Lessons from the Field

Abstract

The Republic of Palau is a small island nation in the North Pacific with a population of 17,501. The islands of Palau are geographically isolated, considered rural, and medically underserved. The prevalence of non-communicable diseases (NCDs) and risk factors are very high and account for more than 75% of all deaths and disabilities. Recognizing that the high rates of NCDs are undermining health and sustainable development of the nation, Palau declared a state of health emergency due to the epidemic of NCDs. It was recognized during the development of the NCD Prevention and Control Strategic Plan of Action 2015–2020 (Palau NCD Plan) that improved collaboration between government agencies, civil society, and the private sector was needed to address this epidemic. A multi-sectoral solution was needed to address a multi-sectoral problem. Through Presidential Executive Order, the National Coordinating Mechanism for Non-Communicable Diseases (CM) was established to mobilize sufficient resources and coordinate actions to prevent and control NCDs, ensure successful implementation of the Palau NCD Plan, the World Health Organization Framework Convention on Tobacco Control, and other related plans and commitments, align such plans to national policies, ensure a health-in–all-policy approach to address health inequities, and bridge the gap between health and quality of life. Though the CM is young, improved coordination between agencies and accelerated action has taken place. Legislation was enacted that mandates 10% of alcohol and tobacco taxes be directed to NCD prevention through the Coordinating Mechanism, thus ensuring sustainability.

Background

The Republic of Palau (Palau) is located in the North Pacific Ocean, 722 miles southwest of Guam and 528 miles southeast of Manila, Philippines. The capital was relocated from the State of Koror to Ngerulmud, Melekeok in 2006; however, Koror remains the economic center where two-thirds of Palau's 17,501 population reside.¹ About 73.5% of the nation's residents are of Palauan ethnicity, followed by Filipinos making up 16% of the population.¹ Approximately 15% of the population has a college bachelor degree or higher.¹ Palau is considered a lowincome country with 60% of households making less than $20,000 annually.²

The prevalence of non-communicable diseases (NCDs), including injuries, and risk factors in Palau are very high and account for more than 75% of all deaths and disabilities on this small island nation.³ There are alarming rates of smoking and alcohol use among youth, betel nut chewing with tobacco, binge drinking, low consumption of fruits and vegetables, physical inactivity, obesity, hypertension, and diabetes in adults (Table 1).^4–6

Table 1.

NCDs and Risk Factors Profile for Palau^4–6

Indicator	Overall prevalence	Males	Females
NCD mortality	Over 70% of all deaths in 2003–2012
Smoking, current, adults	17%	24%	8%
Smoking, current, youth	41%	58%	42%
Betel nut + tobacco, adults	63%	60%	66%
Smokeless tobacco use, youth	29%	31%	27%
Current alcohol consumption, adults	37%	50%	23%
Current alcohol consumption, youth	43%	51%	38%
Binge drinking, adults	Male 43.5% Females 16.6%	44%	17%
Binge drinking, youth	33%	40%	26%
< 5 servings fruits and vegetables, adults	92%	94%	90%
No recreation-related physical activity, adults	52%	42%	62%
Raised blood pressure (measured)	49%	53%	44%
Raised blood glucose (measured)	20%	21%	20%
Overweight/obesity, adults	77%	78%	76%
Raised cholesterol, adults	23%	29%	26%

Adults = 25–64 years old; Youth = 13–25 years old

Recognizing that the high rates of NCDs are undermining health and sustainable development in the nation, Palau, along with the global community, declared a “state of health emergency due to the epidemic of NCDs”.⁷ Progressing from political commitment to action, the government and community stakeholders set national targets, specific goals and objectives, and identified evidence-based and cost-effective strategies in the revised NCD Prevention and Control Strategic Plan of Action 2015–2020 (Palau NCD Plan) during a strategic planning workshop in 2014. Stakeholders understood that collaboration was key to the effective implementation of the Palau NCD Plan and that it was critical to establish a governance framework that could facilitate and allow partners to work together to develop and implement strategies that promote and protect public health. For many years, the Palau Ministry of Health has taken the lead in responding to the NCD crisis, and most health promotion strategies took the form of education and awareness campaigns. Stakeholders at the strategic planning workshop further recognized the complex nature of NCDs and health as determined by social, economic, and cultural factors, that a call for a health-in-all-policy approach was needed, and that collaboration among the “whole of government and society” was necessary. This collaboration was necessary to ensure mobilization of sufficient resources and implementation of sustainable strategies to create environments that support and protect healthy behaviors and lifestyles, which in turn would help to address the health inequities that have led to the high rates of these debilitating conditions.⁸ Parties to the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) also recognized this need for multi-sectoral coordination to address tobacco control issues as articulated in the Treaty's Article 5.2(a) — Palau is a Party to this Convention.

The call to action, resulting from the 2014 strategic planning workshop, was to establish a system or mechanism to focus a multi-sectoral response to the NCD crisis that faces Palau. The prevention and control of NCDs go beyond the health sector and successful intervention requires collaboration across sectors within governments and the community. Health promotion goes beyond the individual and interventions must also be directed at social and physical environments that can either support or deter health; these include interpersonal, organizational, community, and public policy change strategies.⁹ Therefore, in addition to strengthening the health sector to respond effectively to the healthcare needs of people with chronic conditions, sectors outside health such as finance, education, justice, and infrastructure can influence or adopt public policies that address risk factors. Examples of such policies include those that reduce access to and affordability of alcohol and tobacco, such as advertising bans of these products, raised alcohol and tobacco excise taxes, the enforcement of existing regulations such as ones on tobacco sales to minors, and the augmenting of the environment to promote physical activity.¹⁰ Despite historical partnership between government agencies and various civil society groups to address common goals like the prevention and control of NCDs, without consistent or more formalized coordination among the partners, there were duplication of efforts, wasted or untapped resources, and a lack of policy coherence.

Methods

During the NCD strategic planning workshop in March 2014, the planning committee ensured that several presentations relayed information on the critical need for a comprehensive and multi-sectoral response framework. With resource materials (eg, Centers for Disease Control and Prevention [CDC] Four Domains on Chronic Disease Prevention and Health Promotion, WHO FCTC, and Pacific Island Health Officers Association's NCD Policy Toolkit) from technical advisors and the University of Hawai‘i and Coalition for a Tobacco Free Palau, workshop presenters gave in-depth information on the different roles that each government agency, community-based organization, or non-governmental organization could play within the entire scheme of the response. Information was presented on how, for example, the Ministry of Public Infrastructure, Industries and Commerce could influence the design and development of roads to promote walkability and physical activity in Palau. In addition, other presenters explained how the Ministry of Finance was responsible for promulgating tobacco tax regulations as well as having the power and information to influence further increases in both tobacco and alcohol taxes. Each of Palau's eight Ministries and several civil society groups were provided examples of what they already do with respect to NCD prevention and what more they could do. This served to illustrate that there was a need for responses to the NCD crisis from other non-health sectors. A small work group (WG) comprised of Ministry of Health chronic disease program staff and partners from community health coalitions was tasked to consult with more stakeholders to finalize the Palau NCD Plan by the end of 2014 and to facilitate the development of an implementation framework. Stakeholders had suggested such an approach during the workshop out of concern for the successful implementation and evaluation of the Palau NCD Plan and after the realization that an effective NCD crisis response called for multi-sectoral, multi-level actions.

Initial discussions and brainstorming sessions resulted in the idea of a mechanism that would not limit membership but would include relevant government agencies, civil society, and private sector organizations to come to the table and take responsibility for actions that would contribute to the prevention and control of chronic diseases and the promotion of health. The WG organized another workshop to explore ideas and models of such a mechanism and invited a few organizations (largely from the environmental arena) to present their experiences. The WG found limited literature and documented experiences from other countries who have tried to establish similar structures. Formal and informal committees, coalitions, and similar mechanisms were examined and discussed. Participants to this second workshop agreed that a formalized mechanism (eg, formal policy, Executive Order, or legislation), as opposed to a voluntary and informal coalition, would result in stronger support and commitment, at least from the government. Discussions during these two workshops explored why Palau needed stronger commitment and action through this formal mechanism. The increased rates of NCDs globally, regionally, and locally secured Palau's political commitment; yet, work was needed to accelerate action. Initially, many partners were unsure of their roles in the NCD response. Second, the community coalitions did not have strong administrative support, and volunteers, most of whom worked full-time, were stretched to their limits. With a formal mechanism in place, an administrative arm could be mandated and assigned to coordinate and move the activities forward.

Through a year-long series of workshops, meetings, and stakeholder engagement, this mechanism of coordination was developed. Toward the end of 2014, the workgroup drafted terms of reference (ToR) including background information that supported the mechanism, its purpose, membership of the government sectors and civil society that played key roles in disease prevention and health promotion, membership terms, member roles and responsibilities, establishment of a secretariat and working groups, and reporting requirements. With help from the Office of the President and a legal advisor from the Ministry of Health, the ToR were finalized. From January to May 2015, the ToR were presented to Palau's leadership and more partners for review.

Results

As a result of the extensive preparatory work by all stakeholders, the President of Palau signed Executive Order No. 379 in May 2015 “to create a National Coordinating Mechanism to facilitate and coordinate the Government of the Republic of Palau's efforts to combat the occurrences and impacts of non-communicable diseases in the Republic of Palau”, and to engage appropriate civil society and private sector organizations to ensure a “whole of society” approach to the NCD response. The Coordinating Mechanism for Non-Communicable Diseases (CM) was established to mobilize sufficient resources, coordinate actions to prevent and control NCDs, ensure successful implementation of the Palau NCD Plan, the WHO FCTC, and other related plans and commitments, align such plans to national policies, ensure a health-in–all-policy approach to address health inequities, and bridge the gap between health and quality of life.

Membership includes representation from the Office of the President and the entire Executive Branch (education, health, justice, tourism, environment, commerce and trade, public infrastructure, culture, community and state, and finance), as well as from academia, public health insurance, traditional leadership, early childhood education, youth, conservation, farmers’ association, parents’ and families’ associations, students’ association, principals’ association, employers’ alliance, Red Cross, the various health coalitions (tobacco, behavioral health, early childhood, HIV/Sexually Transmitted Infections, community health centers, and cancer), and technical advisors. There are currently 32 active members serving this committee.

A five-member secretariat provides administrative support to the CM. Two of the members are from the Ministry of Health's Non-Communicable Disease Unit and the Prevention Unit within the Bureau of Public Health. The other three secretariat members are chosen by the CM members and serve for two years. During the first year, Ministry of Education, Ministry of Finance, and Ministry of Public Infrastructure, Industries and Commerce also served on the secretariat. A chairperson is elected and serves a year-long term. Members serve on a twoyear rotational basis but may be elected to remain by the head of their respective organizations.

The CM subsequently established Working Groups (WGs) for each of the four major NCD risk factors (tobacco, alcohol use, physical inactivity, and unhealthy diets), a fifth on metabolic risk factors (high glucose and lipids and hypertension), and a sixth on monitoring and evaluation. Members of these WGs are assigned by CM members and there can be more than one WG member from each organization, depending on their roles in the response. For example, the CM recommended that the Ministry of Justice assign two of their staff, one for the alcohol WG and another for the tobacco WG. Palau Community College recognized a need to assign its staff to each of the four major WGs. During one of the CM's early meetings, a substantial amount of time was spent discussing membership and purpose of these working groups.

For the first year of the Palau NCD Plan (October 2015 – September 2016), the CM members determined annual activities from the Plan; however, when the working groups were established, their members were tasked to set their own annual action plans; each working group had set annual activities for year 2 (October 2016 – September 2017) and submitted a proposed budget narrative to the CM for review and approval before submission to the Palau Congress in July 2016. WG members meet between the quarterly CM meetings, once a month or more depending on the activity being implemented.

However, at times, a working group might work more through email or other means, depending on the type of activity. It was decided by the CM that the secretariat provide administrative support to the WGs, coordinate their meetings, provide relevant information to the members, and document and report on their progress to the CM every three months. However, the intent was to build the capacity of working group members to lead the implementation of activities on their own within 12–18 months.

Results of a mid-year evaluation of the CM's first year and the implementation of the Palau NCD Plan reveal over 70% participation rate from CM members, timely implementation of annual activities, and documentation and dissemination of meeting minutes, progress reports, and other pertinent information. Finally, because of the strong NCD Plan and the existence of an organized NCD coordinating mechanism, CM members were successful in allocating 10% of alcohol and tobacco tax revenues towards NCD prevention and health promotion activities through Palau Public Law (RPPL) 9-57. To distribute the funds, the CM will review proposed programs from government and community organizations according to agreed upon selection criteria and submit a budget request to the Palau Congress for approval. Funds are non-lapsing and projected to be up to $1,000,000 every year.

Conclusions

Although the CM is still early in its life, it has far reaching potential. Having a formalized mechanism in existence is significant and the allocation of ten percent (10%) of tobacco and alcohol tax revenues to NCD prevention activities through the CM is landmark legislation. More government organizations are taking action within their respective areas to promote health (eg, the Cabinet has requested that all the Ministers, Directors, and Chiefs be screened for NCDs). The Ministry of Education has revised its physical education curriculum and implemented innovative ways to increase physical activities in schools. More CM member organizations and individuals in the community are taking steps to ensure that meals provided during meetings or in public gatherings are healthier. For example, the public schools’ food service program has revised its menu to ensure healthier meals for students. Recently, a school cook was recognized as an employee of the year for her work and her efforts to ensure that lunches served in the cafeteria are “NCD free”. There is increased networking, sharing, and coordinating of activities.

The established mechanism has underscored the fact that NCDs are not the concern of only the health sector but very much entrenched in daily lives, work, customs, policies, and environments. Changes have already been noted, especially in how people feel about the shared responsibility in working towards a healthier Palau. There is also an overall increase in networking and coordination of activities addressing the NCD epidemic. Coordination of multiple partners is accomplished through the existing multi-sector NCD and Comprehensive Cancer Control Coalitions which have shared goals. Sustainability is ensured, in part, by involvement of the grass roots sector, cultural alignment with all interventions, support by traditional leaders, and support from Palau's Government.

Lessons Learned and Next Steps

Support from the Republic's leadership has been key as well as the engagement of stakeholders every step of the way. Other lessons learned indicate that a strong administrative arm is necessary to sustain coordination and communication among partners. The two Ministry of Health chronic disease programs were designated by the Minister of Health to be permanent secretariat members to this mechanism, tasked to provide administrative and technical support to the members and working groups. Capacity building from the start has been another important lesson. During the first meeting, members were provided a detailed presentation of each of their roles, what they were already doing, and how they fit into the response. This helped to make the case for multi-sectoral action.

However, there remains work to be done to form a firmer understanding of health and the broader social determinants of health and disease. Not yet completed is a code of conduct for members that will ensure no interference from tobacco, alcohol, or junk food industries or their representatives to influence public policy. Continuing technical assistance and capacity building for members is also warranted so that the burden is not placed on the few who are well-informed, resulting in burn out. It is necessary that these select few share their responsibilities for effectiveness and sustainability. The high level of political support and early engagement from stakeholders, in combination with a secure funding stream, should contribute greatly to the sustainability of the mechanism.

Conflict of Interest

None of the authors identify a conflict of interest.