at a population level. These preventive strategies cost a fraction of what a country
could potentially spend on managing hypertension. This makes salt reduction a high priority for highburden countries (Webster 2009). One indicator has been agreed upon:
Age-standardised mean intake of salt (sodium chloride) per day in grams in persons aged 18+
years.
Salt consumption can be measured using a risk factor survey such as STEPS. Questions about
people’s knowledge, attitudes and behaviours related to salt consumption have been developed and
can be easily included. The collection of dietary survey data from a subset will provide additional
quantitative insights into salt consumption levels. Biochemical measurements of urine samples in a
subset has been done in Samoa and the Cook Islands and is an option for countries considering
second-round STEPs surveys.
Reducing sugar and trans fats consumption is also crucial, but monitoring strategies, such as 24-hour
dietary recall, would be very challenging to implement. Once Pacific countries have established
mechanisms for monitoring these high-priority areas, attention should then turn to other important
risk factors, namely, a broader reduction in unhealthy diets, physical inactivity, harmful alcohol
consumption, raised blood pressure, diabetes and obesity.
National systems responses
Two targets have been proposed that fall under the national systems responses pillar of the GMF.
These are: 1) at least 50 per cent of eligible people receive drug therapy and counselling (including
glycaemic control) to prevent heart attacks and strokes, and 2) an 80 per cent availability of the
affordable basic technologies and essential medicines, including generics, required to treat major
NCDs in both public and private facilities.
Priority 4: It is crucial that there is sufficient information so that interventions aimed at preventing
and controlling NCDs can be evaluated, and that countries and researchers can learn what works and
what does not. The targets and indicators that fall under the national systems responses pillar of the
framework do not sufficiently reflect the interventions identified. A comprehensive and effective
NCD prevention strategy must use population approaches as well as one that targets individuals at
high risk of cardiovascular disease (CVD). This latter approach is clinically oriented and aims to treat
those identified by their cardiovascular risk profile. The strength of this approach is that it recognises
the multiple causes of CVD and the relationships between risk factors and their effects. The first of
the two targets proposed for the national systems responses could be monitored by the addition of
a treatment module to the STEPS instrument, similar to that found in the WHO STEPwise approach
to stroke surveillance. The latter target, as mentioned in Table 3, will pose a very large challenge for
PICTs. It will require opportunistic screening at all visits to a clinic by staff trained to assess overall
risk and to refer those at high risk of CVD for treatment.
Lastly, targets on the reduction in the consumption of sugar and trans fats have not been included in
the GMF, but are potential goals for policy-level interventions. It is critical that Pacific countries over
the next years report on the impact of changes made at the policy level and better understand if and
how laws and policies are implemented on the ground. To do this, PICTs will need to come to a
consensus on which policies need to be monitored, the most suitable upstream factors and
indicators to track them. The next section discusses in greater detail what we refer to here as
‘upstream factors’.
31
Highest priority
DATA SOURCES
CRVS
STEPS
Mortality due
to NCDs
Smoking prevalence
Salt intake
History of heart
attack or stroke
Drug therapy and
counselling
GSHS
SARA
Tobacco use prevalence
among adolescents
Essential NCD medicines
availability
Overweight/obesity
prevalence in
adolescents
Hepatitis B vaccine
availability
Alcohol consumption
among adolescents
HPV vaccine availability
Access to palliative care
Cervical cancer
screening
Alcohol
consumption
among adults
Overweight/obesity
prevalence
CRVS – civil registration and vital statistics
GSHS – Global School-based Student Health Survey
HPV – human papillomavirus
NCD – non-communicable disease
SARA – Service Availability and Responsiveness Assessment Survey
STEPS – STEPwise Approach to Risk Factor Surveillance for NCDs
Figure 3 Prioritisation of indicators and data sources
2.4
Trade, regulatory mechanisms and non-communicable diseases
‘If the UN High-Level Meeting leads to more concerted effort by international and domestic actors to
consider interdependencies, and challenge long-established debates over what is in the national
interest, then it can be judged a success’ (Chand 2012)
Globally, attention has begun to turn towards the social determinants of NCDs and upstream factors.
As shown by the recent subregional workshop ‘Trade and NCDs in the Pacific’, this is also true for the
Pacific region. Access to certain foods and products and the trade agreements that provide them are
increasingly recognised as driving forces in the NCD epidemic (Moodie et al. 2013; Thow et al. 2010,
2011,). This is particularly true in PICTs, where rapid economic development, urbanisation, and small
but growing population sizes make these countries particularly dependent on imported foods. In
turn, trade agreements and taxation set food prices that restrict, guide and force people's choices
32
and can eventually lead to malnutrition, as well as obesity and diabetes in the same population
(Basu et al. 2013).
In the Pacific, agreements with the WHO are related to changes in the population’s dietary habits
through many levels of complexity. Regional trade agreements, such as the Pacific Island Country
Trade Agreement and the Pacific Agreement on Closer Economic Relations, often relax the very
measures that are intended to protect people’s health (Rayner et al. 2006). Countries will have to
balance the need for economic development by broadening Pacific markets and trade liberation
with the protection of the health of their populations, and do so equitably (Fa’alili-Fidow et al. 2011).
It will also be necessary for countries to identify and evaluate the most feasible and effective policies
for their context (Snowdon et al. 2010). Capturing the impact of these interventions will be key to
ongoing developments in NCD prevention in the region, as well as globally.
The WHO GMF includes only two indicators to monitor issues at this level. The first of these falls
within the risk factor (or exposures) pillar (Figure 2) and monitors ‘policies to reduce the impact on
children of marketing of foods and non-alcoholic beverages high in saturated fats, trans fatty acids,
free sugars, or salt’. The second one fits in the national systems responses and monitors the
‘adoption of national policies that limit saturated fatty acids and virtually eliminate partially
hydrogenated vegetable oils in the food supply, as appropriate, within the national context and
national programmes’. These indicators do adequately assess and monitor the impact of complex
upstream factors affecting NCD burden. Innovative indicators are urgently needed to track policies
at the national and international level, in addition to the intermediate factors already tracking the
progress and implementation of policies on the ground.
In the first instance, countries should focus monitoring on a small number of comparable indicators
which should reflect the priorities identified for the region. These indicators could include not just
the presence of policies and legislation, but the availability of products and where these products
are easily accessed and, for equity purposes, by whom. For example, two core registries could be
established as follows.

A registry of national regulations controlling food supply issues, including information on:
o regulations controlling levels of salt, sugar, fat and energy in foods
o relevant taxation policies (e.g. fat or sugar taxes)
o relevant planning policies (e.g. locations and density of fast-food outlets)
o national voluntary codes of practice relating to food supply issues (e.g. the cost of
alcohol and harmful foods).

A registry of the extent to which mandatory or voluntary initiatives such as these are
implemented by those required to take action, be they food manufacturers, food retailers or
government departments. These indicators may be obtainable from health impact
assessments which are discussed in more detail in the next section.
A better understanding of the challenges and opportunities associated with collecting, analysing and
interpreting this data will evolve and with this knowledge this area of research can and should
expand. There is a ripe opportunity for PICTs to develop innovative approaches to surveillance and
lead the world in this emergent area of research.
2.5
Data sources
Over the next five years, obtaining health information for NCD monitoring and control in the
Pacific should focus on data that can be retrieved from civil registration and vital statistics (CRVS),
STEPS and GSHS. Strengthening national civil registration systems, conducting population surveys
and improving data collection systems at the primary health care level are essential for sustainable
monitoring and evaluation. This will ensure that health data is balanced by being sourced from both
population and institutional levels (Figure 4).
33
Figure 4 Population-based and institution-based data sources (Source: HMN 2008)
Civil registration and vital statistics
Over the last few years, Pacific countries have taken significant strides to strengthen their CRVS
systems. Ongoing work devoted to improving CRVS, supported by initiatives like the Pacific Vital
Statistics Action Plan, the Brisbane Accord Group (both discussed in more detail in the following
section) and the Health Information System Knowledge Hub (HISHub), has a key role in monitoring
deaths due to NCDs and must continue to be supported. Training and capacity building are necessary
at a number of key levels in a CRVS and these will differ according to country needs. HISHub has
worked with PICTs to assess their health information systems and to develop strategies for
strengthening them (Mikkeleson 2012). The quality of cause-of-death data and the medical
certification of deaths are key areas of concern and therefore the HISHub has been building capacity
to analyse cause-of-death data and assess its quality. The HISHub also developed a handbook on
how to correctly complete death certificates and has worked closely with clinicians across the Pacific
region to develop and improve these often neglected skills.
Where medical certification is not possible and CRVS systems are either weak or absent, verbal
autopsies are crucial for monitoring causes of deaths in Pacific populations. A verbal autopsy
consists of a structured interview between a trained health worker and usually a relative or caretaker of the deceased. It garners information about the signs and symptoms experienced prior to
death. This information is then analysed to ascertain the most likely cause of death. The wide
application of verbal autopsies is a viable and desirable option for improving the current state of
knowledge surrounding patterns of death in the region (Figure 5).
Risk factor surveillance
Risk factor surveillance provides information on the distribution of risk-factor levels in a population,
and changes can be assessed through repeated cross-sectional studies or in panels. Implementation
of risk-factor surveillance based on STEPS provides a simple, cost-effective and sustainable tool.
STEPS is made up of three ‘steps’:
1. conducting a questionnaire
2. making simple physical measurements
3. collecting blood samples for assessment.
At each step, there are three levels of information: core items (mandatory), expanded items (only if
relevant) and optional items (added to reflect local circumstances). Extra modules with contextspecific questions can be added. The three steps do not all have to be administered, although for
face- to-face interviews, it is advised that both Step 1 (self-reports) and Step 2 (measures of BMI and
34
blood pressure using automated devices) are done at the same time. Step 3 (biochemical measures)
add considerably to the cost and complexity of the survey. The flexibility of STEPS means countries
are often tempted to use the most expanded version of the survey. This can add substantial cost and
time to data collection and may lead to an impression that the survey is too difficult or
unsustainable. Instead, a core STEPS survey focusing on the priorities identified for PICTs should be
promoted in the first instance. This core STEPS could collect a minimum set of indicators (Step 1 and
Step 2) every three to five years. Blood samples (Step 3) and the estimation of salt consumption
could be performed every other survey round and/or on a subsample (Figure 5).
Most importantly, to be sustainable and effective, STEPS and GSHS surveillance must be
institutionalised as part of a HIS and integrated into all health systems in PICTs. This means that
countries take ownership of the full framework and that national health systems are held
accountable for their completion and reporting.
Other surveys
Many surveillance systems and surveys are run through agencies in the Pacific, such as the
demographic and health surveillance systems mentioned earlier. Research institutions in various
countries have developed a number of disease-specific and population-specific surveys.
Ongoing health initiatives in the Pacific need to be examined to determine what might be useful for
better understanding the NCD situation in each country. However beyond this, countries must also
develop national survey plans with support from the WHO and SPC. This will enable coordination of
the work in-country to prevent doubling of effort and confusion between results from different
sources. It will also ensure that the right information is being collected at the right time using
standardised definitions of key variables. These plans should be broadly concerned with all aspects
of health and not just NCDs or infectious diseases. The Pacific Public Health Surveillance Network,
for example, is the key framework for public health monitoring in the region and focuses on the
surveillance of communicable diseases. Where capacity allows, extending the remit of the network
to include NCDs could help streamline processes.
The WHO in collaboration with the United States Agency for International Development (USAID)
developed the Service Availability and Readiness Assessment (SARA) survey methodology to fill gaps
in measuring progress in health system strengthening. The SARA survey requires health facility visits
where data is collected using key informant interviews and observation of key items. The survey can
either be carried out as a sample or a census. The objective of the SARA survey is to generate regular
data on service delivery, the availability of key human and infrastructure resources, availability of
basic equipment, basic amenities, essential medicines, and diagnostic capacities, and on the
readiness of health facilities to provide basic health-care interventions.
Clearly there are a number of surveillance and research initiatives that can and do play central roles
in NCD monitoring and control. Having said this, surveys are not enough. Countries should not be
distracted from developing quality routine data systems because they have successfully
implemented surveys.
Primary healthcare data
Health systems needs to be reoriented to a primary health care approach to effectively respond to
the increasing burden of NCDs: this is especially true in resource-limited settings such as the Pacific,
where treatment costs at the secondary and tertiary level rapidly escalate (Waqanivalu 2011). The
WHO ‘Package of essential non-communicable (PEN) disease interventions for primary health care in
low-resource settings’ is a recent initiative aimed at strengthening primary healthcare (WHO 2010).
A ‘basket of essential services’ has been designed as part of the package, along with a number of
protocols for clinical diagnosis and treatment, and various indicators on risk factors that should be
35
collected at each consultation. These risk factors, which include smoking history, waist
circumference, history of diabetes, and others, represent a significant data source for NCD
monitoring and control. Linking this information to secondary, tertiary and national-level data
systems is important for clinical care, but also for predicting future demand and allocating resources.
Better use of such primary healthcare data would also reduce reliance on costly surveys.
Primary health facilities, as well as being the first point of contact with the health system, are also
the only point of contact for many people living in rural and remote communities. They face long
distances to travel to secondary and tertiary care facilities. Furthermore, outreach activities are
often coordinated and implemented at the primary care level. Strengthening data collection,
analysis and dissemination at the primary level is therefore critical for gaining a better
understanding of the burden of disease among isolated communities. It is important to note,
however, that such primary data will lack representation from those who do not make it to clinic,
resulting in a biased dataset. This is particularly significant in light of concerns around equity and the
need to ensure that those who are most in need are identified.
NCDs are chronic conditions and represent a significant challenge to health services. As opposed to
acute conditions, most NCDs require lifelong interaction with health services, be it for routine checkups or ongoing medication for disease management. The ability to track patients over time and
between health facilities is of vital importance for NCD monitoring and control, and is an area
severely in need of investment. In PICTs, patient files are mostly kept in hard-copy logbooks or
health cards at the primary care facility and there are no processes to link this information to higher
levels. In effect, when a patient presents at a secondary clinic or tertiary hospital, they have no
recorded history on file. Although a small number of Pacific countries have implemented a system
of national patient identifier numbers, these numbers are often only assigned at secondary or
tertiary health facilities, and many challenges remain in ensuring patients are not duplicated in the
system.
Hospital-based disease registers
Results from hospital-based disease registers are of limited value for estimating disease burden.
Hospital patients do not represent the whole population and are likely to be a biased sample.
However, hospital registers can be used as starting points for building capacity for community-based
disease surveillance and to expand using more complex data collection when possible (WHO 2012a).
Upstream factors
Data describing national policies and the practices of key industries influencing NCDs are mostly
absent and have not traditionally been part of health information systems. As noted earlier, a
registry of data on policies and policy implementation is recommended. An established method for
assessing the broader impact of policies across different sectors and settings is to employ health
impact assessments (HIAs). HIAs use quantitative and qualitative techniques to synthesise evidence
to inform public policy. Bringing together these types of data in PICTs will require coordination and
cooperation within and between sectors. Not only different sectors within a country’s government,
but also non-governmental organisations collecting data in-country and other international
organisations that collate data from sources such as the United Nations Food and Agricultural
Organization (Basu et al. 2013).
36
Data source
Civil registration and
vital statistics
Immediate action necessary
Training doctors in death certification
Widen the use of verbal autopsies
Simplify surveys to collect the minimum
number of data points
STEPS + GSHS
Integrate the STEPS and GSHS surveys into
routine health information system activity
Build analytical capacity and confidence to
write reports and disseminate messages
Figure 5 High priority actions to improve and strengthen data sources
37
3. Capacity and coordination
3.1
Building capacity for civil registration and vital statistics
Mortality by cause is of central importance to understanding NCD epidemiology and changes over
time. The Brisbane Accord Group (BAG) developed the ‘Pacific Vital Statistics Action Plan (2011–
2014)’ with the aim to improve vital registration in the region. The group was established in 2010 as
an initiative of the HISHub and SPC. BAG has worked with its partners3 to provide continuous
strategic and technical support to countries around vital statistics improvements, and deliver a more
coordinated response from partner agencies. Employing the WHO Vital Statistics Comprehensive
Assessment tool, BAG works closely with countries to assess their collection and reporting systems
for births, deaths and causes of death. BAG then assists these countries with the development of a
country-specific vital statistics improvement plan. Critical to the success of BAG has been country
engagement through the Pacific Statistics Steering Committee and country commitment to report on
progress against their country-specific plans to the Pacific Ministers of Health. The Pacific Health
Information Network (PHIN) aims to support health outcomes and systems by improving the quality,
and strengthening the use of, health information.
Outcomes and achievements of the Brisbane Accord Group as of February 2013







Ten countries are engaged in medical certification training with their doctors.
Two countries are updating their curriculum for medical students on correct
certification practices and procedures.
Four countries are implementing policy changes to adopt the WHO International
Cause-of-Death Certificate.
Six countries are participating in the region’s first Civil Registration and Vital Statistics
Short Course.
Three countries representatives are completing analytical and reporting writing
attachments with SPC for vital statistics data.
Two countries are producing a comprehensive vital statistics report.
Representatives from the areas of statistics, civil registration and health have attended
a number of in-country meetings hosted by members of the Brisbane Accord. Group.
3.2 Generating and managing data
A number of initiatives to consolidate data from the numerous surveillance activities ongoing in the
Pacific and globally have been developed or are in development. For example, the Pan-America
Health Organisation (PAHO) has developed the Virtual Health Library for NCDs and supports
countries to strengthen health information systems to monitor NCDs by providing guidance, tools
and training. PAHO has prepared a summary of NCD indicators from the Americas. The SPC has also
integrated data from countries in the region on all priority communicable and non-communicable
diseases on their central database ‘PRISM’. This kind of work can help stimulate inter-country
discussions and comparisons, forms a baseline for the future, and helps countries to make a stronger
case for aid and support (Hospedales et al. 2012).
3
WHO, UNICEF, Australia Bureau of Statistics, PHIN, Queensland University of Technology, Fiji National
University, United Nations Population Fund, University of New South Wales
38
Research institutes have a growing number of data-generating projects in PICTs. The SPC has played
a central role in NCD surveillance and operational research, hosting a recent meeting in Noumea (6
to 8 February 2013). The Pacific Research Centre for the Prevention of Obesity and NCDs, for
example, is a collaboration between the Fiji School of Medicine and Deakin University and is
engaged in field research in the Pacific on NCDs, and the George Institute for Global Health has been
supporting salt reduction strategies for the region (Webster 2009).
3.3
Building analytical capacity
STEPS has been in operation in the PICTs since 2000, but the process of analysis and producing
reports has often suffered extended delays. In part these delays can be explained by the original
paper-based format of the survey (the Personal Digital Assistant-based eSTEPS Survey has resulted in
much quicker turnaround). Conducting surveys on paper forms adds several steps to the process,
including quality checks in the field, transport of forms to an office, data entry and data cleaning.
The latter two steps are particularly vulnerable to weak information technology (IT) infrastructure
and depend on technical know-how. Often, however, the delays in producing STEPS reports are due
to a lack of in-country capacity to prepare such documents.
A number of initiatives already exist to help develop the analytical capacities of health information
system professionals in PICTs. A STEPS analysis training package is provided by the WHO along with a
comprehensive template to facilitate report production. Also available is ANACoD, a toolkit designed
by HISHub to help build competencies in the analysis of cause-of-death data. Despite these efforts,
there is a noted lack of committed and adequately skilled professionals in most PICTs confident to
complete the tasks. Where they do exist, those trained are often individuals tasked with a number of
responsibilities in the ministry and not dedicated to any particular project, such as NCDs.
Consequently, data is often analysed off site by epidemiologists located outside the country and as
such, a country's sense of data ownership is threatened.
Workforce development is a ‘multifaceted approach which addresses the range of factors impacting
on the ability of the workforce to function with maximum effectiveness’ (Smith 2011). It is more
than just the education and training of individual workers: enhancing capacity needs to be broad and
comprehensive and have a systems focus. It needs to include government policies and strategies;
organisational structures, systems and culture; and knowledge, skills and experience. To meet the
increasing demand for information to measure performance against national priorities and policies,
there is an urgent need to increase data analysis skills. However, those analysing the data may come
from different backgrounds and may require diverse skills to handle a range of data types and
analyses. Effectively, the analytical skills required cover the following 10 key areas of health
information.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Census
Modelling, estimates and projections
Population and household surveys
Behavioural surveillance
Surveillance and response systems
Health research
Continuous monitoring of births and deaths, with certification of cause of death
National health accounts, financial and management information
Service-generated data
Packaging and dissemination of evidence for policy
Furthermore, the Pacific suffers from a severe paucity of human resources skilled in policy analysis
and public health law. These skills will be necessary for the translation of evidence to action through
knowledge dissemination and advocacy. Courses could be run to build specific skills in this area,
39
similar to those initiatives run for health information systems. For example, the Fiji National
University provides a short course in health information systems. It is designed to help professionals
from PICTs gain a better understanding of these systems and master the tools, and from that
knowledge strengthen the systems in their home countries. Another useful initiative would be to
develop a toolbox of sample laws, regulations and policies that can be quickly adapted and/or
adopted to the needs of jurisdictions.
3.4 Building institutional capacity
Institutional capacity and workforce development are important strategic action points in NCD
monitoring and control. This is especially true in the Pacific, as countries are faced with major issues
in relation to workforce (training, retention, coverage etc.). However, it is vital to focus on upgrading
institutions (rather than people), as people move between roles/organisations and countries. By
supporting institutions and the structures that affect performance and outcomes, we can ensure
there will be enough skilled workers for the future.
The skills and competencies required for a well-performing health information system have not
been clearly defined and are not fully appreciated. Limited literature exists on the matter and that
which does points to a lack of specialised health information system staff in developing countries.
General health workers, who have not been trained in such matters, are often expected to fulfil
health information system needs. Related to this, HISHub has recently conducted a study
(unpublished) which employed an expert panel to develop a framework of core health information
system competencies necessary for general health workers in developing countries. This toolkit will
soon be available and can be used to help identify the training needs and professional development
programs in different contexts (Whittaker, Mares & Rodney 2013).
3.5
Coordinating efforts
A number of organisations and partners are involved in capacity building for NCDs in the Pacific,
including PHIN, WHO, SPC, various universities and institutes, as well as government institutions.
Due to the absence of any overarching guidance or framework, however, much of the
implementation has been fragmented. At a regional level, one of the first actions should be a
mapping exercise to outline activities that are underway or planned by countries and organisations.
This could be carried out by a regional body, such as PHIN, or a regional governance structure. To
ensure a systems approach, it is important that broad health information system skills are
developed, rather than taking a narrower focus on NCDs. As such, the strategies proposed in the
PHIN ‘Regional Health Information System Strategic Plan (2012-2017)‘ are applicable for NCD
capacity building. The strategies include:



improving existing pre-service and in-service training for health information system
personnel
developing regional curriculum for training in health information system, such as (but not
limited to) data management, biostatistics, coding, medical record management, and
information and communications technology (ICT)
reviewing the roles and functions of health information units within ministries of health,
such as duties and responsibilities.
For these strategies, emphasis should be placed on developing capacity in medical records
management, death certification, clinical coding, analysis and interpretation, presentation and
dissemination, and how to use information in evidence-based decision-making. These areas are
crucial in any response to the NCD epidemic.
40
A significant increase in financial and technical support is necessary for health information systems
to fill gaps in the data. Pacific countries have often relied on external funding to cover most of the
cost of setting up and implementing surveys and surveillance systems. For these to be sustainable,
cost sharing must be encouraged and country ownership of the data as well as the processes
involved in surveillance must be developed.
Panel 2: Essential areas of capacity building for non-communicable
disease surveillance and control




To develop skills in data analysis and interpretation by developing
toolkits and hands-on training courses.
To build confidence in writing and in producing reports and fact sheets
for informing policy and for public health advocacy.
To develop capacity in the area of public health law and advocacy.
To improve country ownership, encourage cost sharing between
countries and agencies for monitoring activities.
41
4. Regional governance
4.1 The potential role of a regional non-communicable disease monitoring
alliance
Over the last decade, the Millennium Development Goals (MDGs) have demonstrated that simple
and achievable targets can successfully galvanise the world to respond in a time of need. The MDGs,
however, dealt largely with health issues for which, it could be argued; there was relative ease in
gaining support. HIV/AIDS and mother and child health are problems that affect younger individuals
and their impact on families and society are striking. The burden that NCDs inflict, on the other
hand, is more insidious in nature. NCDs are still often perceived to be diseases of the old, the rich or
of those who ‘choose’ unhealthy lifestyles. Given this, voluntary targets and indicators are
commendable but how are we to ensure that countries are putting in the effort to protect their
populations from the NCD epidemic? The WHO GMF is not itself sufficient to provide accountability
for this (Beaglehole, Bonita & Horton 2013).
PICTs would undoubtedly benefit from a regional governance structure with a remit to include
strengthening surveillance efforts and building local capacity for NCD surveillance. This structure
could be tasked with helping countries to track progress towards the prioritised GMF targets and
should be entrusted by PICTs to uphold a regional accountability framework. Governance requires
that actors work together to hold each other accountable. It will be important to agree what it is
countries are accountable for, who in those countries is held accountable and what the
consequences of failing to uphold those responsibilities are.
The approach developed and fostered by the BAG initiative provides an established model of
demonstrated effective collaboration between countries and regional actors, such as the WHO, SPC
and local universities and research institutions, towards the attainment of a specific set of goals. The
BAG first worked closely with Pacific countries to help them conduct self-assessments of their CRVS
systems and to develop country-level improvement plans. This allowed partner agencies to focus
their support on the needs identified in the plans. This country-led approach recognises the
importance of understanding the existing processes and structures in order to ensure real and
sustained improvements. A regional NCD alliance, as described in Panel 3, will likely benefit from a
similar approach to country engagement, capacity building and a deliberative and strategic
coordination of efforts.
Panel 3: Recommended roles and functions of a regional alliance for governance











Work directly with PICTs and reflect the opinions on the ground in those countries.
Encourage all PICT members of the alliance to cost share, that is, to buy into the initiative
by helping to fund activities.
Assist countries identify gaps and resource needs and help mobilise resources for PICTs
for NCDs (e.g. funding, external expertise).
Provide a specialised technical resource for PICTs on NCD monitoring which would
include the coordination of data sources, assistance in analyses and dissemination of
evidence.
Help develop a coordinated approach to building in-country capacity in analytical skills
and advocacy.
Develop resource kits in partnership with countries to help strengthen health
information systems.
Develop tools to encourage collaboration between sectors and integration of NCD data
collection into national information systems.
Coordinate training in NCD epidemiology specialising in areas relevant to local needs,
such as CRVS and STEPS data analysis and interpretation.
Coordinate specialised training in knowledge translation and public health law.
42
Stimulate applied and translational research on NCDs in the Pacific.
Provide data management expertise and/or act as a data repository.
Crucially, no systems of data collection or processing outside the existing systems in PICTs should be
developed. The key would be to strengthen the health information system of countries by guiding
investments, building confidence in analysing data and its translation to law and policy, and
incorporating a coordinated approach to surveillance and evaluation that best fits each country's
needs. Strengthening existing systems, rather than building parallel ones, has the potential to
benefit not just NCDs but all aspects of population health and wellbeing. It is important to recognise
that NCDs are one of many health concerns in PICTs and efforts to strengthen systems to control
NCDs should also aid health systems in general.
Data management is also an area that demands immediate attention. Information technology
capacity is limited in many PICTs and countries have voiced a need for a data repository for NCD
surveillance data. A potential role for an external body like an NCD alliance could be to act as such a
repository, housing an accessible database and coordinating the dissemination of analytical tools to
help countries produce reports and policy briefs.
Furthermore, the governance of harmful products such as alcohol, sugary drinks and food high in salt
and trans fats must be strengthened. This may be beyond the powers of ministries of health and
even individual countries, particularly smaller countries such as those in the Pacific. Working
together, PICTs, along with partners such as the SPC and WHO, can form an alliance to help support
actions taken to regulate the industry and trade of harmful products. Tobacco control in wealthy
countries represents a great success in public health and these initiatives provide a useful template
for other NCD risk factors. Past experience suggests that it is particularly useful to have a small group
of devoted people committed to working with the state to restrict access to tobacco products. The
alliance could help to develop these working groups and to build their capacity for advocacy.
4.2 Translational research
In dealing with NCDs, Pacific countries face very big challenges with often very limited resources.
They will have to make a number of difficult decisions about NCD monitoring and control strategies.
Evaluation of interventions, policies and programs is critical to inform investments in NCDs and to
ensure that strategies and programs are being implemented as intended, and are having the desired
impact. Ministries of health also need to know how much it costs to run programs, the incremental
costs to monitor them and what aspects of their systems need the most investment.
There is very limited cost information by disease type (e.g. communicable versus non-communicable
diseases) available from Pacific countries (Rayner et al. 2006). Some key areas of research that need
to be pursued to strengthen health information systems in PICTs and to aid in the decisions they
need to make are:



costing measurement including national surveillance, surveys and ongoing program
evaluation to improve budgeting decisions. Countries need to know the incremental costs of
monitoring each added indicator.
assessing human resources for health information systems, the skill mix available and the
identifying capacity-building needs and opportunities
determining the impact of measurement and data on policy and program decision-making,
and the best ways to report and present data for greatest influence.
A governance structure as outlined would be well placed to guide and support this research,
identifying in the first instance the priority areas and coordinating the appropriate actions for
obtaining the most useful information to guide action.
43
5. Conclusion
The WHO Global Monitoring Framework has been designed to provide guidance for countries on
how they should best respond to the challenges posed by NCDs. The recommendations outlined in
this working paper, however, are intended to help PICTs get the most out of this framework by
focusing on the most relevant and cost-effective strategies. Four key recommendations are
presented here:
Recommendation 1. PICTs should focus on making strong and sustained commitments towards a
limited number of realistic targets, rather than 9 voluntary targets and 25 indicators.
We have prioritised the targets according to the available scientific evidence on cost-effectiveness of
interventions and the feasibility of PICTs to implement such programs. This will ensure the most
cost-effective return in health outcomes.
To reach the most important goal of a 25 per cent reduction in premature mortality from NCDs, we
have identified three priority targets for intervention:
i. reduce smoking
ii. reduce the consumption of unhealthy diets
iii. treat those at high risk of heart attack and stroke.
Recommendation 2. Monitoring progress towards the main goal and the three priority targets
must be kept as simple as possible and efforts must be integrated into existing health information
systems.
Continued strengthening of vital registration systems reporting mortality by cause is essential
for all health monitoring. Indicators to monitor risk factors and treatments can be collected
using GSHS surveys and a modified version of STEPS, which includes modules to measure salt
consumption and the coverage of treatments to prevent heart attacks and stroke. These
population surveys must also be integrated into health information systems and implemented
regularly. A STEPS survey with a minimum number of questions would ideally be implemented
at least every five years and biological samples collected on alternate rounds.
Recommendation 3. Monitoring should track changes on the international trade, policy and policy
implementation levels.
The GMF fails to provide strong guidance on monitoring upstream factors. There has been an
implicit assumption that NCDs result from lifestyle choices. Trade and market regulations and
the exposure to marketing have only recently been recognised as drivers of the global NCD
epidemic. Without these indicators, it will be difficult to grasp the full picture of how and where
policy interventions do or don’t work.
Recommendation 4. Develop a multilateral external governing body empowered to oversee
country progress on NCD surveillance efforts and equipped to provide technical support.
The GMF lacks a suitable accountability mechanism. Here we recommend that the key to the
strategic success of NCD control in the Pacific region is country engagement at every step, the
harmonisation of efforts and the clarification of the roles of the many actors already involved.
Complementary efforts must be made a priority to ensure that health information is collected
and disseminated in a timely fashion so as to allow for appropriate actions to be taken.
A crucial caveat, however. Although there is recognised benefit in having a coordinating body
that sits regionally, it is essential that actions taken to develop NCD monitoring and surveillance
sit within existing country systems of data collection. Strengthening health information systems
through strategic- and evidence-based capacity building and enhancing country ownership will
ensure sustainable change for PICTs. Likewise, the health information system response to the
44
NCD crisis must also be embedded in broader health system development. The quality of
healthcare services and the collection of quality information are inseparable. Countries cannot
have one without the other and thus efforts to improve one must be designed to also advance
the other.
Countries need to provide coordinated actions in NCD prevention and treatment and this will
not be possible without quality information to guide plans and decisions. Experts and
institutions engaged in health activities and research in the region must prepare to support
health ministers to identify their information needs and strengthen their information systems.
This will entail fostering collaborations with other sectors and crucially, seeking the support and
commitment from the Heads of State. Nonetheless, it is important to have realistic
expectations of the impact of measures taken today on the health of populations in the future.
What can a Pacific Island Country or Territory expect from all this activity? What will they have
to show for it in 2020?
The recommendations set out in this working paper have been carefully considered to represent the
most pressing issues in the region, to exploit the most rigorous and up-to-date scientific evidence
and to reflect what PICTs can do with the available resources. If these recommendations are
followed by PICTs, the data and information they generate will undoubtedly place PICTs in a far
better position to manage and control NCDs in their populations. By 2020, if countries commit to
strengthening their civil registration systems and have succeeded in improving information on
mortality by cause, ministries of health will be able to a cost-effectively direct interventions to highrisk populations and vulnerable groups. Better information will be available on risk factor prevalence
and upstream factors, such as trade regulation and national policies. This will provide researchers
and ministries with a better understanding of what measures work and what actions need to be
taken to help keep their populations healthy and limit the burdens experienced from NCDs.
45
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