Ashgabat Declaration signed: day 2 of Ashgabat conference on noncommunicable diseases

WHO/Ahmed Hallyyew

On the second and final day of the Ashgabat conference on noncommunicable diseases (NCDs), many country examples of national NCD policies and interventions were described. The Ashgabat Declaration on NCDs was endorsed by Member States, and signed by Dr Nurmuhammet Amannepesov, Minister of Health and Medical Industry of Turkmenistan, and Ms Zsuzsanna Jakab, WHO Regional Director for Europe.

Strengthening national responses to NCDs

During the fourth plenary session, many countries took the floor to explain how they are adapting their health systems to address the challenges of NCDs, working across sectors, and developing appropriate health information systems.

Dr Nurmuhammet Amannepesov explained the far-reaching health system developments that are taking place in Turkmenistan, initiated thanks to high-level political support. This health system strengthening covers the whole country, and includes the reconstruction of 29 health centres in rural areas, and the building of 4 new centres.

The Minister underlined the need for a balance between better information, advocacy and practical services to encourage healthy behaviour, combined with stronger legislation (such as on tobacco use). Other key developments include improving the availability of health services and health professionals in rural areas.

NCD developments in countries

  • The Minister of Health of the Republic of Moldova described recent developments to the country’s health system to address NCDs. He noted that the recently-held second national health forum brought representatives from the agriculture, transport and education ministries together to encourage cooperation and integration, as well as the involvement of civil society and local government.
  • The Azerbaijan delegate spoke of a recent review of its health system and NCD plan, undertaken with WHO support to develop an appropriate NCD strategy.
  • A participant from Bosnia and Herzegovina explained the importance of subregional collaboration in addressing NCDs, citing the South-eastern Europe Health Network as an effective example. The country is also introducing a personalized cardiovascular risk assessment package to be delivered through the primary health care system.
  • The focus of Bulgaria’s NCD programme is prevention and early diagnosis to reduce levels of premature mortality. Targets are based on national conditions, but take account of the global NCD monitoring framework.
  • Smoking is the key challenge in Georgia, where 70% of adults smoke and 25% of total mortality can be attributed to tobacco use.
  • The delegate from Kazakhstan explained that from 2014 health budgeting will be based on a per capita figure, radically changing the financing available for NCDs. The country is moving away from a paternalistic approach to addressing NCDs, to one that promotes self-management as a joint responsibility between patient, doctor and government.
  • The delegation from Lithuania highlighted the many challenges facing health systems in adapting to the NCD epidemic, including an ageing population.
  • The Kyrgyzstan delegate spoke of the effectiveness of a subregional statistical system for countries in central Asia that brings their information systems together to develop joint indicators and information, and expressed a wish to reignite the project.
  • The delegate from Romania described “reversing the pyramid” in the country, from hospital to community-based services. She referred to the introduction of a performance-based wage system based on the Turkish model.
  • A programme in Ukraine to regulate the price of medicines has had a wide-reaching effect on cardiovascular disease in the country. The number of patients receiving medicine for high blood pressure increased by 65% after a generic price was introduced. The number of those with high blood pressure seeking treatment has also risen from 5% to 50%. In addition, there has been a reduction in the call-out for ambulances for such cases.
  • Tajikistan expressed its support for the Ashgabat Declaration and called on international financial institutions also to align themselves to it.
  • The delegation from Belarus described a change in the public attitude to smoking since, although 30% of people smoke, there is increasing support for a ban.
  • Croatia also described the effectiveness of subregional cooperation through the South-eastern Europe Health Network, and the usefulness of the WHO Framework Convention on Tobacco Control in creating smoke-free environments.
  • The German delegate described the significant progress made in tackling smoking among young people in the country, where the number of young smokers has fallen by 50% over the past 12 years. Today, over 70% of young people have never smoked.

Strengthening health systems for better NCD outcomes

Dr Taavi Lai, Senior Analyst in the Department of Public Health, University of Tartu, in Estonia presented the results of a WHO project that has distilled the different aspects that health systems face in combating NCDs into 15 opportunities. These opportunities include introducing incentive systems for health workers and the integration of care.

Taking the example of Estonia, Dr Lai explained recent initiatives to strengthen the health system. A quality bonus system has been introduced, offering doctors an incentive to identify and target patients at risk from chronic diseases. Patients are scored according to their level of risk, which also influences their path through the health system. Using an e-health platform allows doctors, nurses and patients to access their case histories and every case note made, thus making monitoring as easy as possible. Patients can grant or deny access to their own data through this system.

Launch of country assessment guide on health system challenges and opportunities for better NCD outcomes

This country assessment guide, piloted in five countries, identifies ways in which Member States can strengthen their health systems. Despite addressing different NCDs, the pilot countries highlighted common issues such as challenges in scaling up services, a lack of effective mechanisms for intersectoral and interagency cooperation, and unclear priority setting. Describing the next steps after launch, Elke Jakubowski, WHO/Europe, explained that there will be policy follow-up in the initial five countries, and a sharing of good practices, with the aim of having a regional synthesis report by 2015.

Panellists in the subsequent discussion highlighted several health system needs:

  • to strengthen health information systems for NCDs;
  • to develop a different service mix, with less paediatrics and more outreach and home-based care, to take account of multi-morbidity and an ageing population; and
  • to include NCDs in Member State discussions of the post-2015 development agenda and new global targets.

Role of civil society

Sir George Alleyne, Director Emeritus of the Pan American Health Organization, introduced his presentation by stating that “the focus of civil society is on exercising influence not wielding power”. The thesis of his presentation was a proposal outlining the three most important roles for civil society:

  • advocacy
  • a watchdog ensuring accountability
  • direct provision of services.

All three roles are supported through capacity building and strategic alliances. The NCD Alliance is an example of such a successful cooperation.
Dr Alleyne cautioned that national and regional strategies function best in tandem with international strategies, and noted that civil society is strongest with a well-functioning public sector. Civil society adds a dimension that is not available to governments, which traditionally have three instruments at their disposal: taxation, regulation and legislation.

It has a role to play in ensuring that NCDs find their proper place in the Health 2020 agenda, and has a crucial role in providing pressure to promote recognition of the seriousness and global reach of issues; the HIV epidemic is one example of this.

As advocacy is not effective if based on false claims, providing information and checking evidence is a vital role of civil society. This complements a basic function – providing social scrutiny so that governments are moved to take action.

Participatory governance is embodied in the Ashgabat Declaration. This is an example of the nature of today’s civil society and the role it can and does play in NCDs. Dr Alleyne finished his presentation by urging all to take advantage of the power and reach of civil society, to make the world a better place through the prevention and control of NCDs.

Ashgabat Declaration signed

Following its adoption by acclamation by Member States, the Ashgabat Declaration was signed by Dr Nurmuhammet Amannepesov, Minister of Health and Medical Industry of Turkmenistan, and Ms Zsuzsanna Jakab, WHO Regional Director for Europe.

The Declaration commits countries to accelerate their efforts to fully implement the WHO Framework Convention on Tobacco Control, addressing the supply as well as the demand for tobacco, with the aim of “denormalizing” its use, and expresses the shared ambition of ultimately making the WHO European Region tobacco free.

The document has three pillars: tobacco, acting across the whole of government, and specific recommendations on accelerating the development of national targets.

Press conference

Over 30 print and broadcast journalists from national and international agencies took part in a press conference announcing the signing of the Ashgabat Declaration.

Conference closure

At the closure, Ms Zsuzsanna Jakab, WHO Regional Director for Europe thanked His Excellency the President of Turkmenistan, the Minister of Health and Medical Industry, and the Minister of Foreign Affairs, as well as all Member States, representatives of international organizations and civil society, and experts, who had been instrumental in organizing the conference and developing the Ashgabat Declaration.

Ms Jakab summarized three issues brought to the fore by the conference that the Ashgabat Declaration will contribute to addressing.

  • All countries have affirmed the importance of the principles of Health 2020, including reducing health inequities, and their commitment to the global action plan on NCDs and its monitoring framework.
  • There is strong political will to move forward with the NCD agenda, and significant progress has been made in countries in the past two years. Future action will feed into the broader development agenda.
  • There remains a disjunction between the high level of ratification of the WHO Framework Convention on Tobacco Control and the low level of implementation. The tobacco industry is experiencing an apparent resurgence, and Member States must remain vigilant as to its influence. A renewed effort on tobacco control is needed.

“The Ashgabat Declaration is a landmark that will go down in the history of public health in Europe,” Zsuzsanna Jakab said in conclusion.