NCD in Bulgaria Assoc. Prof. Plamen Dimitrov, MD, PhD Assoc. Prof. Zdravka Valerianova, MD, PhD

Mortality by causes in Bulgaria Cancer CVD Digestive system External causes Endocrine system Respiratory system Symptoms, undefined conditions Other Source: National Statistical Institute, Bulgaria

Trends in mortality by selected causes in Bulgaria and EU Source: HFA-DB, WHO/EURO, 2010

NCD situation in Bulgaria Total NCD deaths (‘000s) NCD deaths under age 70 (percent of all NCD deaths) Age-standardized death rate per 100,000 (Males) Age-standardized death rate per 100,000 (Females) m f All NCDs CA COPD CVD and diabetes 53.2 50.6 40.0 21.0 849.2 179.1 26.3 566.6 513.9 100.6 10.8 367.7 Source: Global status report on noncommunicable diseases 2010. WHO

NCD situation in Bulgaria Age-standardized mortality rates by cause (per 100 000 population) Communicable diseases - 31 Noncommunicable diseases - 693 Injuries - 42 Distribution of years of life lost by broader causes (%) Communicable diseases - 5 Noncommunicable diseases - 86 Injuries - 9 Source: World Health Statistics 2010

Change in structure of leading causes of death with the advancement of age in Bulgaria, in 2002 Source: Project HEM – Closing the Gap – funded by the European Union (grant agreement no: 2003121) and from the Ministry of Science and Higher Education of Poland (grant agreement no:167/PUBLIC HEALTH/2006/7)

Prevalence of selected risk factor in Bulgaria Men Women Total Rank in WHO/EURO Smoking 41.9 27.2 34.3 M-10 F-4 Low physical activity 24.6 31.8 28.4 M-27 F-23 Obesity 23.1 24.3 23.7 High blood pressure 52.6 50.3 51.4 M-7 F-7 Source: Global status report on noncommunicable diseases 2010. WHO

Proportion (%) of tobacco-related deaths by age groups among men in 2002 Lung cancer All cancers CVD age35-44 age45-64 age64+ Source: Project HEM – Closing the Gap – funded by the European Union (grant agreement no: 2003121) and from the Ministry of Science and Higher Education of Poland (grant agreement no:167/PUBLIC HEALTH/2006/7)

Structure and organization involved in prevention services and resources available Ministry of Health National Centers within MoH (NCPHA, NCRRP, NOC, etc.) Regional Health Inspectorates Resources Financial resources - MoH funds National Programs Human resources – Since 2001 Medical University offer MPH program. Training of staff involved in prevention activities – trainings in the National Centers, Medical Universities, international training, etc.

Risk factor surveys National International National Risk factor survey - 2007 CINDI health monitor – 2002, 2004, 2008 International GYTS ESPAD Childhood obesity surveillance initiative EHIS others

National strategies and programs National Health Strategy 2008-2013 – strategic aim 1 – Ensuring conditions for health promotion and disease prevention CINDI - Country-wide Integrated Noncommunicable Diseases Intervention program National Action Plan on Foods and Nutrition National Program on Tobacco Control National Program against osteoporosis National Mental Health Policy Under development – Action plan on health enhancing physical activity National Program on Alcohol control an prevention

Early detection, screening Project of MoH for screening STOP and GO (for check-up) Funded by Operational Program “Human resources 2007-2014. Activities Establishment of National Screening Registry Media Campaigns Screening of breast cancer, cervical cancer and colorectal cancer.

Few selected achievements in tackling NCDs and their risk factors Success in implementation of CINDI – for the period of 10 years: Increase the percentage of persons controlling main risk factors for NCD, Decrease of population levels of blood pressure, cholesterol, Increase the percentage of persons with normal BMI, Decrease number of persons with increase BMI, Increased physical activity, Decrease of alcohol consumption Tobacco ban legislation, National Program on tobacco control Introduction of healthy nutrition in schools – Regulation on nutrition in schools

Some main challenges Intersectoral collaboration No national strategy on NCD No programs/plans on any of 4 main NCD (CVD, Cancer, Diabetes, COPD) On risk factors – two national programs – tobacco and foods and nutrition. Currently Plan on Physical activity is under development; on alcohol – the plan is waiting its approval by MoH Disproportionate funding for Public Health, comparing with funding for medical treatment. In the last few years all preventive programs/plans have not been funded, or have been funded only very limited No population based screening program for selected cancer sites NCD information system is lacking and no monitoring and evaluation of the preventive programs

Few selected lessons learnt over the last 5 years NCD should be put on the top agenda in the society Integrated approach – intervention at several risk factors Intersectoral collaboration is necessary for success of the NCD prevention and control. Health sector is leader, but other sectors has to be involved Need to mobilize resources of the society, including NGOs, Academia, Business, Local authorities, etc. International collaboration and usage of international experience is crucial Combination of various strategies, including policy development, capacity building, partnership and information support at all levels

Few selected main next steps National NCD strategy Programs on Cancer/CVD/Diabetes/COPD prevention and control Continuation of the Programs on control of the main risk factors – tobacco, alcohol, physical activity, unhealthy nutrition Integration of prevention services into primary health care