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Cancer, diabetes, heart disease and chronic respiratory diseases are killing millions of people each year, making noncommunicable diseases the leading global cause of human deaths, many of them premature. This week, the World Health Assembly endorsed an updated set of policy options for countries to help them with the prevention and control of those diseases. On the list is a suggestion for tax increases on tobacco products and alcoholic beverages, and the reduction of salt intake. Supported by many countries, it was resisted by the United States and Italy.

The World Health Assembly, which took place from 22-31 May, adopted a resolution endorsing a list of policy options, known as “Appendix 3,” part of the global action plan for the prevention and control of noncommunicable diseases 2013-2020.

The resolution also supports the preparation for the third High-level Meeting of the [United Nations] General Assembly on the Prevention and Control of Noncommunicable Diseases, to be held in 2018.

Discussions were not that easy to agree on the resolution. The United States and India, had proposed an amendment each to the resolution, which was first adopted in January by the WHO Executive Board meeting. India asked that a mention be added to say Appendix 3 is applicable in the country context and priorities, and the US introduced a new paragraph focusing on a life-course approach, best practices, and voluntary approaches, supported by Italy.

None of these amendments were retained and the WHA adopted the resolution as adopted by the EB in January.

The resolution also notes a WHO workplan for the global coordination mechanism on the prevention and control of noncommunicable diseases covering the period 2018–2019.

WHO estimates that in 2015, 15 million people between the ages of 30 and 69 died from noncommunicable diseases.

Revised Appendix 3 Targets Tobacco, Alcohol, Salt, Sugar

According to the WHO, Appendix 3 consists of “a menu of policy options and cost-effective interventions to assist Member States in implementing, as appropriate for national context (without prejudice to the sovereign rights of nations to determine taxation among other policies), actions to achieve the nine voluntary global targets for the prevention and control of noncommunicable diseases.”

Appendix 3 has been updated, at the request of WHO member states, “to take into consideration the emergence of new evidence of cost-effectiveness and the issuance of new WHO recommendations since the adoption of the global action plan in 2013.”

The appendix now includes 86 interventions and actions, compared to 62 in the previous version.

Among the interventions and actions recommended by the appendix is the increase of taxes and prices on tobacco products, the implementation of plain packaging for tobacco products, and a ban on tobacco advertising. The appendix also suggests to increase taxes on alcoholic beverages, to enforce bans or restrict exposure to alcohol advertising, and enact and enforce restrictions on the physical availability of retailed alcohol through reduced hours of sale.

To combat unhealthy diet, the appendix recommends to reduce the salt intake “through the reformulation of food products … and the setting of target levels for the amount of salt in foods and meals.” Additionally, the appendix suggests that salt intake be reduced through the implementation of front-of-pack labelling.

The updated Appendix 3 is attached as Annex 1 in the WHO report on the preparation for the third High-level Meeting of the General Assembly on the Prevention and Control of Noncommunicable Diseases, which was noted by the WHA this week. The report provides an update on the preparation of the meeting.

Most Agree, US and Italy No

Most countries taking the floor spoke in support of Appendix 3, such as Botswana, Zambia, China, Canada, Uruguay, Australia, Ghana for the African region, and Denmark on behalf of the Nordic and Baltic countries.

The United States said on 31 May that strategies to tackle the problem of NCDs can include regulatory and voluntary measures appropriate to each national and local context, consistent with member states’ domestic and international obligations. Such strategies, the delegate said, should incorporate public-private partnerships. The US, he said, cannot endorse the updated Appendix 3 and must dissociate from the Paragraph 1 of the resolution (which endorses Appendix 3).

He said the US understands that Appendix 3 “as a non-exhaustive list of menus and options and non-binding guidance for member states to consider in developing strategies tailored to their national circumstances.” The delegate added that the US “strongly supports” many of the recommendations in Appendix 3 but “the evidence underlying certain interventions is not yet sufficient to recommend them.”

The US delegate also explained that in a federal system, such as in the US, many decisions suggested by the recommendations in Appendix 3 rest with states and municipalities.

Italy also explained that the country cannot endorse the appendix, which the delegate said focuses on reducing the consumption of specific nutrients but does not sufficiently highlight the benefit of a varied and healthy diet that does not exclude any food, such as the Mediterranean diet, to which the “notorious Italian longevity” is an illustration.

The Italian delegate also explained that the country had concerns about the fiscal policies suggested in the appendix, in particular taxation of sugar-sweetened beverages. More detailed studies and analysis are needed to assess the impact of such fiscal measures, she said.

High Burden of NCDs, Industry Influence

Botswana remarked on the high burden of NCDs, while Zambia noted the increasing number of premature deaths due to NCDs, and the resource mobilisation challenge.

Ghana, for the African region, also mentioned the “glaring underfunding” in the region and obstacles in the implementation of national commitments. The delegate said industry interference is blocking measures to implement domestic taxes, which could help ensure the self-financing of national responses.

He noted the growing influence of industry in the global coordination mechanism.