Considering that the prevention and control of NCDs require multisectoral collaboration at the national, regional, and international levels, it is important to examine the actions and perspectives of actors involved in GHD for NCDs. The present qualitative study investigated this using the framework of the emergence and effectiveness of global health networks. Three general domains were investigated, including the features of the network and the actors, the policy environment, and the characteristics of the issue.
In this study, the features of the network and the actors involved in NCDs prevention were identified and divided into four main categories: leadership, governance, composition, and framing of strategies. Shiffman has mentioned that “network and actor features” are associated with factors internal to the network, inclusive of strategy and structure, and attributes of the actors that constitute the network or have a function in creating it [20]. The present study showed that the leadership role in the network of NCDs actors is mostly played by the UN and especially WHO. Due to the rising trends in mortality from NCDs, WHO has declared NCDs as one of the top health priorities of countries for the last two decades [2] and has requested policymakers to develop effective strategies to stop NCDs [22].
With the recent efforts of the UN, WHO, and the heads of countries to tackle NCDs at the global level, goals and policies related to the prevention and control of NCDs have been designed, and various mechanisms and guidelines/recommendations have been created that represent the official policy of these are organizations [23]. For example, the Global Coordination Mechanism on the Prevention and Control of NCDs will accelerate the implementation of the WHO Global Action Plan NCDs prevention and control and NCDs-related SDGs by promoting high-level commitments on NCDs at the local, national, regional, and global levels. This global mechanism brings together a wide range of stakeholders, identifies and strengthens partnerships, and seeks to find innovative solutions to reduce NCDs through five key activities: advocating and raising awareness; dissemination of knowledge and information; encouraging innovation and identifying barriers; advancing multisectoral actions; and advocating for mobilization of resources [24].
The next feature of the global NCDs prevention and control network is its type of governance. The highly complex nature of NCDs requires complex strategies that can only be implemented with strong governance. Since the highest level of each country is responsible for developing policy guidelines and garnering the political will to support collaboration in the field of NCDs, a comprehensive multisectoral mechanism should be established at the highest level. The most effective public health interventions consist of an evidence-based technical package that is a combination of actions at different levels that together will lead to progress in the prevention and control of NCDs [25].
This study proposes a comprehensive intersectoral mechanism for the governance of NCDs prevention and control at the national level, consisting of a high-level council, an advisory group, and an executive committee (Fig. 2) with five responsibilities: research, policy-making, advocacy, implementation, and monitoring (Fig. 3). Various national mechanisms have been established in different countries. The Health Sciences Authority (HAS) in Singapore, established in 2001, coordinates national health promotion efforts and disease management programs to reduce NCDs by involving multiple sectors [26]. The National Health Commission (NHC) in Thailand is also a cross-sectoral mechanism that is chaired by the Prime Minister and includes three broad sectors—government, academia, and civil society—to emphasize health promotion and support the development of healthy public policies [27].
Proposed coordination mechanism for NCDs.
The proposed model for the responsibilities of a multisectoral NCDs mechanism
The next issue in the global NCDs prevention and control network is the composition of actors. Since the health sector alone has the role of calling and bringing together other sectors and requires the advocacy of all actors, the right composition and overall design must be determined in line with a comprehensive national response that also requires strong health diplomacy. Comprehensive multisectoral NCDs action in Iran also requires a collaborative approach that combines the contributions of all relevant stakeholders. Hence, by involving several government agencies, a ‘whole-of-government’ or ‘health in all policies’ approach can be implemented to influence public health policy [8].
A study in India proposes a mechanism for multisectoral action on NCDs that engages various government agencies such as ministries of health, finance, housing, education, agriculture, urban and rural development, transport, commerce, environment, information, and broadcasting. The prime minister is at the core of this mechanism to ensure effective coordination. NGOs link government programs and the community and play an important role in this multisectoral mechanism [28]. The global commitment to tackling NCDs has resulted in the development of strategies such as a multi-stakeholder structure as a holistic platform to enable transparency and accountability to negotiate policy space for NCDs [29].
The tendency to advocate for a whole-of-society approach and promote public-private partnerships without establishing a robust system for managing conflicts of interest is the worst possible combination from the perspective of many NGOs and public health advocates [30]. Given the relative lack of evidence that industry self-regulation or public-private partnerships are effective in reducing NCDs risk factors, the current form of multi-stakeholder collaboration that is guiding global NCDs policies toward voluntary action and public-private partnerships rather than government regulation is worrying [31]. Suzuki et al., in an analysis of the influence of stakeholders on political declarations on NCDs, found that NGOs, academia, and low and middle-income countries (LMICs) countries generally pursue “stricter” governance of NCDs risk factors, while the private sector and high-income countries generally oppose more restrictions on commercial activities and promote a whole-of-society approach that includes cooperation with the private sector [30].
In the present study, three general strategies were identified that the global network and actors in NCDs prevention and control should focus on. The first strategy is that people should be the focus, not the disease. Many NCDs can be controlled by adopting a healthy lifestyle. Community interventions are very useful in reducing these types of diseases because they have a direct impact on everyday life and can be tailored to complex situations [32]. Therefore, community interventions are essential elements in health promotion and NCDs prevention. The effectiveness of interventions has been documented at different ages [33, 34], in different community settings [35], and in different countries [36], for various risk factors such as obesity [37, 38], and public participation in vaccination programs [39].
The second strategy is to continuously inform people about healthy products, behaviors, and lifestyles. In this regard, two distinct and effective functions can be defined for GHD in the area of NCDs prevention and control. Raising awareness, changing discourses, and adopting better educational approaches can change attitudes and increase public demand on the agenda and policies of countries. Therefore, it is possible to influence health policies by promoting health literacy and advocacy by social actors such as NGOs. On the other hand, increased awareness and lifestyle changes will enhance public health in the country. In addition, NGOs and civil society organizations play a prominent role in promoting NCDs prevention and control policies by producing evidence, advocating, and providing technical and financial assistance [16]. Therefore, it is necessary to adopt a comprehensive approach to the development of informal health diplomacy by changing attitudes and promoting healthy lifestyles, and using new diplomacy tools such as social media and social networking.
The third strategy relates to resource mobilization and promotion of investment at the national level to strengthen multisectoral collaborations and support the implementation of cost-effective interventions in NCDs programs. Prioritizing affordable, actionable, fair, and evidence-based interventions will bring the highest return on investment for public health in line with national priorities and will put countries on the path to achieving SDGs [40]. Jackson-Morris and Nugent provide a model of support for national NCDs policy and program in which investment is a key component. This model emphasizes working with national stakeholders to select the most effective and cost-effective policies and programs for a specific national context, identifying sustainable sources of funding, and creating a costed and actionable implementation plan [41], which are consistent with the present findings.
The second dimension in the framework of the emergence and effectiveness of the global NCDs network is the policy environment. The information obtained from the interviews regarding the policy environment and the diplomacy context for NCDs prevention and control was categorized into three main themes: allies and opponents, funding, and norms. The policy environment relates to factors external to the network that shape both its nature and the effects that the network hopes to produce. It is assumed that networks do not operate in a vacuum; rather, they are shaped by outside forces [20].
The findings of this study show that allies and opponents are very influential in the emergence and effectiveness of the global NCDs network. This is consistent with the results of Suzuki et al. regarding the influence of stakeholders on the UN’s political declarations on NCDs [20]. They found that many of the issues mentioned in these declarations are highly contested among stakeholders and tend to be included in the declaration using vague language. Drug prices and regulation of harmful products are among the areas of disagreement among stakeholders [20].
Other studies have also shown that public health advocates emphasize the social and commercial determinants of health and the role of public regulations. Meanwhile, the private sector seeks to promote market-oriented policies backed by neoliberal assumptions [41,42,43,44]. According to Suzuki et al., there is so much ambiguity regarding the actors involved in NCDs diplomacy that the Political Declaration of the Third High-level Meeting (HLM) on the Prevention and Control of NCDs (2018) merely uses the term “conflict of interest” without specifying how to manage it [20].
According to the present findings, the financial resources of a country are used for competing priorities, which are sometimes not in line with the country’s NCDs diplomacy goals. In terms of allocation of funds and implementation, there is poor coordination between health-related policies and development policies. NCDs-specific programs do not necessarily expand along the lines established in the national health plan and may be completely independent. Moreover, the development of NCDs-specific programs is in most cases coordinated by the Ministry of Health, and the role and influence of the country’s planning and policymaking units in the development of these policies is not completely clear. An important factor in ensuring the implementation of NCDs policies and programs is the level of political consensus and commitment. This is achieved by involving key stakeholders in the preliminary stages of NCDs strategies [45].
The next issue in shaping the NCDs policy environment is norms. Widely held expectations that global actors address a specific condition are influential in the emergence of the network [20]. According to the present findings, the main norms affecting the global NCDs network are SDGs. SDG Target 3.4 calls for reducing premature death from NCDs, which has been neglected in the Millennium Development Goals (MDGs) [46]. However, the achievement of both MDGs and SDGs depends on NCDs prevention and control, which highlights the importance of coordinated action on NCDs at local, national, and global levels.
In addition, governments should interact with the private sector, academia, civil society, and the general public to develop community-based models of NCDs prevention and control that take into account experiences and challenges. Efforts should be made to create healthier environments through effective regulations based on national health priorities with people’s participation and with clear objectives. Interactions should be transparent and include accountability, evaluation, and specific time frames. The government should engage the private sector and look for ways to strengthen commitments and help achieve the goals of the health system [47, 48]. Participation of civil society organizations, the private sector, the media, and donor organizations is equally important because the policies and programs that are carried out to promote health must be widely accepted in order to be successful [49].
The third dimension in the framework on the emergence and effectiveness of the global NCDs network relates to issue characteristics, which are the features of the problem the network tries to address. This dimension is based on the idea that issues vary in several characteristics that make them more or less difficult to tackle [20]. Among the challenges in tackling NCDs are the complications of these diseases, the multitude of risk factors from global (international fast food companies) to local (unpaved roads), and the fact that not all NCDs are preventable. Due to these complexities, it is difficult to set targets and finance them. The global response to NCDs should focus on generating multisectoral evidence on the transnational factors contributing to the increase of NCDs and the potential impact of the policies proposed to control them [5, 47, 48].
In addition, poverty is closely linked with NCDs. Bloom et al.’s study showed that the economic burden of NCDs is estimated to be US$ 81.96 billion for Costa Rica, US$ 18.45 billion for Jamaica, and US$ 477.33 billion for Peru during the period 2015–2030 [50]. The rapid rise in NCDs hinders the success of poverty reduction initiatives in low-income countries, mainly due to the increase in household healthcare expenditure. Vulnerable and socially disadvantaged people get sick more often and die earlier than people of higher social status, especially because they are more exposed to harmful products such as tobacco or unhealthy food and have limited access to health services. In resource-poor settings, healthcare expenditure for cardiovascular disease, cancer, diabetes, or chronic lung disease can quickly deplete household resources, pushing a family into poverty. The exorbitant costs of NCDs, including often lengthy and expensive treatment, together with the loss of income, push millions of people into poverty every year and stifle development.
Effective management of NCDs is complex and costly and requires the contribution of a wide range of actors. Given the increasing pressures that developing countries face with unprepared systems and economies, diverse partnerships may be considered a more important component in the prevention and effective management of NCDs [51]. Since global health networks will be effective when they create compelling framings of the issue and build political coalitions that extend beyond the health sector [52], it can be inferred that to increase the effectiveness of the NCDs prevention and control network, a more comprehensive approach focused on the three dimensions proposed in the Shiffman’s model can be helpful.
Increasing interaction in strengthening multilateral cooperation and networking at the national and transnational level creates sufficient ability and power to improve and promote negotiations for the benefit of health. The non-communicable diseases diplomacy network can help coordinate and raise the priorities of non-communicable diseases. Conducting case studies in the future, using the network approach to promote health diplomacy regarding tobacco control policies, nutrition and physical activity in Iran can help to develop relationships and advance health goals through creating lessons learned for increasing the effectiveness of these networks.
On the other hand, building strong educational and research connections between collaborative networks of physicians and healthcare professionals could be an ideal means of delivering health diplomacy. Therefore, it is suggested to create a network of domestic academics and researchers for national and transnational studies with the approach of capacity building, creating evidence for policy making and training health diplomats. The purpose of creating such a network is to expand the exchange of evidence-based knowledge and information with other countries regarding non-communicable diseases by creating a cooperation network between specialized organizations and researchers to model international health achievements and model national achievements at international levels.
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