Implementation of non-communicable disease policies from 2015 to 2020: a geopolitical analysis of 194 countries

Background: Non-communicable diseases (NCDs) are the leading cause of morbidity and mortality globally. We aimed to analyse trends in implementation of WHO-recommended population-level policies and associations with national geopolitical characteristics. Methods: We calculated cross-sectional NCD policy implementation scores for all 194 WHO member states from the 2015, 2017, and 2020 WHO progress monitor reports, and examined changes over time as well as average implementation by geographical and geopolitical region and income level. We developed a framework of indicators of national characteristics hypothesised to influence policy implementation, including democracy, corporate permeation (an indicator of corporate influence), NCD burden, and risk factor prevalence. We used multivariate regression models to test our hypotheses. Findings: On average, countries had fully implemented a third (32·8%, SD 18·2) of the 19 policies in 2020. Using aggregate policy scores, which include partially implemented policies, mean implementation had increased from 39·0% (SD 19·3) in 2015 to 45·9% (19·2) in 2017 and 47·0% (19·8) in 2020. Implementation was lowest for policies relating to alcohol, tobacco, and unhealthy foods, and had reversed for a third of all policies. Low-income and less democratic countries had the lowest policy implementation. Our model explained 64·8% of variance in implementation scores. For every unit increase in corporate permeation, implementation decreased by 5·0% (95% CI –8·0 to –1·9, p=0·0017), and for every 1% increase in NCD mortality burden, implementation increased by 0·9% (0·2 to 1·6, p=0·014). Democracy was positively associated with policy implementation, but only in countries with low corporate permeation. Interpretation: Implementation of NCD policies is uneven, but broadly improving over time. Urgent action is needed to boost implementation of policies targeting corporate vectors of NCDs, and to support countries facing high corporate permeation. Funding: The National Institutes for Health Research, the Swedish Research Council, the Fulbright Commission, and the Swedish Society of Medicine.