National strategic plan for the prevention and control of noncommunicable diseases

Objectives

Cambodia’s National Strategic Plan for the Prevention and Control of Non-Communicable Diseases 2013–2020 seeks to ensure that cardiovascular disease, cancer, chronic respiratory disease and diabetes are prevented and controlled effectively and equitably, while minimising their burden on households and society.[1][2]It responds to a substantial and growing health and development challenge: non-communicable diseases accounted for 46% of deaths in 2008 and approximately 90% of the country’s non-communicable disease burden is attributable to the four priority conditions.[3][4]

• Reduce premature mortality and disability from the four priority conditions, while reducing exposure to tobacco, harmful alcohol use, unhealthy diet and physical inactivity.[2][5]
• Reduce population exposure to shared behavioural, environmental and physiological risks, including tobacco, alcohol, unhealthy diet, excess salt and trans-fat intake, physical inactivity, indoor air pollution, hypertension, raised blood glucose, overweight, obesity and high cholesterol.[6][7]
• Prevent cancer through tobacco control, cleaner household cooking, hepatitis B birth-dose immunisation, cervical screening and treatment, and eventual human papillomavirus vaccination.[8][9]
• Pursue cost-effective detection, treatment, secondary prevention and palliative care, with primary care as the principal platform and particular attention to poor and geographically disadvantaged populations.[5][4][10]
• Enhance surveillance through risk-factor surveys, improved health-service data, hospital-based cancer registration and longer-term population-based cancer-registration capacity.[11][12]
• Strengthen governance, coordination, workforce capacity and sustainable resourcing through a coherent, integrated national response rather than separate disease-specific programmes.[5][11]

The strategy adopts equity, affordability and cost-effectiveness as guiding principles. It prioritises interventions that can deliver the greatest population health benefit from limited human and financial resources, recognises that preventable risk exposure and barriers to care disproportionately affect poorer households, and envisages a gradual programme that can be expanded as resources and technical capacity increase.[2][4][13]Its stated 2020 ambitions include lower tobacco use and heavy episodic drinking, broader access to integrated treatment and risk-factor management, increased cervical screening, strengthened cancer registration, repeated national risk-factor surveys and a functioning whole-of-government implementation mechanism.[11]

Implementation

Implementation combines population-wide policy action with integrated, decentralised chronic-care services, staged pilots and progressive national scale-up. The Ministry of Health is intended to lead health-sector coordination, while effective prevention requires a multisectoral, whole-of-government response involving finance, trade, education, industry, local authorities, public health institutions, development partners, non-governmental organisations and communities.[5][14][15]

• Implement tobacco and alcohol control through taxation, smoke-free environments, health warnings, advertising restrictions, sales and availability controls, vendor regulation and drink-driving enforcement.[16][17]
• Promote healthier diets and physical activity through salt-reduction initiatives, trans-fat replacement, food-policy measures, schools, workplaces, Healthy Cities activities, mass media and collaboration with agriculture, industry, the private sector and food vendors.[18][9]
• Improve household air quality through cleaner fuels and efficient cook-stoves, including the National Efficient Cook Stove Programme.[19]
• Deliver the World Health Organization Package of Essential Noncommunicable Disease Interventions through primary care, beginning with pilots, evaluation and adaptation before progressive extension to health facilities nationwide.[20][10]
• Expand community management through peer educator networks for diabetes and hypertension, while using specialist clinics in provincial referral hospitals for unstable or complex cases.[20][21]
• Implement single-visit cervical screening and treatment using visual inspection with acetic acid and cryotherapy, initially through demonstration projects and phased expansion, while maintaining records of women screened.[22][21]
• Develop community-based and home-based palliative care linked to district hospitals, health centres, Village Health Support Groups, families and non-governmental organisation partners; improve access to palliative medicines and opioid analgesics; and embed palliative care in professional training.[23][24]

Governance arrangements centre on the non-communicable disease taskforce, supported by a secretariat, to oversee delivery, monitor progress and guide allocation of resources at national, provincial and operational-district levels. Departments are expected to report activity progress to the taskforce, provincial health departments are to develop annual operational plans, and cross-departmental work is to be coordinated through inter-departmental meetings.[25]The strategy also envisages a national multisectoral action plan and a whole-of-government mechanism to specify cross-sector responsibilities and accountability beyond the Ministry of Health.[26][25]

A learning cycle of piloting, evaluating, modifying, implementing, monitoring and review underpins service development.[2]Monitoring is intended to align with the Global Monitoring Framework for non-communicable diseases and cover risk factors, health-system response and outcomes, with analysis by province, operational district, sex and urban or rural residence where possible.[27][28]Core data sources include STEPS risk-factor surveys, the National Adult Tobacco Survey of Cambodia, the Cambodian Demographic and Health Survey, health-facility and health-information-system data, vital registration, public-hospital cancer data and international datasets.[25][27][29]A mid-term review was scheduled for early 2016, using the final Health Strategic Plan 2 review and 2015 STEPS findings to adjust remaining activities.[25]

Resource mobilisation is expected to combine government budgets, donor support, pooled Health Sector Support Programme 2 funding, health-financing schemes, user co-payments for some public-facility services, and a proposed dedicated fund financed from tobacco and alcohol taxation.[30]Health Equity Funds, community-based health insurance and social security schemes are identified as mechanisms to improve equitable access to chronic care.[17][15]The plan specifies activity-level indicative costs, including total planned costs of US$1,711,648 for 2013 and US$1,722,967 for 2014, but the supplied material does not establish a complete long-term budget or quantified funding gap.[31]

Monitoring & Evaluation

The plan establishes a monitoring, surveillance and accountability system combining regular population surveys, routine health-service data, cancer registration, implementation reviews and intersectoral oversight. It is designed to measure risk-factor exposure, health-system responses and health outcomes, with analysis by sex, province, operational district and urban or rural residence where possible.[25][27][28]

• Conduct nationally representative surveys using consistent and internationally comparable methods, including the World Health Organization STEPwise approach to noncommunicable disease risk-factor surveillance survey in 2015 and 2020, the Cambodian Demographic and Health Survey in 2015 and 2020, and the National Adult Tobacco Survey of Cambodia in 2016 and 2021.[25][27]
• Measure risk factors including daily tobacco use, alcohol consumption, salt intake, fruit and vegetable consumption, overweight or obesity, raised blood glucose or diabetes, and hypertension.[32][33][29][34]
• Track annual health-system and outcome measures, including hepatitis B vaccination within 24 hours of birth, human papillomavirus immunisation once introduced, treatment coverage for diabetes and hypertension, cervical screening coverage, opioid analgesic consumption per cancer death, and cancer incidence and mortality by type.[33][35][36]
• Use health-facility records, the health information system, population surveys, census data, international estimates and industry data as indicator sources; detailed calculation methods are referenced in Annex 1, although the annex is not included in the supplied material.[37][29][35][36]
• Strengthen vital registration, improve disease classification and causes-of-death data, integrate diabetes-clinic and peer-educator databases into the health information system, and maintain interim databases where integration is not yet feasible.[27][12][24][38]
• Establish and sustain a hospital-based cancer registry, including at the National Cancer Centre at Calmette Hospital, as a step towards a population-based registry.[27][33][36]
• Evaluate pilots before expansion, including the World Health Organization Package of Essential Noncommunicable Disease Interventions, cervical screening and treatment, human papillomavirus vaccination, and community-based palliative care.[9][20][21][23]
• Maintain records of women screened for cervical cancer and use pain management as a hospital-care quality criterion.[8][23][39]

Indicators are intended to supplement or replace non-communicable disease indicators in the second Health Strategic Plan and to be incorporated into annual review and Annual Operational Planning processes. A mid-term review was scheduled for early 2016, using the final Health Strategic Plan 2 review and 2015 STEPS results to adjust remaining activities.[25]Accountability arrangements include departmental progress reporting to the Noncommunicable Disease taskforce, taskforce oversight of implementation and resource allocation, provincial annual operational plans, and a proposed whole-of-government mechanism for multisectoral implementation.[25][26][31]

The framework aligns with the Global Monitoring Framework for non-communicable diseases but identifies a need for additional multisectoral indicators, as existing process measures predominantly cover the health-sector response.[27][28]The supplied material does not provide a complete consolidated reporting timetable, independent evaluation structure or fully specified cross-government accountability procedures; these were to be elaborated through the National Multisectoral Action Plan for Noncommunicable Diseases.[25][27]

Costing & Financing

Financing is framed around cost-effective, equitable and progressively sequenced implementation because financial and human-resource constraints prevent simultaneous delivery of all recommended interventions.[2][13]The strategy prioritises public investment in population-based prevention, secondary prevention and long-term primary-care management, while recognising that more expensive curative care can consume limited resources.[5][26]

• Mobilise domestic resources by increasing tobacco and alcohol taxation and dedicating a proportion of revenues to a fund for non-communicable disease prevention and control.[11][12][17]
• Use government budgets for central and provincial operational costs, public-sector prevention and care, planning, surveillance, governance, essential medicines, equipment and multisectoral policy implementation.[30]
• Mobilise government and donor resources through provincial annual operational plans and pooled support through the Health Sector Support Programme 2.[26][38][30]
• Link training and equipment assistance to defined delivery packages, including cervical screening and treatment and the World Health Organization Package of Essential Noncommunicable Disease Interventions, rather than financing stand-alone inputs.[30][25]
• Review Health Equity Funds, community-based health insurance, the National Social Security Fund and related benefit packages to improve equitable access to chronic care, particularly for poorer patients.[17][26][15]
• Explore subsidies and taxation to improve the affordability and availability of healthy diets, and incentives for preventive strategies at operational-district and provincial levels.[18][9][26]

Available cost estimates indicate that population-based tobacco, alcohol, salt and dietary measures cost less than 0.40 US dollars per person annually in low-income countries, while an individual intervention package for cardiovascular disease, diabetes and early cervical cancer detection costs less than 1 US dollar per person annually.[40]Peer-educator networks for diabetes management were reported to cost 0.50 US dollars per adult per year, and a Neang Kongrey improved cook-stove cost 1.50 US dollars per unit.[19][20]Human papillomavirus vaccination was considered cost-effective below 10 to 25 US dollars per girl, while the vaccine price offered to GAVI was 5 US dollars per dose.[22]

The indicative activity budget records total planned costs of 1,711,648 for 2013 and 1,722,967 for 2014, but does not identify the currency.[31]It includes specific allocations for palliative medicine availability, a community-based palliative-care pilot, training, pilot evaluation, hospital pain-management assessment, cancer registration, taskforce strengthening, provincial focal-point capacity and multisectoral planning.[39][31]Across the supplied material, no comprehensive total programme budget, expenditure forecast, tax rate, domestic allocation, quantified funding gap or complete economic model is specified.[15][30][31]