Why should we care about WHO?

The World Health Organization’s (WHO) primary role is to offer “science-based recommendations” regarding health policy to countries around the world. Through such recommendations WHO establishes “soft law instruments containing specific, concrete provisions”. In plain language, WHO wields no legal authority and member states are under no obligation to follow those recommendations, but it aims to set accepted standards for global health. WHO’s aims aside, do these recommendations actually matter for policymakers, patients and health system leaders?

Beyond infectious disease

During the COVID-19 pandemic, WHO was a high-profile, closely followed and relevant institution. Despite setbacks and mistakes during the height of the pandemic, the Organization demonstrated its unique capability to maneuver the transnational nature of infectious disease. WHO remains uniquely suited for global health diplomacy, due to its “constitutional mandate for the establishment of norms and standards, [and] high level of legitimacy”. However, this relevance in an immediate international crisis does not necessarily translate to noncommunicable diseases.

In our Pressures and Perspectives report, health policymakers from the EU5 told us that WHO does matter to them, as the recommendations and targets form a framework for national governments to be held to account locally, such as by the media or pressure groups.

Internationally coordinated efforts to address NCDs are relatively recent. At the turn of the millennium, WHO released the Global Strategy for the Prevention and Control of Noncommunicable Diseases. Subsequent agreements followed, such as the 2008 WHO Framework Convention on Tobacco Control and the 2008-2013 Action Plan on the Prevention and Control of NCDs. When it comes to NCDs, the three main tactics that WHO employs to combat NCDs from a treatment perspective (not a prevention perspective), are:

• Policy development: WHO develops evidence-based policies and guidelines, which serve as a blueprint for national health systems to implement appropriate strategies, examples include the WHO Package of essential noncommunicable disease (PEN) interventions for primary health care in low-resource settings
• Setting targets: WHO sets global targets by providing benchmarks and regular assessments, thereby encouraging countries to work towards specific goals and promoting accountability and fostering improvements in national health systems
• Capacity development: WHO assists countries in assessing the capacity of their health workforce to handle NCDs, and providing resources to advise the strengthening of overall health system performance

But how have these policy documents and activities actually impacted national health policy?

25 by 25: a key target

More recently, in 2012, the 65^th World Health Assembly published the resolution for a “global target of 25% reduction in premature mortality from non-communicable disease such as cardiovascular disease, cancer, diabetes, and chronic respiratory disease by 2025”, which was adopted by all 194 member countries.

At the time, it was discussed how challenging this target would be to meet. A paper published in Circulation modelled the region-specific estimates of some elements of the 25 by 25 target and found countries would have to conduct “region- and country-specific priority setting” in the form of identifying local risk factor trends and cost-effectiveness of interventions, and as a result, fund additional investments in health surveillance, in order to achieve the target.

Hypertension target

Within the 25 by 25 target, WHO published eight voluntary global targets designed to aid in the overall goal. These fall under two categories:

• Risk Factors (biological and behavioral)
• National Systems Response

One of these targets, relating to hypertension, one of the most important risk factors for heart disease, stroke and chronic kidney disease is: “25% relative reduction in the prevalence of raised blood pressure”. The same Circulation study mentioned above found all three pillars of global strategy would be necessary in order to achieve this hypertension target: surveillance, prevention and healthcare delivered through strengthened health systems. However, it was noted that the model showed that the impacts of the 25 by 25 target “differ significantly by world region.”

Hypertension globally today

This predicted regional variance has been shown to be true today, in a study published in the Lancet. This study, the first ever comprehensive global analysis of trends in hypertension, shows that although there has not been much change in the rate of hypertension in the world population in the last thirty years, the burden of hypertension has shifted from high-income countries to low- and middle-income countries. Senior author of the study and Professor of Global Environmental Health at Imperial College London, Professor Majid Ezzati, calls this a “public health failure”, citing the fact that hypertension is “easy to diagnose and treat with low-cost medicines”.

Indeed, four classes of hypertension medicines are included within the WHO PEN are explicitly designed to be implemented in ‘low resource’ settings and has been found to be implementable in many countries.

Clearly, even when WHO is developing and monitoring outcomes-based targets, and developing implementable guidance alongside it, this is no guarantee of success.

Hypertension in Sub-Saharan Africa

Hypertension poses a significant burden in Sub-Saharan Africa, affecting 46% of adults aged 25 and over. Rates of systolic and diastolic blood pressure have risen in Sub-Saharan Africa from 1975 to 2015, in contrast to most other regions around the world. In fact, hypertension has been described as “one of the continent’s greatest health challenges after HIV/AIDS”.

In response to WHO’s 25 by 25 hypertension target, the Pan African Society of Cardiology (PASCAR) developed a 10-point action plan, customised for the region, to be implemented by African ministries of health to increase the treatment and control of hypertension by 25% in Sub-Saharan Africa by 2025. The plan involves strategies for implementing hypertension into existing health services, such as those for HIV, as well as task-sharing with trained community health workers.

In South Africa, hypertension prevalence is growing substantially, and healthcare services are struggling to cope with the expanding disease burden. Task-shifting, as suggested by the PASCAR action plan, is being considered to reduce burden in overloaded clinics. South Africa historically has substantial experience with task-shifting, something else that WHO has advocated for, particularly in the context of working with HIV-infected patients. The implementation of such a policy change in the country could result in significant improvements in hypertension management and care.

WHO matters

This South African example underscores the considerable potential of WHO targets to drive local action. WHO may wield no formal legal power over states, but it clearly drives action. It plays an influential role in framing the discourse on NCDs and prompting further implementation and practice change. However, as we’ve seen, successful implementation depends on regional and local actors deploying evidence, argumentation and guidance from WHO.

The last few years have seen an increase in targets, guidance and reports on NCDs from WHO. On current trends, we would only expect that to increase. If done well, this could lead to more global to local action on NCDs and better outcomes for patients around the world.