Task Force 6: Accelerating SDGs: Exploring New Pathways to the 2030 Agenda

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Non-communicable diseases (NCDs) are responsible for more than 70 percent of all deaths worldwide, with 41 million deaths per year. The economic impact of NCD treatments and deaths is significant, resulting in a total economic loss of approximately US$47 trillion between 2010-2030. Addressing NCDs requires a multi-sectoral approach, as it involves many sectors beyond health. The Health in All Policies (HiAP) framework provides a comprehensive approach to addressing NCD risks. Unfortunately, in many countries like Indonesia, cooperation between health and non-health sectors is still fragmented due to factors such as a lack of political commitment and low awareness of the impact of other sectors on health. The G20 should strengthen its efforts at promoting the HiAP framework, as well as consolidating investments in NCD prevention and treatment among its member countries.

1. The Challenge

Approximately 41 million of the 57 million deaths in 2016 were caused by non-communicable diseases (NCDs). This figure is equivalent to 74 percent of deaths worldwide in the same year.^[1] The magnitude of morbidity and mortality from NCDs also impacts the financial burden worldwide, with an estimated total economic loss of approximately US$47 trillion between 2010 and 2030.^[2] These challenges disproportionately affect populations in low- and lower-middle-income countries (LMICs), where nearly three-quarters of NCD deaths worldwide occurr.^[3] In 17 of the 19 G20 countries (excluding the EU), 70 percent of annual mortality is closely linked to NCDs.^[4]

 Reducing the incidence of NCDs is closely related to many sectors outside of health, as these diseases are driven by various risk factors including behaviours such as smoking, alcohol and drug consumption, excessive consumption of sugar, fat or salt, and lack of physical activity. There are also socio-environmental factors like education, socio-economic status, and the environment. Additionally, the efforts to tackle NCDs are also influenced by the attainment of other goals within the Sustainable Development Goals (SDGs) agenda, which are described in Table 1.

Table 1. Role of SDGs Agenda in Reducing NCDs

SDGs Agenda	Role in Reducing NCDs
SDGs 1 (No Poverty)	Providing more choices to the access of preventive health services
SDGs 2 (Zero Hungry)	Preventing malnutrition that leads to stunting
SDGs 4 (Quality Education)	Improving economic and social stability that is closely linked to the alleviation of NCDs
	Improving health literacy in order to reduce NCD risk factors and control health conditions
SDGs 5 (Gender Equality)	Promoting women’s rights to have better access to health care and control over their income to afford health care
SDGs 6 (Clean Water and Sanitation)	Contributing to the enhancement of nutrition quality correlated with healthy diets
SDGs 8 (Decent Work and Economic Growth)	A good working environment can improve workers’ well-being, linked to NCD prevention.
SDGs 10 (Reduced Inequality)	Helping to decrease inequality in order to increase the access of health care that can help in early detection, prevention, and treatment of NCDs
SDGs 11 (Sustainable cities and communities)	Reducing the impact of environmental degradation in cities, which might have an impact on respiratory diseases
	Enhancing the quality of lifestyle to encourage physical activity in order to prevent obesity and cardiovascular diseases
SDGs 12 (Responsible Consumption and Production)	Producing local and sustainable foods can provide access to nutritious fruits and vegetables associated with healthy diets.
SDGs 13 (Climate Action)	Contributing to the prevention of NCDs caused by global warming, such as heart attacks and strokes

Sources: Rachel et al.;[5] NCD Alliance[6]

It is important to develop multi-sectoral approaches to address the risk factors of NCD prevalence beyond medical care. The World Health Organization’s (WHO) Global Action Plan for NCDs urges countries to adopt multi-sectoral frameworks to mitigate the risk factors of NCDs. This brief focuses on the Health in All Policies (HiAP) framework.

HiAP is a comprehensive approach to public policies that seeks to address the problem of NCD risk factors across sectors. It provides tools such as health impact assessment, health equity impact assessment, and socio-environmental impact assessment to measure the impact of policies made by all sectors on health systems. The HiAP framework was introduced in the 1978 Declaration of Alma Ata, which conceptualised the determinants of health and multisectoral action.[7] However, due to the complexity of health determinants, it has resulted in a tug-of-war of interests between various sectors, thereby hindering the implementation of HiAP and the achievement of health outcomes.

In certain sectors, especially at the city or district level, there are in place integrative policies between health and non-health sectors, albeit on a smaller scale. One of the most frequently referenced is the HiAP approach developed by the South Australia Government since 2007.[8] This HiAP approach succeeded due to government support, a flexible framework for diverse programs, collaborative partnerships across agencies, and rigorous evaluations.^[9] Without a holistic and long-term strategy from the government, it is difficult to harmonise policies across sectors and levels.

In Indonesia, cooperation between health and non-health sectors has not been fully established due to jurisdictional challenges. As a country where governance is decentralised, the development of policies for preventing NCDs should involve various stakeholders at different levels of government, thus requiring further collaboration between national and sub-national stakeholders. For instance, the Health Law Number 36/2009 mandates that local governments implement regulations for smoking-free areas within their jurisdictions, but several regions have yet to comply.^[10]

Another challenge in addressing NCDs is the lack of a leading actor/unit who will be responsible for managing prevention programs.^[11] However, there is no regulation that mandates a leading actor to direct and negotiate the roles of all stakeholders in preventing NCD risk factors. Presidential Instruction Number 1/2017 only instructs several ministers, governors, and mayors/regents on their respective roles and responsibilities under the Healthy Living Society Movement (Gerakan Masyarakat Hidup Sehat), without mandating a specific leading actor to coordinate the entire government’s efforts to prevent NCDs.

This situation is exacerbated by the lack of a dedicated budget mechanism in NCD prevention programmes. Indonesia has initiated, for instance, an earmarking mechanism for tobacco taxes through Law number 8/2009 on Local Taxes and Local Levies—at least 50 percent of the cigarette tax revenue must be allocated to public health services and law enforcement. However, the public health services refer to all diseases and are not particularly dedicated to NCDs caused by tobacco use. This earmarking mechanism is known as “symbolic earmarking”, which has no direct impact on certain expenditures, and the tax revenue is still included in the general fund.^[12]

In another context, Indonesia continues to struggle with an inadequate regulatory system to govern sugar-sweetened beverages (SSB) taxes aimed at curbing high sugar consumption. Indonesia’s sugar consumption has increased by 40 percent over the last decade, whereas the average global growth in sugar consumption was only 9 percent during the same period.^[13] Sugar intake can be reduced effectively by raising the price of SSB through SSB taxes.[14],[15] Moreover, SSB taxes can generate government revenue and a commitment to tackle NCDs by earmarking revenue for NCDs prevention programmes. In the long term, SSB taxes can also help reduce the burden on health finances caused by the prevalence of NCDs arising from high consumption of SSB products.^[16]

Finland is another illustration of the challenges in implementing HiAP, particularly for the application of a high tax policy for alcoholic beverages since the 1970s. An economic assessment by the Ministry of Finance estimates that there will be reduced profits for Finnish breweries and other local businesses that depend on the production and sale of alcohol due to the large import of alcohol from Estonia.[17] To avoid this scenario, the Ministry of Finance is proposing to reduce the alcohol sales tax by up to a third. However, the Health Impact Assessment undertaken by the Ministry of Social and Health on the proposal projected that lower alcohol costs would lead to increased consumption and associated negative health impacts (relevant to the Ministry of Social and Health sectoral goals). The Health Impact Assessment stated that a 33-percent reduction in taxes would increase the number of heavy drinkers by 200,000 (4 percent of the total population) and increase alcohol-related deaths by 600 per year. In the end, the policy taken by the political elite in the government is tax reduction.[18]

2. The G20’s Role

In the context of NCD financing, it is estimated that US$140 billion in new spending will be required during 2023-2030 to achieve the worldwide SDG target 3.4 related to NCDs.^[19] However, the allocation of Development Assistance for Health (DAH) related to NCDs is currently only below 2 percent,^[20] and this proportion has remained unchanged for the past 10 years, making it inadequate to meet the needs of NCD programs. Achieving the NCD financing needs could reduce 39 million death cases over this period, while generating an economic benefit of US$2.7 trillion. As the biggest contributors of DAH funds, G20 countries can channel resources to support NCD programs to strengthen the upstream and downstream aspects of NCDs.[21] The G20 countries should consider how to drive the allocations for the improvement of primary healthcare and other cost-effective services. NCD prevention and treatment are part of this development, which also improves and supports leadership, governance, and accountability at all levels of the health system.

G20 has the means to influence global policies, especially to address global health issues by preventing NCDs through the HiAP framework. They represent around 64 percent of the global population and 86 percent of the world’s GDP. G20 countries also play a crucial role in development assistance for health (DAH). In 2018, the total amount of DAH was US$38.9 billion, and G20 countries contributed 65.2 percent to the total amount of DAH funds. Therefore, the G20 forum has potential to not only facilitate initiatives and cooperation among its stakeholders, but also to consolidate efforts and investments towards enhancing prevention and treatment of NCDs within its member countries.

However, despite their influence, G20 countries are also responsible for tackling the risk factors of NCDs. For instance, G20 countries are responsible for around 75 percent of the world’s greenhouse gas emissions, yet most G20 members have insufficient targets of Nationally Determined Contributions (NDC) to comply with 1.5°C climate emissions pathway pledges. Similarly, the implementation of NCD prevention programs in the domestic policies of G20 members is still lacking, and most of the policies regarding tobacco control, reduction of harmful use of alcohol, and unhealthy foods have not been fully implemented.

Table 2. The G20 Health Ministers’ Commitments to SDG 3 

SDG 3 Health Targets	Weak/Indirect Reference(s)	No Reference/Commitment
Non-Communicable Diseases	☒	☐
Mental Health	☐	☒
Substance Abuse (Narcotic Drugs and Alcohol)	☐	☒
Road Traffic Injuries	☐	☒
Environmental Pollution	☐	☒
Tobacco (WHO Framework Convention on Tobacco Control)	☐	☒

Source: McBride, B., Hawkes, S. & Buse, K.[22]

3. Recommendations to the G20

This Policy Brief recommends that G20 consider health issues in all policy approaches to achieve health for all. To shape new policies, G20 should take inspiration from governments that have already integrated health impact assessment into their governance and legislation. G20 must recognise health as a basic human right as economic factors alone are inadequate for achieving sustainable development. This broad definition of health encompasses physical, mental, and social well-being, and implies a set of legal obligations for states to create enabling conditions that ensure high health standards for all.

In many situations, underprivileged populations bear a disproportionate burden of disease, disability, and premature death. International forums such as G20 can demonstrate a commitment to addressing health disparities by bolstering the ratification and strengthening of international policies such as the WHO Framework Convention on Tobacco Control (FCTC) and the Paris Agreement to address the challenges posed by NCDs.

As one of the largest contributors to DAH funds, G20 countries should evaluate ways of allocating funds to strengthen primary healthcare and other health services that include the prevention and treatment of NCDs. The group should also reinforce leadership, governance, and accountability at every level of the healthcare system.

1. Integrating data and information systems between services in pursuing a continuum of care

Improving data governance is crucial for monitoring progress towards preventing NCDs and achieving the SDGs related to health outcomes. Although this effort requires commitment and assistance from many parties, optimising high-quality data are essential to design, monitor, and evaluate effective interventions in preventing NCD risk factors. To address the challenge of health data gaps, G20 nations should explore strategies for providing technical and financial support to enhance the data governance capacity of each country. Collaborating with various stakeholders with different areas of expertise will help bridge health data gaps and increase transparency and accountability in public policy-making processes.

2. Develop joint/shared multi-sector indicators including details regarding the responsibilities of each sector and the leading sector

The Brazilian Health Regulatory Agency (Anvisa) is an example of successful intersectoral collaboration in reducing smoking prevalence. Anvisa was established with the intention of advancing public health protection through control and supervision over cigarettes and other tobacco products as one of its duties. Anvisa regulated tobacco products, enforced tobacco control regulations, and encouraged public dialogue to change attitudes towards tobacco use. These interventions resulted in a decrease in smoking prevalence from 34.8 percent in 1989 to 17.2 percent in 2008, despite Brazil being a major tobacco producer. Brazil now forbids cigarette companies from sponsoring cultural and sports events and prohibits tobacco advertising in the mainstream media. At the same time, the Brazilian bureaucracies also play an important role in coordinating initiatives and to formulate the co-benefits for all sectors. Brazil conducted an initial experiment with a deterrence program that generated incentives for national political leaders to introduce similar policy measures early on, thereby establishing bottom-up policy diffusion.

3. Initiating a multi-sector platform that accommodates discussions and negotiations, so that co-benefits and implementation of health lens analysis are arranged for each agency

A multi-sector platform is essential in promoting policy dialogue and implementing HiAP. Even though they often face challenges from sectoral self-centeredness and skewed budget allocations in each sector, this platform can facilitate regular dialogues between health system stakeholders to prevent NCDs and generate innovative collective efforts to address their risk factors. The platform can also develop a shared vision among stakeholders of what the HiAP framework entails, including a common understanding of health’s intersectoral nature and the importance of collaboration among various sectors.

4. Implementing Health Impact Assessment to oversee the potential impacts of public policies on health development

With Health Impact Assessment (HIA) tools, decision-makers can better understand the potential health impacts of their proposals and make more informed decisions that prioritise the health and well-being of the communities they serve. Moreover, HIA can enable the recognition of how the combined impacts of projects affect health and healthcare systems, which are usually not considered in project implementation. Overcoming this challenge should involve fostering cooperation between countries that have successfully implemented HIA and countries that have no experience in implementing HIA. In order to improve the implementation of HIA and the quality of decision-making processes that could improve health outcomes for communities, countries with sufficient experience implementing HIA in the G20 should offer assistance to nations with resource limitations and knowledge gaps.

5. Encouraging each country to allocate dedicated resources for implementing the HiAP framework

Allocating dedicated resources, such as funding, staff, and technical assistance, can strengthen HiAP implementation by building capacity among stakeholders and promoting multisectoral collaboration. By committing resources, different sectors can bring their expertise and work together to address the challenges of health determinants. This will ensure the HiAP framework is implemented effectively and efficiently, promoting a more comprehensive approach to NCDs prevention.

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Attribution: Muhamad Fachrial Kautsar and Muhammad Arief Virgy, “Reconsidering Health in All Policies (HiAP) to Tackle Non-Communicable Diseases: Lessons from Indonesia,” T20 Policy Brief, July 2023.

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Endnotes

^[1] World Health Organization, Noncommunicable Diseases Country Profiles 2018 (Geneva: World Health Organization, 2018), https://apps.who.int/iris/handle/10665/274512.

^[2] “The Financial Burden of NCDs,” NCD Alliance, accessed 2023,  https://ncdalliance.org/why-ncds/financing-ncds

^[3] Julianne Williams, Luke Allen et al., “A systematic review of associations between non-communicable diseases and socioeconomic status within low- and lower-middle-income countries,” J Glob Health (December 8, 2018) (2): 020409, doi: 10.7189/jogh.08.020409, https://pubmed.ncbi.nlm.nih.gov/30140435/

^[4] Hidechika Akashi, Aya Ishizuka et al., “The role of the G20 economies in global health,” Glob Health Med 1 (October 31, 2019) (1):11-15, doi: 10.35772/ghm.2019.01008, https://pubmed.ncbi.nlm.nih.gov/33330748/.

[5] Nugent, Rachel, Melanie Y Bertram, Stephen Jan, Louis W Niessen, Franco Sassi, Dean T Jamison, Eduardo González Pier, and Robert Beaglehole. ‘Investing in Non-Communicable Disease Prevention and Management to Advance the Sustainable Development Goals’. The Lancet 391, no. 10134 (May 2018): 2029–35. https://doi.org/10.1016/S0140-6736(18)30667-6.

[6] NCD Alliance. NCDs Across the SDGs, A Call for an Integrated Approach. n.d. https://ncdalliance.org/sites/default/files/resource_files/NCDs_Across_SDGs_English_May2017.pdf.

[7] World Health Organization. “Global strategy for health for all by de year 2000.” In Global strategy for health for all by de year 2000, pp. 90-90. 1981.

[8] Delany, Toni, Angela Lawless, Frances Baum, Jennie Popay, Laura Jones, Dennis McDermott, Elizabeth Harris, Danny Broderick, and Michael Marmot. “Health in All Policies in South Australia: what has supported early implementation?.” Health promotion international 31, no. 4 (2016): 888-898.

^[9] “South Australia’s HiAP approach,” Government of South Australia, last modified 2007, https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/about+us/about+sa+health/health+in+all+policies/south+australias+hiap+approach

^[10] Randy Ferdi Firdaus, “Kemendagri Ungkap Ada 133 Pemda Tak Punya Aturan Kawasan Tanpa Rokok,” Merdeka, November 22, 2022, https://www.merdeka.com/peristiwa/kemendagri-ungkap-ada-133-pemda-tak-punya-aturan-kawasan-tanpa-rokok.html

^[11] Yodi Christiani, Paul Dugdale et al., “The dynamic of non-communicable disease control policy in Indonesia,” Australian Health Review 41 (2017): 207-213.

^[12] Maisarah Putriyandri Atsani et al., “The Implementation of Earmarking Tax Policy on Cigarette Tax in West Java Province,” Jurnal Ilmu Sosial dan Ilmu Politik 23 (2019) (1): 45.

^[13] Albert Mackenzie, “How High Can Indonesian Sugar Consumption Go?,” Czapp, December 15, 2021, https://www.czapp.com/analyst-insights/how-high-can-indonesian-sugar-consumption-go-2/

[14] M.A. Colchero, Carlos Manuel Guerrero-López et al., Beverages Sales in Mexico before and after Implementation of a Sugar-Sweetened Beverage Tax, PLOS One 6 (September 2016) (9):e0163463, https://doi.org/10.1371/journal.pone.0163463.

[15] Pan American Health Organization (PAHO), Sugar-sweetened beverage taxation in the Region of the Americas, (PAHO, 2021).

^[16] CISDI, Policy Brief: The Urgency of Implementing Sugar-Swetened Beverage Tax Policies in Indonesia (CISDI, 2022), https://cdn.cisdi.org/reseach-document/fnm-Ringkasan-Kebijakan-Urgensi-Implementasi-Kebijakan-Cukai-Minuman-Berpemanis-Dalam-Kemasan-MBDK-di-Indonesiapdf-1674995915344-fnm.pdf

[17] Tigerstedt C, Karlsson T, Mäkelä P, Österberg E, Tuominen I. Health in alcohol policies: The European Union and its Nordic Member States. In: Ståhl T, Wismar M, Ollila E, Lahtinen E, Leppo K, editors. Health in All Policies: Prospects and Potentials. Helsinki: Ministry of Social Affairs and Health; (2006).

[18] Ketan Shankardass, Carles Muntaner et al., “The implementation of Health in All Policies initiatives: a systems framework for government action,” Health Research Policy and Systems (March 2018) (1):26. doi: 10.1186/s12961-018-0295-z, https://health-policy-systems.biomedcentral.com/articles/10.1186/s12961-018-0295-z.

^[19] David A. Watkins et al, “NCD Countdown 2030: Efficient Pathways and Strategic Investments to Accelerate Progress towards the Sustainable Development Goal Target 3.4 in Low-Income and Middle-Income Countries,” The Lancet 399(10331): 1266–78, 2022.

^[20] Kanykey Jailobaeva, Jennifer Falconer et al., “An analysis of policy and funding priorities of global actors regarding noncommunicable disease in low- and middle-income countries,” Globalization and Health 17 (2021): 68.

[21] Dieleman, Joseph L, Krycia Cowling, Irene A Agyepong, Sarah Alkenbrack, Thomas J Bollyky, Jesse B Bump, Catherine S Chen, et al. “The G20 and Development Assistance for Health: Historical Trends and Crucial Questions to Inform a New Era”. The Lancet 394, no. 10193 (July 2019): 173–83. https://doi.org/10.1016/S0140-6736(19)31333-9.

[22] McBride, B., Hawkes, S. & Buse, K. Soft power and global health: the sustainable development goals (SDGs) era health agendas of the G7, G20 and BRICS. BMC Public Health 19, 815 (2019). https://doi.org/10.1186/s12889-019-7114-5