With a political declaration on non-communicable diseases (NCDs) on the agenda of the World Health Assembly, we unpack the WHO’s  “Best Buys” that provide countries with tools to address the diseases that are responsible for three-quarters of global deaths

Health Policy Watch: The WHO’s “Best Buys” to prevent and control NCDs comprise 90 interventions, which can be overwhelming to countries that don’t have many resources. What are the key interventions?

Nandita Murukutla: Countries have much to gain by implementing policies aimed at preventing noncommunicable diseases (NCDs), the world’s biggest killers. WHO’s “Best Buys” are interventions that are inexpensive for governments to implement, including those that target behavioural risk factors such as tobacco use, unhealthy diets, alcohol consumption and inadequate physical activity.

These risk factors often share common policy solutions. The effectiveness of excise taxes, marketing restrictions and labelling policies, for instance, have been demonstrated to reduce the consumption of unhealthy products. Were governments to adopt the recommendations as official policies, they could, in a unified and coordinated approach, significantly reduce the proliferation of unhealthy products and make an impact on the growing trajectory of NCDs, including heart and lung disease, diabetes, and cancers.

HPW: What measures would you advise a low-income country that is facing increasing obesity and diabetes to adopt?

Murukutla: Globally, we have undergone a massive nutrition transition, with more and more ultra-processed foods in our diets. This is a disaster for health. Unhealthy diets—those high in sugar, salt and fat—are responsible for an estimated 11 million preventable deaths each year.

Most governments are failing to take advantage of proven public health interventions that can prevent today’s most common drivers of disease and death. Healthy food policies such as sugary beverage taxes, front-of-package warning labels and marketing restrictions are effective. Sugary drink taxes are a triple-win, cost-effective policy option that can improve population health, increase government revenue and reduce health care and environmental costs. The latest worldwide, systematic review, authored by Andreyeva et al. in 2022, found sugary drink taxes have been associated with significantly increased prices on targeted beverages and 15% lower sales of sugary drinks, with no negative impact on employment.

Reducing sugary drink consumption can especially benefit lower-income populations, who in many places experience obesity and other NCDs at higher rates. Taxes on sugary drinks generate significant revenue that can be used to enhance access to healthy food, health care or other public services.

 There’s hope. In countries that have taken up healthy food policies, we are seeing better diets and improved overall health as the policies reduce demand for unhealthy foods and beverages. More countries should follow.

HPW: What do the “commercial determinants of health” really mean?

Murukutla: Commercial determinants of health are the systems, practices, and pathways through which commercial actors drive health and inequity.

Tobacco, alcohol and ultra-processed foods contribute to the most common NCDs. The industries that produce and market these products use their considerable resources to influence governments to reject or soften restrictions on their products.

The burden of unhealthy products falls heaviest on countries and communities that are least able to manage the effects because of historically poor access to nutritious food and weak infrastructure buckling under the demands of planetary damage. These structural inequalities perpetuate a cycle of chronic disease that shows no signs of slowing. Meanwhile, profits for commercial actors keep climbing.

The situation is urgent. The actions of multinational companies are not only going to further undermine people’s health—they’re going to undermine development and result in serious economic costs for countries.

HPW: Tobacco control is one of the global success stories. What are the key elements behind this success?

Murukutla: Tobacco control offers a clear example of how the public health community achieved huge policy wins and a strong public understanding of the consequences of consuming a dangerous product.

Since 2007, global smoking rates have fallen from 22.7% to 17.5%. Global cigarette sales have also plummeted, with 750 billion fewer cigarettes sold in 2021 compared to 2012, and 57 countries have implemented smoke-free laws.

There are several reasons for these successes: The World Health Organization’s Framework Convention on Tobacco Control brought countries together in a global treaty to reduce tobacco use. This, alongside steady and committed investments and the implementation of WHO’s technical package, MPOWER, put the focus on smoke-free policies, pack warnings on tobacco products, and media campaigns designed to change risky behaviors and build support for healthy policies.

While global smoking rates are dropping, tobacco remains a serious health threat. Tobacco taxes are still greatly underused worldwide despite being the most effective intervention to reduce purchases. In addition, the tobacco industry continues to try and expand their reach and profits by targeting countries with the weakest regulatory environments and pushing novel products in previously untapped markets.

HPW: While alcohol is widely taxed, it appears to have evaded many of the legislative measures that tobacco has faced—despite the fact that it has significant health costs, and it is a key driver of disease, car crashes and interpersonal violence, particularly in low- and middle-income countries. Is this accurate and is this changing?

Murukutla: Alcohol is a leading driver of deaths, resulting in three million deaths worldwide each year. The immense toll of death and disability makes alcohol use among the top 10 risk factors for mortality. And yet, compared to tobacco, the global effort to address the harms of alcohol is markedly subdued.

We know what works to tackle the harmful use of alcohol: Effective, evidence-based measures are available to all countries. Yet alcohol has faced fewer legislative measures compared to other commercial determinants of health, despite its significant health costs and contribution to injuries and violence.

Slower progress in the accumulation and publication of information, particularly information as outlined in the WHO’s SAFER technical package, is one issue. Policies outlined in SAFER include taxation to raise the cost of alcohol—the gold standard, as well as regulating the availability of and access to alcohol to avoid underage consumption and excess drinking. It’s also important to restrict alcohol advertising, especially when it’s aimed at youth and women.

From a global perspective, there has been little and fragmented movement and no major investment to tackle the harms of alcohol. Nonetheless, many countries have made progress, including Scotland, Ireland and Russia.

 The current alcohol environment is changing as more and more guidance has emerged. A new initiative, Vital Strategies’ RESET Alcohol, works to reduce alcohol-related harms in hard-hit countries through policy change.

HPW: Most countries face some economic pressure from “unhealthy” sectors – such as the ultra-processed food industry and sugar producers – not to act against them, with threats of economic consequences and job losses. What role can the WHO and others play to protect countries from corporate influence? 

Murukutla: We would argue that it is not just “some” pressure but a significant amount of it. In fact, a paper in Social Science & Medicine shows that corporate influence is among the chief reasons for the delay in the implementation of the best buys. The producers of unhealthy commodities including tobacco, alcohol, and ultra-processed foods have a direct stake in maintaining their markets and will attempt to dilute and derail WHO’s recommended policies and best buys at every step of the process.

That is why it is imperative that governments dictate policies—with the support of trusted actors such as civil society organizations—to prevent efforts by self-interested commercial entities to undercut proposed solutions to address NCDs. 

At this week’s World Health Assembly, it’s critical we recognize that even the latest iteration of the best buys leaves room for improvement. Corporate influence has been identified as key reason for the poor implementation of NCD policies in countries around the world. WHO must recognize conflict-of-interest policies as a core intervention – not just an aspirational goal. I wrote more about this in a previous op-ed for Health Policy Watch.

Global advocates must also hold the process accountable. WHO leadership must welcome this committed activism and collaboration by offering recommendations with real potential to thwart industry influence and support countries in their efforts.

Dr Nandita Murukutla is the Vice President of Global Policy and Research at Vital Strategies.

Kerry Cullinan asked the questions.

Image Credits: Medtronics, Kerry Cullinan, Taylor Brandon/ Unsplash, Vital Strategies.