Review of NCDs: Current Situation &Future Prospect Orratai Waleewong Health Promotion Policy Research Center (HPR) International Health Policy Program (IHPP), Thailand

Global Epidemic of NCDs NCDs and Socio-economic development Outline Global Epidemic of NCDs NCDs and Socio-economic development Poverty and productivity MDGs Global movement on NCDs Best Buy Intervention: Policy and intervention to prevent and control NCDs

Global Risks Landscape 2013 (World Economic Forum) The Dangers of Hubris on Human Health Impact if the risk were to occur Likelihood to occur in the next

Global Epidemic of NCDs NCDs caused  36 million deaths (60 %) of global deaths (2008)  80% of these occur in developing countries Annual number of deaths in the world 25 million Low-income countries 6.8 M 13.6M 3.7M 2.3M Injuries Other deaths from NCDs 20 million Lower middle-income 2.3M 10.2M 3.3 M 3.0M Premature deaths from NCDs (below age of 60), which are preventable 15 million 10 million Communicable diseases, maternal, perinatal and nutritional conditions High-income countries 5.9M 0.9M 0.5M 0.6M Upper middle-income 3.0M 1.1M 3.3M Source: The Global Burden of Disease 2004

10 leading diseases & injuries and 10 leading risk factors based on percentage of global deaths and DALYs, 2010. NCDs account for 65.5% of all deaths, 54% of DALYs Source: Institute for Health Metrics and Evaluation, ‘The Global Burden of Disease: Generating Evidence, Guiding Policy: 2012.

NCDs mortality by countries (2008 estimates) % NCD deaths (all ages) % NCD deaths under age 60 Males Female Australia 90 13.4 9.2 Bangladesh 52 37.5 38.7 Bhutan 53 32.5 32.6 China 83 22.8 17.4 India 38.0 32.1 Indonesia 64 33.9 26.3 Japan 80 11.6 7.0 Myanmar 40 32.4 Thailand 71 32.3 25.0 Vietnam 75 26.4 19.4 World Health Organization - NCD Country Profiles , 2011.

Poverty contributes to NCDs and NCDs contribute to poverty

NCDs undercut the attainment of the MDGs Poverty: Household income is spent on health care for NCDs, medicines, tobacco and alcohol use Hunger: Underweight children and overweight adults are often found in the same households Maternal health: Malnutrition increases the risk of gestational diabetes and poor maternal health, high prevalence of cervical cancer (300,000 a year) Child health: Malnutrition in pregnancy is associated with a vulnerability to obesity, cardiovascular disease and diabetes later in life Education: NCD-related costs displace household resources for education HIV/AIDS: Increases the risk of cancers, and ARVs increase the risk of cardiovascular diseases Tuberculosis: Tobacco and alcohol use, and diabetes are associated with TB deaths Essential drugs: Cost-effective medicines to treat NCDs are available in low-cost generic forms, but remain inaccessible and unaffordable to most who need them NCDs hamper the achievement of MDGs. 8

Cost of inaction Vs Cost of action The cumulative economic lost output in developing countries associated with NCDs US$ 7 trillion over 2011-2025 US$ 500 billion per year US$ 25 in LICs, 50 in LMICs & 139 in UMICs The average cost for LMICs to scale up action by implementing the “best buy interventions” US$ 170 billion for 2011-2025 US$ 11.4 billion per year US$1 per capita in LICs, 1.5 in LMICs & 3 in UMICs

4 NCDs X 4 common risk factors Tobacco use Harmful use of alcohol Unhealthy diet Physical inactivity 4 Risk factors Chronic respiratory disease 4 NCDs Cardiovascular disease Diabetes Cancers

What is driving the NCD epidemic? Social Determinants of Health 11

Global action against NCDs Political Declaration on NCDs UNGA High-level Meeting on the prevention and control of NCDs A/RES/66/2 Doha Declaration on NCD & Injuries ECOSOC 2009 WHO Global Status Report on NCDs Global Strategy for the Prevention and Control of NCDs WHA53.17 WHA61.14 Action Plan on the Global Strategy for the Prevention and Control of NCDs 2008-2013 Moscow Declaration WHA64.11 WHA60.23 Implementation Global Strategy WHA66.10 2003 WHA56.1 Global Strategy on Diet, Physical Activity and Health WHA57.17 Global Strategy to Reduce the Harmful Use of Alcohol WHA63.13 WHA63.14 Marketing of food & non-alcoholic beverages to children 2004 A Comprehensive global monitoring framework Global Action Plan 2013-2020 Options & timeline for strengthening and facilitating multisectoral action 2000 2007 2008 2010 2011 2013 12

UN High-level Meeting on NCDs (19-20 September 2011, New York) It was only the 2nd time in history that the UN General Assembly discussed a health issue 113 Member States 34 Presidents & Prime-Ministers 3 Vice-Presidents & Deputy Prime-Ministers 51 Ministers of Foreign Affairs and Health 11 Heads of UN Agencies 100s of NGOs Political Declaration on NCDs (A66/RES/2)

UNGA High-level Meeting on the prevention and control of NCDs Political Declaration on NCDs (A66/RES/2) Establish multisectoral national plans by 2013 Integrate NCDs into health-planning processes and the national development agenda Promote multisectoral action through whole-of-government approaches Set national targets and measure results Increase domestic resources Head quarter WHO Regional Offices Member states Develop a global monitoring framework and targets Develop a global implementation plan 2013-2020 Provide technical support to developing countries Identify options for multisectoral actions Coordinate work with other UN Agencies Measure results and report

World Health Organization (WHO) Vision: The promotion of equity, universal access, and self-reliance in health development Strategies to deliver on this vision: Health systems and capacity building NCDs, mental health & disabilities Health security Health development for poverty reduction (by accelerating MDGs) Improving access to medical products Improving performance through reform

WHO reform: Global Programme of Work (Draft 12th)

Rio+20 United Nations Conference on Sustainable Development [June 2012] “ We understand the goals of sustainable development can only be achieved in the absence of a high prevalence of debilitating communicable and NCDs, and where populations can reach a state of physical, mental and social well-being. ” (paragraph 138) “ We acknowledge that the global burden and threat of NCDs constitutes one of the major challenges for sustainable development in the 21st century. ” (paragraph 141)

UN Task Team on the post-2015 UN development agenda [June 2012] “ The MDGs did not adequately address … increase in NCDs . ” (paragraph 19) “ Priorities for social development and investments in people would include: … NCDs. Access to sufficient nutritious food and promotion of healthy life styles with universal access to preventive health services will be essential to reduce the high incidence of NCDs diseases in both developed and developing countries” (paragraph 67)

Global Action Plan for the Prevention and Control of NCDs 2013–2020 Objectives To raise the priority accorded to the prevention & control of NCDs in global, regional and national agendas and internationally agreed development goals, through strengthened international cooperation and advocacy To strengthen national capacity, leadership, governance, multisectoral action and partnerships to accelerate country response for the prevention & control of NCDs To reduce modifiable risk factors for NCDs and underlying social determinants through creation of health-promoting environments To strengthen and orient health systems to address the prevention & control of NCDs and the underlying social determinants through people-centred primary health care and universal health coverage To promote and support national capacity for high-quality research and development for the prevention & control of NCDs To monitor the trends and determinants of NCDs and evaluate progress in their prevention & control

, but implementation in developing countries is still weak NCDs is preventable ! The package of low-cost "best buys" interventions exist , but implementation in developing countries is still weak

Implementing low-cost workable solutions in developing countries could prevent most premature deaths from NCDs 2/3 + 1/3 Implementing cost-effective interventions that reduce exposure to NCDs risk factors of populations will contribute up to 2/3 of the reduction in premature mortality. In addition, health systems that respond more effectively and equitably to the health-care needs of people with NCDs can reduce premature mortality by another 1/3 up to 1/2.

Population-based interventions addressing NCD risk factors: “Best buy” & “Good buy” interventions Tobacco use Protect people from tobacco smoke Warn about the dangers of tobacco Enforce bans on tobacco advertising Raise taxes on tobacco Offer counseling to smokers Harmful use of alcohol Restrict access to retailed alcohol Enforce bans on alcohol advertising Raise taxes on alcohol Enforce drink-driving laws (breath-testing) Offer brief advice for hazardous drinking Unhealthy diet Reduce salt intake Replace trans-fat with polyunsaturated fat Promote public awareness about diet Restrict marketing of food& beverages to children Replace saturated fat with unsaturated fat Manage food taxes & subsidies Offer counseling in primary care Provide health education in worksites Promote healthy eating in schools Physical inactivity Promote physical activity (mass media) Promote physical activity (communities) Support active transport strategies Promote physical activity in worksites Promote physical activity in schools Infection Prevent liver cancer via hepatitis B vaccination

>> integrate into primary health care Individual-based (Health care) interventions addressing NCD risk factors: “Best buys” Risk factor Best buy Good buy Cardiovascular disease (CVD) & diabetes Counseling & multidrug therapy (including glycemic control for DM) for people (≥30 years), with 10-year risk of fatal or nonfatal cardiovascular events ≥ 30% Aspirin therapy for acute myocardial infarction Counseling & multidrug therapy (including glycemic control for DM) for people ( ≥ 30 years), with a 10-year risk of fatal and nonfatal cardiovascular events ≥ 20% Cancer Cervical cancer screening (VIA), & treatment of pre-cancerous lesions to prevent cervical cancer Breast cancer – treatment of stage I Breast cancer – early case-finding through biennial mammographic screening (50–70 years) & treatment of all stages Colorectal cancer-screening at age 50 and treatment Oral cancer – early detection and treatment Respiratory disease Treatment of persistent asthma with inhaled corticosteroids and beta-2 agonists Early detection & care, using cost-effective & sustainable health-care interventions >> integrate into primary health care

Orratai Waleewong, B.Pharm, MSc Health Promotion Policy Research Center (HPR) International Health Policy Program (IHPP) orratai@ihpp.thaigov.net