ABSTRACT

Non-communicable diseases (NCDs) are increasingly responsible for serious health and
economic burdens to governments around the world. We examine both the costs of obtaining
medical care and the costs associated with being unable to work, while discussing the
methodological issues of particular studies. The results suggest that NCDs pose a heavy
financial burden on many affected households; poor households are the most financially
affected when they seek care. Medicines are usually the largest component of costs and the
use of originator brand medicines leads to higher than necessary expenses. Most NCDs in all
countries stem from risk factors including tobacco use, harmful use of alcohol, and the over-
consumption of saturated fat, sugar and salt, and lack of physical activity. Because treatment
of these diseases is expensive, prevention is highly cost-effective. One way for governments
to respond to the growing burden of NCDs is through the use of public health law in order to
reduce exposure of their populations to these risk factors.

There are many effective ways in which public health law can be utilised to influence these
risk factors. These may include litigation against industry, advertising or marketing
restrictions, or taxation or pricing restrictions, all of which have proven remarkably effective
in reducing risk factors. However, it may be politically difficult or unfeasible for individual
local governments to pursue these types of legislation on their own, in the absence of more
over-arching powers. This paper instead concentrates on four types of potential legislation
highlighted in the recent Welsh consultation on public health law. These include: 1)
extending the requirement to use Health Impact Assessments; 2) imposing a statutory duty on
a range of bodies to reduce health inequalities; 3) legislation to bring about a renewed focus
on prevention of ill health; and 4) legislation to strengthen community action around health
protection and health improvement.

The paper examines a number of pieces of legislation in each of these four areas, from
different jurisdictions in the UK and other countries in Europe, and in the United States,
Canada, Australia and New Zealand, in order to provide precedents and, where available,
feedback about success or challenges of each given approach. Throughout these approaches,
the themes of multi-sectoral approaches and equity appear repeatedly. Faced with the
growing burden of NCDs, governments have been finding effective and in some cases novel
ways to use public health law to address relevant risk factors over the last decade. The four
focuses of legislation listed above may be particularly appealing as ways of enabling local
governments to effect changes in NCD rates, for three reasons: they are relatively less
politically controversial than other possibilities; they are multi-sectoral approaches; and they
focus on health inequalities.
 INTRODUCTION

1 Overview

Non-communicable diseases (NCDs) create a serious health and financial burden for local
and national governments. NCDs can be defined as diseases that are not infectious. These
diseases may result from genetic or behavioural factors and include coronary heart disease,
stroke, hypertension (high blood pressure), diabetes, kidney disease, certain forms of cancer,
respiratory and liver diseases, and overweight and obesity, as well as certain mental health
conditions. Most NCDs can be linked to the modifiable determinants of tobacco use, harmful
use of alcohol, poor diet and lack of physical activity.

Legislation is one key tool to address these risk factors and determinants. While traditionally
public health law has addressed issues of communicable diseases, the changing global burden
of disease means that in recent decades it has also been used to address non-communicable
disease.

There is a broad spectrum of ways in which public health law can address the determinants
of non-communicable diseases. However, this paper will address four specific options in light
of the over-arching themes of multi-sectoral engagement and the reduction of health
inequalities. The first such option is legislation requiring Health Impact Assessments – tools
that help decision-makers identify the public-health consequences of proposals that
potentially affect health. The second involves imposing a statutory duty on a range of bodies
to address and reduce health inequalities. The third is the use of legislation to bring about a
renewed focus on prevention of ill health, both within and outside the health sectors.
Fourthly, the use of the legislation to strengthen community action around health protection
and health improvement will be reviewed.

1.2 Objectives

The major objectives that the researcher aims to attain are to analyse the economic burden
that are imposed on the State by the people suffering from NCDs and to analyse the
effectiveness of the public health laws of the various countries. This paper also reviews
legislations of few countries to analyse the approaches adopted in those legislations.

1.3 Research Methodology

The methodology adopted for the purpose of this research paper is doctrinal in nature.
Primary and secondary sources of data have been used for the same. Primary data includes
legal treaties, conventions, surveys, statistics, records of organisations and government
agencies and various legislations. Secondary sources include books, articles and various other
literature available on this subject have also been reviewed.

1.3 Research Problem

This paper assesses progress in the development of a global framework for responding to
non-communicable diseases, as reflected in the policies and initiatives of the World Health
Organization (WHO), World Bank and the UN: the institutions most capable of shaping a
coherent global policy. The problem area of this research paper has been divided into two
parts. Firstly, it analyses the financial burden that the government faces when a large part of
the population suffers from non-communicable diseases. Secondly, the tools to address these
risk factors. This paper also analyses the various approaches that has been adopted in various
parts of the world to address the issue of non-communicable disease and the economic burden
on the State arising thereby.

1.3 Hypothesis

Public health legislation can be an extremely powerful mechanism to address the issue of
non-communicable disease. NCDs pose a serious threat to the lives of the population. Public
health legislations of the various countries have tried to mitigate the problem by suggesting
preventive measures and forms of treatment to be adopted. The approaches adopted by the
legislations also reduce the economic burden on the State to some extent by multi sectoral
approaches and equity perspective.

1.4 Literature Review

The researcher has reviewed various articles for the purpose of this research project. A short
report on Non-communicable diseases and global health governance: enhancing global
processes to improve health development by Roger S Magnusson was reviewed which
assesses progress in the development of a global framework for responding to non-
communicable diseases, as reflected in the policies and initiatives of the World Health
Organization (WHO), World Bank and the UN. Non-communicable diseases and health
systems in the Asia-Pacific region: A review of the literature by Abdullah, A., Mannava, P.
and Annear, P. (2013) was analysed which suggested how these health systems can be better
adapted or strengthened to cope with the rising burden of NCDs requires an understanding of
how the systems and NCDs interact. Sarah Galbraith-Emami’s Public Health Law and Non
communicable Diseases (July 2013) published by the UK Health Forum was reviewed which
very mentioned about the public health laws and the approaches that can be adopted to
minimise the risk factors causing NCDs. Mirta Roses-Periago, director, Pan American Health
Organization’s article Fiscal stability, economic growth and non-communicable diseases
which very descriptively stated that Non-communicable diseases such as diabetes are both a
cause and an effect of poverty, with huge costs at the micro and macroeconomic levels.
However, coordinated policy interventions can work.

1.5 Research Scheme

The researcher has divided the project into six sections to make it a more comprehensible
article. The first section deals with the introduction to the entire project. The second section
deals with the background to non-communicable diseases and public health laws. The third
section deals with the issue of Health Impact Assessment. The fourth section deals with the
issue of imposing a statutory duty on various bodies to reduce health inequities. The fifth
section analyses how the legislation can bring about a renewed focus on preventing ill health.
The sixth section deals with how the legislations can bring about community action to
prevent ill health. Lastly, the researcher concludes by elaborating on the effectiveness of the
four sector model adopted by the public health laws.
2 Background to non-communicable diseases and public health law

2.1 The burden of disease

Non-communicable diseases (NCDs) include coronary heart disease, stroke, hypertension,

type 2 diabetes, kidney disease, certain forms of cancer, respiratory and liver diseases,
overweight and obesity, and mental health conditions such as vascular dementia. These
diseases, which are often treatable but not always curable, are responsible for sizable
economic burdens on governments. Most NCDs can be linked to the modifiable determinants
of tobacco use, harmful use of alcohol, poor diet and lack of physical activity. Over the past
few decades, global health has witnessed a shift in the burden of disease from communicable
to non-communicable diseases. Worldwide, the contribution of different risk factors to
disease burden has changed substantially, with a shift away from risks for communicable
diseases in children towards those for non-communicable diseases in adults1. In 2008, nearly
two-thirds of all deaths – 36 million – resulted from NCDs, comprising mainly cardiovascular
diseases, cancers, diabetes and chronic lung diseases2. NCDs disproportionately impact
young and middle-aged adults, and on a global scale they are quickly becoming dominant
causes of death and disability3. Within the WHO European Region, NCDs account for 86%
of deaths and 77% of the disease burden4. In the UK, NCDs are the leading cause of death,
and in 2008 there were 518,400 deaths from NCDs, of which 23.75% were among the under-
70s5.

The economic burden of NCDs is sizable. A 2011 projection of costs carried out by the
World Economic Forum and Harvard School of Public Health suggests that the cost of NCDs
to the global economy will amount to $47 trillion over the next two decades, approximately
75% of the 2010 global GDP6. The cost of diabetes and related complications to the NHS in

1
Lim S, Vos T, Flaxman AD et al (2012). A comparative risk assessment of burden of disease and injury ,1990-
2010.
2
World Health Organization (2011). Global Status Report on Non communicable Diseases 2010: p. 106.
3
Vos T, Flaxman AD, Naghavi M et al (2012). A systematic analysis for the Global Burden of Disease Study
2010.
4
WHO Regional Office for Europe (2012). Action Plan for Implementation of the European Strategy for the
Prevention and Control of Non communicable Diseases 2012-2016,
5
Non-communicable Diseases in the UK Global Status Report on Non communicable Diseases 2010, p. 106.
6
World Economic Forum and Harvard School of Public Health (2011). The Global Economic Burden of Non-
communicable diseases.
England and Wales amounts to an estimated £9 billion a year7, and over half of these cases
could have been prevented. According to the World Health Organization, “Investing in
prevention and better control of this broad group of disorders will reduce premature death and
preventable morbidity and disability, improve the quality of life and well-being of people and
societies, and help reduce the growing health inequalities they cause”[Link] too rich and
complex to explore comprehensively in this paper, there has been a sizable international
response to the problem of NCDs. One of the most notable was the September 2011 UN
High-level Meeting on Non-communicable Diseases which generated substantial global
attention for the problem of NCDs. Similarly, in a World Health Assembly Resolution of
May 2012, governments pledged to adopt a global target of a 25% reduction in premature
mortality from NCDs by 20259. NCDs are related to sustainable development issues
including nutrition and energy, and there have also been calls to integrate NCDs carefully
into the United Nations’ Sustainable Development Goals as well as the post-2015 Millennium
Development Goals10. Clearly, governments have much to gain – and certain targets to meet –
through the implementation of effective prevention techniques.

2.2 NCD risk factors and interventions

As stated above, the proximate causes of NCDs across all countries include tobacco use,
harmful use of alcohol, and the over-consumption of saturated fat, sugar and salt, and lack of
physical activity. While many interventions may be cost-effective, WHO has classified some
as ‘best buys’ – meaning “actions that should be undertaken immediately to produce
accelerated results in terms of lives saved, diseases prevented and heavy costs avoided.”
Some of the World Health Organization’s ‘best buys’ for NCD interventions are: Protecting
people from tobacco smoke and banning smoking in public places, Warning about the
dangers of tobacco use, Enforcing bans on tobacco advertising, promotion and sponsorship,
Raising taxes on tobacco, Restricting access to retailed alcohol, etc.

There is substantial evidence of the success of preventive interventions. Frequently cited is

the case of Finland’s North Karelia province, where a policy focused on healthy diet, exercise
and reduction of smoking was implemented in the early 1970s. Between 1972 and 2006,
7
Novo Nordisk and C3 Collaborating for Health (2011). Diabetes: the Human, Social and Economic Challenge:
p. 14.
8
WHO Regional Office for Europe (2012). Action Plan for Implementation of the European Strategy for the
Prevention and Control of Noncommunicable Diseases 2012-2016.
9
World Health Assembly Resolution A65/54 (25 May 2012).
10
NCD Alliance (2012). Lessons learned from the adoption of the International Development Targets and the
Millennium Development Goals, in particular how effective has the MDG process been to date?
North Karelia witnessed an 85% decrease in annual mortality rate from coronary heart
disease11.

More recently, in New York City, a five-year-old Health Department regulation banning
trans fats has reduced the consumption of trans fats among fast-food customers from about 3
grams to 0.5 grams per purchase – showing also that local health regulations can significantly
influence public consumption12. It should be noted that corporate interests have markets to
protect, and legislation restricting advertising, marketing or use of alcohol, tobacco and
unhealthy foods may face numerous legal and political obstacles. Certain interventions
require a cross-border approach. These may include advertising restrictions, labelling
requirements, taxation and minimum unit pricing measures. A key example is the WHO’s
Framework Convention on Tobacco Control – developed in response to the globalisation of
the tobacco epidemic and the cross-border effects of many factors – which has made
substantial progress in reducing tobacco consumption13. One advantage of the four
approaches outlined in this paper – and which will be appealing to national and local
governments – is that the general and multi-risk-factor NCD prevention strategies may be
less likely to incur this kind of industry opposition.

2.3 The importance of public health law in improving population health

A central question in public health law and policy is what degree of intervention is
appropriate to improve population health. In response to this, in 2007 the Nuffield Council on
Bioethics presented a vision of the stewardship role of the state14. Under this model, it is
understood governments have a “duty to look after important needs of people individually
and collectively”. Goals of public health programmes in this perspective should encompass
reduction of risk, environmental protections, protections for vulnerable populations, health
promotion, enabling the population to make healthy choices, access to medical services and a
reduction of health inequalities15. Public health law can be defined as “the study of the legal
powers and duties of the state to assure the conditions for people to be healthy (e.g. to
identify, prevent and ameliorate risks to health in the population) and the limitations on the

11
World Bank (2011). The Growing Danger of Non-communicable Diseases: Acting Now to Reverse Course.
Washington, DC: World Bank, p 11.
12
Angell SY, Cobb LK, Curtis CJ et al (2012). Change in trans fatty acid content of fast-food purchases
associated with New York City’s restaurant regulation, pp.81-86.
13
WHO Framework Convention on Tobacco Control. About the WHO Framework Convention on Tobacco
Control.
14
Nuffield Council on Bioethics (2007). Public Health: Ethical Issues. London: Nuffield Council on Bioethics.
15
Nuffield Council on Bioethics (2007). Public Health: Ethical Issues. London: Nuffield Council on Bioethics.
power of the state to constrain the autonomy, privacy, liberty or other legally protected
interests of individuals for protection or promotion of community health”16. Law can be used
to advance public health in a number of different ways. A 2011 report from the WHO
Regional Office for Europe sets out four major roles: defining the objectives of public health
and influencing its policy agenda; authorising and limiting public health action with respect
to protection of individual rights, as appropriate; serving as a tool for prevention; and
facilitating the planning and coordination of governmental and non-governmental health
activities17. While in most European countries public health legislation is contained in
separate acts and regulations because of the scope of the issues and stakeholders, another
approach is to develop a law specifically addressing public health. In practice, most
jurisdictions use a combination of the above approaches, with a specific public health law as
well as provisions integrated into other legislation.

2.4 How public health law is used to address NCDs and their risk factors

As explained in section 2.2, the risk factors for NCDs fall primarily into four categories:
tobacco use, harmful use of alcohol, poor diet and lack of physical activity. Although public
health law can be an effective mechanism for NCD prevention, two potential political
obstacles include: firstly, strong public and political resistance to laws intended to influence
choices and behaviours, with a perception of NCD risk factors being a matter of personal
choice; and secondly, that effective interventions are difficult politically because it means
challenging the rights of profitable businesses to manufacture and sell potentially harmful
products18. One Canadian article points out that – despite the public health crisis around
NCDs – jurisdictional disputes, legal challenges, ideological opposition and doubts about
effectiveness can all serve to forestall legislation in this area19.

There are a number of ways in which law can influence behavioural risk factors for NCDs.
These fall into the following categories: health infrastructure and governance; shaping the
informational environment; creating economic incentives and subsidies; designing or altering
the built environment; addressing health inequalities through economic policies; and
command and control regulation, i.e. directly regulating persons, professionals, businesses

16
Chichevalieva S (2011). Developing a Framework for Public Health Law in Europe.
17
Chichevalieva S (2011). Developing a Framework for Public Health Law in Europe.
18
Law and non-communicable diseases in the Asia-Pacific. Presentation of R Magnusson.
19
Ries NM, von Tigerstrom B (2010). Roadblocks to laws for healthy eating and activity. Canadian Medical
Association Journal.
and other organisations20. For example, improved infrastructure might be accomplished
through the establishment of structures or institutions that support whole-of-government
approaches to NCD risk factors. An improved informational environment could include
restrictions on advertising of harmful products, inclusion of health warnings, or nutritional
labelling. Fiscal strategies might include increasing excise taxes on tobacco and alcoholic
beverages to reduce demand, and grants to encourage other levels of government to fund
worthwhile interventions. An improved built environment could mean smoke-free places,
zones with restrictions on sales of tobacco, alcohol or certain foods, improved school food, or
environments facilitating physical activity21. In recent years in Europe, public health laws
have often been introduced in response to specific disease threats, or to strengthen national
public health institutes. However, as NCDs become an increasing burden on economies
through treatment costs and loss of productivity, more and more governments are exploring
how public health law can best manage NCD risk factors. Current laws relating to NCDs
have proved to be an effective and central component of comprehensive prevention and
control strategies. Magnusson et al, in an Australian paper, wrote:

“Although governments are increasingly using law in innovative ways to support chronic
disease prevention, law’s role remains controversial. The food, tobacco and alcohol industries
have lucrative markets to protect and there is a pervasive assumption that the solution to
galloping rates of obesity, diabetes and other lifestyle diseases lies in individuals exercising
greater self‐control. But preaching self‐control will not work if healthy choices are constantly
undermined by other, more powerful influences. While law is not a complete answer, it can
help to create supportive environments for changing the average behaviour of populations22.”
The next four sections of this paper outline how the approaches identified in this discussion
have been and can be used as tools in public health law. These four were selected as they are
the focus of a current Welsh consultation on public health law23. They are- extending the
requirement to use Health Impact Assessments, imposing a statutory duty on a range of
bodies to reduce health inequalities, legislation to bring about a renewed focus on prevention
of ill health, and legislation to strengthen community action around health protection and
health improvement
20
Magnusson R, Colagiuri R (2008). The law and chronic disease prevention: Possibilities and politics. Medical
Journal of Australia, pp. 104-105.
21
Law and non-communicable diseases in the Asia-Pacific. Presentation of R Magnusson.
22
Magnusson R, Colagiuri R (2008). The law and chronic disease prevention: Possibilities and politics. Medical
Journal of Australia, pp. 104-105.
23
Welsh Government (2012). Consultation to collect views about whether a Public Health Bill is needed in
Wales.
3 Extending the requirement to use Health Impact Assessments

There has been increasing recognition that addressing public health issues effectively is a
multi-sectoral undertaking-i.e. that public health care delivery system need support to
adequately address the social, economic and cultural environments which impact health. This
approach has been endorsed by many national governments, as well as by the WHO and the
EU.

3.1 Background to Health Impact Assessments

In keeping with the emphasis on a multi-sectoral approach, HIAs provide a means to assess
all policy development in terms of its health impact. For example, transport, housing or
education policy. All potentially protect or damage people’s health. WHO defines HIA as “a
combination of procedures, methods and tools by which a policy, programme, or project may
be judged as to its potential effects on the health of a population, and the distribution of those
effects within the population”24. The National Research Council ( in US) defines HIA as a
“systematic process that uses an array of data sources and analytic methods and considers
input from stakeholders to determine the potential effects of a proposed policy, plan,
program, or project on the health of a population and the distribution of these effects within
the population”.25 The Health in All Policies (HIAP) approach likewise recognises and
addresses the fact that many of the determinants of health lie outside the health secto, and
encourages governments to take a more inclusive approach through inter-sectoral and ‘whole-
of-government’ policy and governance.26

HIAs are widely used internationally and nationally by public (and private) sectors. WHO
notes that the benefits of HIAs include: the promotion of cross-sectoral cooperation; a
participatory approach which values community views; provision of the best available
evidence to decision makers; improvement of health and reduction of inequalities; the
possibility to strengthen the features of a proposal which will positively impact population
health; flexibility; and links with sustainable development and resource management. 27 HIAs
may also be effective in promoting accountability for decision-makers whose policies may
have negative impacts on health. This aspect may explain why HIAs are also increasingly

24
Gothenburg Consensus Paper: Health Impact Assessment: Main Concepts and Suggested Approach.
25
National Research Council of the National Academies (2011). Improving Health in the United States: The
Role of Health Impact Assessment.
26
Global Health Europe. Health in All Policies.
27
World Health Organization. Health Impact Assessment (HIA): Why Use HIA?.
used b international organisations such as the World Bank and the International Monetary
Fund as a condition for loans, and by international industry, for example mining.

In terms of NCDs, there are clear links between policy decisions in sectors such as
agriculture, energy, housing and transportation and the risk factor for disease. These include,
for example: agricultural policies which promote healthy food production; energy and
housing policies which relieve fuel poverty and reduce the risk of respiratory and heart
diseases; and transport policies which facilitate physical activity, helping to combat rates of
obesity and diabetes.

3.2 The legal basis for a statutory duty to promote Health Impact Assessments

One means of ensuring that the public-health impacts of decisions taken in other sectors are
considered is to impose a statutory duty on organisations and authorities to promote or to
require HIAs.

At the European level, Article 152 of the Amsterdam Treaty states that: “A high level of
health protection shall be ensured in connection with the formulation and implementation of
all Community policies and all Community measures”; and Health 21 lists as one of its key
strategies that “multi sectoral strategies … tackle the determinants of health, taking into
account physical, economic, social, cultural and gender perspectives, and ensuring the use of
health impact assessment”[Link] adoption by the EU of a White Paper on HiAP (Health in All
Policies) requires the European Commission and the Member States to ensure that health
concerns are better integrated into all policies at Community, Member State and regional
level, including in environment, research and regional policies, regulation of pharmaceuticals
and foodstuffs, and governance of tobacco taxation and foreign policy29. Another precedent
can be found within UK legislation, where HIAs form part of the mandatory ‘Impact
Assessment’ required by Government for all relevant policies, with the aim of developing
better, evidenced-based policy by careful consideration of the impact on the health of the
population30. Impact Assessments are obligatory for all UK Government interventions of a
regulatory nature that affect the private sector, civil society organisations and public services,
and apply to primary and secondary legislation, as well as codes of practice or
guidance.43Section 54 of Québec’s 2001 Public Health Act (implemented in 2002) requires

28
Ibid.
29
Commission of the European Communities (2007). White Paper: Together for Health: A Strategic Approach
for the EU: 2008-2013, 23 October 2007.
30
Department of Health (Undated). Health Impact Assessment.
government ministries and agencies proposing laws or regulations to first undertake an HIA.
This obligation aims to ensure that legislation does not negatively impact population health
and, concomitantly, to allow the Minister of Health and Social Services the capacity to share
health-related concerns with other government ministries or agencies as necessary. A 2012
assessment found that, while initially there had been resistance to the measure from the
affected ministries and agencies, there has been a consistent trend towards acceptance of the
HIA process, with 519 requests for consultations between 2002 and 2012.31

While HIAs are increasingly popular within the United States, they are rarely legislatively
mandated at State or local level. A 2012 US Study commissioned by the Health Impact
Project looked at 36 selected jurisdictions where existing laws offered opportunities for
health to be factored into a range of decision-making in which it would typically not
otherwise be considered. Sectors included were environment and energy, transportation,
agriculture, and waste disposal and recycling32. Only 22 of the 36 jurisdictions surveyed had
laws requiring or facilitating HIAs. The authors highlighted that the laws that most clearly
facilitate HIAs feature two criteria: either “They refer to a broad range or description of
health impacts, such as effects on public health, safety, general welfare, environmental
health, health disparities, social or economic well-being, or effects that are borne
disproportionately by vulnerable populations,” or “They call for studies or assessments that
are used to inform public policy, programs, projects, regulations, or decision making”. Other
less ‘strong’ laws may simply allocate funding for or authorise evaluations of health impacts
without making the link to policy decisions. One example cited was an Oregon statute
authorising the state’s health authority to survey and investigate how the production,
processing or distribution of agricultural products may affect the public’s health33.

4 Imposing a statutory duty on a range of bodies to reduce health inequalities

There is a clear link between social inequalities and ill health, both because disadvantaged
groups have poorer access to services, and also fewer resources in education, employment,
housing, and transport, and reduced participation in civic society to make healthy choices.
NCDs have a strong link to health inequalities, since opportunities to make healthy choices

31
HM Government (2011). Impact Assessment Guidance: When to Do an Impact Assessment.
32
National Collaborating Centre for Healthy Public Policy (2012). Briefing Note: Implementation of Section 54
of Québec’s Public Health Act.
33
US Senate Committee on Health, Education, Labor and Pensions (2013). Harkin Bill Outlines Critical Public
Health and Prevention Initiatives.
may be affected by social determinants including socioeconomic status, gender, ethnicity or
education. Health inequalities are costly.

A focus on health inequalities may serve to better inform public health choices about the
types of interventions used. For example, tobacco use and poor diet are major risk factors for
cardiovascular disease, and a high-risk approach to cardiovascular disease prevention usually
involves population screening, with those individuals above a particular risk threshold being
given advice on behaviour change and/or medication to reduce blood cholesterol and blood
pressure. However, it has been found that this approach exacerbates socioeconomic
inequalities which have been reported in screening, healthy diet advice, smoking cessation,
and statin and anti-hypertensive prescribing and adherence, and that a population-wide
approach which legislates for smoke-free public spaces or for reducing salt intake could be
more effective and reduce health inequalities34. A 2012 American study suggested that – after
adjustments for demographics, health care access, and physiological distress – the level of
education attained and financial wealth remain strong predictors of mortality risk among
adults with diabetes35. Many public health laws explicitly consider the issue of inequities.
This could be either as a general principle to be applied in interpretation of the entire act, as
well as specific duties such as in the Finnish act which gives new choices to patients, the New
Zealand act which sets out responsibilities to district health boards, or the UK act which
requires bodies to consider the reduction of inequalities when commissioning health services.

5 Legislation to bring about a renewed focus on prevention of ill health

Legislation may support prevention through reduction of risk factors, through the creation of
bodies charged with disease prevention, or through specific activities relating to the financing
of prevention.

5.1 Flexible legislation to reduce risk factors

While the category of ‘legislation to reduce risk factors’ could be construed quite broadly,
this paper will focus specifically on public health laws which provide flexibility to address
current and future NCD threats. This type of flexibility is another approach to dealing with
particular threats as they arise – which we might see, for example, in Scotland’s 2008 Public

34
Capewell S, Graham H (2010). Will cardiovascular disease prevention widen health inequalities? PLOS
Medicine; 7 (8): e1000320.
35
Saydah SH, Imperatore G, Beckles GL (2013). Socioeconomic status and mortality: Contribution of health
care access and psychological distress among US adults with diagnosed diabetes. Diabetes Care; 36 (1): 49-
55. DOI: 10.2337/dc11-1864.
Health Law which contains a provision prohibiting operators from allowing minors to use
sunbeds36. Two relatively novel approaches can be found in the British Columbia Public
Health Act and the South Australian Public Health Act.

The British Columbia Public Health Act (2008) not only allows the Minister of Health to
require development of public health plans for health promotion and protection to address
issues such as chronic disease prevention or inclusion of mental health and substance services
in communities. It also enables the development of health impediment regulations, which
address matters that adversely affect public health from long-term, cumulative exposures that
cause significant chronic disease or disability, interfere with the goals of public health
initiatives, or are associated with poor health in the population (e.g. foods high in trans fats).
In Part 8 of the South Australian Public Health Act 2011 (Prevention of non-communicable

conditions), the Minister of Health is vested with the power to declare a particular non-
communicable condition to be of significance to public health, which then allows the
Minister to develop a code of practice in relation to preventing or reducing the incidence of
the non-communicable condition. Such a code of practice can relate to: an industry or sector;
a section or part of the community; or an activity, undertaking or circumstance. It may relate
to: goods, substances and services; advertising and marketing; manufacturing, distribution,
supply and sale; building and infrastructure design; or access to certain goods, substances or
services. While not mandatory performance reports can be published and breaches of a code
of practice may result in enforceable compliance notices being issued. Additionally, there is a
specific regulation-making power for taking measures to manage any non-communicable
condition.37

These two laws grant Ministers of Health the powers to creatively and flexibly regulate those
products and activities that impact the public health- a potentially valuable tool for reducing
the risk factors for NCDs. This kind of flexibility can make it easier to respond to public
health threats as they emerge and as evidence becomes available, without needing to resort to
lengthy legislative processes.

5.2 Creating bodies and expanding mandates to tackle NCDs

Finland has merged the National Public Health Institute (KTL) and the National Research
and Development Centre for Welfare and Health (STAKES) into one large and
36
Public Health etc. (Scotland) Act 2008.
37
South Australian Public Health Act 2011.
comprehensive entity, the National Institute for Health and Welfare (THL), which “provides
the government with broad background research and expertise to serve public health and
welfare and to support health and social services with expert advice, development, and
monitoring and to help protect and promote the welfare of Finnish people by active
communication and interaction in Finnish society.” This supports a multi-sectoral approach to
health and has led to increases in alcohol and tobacco tax, a new soft drink and sweets tax,
strengthening of tobacco control legislation and discussions with the Ministries of
Agriculture, Education and Communications.

In Article 6 of Greece’s Law on Public Health (2005), the Centre for the Control of Special
38
Communicable Diseases was renamed the Hellenic Center for Disease Control and
Prevention and its mission broadened to include NCDs, accidents, environmental health, a
central public health laboratory, and the evaluation of health services.

In Iceland, amendments made in 2011 to the Medical Director of Health and Public Health
Act incorporated the Public Health Institute of Iceland into the Directorate of Health, and
expanded the mandate of the Directorate of Health to include public health measures and
health promotion39. Functions include: advising the Minister of Welfare and other
government bodies, health professionals and the public on matters concerning health, disease
prevention and health promotion; and sponsoring and organising public health initiatives40.

Similarly, the South Australian Public Health Act establishes a South Australian Public
Health Council (SAPHC). This is the successor body to the Public and Environmental Health
Council established under the previous Act. The principal difference between these two
bodies is that the SAPHC has an expanded membership that reflects the broader scope of
contemporary public health. The Act also provides terms of reference for the SAPHC that
define a high-level strategic advisory role41.

5.3 Increasing budgets for prevention of ill health

Investments in prevention and in protecting and improving the population’s overall physical
and mental health will have positive consequences in terms of healthcare spending and

38
Puska P, Ståhl T (2010). Health in all policies – the Finnish initiative: background, principles, and current
issues. Annual Review of Public Health, pp. 315-328.
39
Ministry of Welfare (Iceland) (2007). Medical Director of Health and Public Health Act, No. 41/2007.
40
The Directorate of Health (Iceland).
41
Department for Health and Ageing, Government of South Australia (Undated). Fact Sheet: South Australian
Public Health Council (SAPHC).
productivity. 2006 OECD data suggest that spending on prevention currently amounts to an
average of 3% of OECD Member States’ total annual budgets for health, as opposed to 97%
spent on healthcare and treatment.6Since prevention is a cost-effective measure, government
intervention to shift resources towards prevention will result in long-term benefits.

The US Affordable Care Act establishes a Prevention and Public Health Fund (Section
4002). The Fund “aims to provide an expanded and sustained national investment in
prevention and public health programs to improve health and help restrain the rate of growth
in private and public sector health care costs, with a dedicated fund for prevention and
wellness”. The Secretary of Health and Human Services has the authority to transfer amounts
from the Fund to increase funding for any programme authorised by the Public Health
Service Act for “prevention, wellness, and public health activities including prevention
research and health screenings, such as the Community Transformation grant program, the
Education and Outreach Campaign for Preventive Benefits, and immunization programs.”
The Fund will invest $12.5 billion in prevention activities over the decade 2013-2022. The
Fund also supports the Community Transformation Grants that support local initiatives for
chronic disease prevention42.

This category may also include channelling specified funds into prevention. In Switzerland,
the 2009 law on prevention and health promotion includes provisions requiring that certain
proceeds from the LAMal (health insurance) are used for prevention, health promotion and
early detection of diseases. Similarly, tax collected from tobacco producers and importers
(destined under a 1969 law for health promotion measures) must be used specifically for
tobacco control.

6 Legislation to strengthen community action around health protection and health

improvement

The fourth and final topic involves giving local communities an opportunity to be more
involved in local decision-making on improving public health. Support for this approach can
be found in documents such as the Action Plan for Implementation of the European Strategy
for the Prevention and Control of Non-communicable Diseases, which endorses
empowerment and the ‘whole-of-society’ as key principles43. ‘Empowerment’ means that all
public health and healthcare activities should support community action, promote health
42
Trust for America’s Health (2012). The Prevention and Public Health Fund: Backgrounder and Fact Sheet.
43
WHO Regional Office for Europe (2012). Action Plan for Implementation of the European Strategy for the
Prevention and Control of Noncommunicable Diseases 2012-2016
literacy, and respect the patient, while the ‘whole-of-society’ approach is understood as
encouraging cooperation and collaboration between public health and health care and
between State and non-State actors, and engaging civil society, businesses and individuals in
public health and healthcare decisions44. Strategies like this are intended to facilitate patients
to manage disease, adopt healthy behaviours and use health services effectively.

This section will focus on three interpretations of this type of legislative action: 1) using
Health Impact Assessments as a support for community action; 2) mandates or programmes
to share information about NCDs with communities; and 3) increasing the role of local
government.

6.1 Using Health Impact Assessments as a support for community action

Clearly, this is closely linked to the discussion on HIAs in section 3, as throughout the HIA
process communities will ideally play a critical role in identifying the health consequences of
a given proposal. A participatory approach that values the views of the community, treating
them as relevant stakeholders, will reinforce this perspective. Furthermore, the HIA process
can demonstrate that organisers of a given project are eager to listen to, involve and respond
to community members45.

6.2 Sharing information about NCDs with communities

The concept of legislation to strengthen community action is also based upon the principle
that communities have the right to receive appropriate information on reducing the risk of
NCDs, empowering them to make appropriate healthy choices. Legislative precedents – and
innovative policy and incentives – can be found in the United States, the UK, Finland and
South Australia.

6.3 Increasing the role of local government

A broader interpretation of the objective of strengthening community action would be to

involve local government more in making public health decisions and policy. For example:

 Finland – The Health Care Act aims to give key responsibility for public health promotion
to the municipalities in order to improve prevention and to reduce the demand for services

44
Ibid.
45
World Health Organization. Health Impact Assessment (HIA): Why Use HIA?.
which accompanies later stages of NCDs. The Act requires each municipality to monitor the
health and welfare of its residents and to compile relevant statistics during terms of office 46.

 UK – Similarly, in the UK, the Health and Social Care Act (2012) grants new
responsibilities to local authorities for improving the health of local populations. Components
of the legislation require the engagement of a director of public health, a ring-fenced budget,
and annual progress-charting reports. The rationale for this move is the notion that “wider
determinants of health (for example, housing, economic development, transport) can be more
easily impacted by local authorities, who have overall responsibility for improving the local
area for their populations47.”

46
Public [Link] (2012). Public Health Care Act – Bridging the Gap.
47
Department of Health (2012). New Focus for Public Health – The Health and Social Care Act 2012.
 CONCLUSION

There are a number of tools available to national and local governments in order to address
non-communicable diseases. Public health legislation, where appropriate, can be an
extremely powerful mechanism in this regard. This paper has explored four legislative
options: extending the requirement to use Health Impact Assessments; imposing a statutory
duty on a range of bodies to reduce health inequalities; legislation to bring about a renewed
focus on prevention of ill health; and legislation to strengthen community action around
health protection and health improvement. Precedents in each of these areas, and particularly
novel precedents in terms of granting flexibility to health authorities to address NCDs, will
help governments to craft their own policy options.

The first discussion showed the increasing use of Health Impact Assessments, and cited a
Québec study suggesting that mandatory HIAs will lead to better inter-sectoral collaboration.

The second considered the issue of inequities and a statutory duty on bodies to address and
reduce health inequalities. Many public health laws list reducing inequities as a key principle
(particularly in Scandinavian legislation). Furthermore, there are specific duties in, for
example: the Finnish act which gives new choices to patients; the New Zealand act which
sets out the responsibilities of district health boards; or the UK act which requires bodies to
consider the reduction of inequalities when commissioning health services.

Legislation can bring about a renewed focus on prevention work through measures including
flexible approaches to the reduction of risk factors, the creation of bodies charged with
disease prevention, or through specific activities relating to the financing of prevention. Of
particular interest are: British Columbia’s and the South Australian legislation granting health
ministries the ability to respond flexibly to NCD concerns as they arise; and refocusing
national health institutions to consider NCDs or earmarking funds for prevention, as in the
US 2010 Affordable Care Act.

Fourthly, public health law can strengthen community action promoting health protection and
improvement. This can be through programmes which endorse a multi-sectoral and
community-oriented approach such as HIAs, community-based information-sharing
programmes such as UK Health watch or the US Community Transformation Grants
programmes, or increasing the role of local governments in health promotion and disease
prevention as in Finland and the UK.
Throughout the discussion of the four highlighted legislative options we have repeatedly seen
the key concepts of multi-sectoral approaches and of reducing inequalities. This paper has set
out a few of the many precedents for ways in which public health law can be used to reduce
risk factors for NCDs.
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