Hon. Dr. Rajitha Senaratne is the current Minister of Health of the Democratic Socialist Prevention Control and Diseases of Noncommunicable Republic of Sri Lanka and Cabinet Spokesman of the Government. He was elected as a Vice- Prevention and Control of Chair of the Executive Board of the World Health Organization for a term of one year, in May 2018. As a Member of Parliament for over 22 years, from 1994, he has held many portfolios; Noncommunicable Diseases Minister of Lands (2001 – 2004), Minister of Construction and Engineering Services (2007 Think Globally-Act Locally; Lessons from Sri Lanka -2010) and Minister of Fisheries and Aquatic Resources Development (2010-2014). In 2015 Think Globally-Act Locally; Lessons from Sri Lanka he was re-elected to parliament from the Kalutara District, securing the highest number of preferential votes and was appointed to the Cabinet as the Minister of Health.He graduated from the University of Peradeniya, Sri Lanka as a Dental Surgeon in 1974. He was a student leader and the General Secretary of the Inter-University Students Federation from 1971 to 1973 and represented the then Prime Minister of Sri Lanka in the Sri Lanka Delegation to the Asian Youth Conference in 1973, in Japan. He was the Hon. Secretary of the Government Dental Surgeons Association for 14 years from 1975 to 1989 and was a popular trade union activist. In 1992, he was awarded the Fellowship of the International College of Continuous Dental Education. He is a NCD champion and has provided steadfast political leadership for NCD Prevention and Control in Sri Lanka. After assuming duties, he continued the work of his predecessor in the fight against tobacco and enforced 80% pictorial warning soon to be followed by an upward revision of tax on tobacco and plain packaging. Setting up of the National Medicine Regulatory Authority was another move he took towards reducing the price of drugs and wastage, in line with the drug policy espoused by Prof. Senaka Bibile. As a result, the price of 48 mostly used drugs have been slashed making medicines more affordable to people. He has been successful in raising funds for the rehabilitation of hospitals and primary health care units island wide and has also taken steps to regulate fees charged for health services in the private health sector. Professor Shanthi Mendis served the World Health Organization (WHO) for 20 years as Senior Adviser, Noncommunicable Diseases (NCD) and in other senior capacities. She was Professor of Medicine, University of Peradeniya, Sri Lanka before joining WHO on a Rockefeller Global Health Leadership Fellowship. During her tenure in WHO, she led and coordinated the development of the global NCD action plan 2013, the global NCD report (2014) and the global programme on NCDs and cardiovascular diseases. She graduated in 1974 with First Class Honours from the University of Peradeniya, Sri Lanka and specialized in Internal Medicine, Edited by: Cardiology and Public Health in the UK and USA. She practiced Clinical Medicine and Cardiology in the UK, USA and Sri Lanka and is a Fellow of the Royal College of Physicians of London and Edinburgh and a Fellow of the American College of Cardiology. In 2005, she Rajitha Senaratne & Shanthi Mendis was awarded National Honours for her contribution to research in Sri Lanka. In her medical career spanning 44 years she has gained wide experience in the fields of Global Health, Cardiology, Medical Education and Operational research. She has coauthored 5 books, many book chapters and has published over 150 papers in peer reviewed international journals. https://scholar.google.com/citations?view_op=list_works&hl=en&user=NlYS3EUAAAAJ Edited by: Rajitha Senaratne & Shanthi Mendis 2018 Ministry of Health, Nutrition and Indigenous Medicine, Sri Lanka Credits and Permissions listed in Annex 2. Citation: Rajitha Senaratne & Shanthi Mendis (Editors). (2018). Prevention and Control of Noncommunicable Diseases: Think Globally - Act Locally; Lessons from Sri Lanka. Ministry of Health, Nutrition and Indigenous Medicine, Sri Lanka. ISBN 978- 955 -3666-20 - 8 Prevention and Control of Noncommunicable Diseases Think Globally - Act Locally; Lessons from Sri Lanka Editors: Rajitha Senaratne & Shanthi Mendis i ii Contents Acronyms and abbreviations v Preface vii Contributors ix Executive summary xi PART I Chapter 1 Sri Lanka today: A snapshot 3 Chapter 2 Spending for health: Where, what and by whom? 21 PART II NCD targets and SDG targets 47 Chapter 3 National NCD target 1: Reduce premature mortality 53 Chapter 4 National NCD target 2: Reduce harmful use of alcohol 69 Chapter 5 National NCD target 3: Reduce physical inactivity 89 Chapter 6 National NCD target 4: Reduce salt consumption 109 Chapter 7 National NCD target 5: Reduce tobacco use 123 Chapter 8 National NCD target 6: Reduce prevalence of hypertension 143 Chapter 9 National NCD target 7: Halt obesity and diabetes 159 iii Chapter 10 National NCD target 8: Prevent heart attacks and strokes 183 Chapter 11 National NCD target 9: Improve access to medicines and technologies 203 Chapter 12 National NCD target 10: Reduce air pollution 217 PART III Chapter 13 Other cost effective NCD interventions and key partnerships 237 Chapter 14 Journey to tackle NCDs in Sri Lanka: Lessons learned 255 Annex 1 269 Annex 2 287 Subject index iv Acronyms and abbreviations CCS Country Cooperation Strategy CKDu chronic kidney disease of uncertain etiology DHS Demographic and Health Survey FCTC WHO Framework Convention on Tobacco Control FHB Family Health Bureau HIES Household Income and Expenditure Survey HPV human papillomavirus HTA health technology assessment LKR Sri Lankan rupee MCH maternal and child health MDG Millennium Development Goal MoH Ministry of Health, Nutrition and Indigenous Medicine NATA National Authority on Tobacco and Alcohol NCD noncommunicable disease NHA National Health Accounts NMRA National Medicines Regulatory Authority OOPE out-of-pocket expense SDG Sustainable Development Goal SSB sugar-sweetened beverage UNICEF United Nations International Children's Emergency Fund WHO World Health Organization v Preface Since Sri Lanka gained independence in 1948, all governments that came into power have steadfastly continued to support the provision of free health care and free education to people. This has paid rich dividends exemplified by high levels of literacy of the population and many public health successes. These include very low maternal and neonatal mortality rates, elimination of many communicable diseases such as malaria, and increased life expectancy. Despite these achievements, challenges persist and newer ones have emerged. Currently, Non-Communicable Diseases (NCDs), constitute a major public health challenge threatening the well-being of people and sustainable development of Sri Lanka. The challenge of NCDs is compounded by the increasing proportion of the elderly in the population. Addressing the complexity of risk factors of NCDs - tobacco use, physical inactivity, harmful use of alcohol, unhealthy diet and air pollution - requires multisectoral responses which are challenging to implement. In this regard, over the last two decades Government of Sri Lanka has strived to provide strategic leadership for tackling NCDs by promoting greater policy coherence and coordination across government. Actions to address NCDs have engaged all stakeholders, including civil society and the private sector. Although much remains to be done, as documented in this publication, Sri Lanka has overcome tough obstacles and has made commendable progress in tackling the risk factors of NCDs. In addition, considerable investments are being made to reorganize Primary Health Care to better manage NCDs and to achieve Universal Health Coverage. High level political commitment is driving the implementation of political commitments made in 2011 and 2014 at the United Nations General Assembly on the Prevention and Control of NCDs, as part of the national response, in the overall implementation of the 2030 Agenda for Sustainable Development. This document, ` Prevention and Control of Noncommunicable Diseases : Think Globally, Act Locally ; Lessons from Sri Lanka` comes at a time when the United Nations General Assembly is convening the 3rd High Level Meeting on NCDs on the 27th of September 2018 vi in New York, in order to take stock of the global progress in tackling these diseases. Sri Lanka has been a forerunner in the implementation of global public health treaties and through this publication, aims to further its contribution to global health and prevention and control of NCDs, by sharing best practices and disseminating lessons learned. Editors Dr. Rajitha Senaratne Minister of Health, Nutrition and Indigenous Medicine, The Democratic Socialist Republic of Sri Lanka. Prof. Shanthi Mendis Former Senior Adviser NCDs World Health Organization, Geneva, Switzerland. vii Contributors: Noncommunicable Diseases Unit: Champika Wickramasinghe (Deputy Director General/ NCD), Tilak Siriwardana, Virginie Mallawaarachchi Ministry of Health: Sujatha Senaratne (Private Secretary to the Hon. Minister of Health), Anil Jasinghe (Director General of Health Services), Lakshmi Somatunga (additional Secretary/ Pubic Health Directorate), S. Subasinghe (Adviser) Environmental and Occupational Health Directorate: Lakshman Gamlath (Deputy Director General/ Environmental & Occupational Health), I. Suraweera, S. Dhanapala Family Health Bureau: Ayesha Lokubalasooriya, Nethanjali Mapitigama National Cancer Control Programme: Sudath