1. Gojka Roglic World Health Organization, Geneva, Switzerland
What can WHO do to control the epidemic of diabetes?
Gojka Roglic World Health Organization, Geneva, Switzerland

2. The World Health Organization
United Nations specialized agency for health
Governed by 192 Member States
Headquarters in Geneva
Six regional offices
Numerous country offices
Support to member states to enhance the health of their populations

3. The World Health Organization
First World Health Assembly 1948
Priorities for the organization:
Malaria
Tuberculosis
Venereal diseases
Maternal and child health
Sanitary engineering
Nutrition
Support to member states to enhance the health of their populations

4. Examples of WHO activities
Successful: Smallpox eradication 1977
Campaigns against yaws, endemic syphilis, leprosy, trachoma, malaria in Europe
Control of cholera pandemic

5. Examples of WHO activities
Moderately successful, ongoing:
Polio eradication (since 1988)
Expanded programme on Immunization (since 1974)
"3 by 5" initiative (antiretroviral therapy for 3 million people in low and middle-income countries by end of 2005)

6. Examples of WHO activities
Unsuccessful: Safe Motherhood Initiative (aim in 1987: reduce maternal morbidity & mortality by 50% by the year 2000)

7. The comparative advantages of WHO are:
Neutral status
Nearly universal membership
Impartiality
Strong convening power
Normative and technical roles

8. Three sources of funding
Assessed Contributions
and Miscellaneous Income
(Regular budget )
Negotiated core
voluntary
contributions
WHO
Programme
budget
Project-type
voluntary contributions

9. Assessed contributions to Regular Budget - 10 member states pay 77 %
22 %
<1 %
This is assessed contributions – gives an indication of the major contributors –
Assessment Fee
Based on
Population
GNP
Status of health system
Complicated formula –
One member state = one vote
NOT based on how much you pay
WHAT DO YOU THINK ARE THE 10 MAJOR CONTRIBUTORS?

10. Top 10 Country contributions to WHO's Regular Budget 2008-09 in %
1- USA 22 %
2- Japan 16.6%
3- Germany 8.57%
4- UK + Northern Ireland 6.64%
5- France 6.30%
6- Italy 5.07%
7- Canada 2,97%
8- Spain 2,96%
9- China 2.66%
10- Mexico 2.25%
Following countries: Republic of Korea 2.17% Netherlands 1.87% Australia 1.78% / Brazil 0.87%
Switzerland 1.21%
Interesting slide – top 10 contributions to the regular budget
Any surprises?

11. Source of voluntary contributions 2006-2007
77 %
22 %
<1 %
This is assessed contributions – gives an indication of the major contributors –
Assessment Fee
Based on
Population
GNP
Status of health system
Complicated formula –
One member state = one vote
NOT based on how much you pay
WHAT DO YOU THINK ARE THE 10 MAJOR CONTRIBUTORS?

12. Without action the imbalance between voluntary contributions and regular budget will continue to increase
Voluntary Contributions
Regular Budget
83%
72%
28%
17%

13. What about chronic, noncommunicable diseases (NCDs)?

14. Adult mortality
Communicable and noncommunicable diseases

15. Noncommunicable diseases
2005
(cumulative)
Geographical regions (WHO classification)
Total deaths (millions)
NCD deaths (millions)
Trend: Death from infectious disease
Trend: Death from NCD
Africa
10.8
2.5 28
+6%
+27%
Americas
6.2
4.8 53
-8%
+17%
Eastern Mediterranean
4.3
2.2 25
-10%
+25%
Europe
9.8
8.5 88
+7%
+4%
South-East Asia
14.7
8.0 89
-16%
+21%
Western Pacific
12.4
9.7
105 +1
+20%
Total
58.2
35.7
388
-3%
WHO projects that over the next 10 years, the largest increase in deaths from cardiovascular disease, cancer, respiratory disease and diabetes will occur in Sub-Saharan Africa (+27%)

16. Importance of Chronic Diseases
57 Million Total Deaths
35 Million due to Chronic Disease
16 Million Deaths less than 70 yrs

17. Expenditure within WHO HQ
ONLY US$ 0.50 SPENT ON LEADING CHRONIC DISEASES PER DEATH COMPARED WITH $7.50 FOR LEADING COMMUNICABLE DISEASES

18. Funding for Noncommunicable Chronic Diseases at WHO
Total WHO expenditure on NCDs
Global NCD disease burden
In 2002, 3.5% of total budget of
US$ 43.6 million on NCDs
Source: WHO long-term strategy for prevention and control of leading chronic diseases
© World Health Organization [2004]

19. Donor aid for the health sector
Increased health support by donors mostly directed towards HIV/AIDS, not NCDs
$2.9 billion
Official Overseas Development Aid to the health sector in 2002
0.1%
allocated to NCDs
(including mental health)
Source: WHO long-term strategy for prevention and control of leading chronic diseases
© World Health Organization [2004]

20. World Bank loans for chronic diseases
World Bank and Regional Development Banks
2.5 %
of their $4.2 billion total to health, population and nutrition
between 1997 and 2002
World Bank loans for chronic diseases
Source: WHO long-term strategy for prevention and control of leading chronic diseases
© World Health Organization [2004]

21. 37 % unspecified chronic disease components
Nevertheless…..
WHO is the largest source of funding for chronic diseases
WHO provides tenfold more funds than all bilateral agencies combined
WHO expenditure for chronic disease
1998
2002
Overall
US$ 16 million
US$ 43.6 million
Tobacco
US$ 383,000
US$ 13.2 million
Mental disorders
US$ 7.1 million
US$ 13.3 million
Other chronic disease activities
US$ 9.4 million
US$ 14.3 million
33 % mental health
30 % tobacco
37 % unspecified chronic disease components

22. What about chronic, noncommunicable diseases?
1998 – Tobacco Free Initiative to coordinate a global response to the Tobacco epidemic

23. What about chronic, noncommunicable diseases?
2000 World Health Assembly adopts the Global Strategy for the Prevention and Control of Noncommunicable diseases

24. What about chronic, noncommunicable diseases?
2003 – World Health Assembly adopts the Framework Convention on Tobacco Control – first treaty negotiated under the auspices of WHO (in force since 2005)

25. What about chronic, noncommunicable diseases?
2004 – World Health Assembly adopts the Global Strategy on Diet, Physical activity and Health

26. What about chronic, noncommunicable diseases?
2005 – First WHO report on chronic,
noncommunicable diseases

27. 2008: Action Plan for the Global Strategy
February – Informal consultations with Member States, International Partners and the business community
April – Final draft of Action Plan available online
May – adoption by the World Health Assembly

28. Scope of the Action Plan
The major noncommunicable diseases:
Cardiovascular disease
Cancer
Respiratory disease
Diabetes
The main causes are 4 shared preventable risk factors:
Tobacco use
Unhealthy diet
Physical inactivity
Harmful use of alcohol

29. What about diabetes?

30. Noncommunicable Diseases and Mental Health Cluster
Cardiovascular diseases: 1 person
Cancer: 2 persons
Asthma and COPD: 2 persons
Diabetes: 1 person

31. The beginnings of the WHO Diabetes Programme in the 1980s…….
Dr Hilary King

32. The WHO Diabetes Programme at its strongest (early 2000s) …..

33. The core functions of WHO
Providing leadership and engaging in partnerships where joint action is needed
Shaping the research agenda, stimulating the generation and translation of knowledge
Setting norms and standards
Articulating ethical and evidence-based policy options
Providing technical support
Monitoring the health situation and assessing health trends
High-level advocacy and awareness raising on matters critical to health

34. WHO core function: Partnership where joint action is needed
International Diabetes Federation (IDF)
A natural ally and partner to WHO
In official relations since 1957

35. Partnership where joint action is needed
IDF
Works through member associations
Strong lay and professional advocacy voice
Network of member associations
Well-developed secretariat to respond to calls for information
Has prestige among NGOs and private sector
WHO
Works with governments
Strong public health voice
WHO offices in almost every country
Global reference centre for health statistics
Has prestige among governments/health ministries

36. WHO-IDF Collaboration
Norms and standards
Capacity building (Cambridge Seminar)
Global estimates
Management of diabetes in crises and humanitarian settings
Awareness raising
Access to essential medicines/equipment

37. WHO core function : Awareness- raising and advocacy
Rationale for investing in chronic diseases that share the same risk factors
Evidence for dispelling myths on chronic diseases

38. Joint WHO-IDF project, supported by the World Diabetes Foundation

39. Main aim of Diabetes Action Now…..
To achieve a major increase in the awareness of the impact of diabetes in low and middle income countries

40. Chronic noncommunicable diseases effectively excluded from Millennium Development Goals
Chronic diseases excluded from UNICEF Action Plan for "A World Fit for Children" and from WHO/UNICEF high level consultation
Chronic diseases excluded from UNFPA initiatives, and from WHO/UNFPA high-level consultations

41. Diabetes is an obstacle to achieving the Millennium Development Goals……
Diabetes is likely to be responsible for 15% of all new tuberculosis cases in India
(AIDS accounts for 3-4%)

42. Diabetes Action Now – Diabetes Awareness in Chennai (Murugesan et al, 2007)
Policy makers (n=20)
General public (n=3681)
Do not know what diabetes is
35%
60%
Think diabetes is preventable by meditation
61%
6.3%
Correctly identify healthy body size
15%
25%
Correctly identify healthy body shape 0%

43. Analysis of articles on diabetes in India (2005)
Online newspapers:
The Hindu – 39 articles
The Hindustan Times – 21 articles
The Indian Express – 2 articles
The Times of India – 17 articles
WHO needs to educate our partners on what we want them to do, how and when to make interventions, how we measure success, set the guidelines.

44. WHO/IDF key messages in newspaper articles (India, 2005)
Diabetes is a life threatening illness: 10%
Diabetes is a common condition and its frequency is increasing dramatically: 40%
A full and healthy life is possible with diabetes: 30%, but only a clear statement in a few articles
In many cases, diabetes can be prevented: 40%

45. Raising awareness….

47. UN Resolution on Diabetes…..

48. Percentage of countries with specific action plan for diabetes control (WHO, 2007)
WHO Region
2000
2006
AFR 17 25
AMR 46 63
EMR 69
EUR 53 67
SEAR 50
WPR NA
TOTAL 41 56

49. WHO core function: Setting norms and standards
What is diabetes?
Definition, Diagnosis and Classification of Diabetes Mellitus
WHO report 1965
WHO report 1980
WHO report 1985
WHO report 1999

50. Norms and standards
Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycaemia
WHO/IDF consultation report 2006

51. Norms and standards
Definition,Diagnosis and Classification of Diabetes Mellitus, 2009
HbA1c for diagnosis
"Pre-diabetes"
Refinement of etiological classification

52. Norms and standards
The metabolic syndrome: useful concept or clinical tool?
2009

53. WHO core function: Monitoring the health situation
Surveillance of chronic, noncommunicable diseases
STEPS – stepwise methodology for monitoring risk factor prevalence in countries
Global InfoBase – data warehouse that collects, stores and displays information on chronic diseases and risk factors by country (country profiles, comparison of countries)

54. Monitoring the health situation
Is diabetes a public health problem?
Global estimates and projections of diabetes prevalence
King et al, 2000
Wild et al, 2004

55. Monitoring the health situation
Is diabetes a public health problem?
Number of deaths attributable to diabetes in the world in 2000
= 2.9 million
(routine health statistics estimate ~1 million deaths)
Roglic et al, 2005

56. Update: Global Burden of Diseases, Injuries, and Risk Factors Study Harvard Initiative for Global Health Institute for Health Metrics and Evaluation, University of Washington Johns Hopkins University University of Queensland WHO
Prevalence
Incidence
Mortality
Complications

57. WHO core function: Articulating evidence-based policy options
What can countries do to prevent diabetes?
Global Strategy on Diet, Physical Activity and Health
2004

58. WHO Global Strategy on Diet, Physical Activity and Health (DPAS) - a public health tool to support countries fight the increasing burden of NCDs by
reducing major risk factors through public health actions
Increasing awareness of importance of healthy diet and physical activity
Developing, strengthening and implementing policies and plans on healthy diet and physical activity and engaging all sectors
Monitoring science and promoting research

59. DPAS Implementation should be coordinated by governments
Based on multisectoral action involving the private sector and civil society
Makes specific recommendations for governments, civil society groups, international agencies and the private sector
WHO has initiated dialogue with the food and non-alcoholic beverages industry on issues of food labelling, salt content and marketing

60. DPAS implementation at country levels
Several countries have developed national diet & PA strategy / plans /materials / platform, modelled after DPAS, e.g.
Chile
New Zealand
Spain
Healthy Eating - Healthy Action Oranga Kai - Oranga Pumau
Stategic Framework and
Implementation Plan
CAN WE PUT SWISS BALANCE HERE ?
Diet, PA & tobacco guide

61. Percentage of countries implementing the Global Strategy on Diet and Physical Activity (WHO, 2007)
WHO Region
2006
AFR 8
AMR 26
EMR
EUR 45
SEAR 50
WPR NA
TOTAL

62. Articulating evidence-based policy options
What is the evidence for prevention of diabetes and prevention of its complications?
Prevention of diabetes mellitus (1994)
Update 2009

63. Articulating evidence-based policy options
To screen or not to screen?
Screening for Type 2 Diabetes
2003

64. WHO core function: Stimulating and supporting research
1975 Multinational Study of Vascular Disease in Diabetes
Follow-up

65. Stimulating and supporting research
1991 DiaMond study of global incidence of type 1 diabetes (coordinated by Helsinki and Pittsburgh)

66. Stimulating and supporting research
Health beliefs and awareness of diabetes in Chennai (Murugesan et al, 2007)
Health beliefs and awareness of diabetes in Cameroon (ongoing)
Cost of diabetes in Shanghai (China) and Tanzania

67. Stimulating and supporting research
In China, the DM/nonDM ratio of
Direct Health Expenditure is 2.4
Indirect Health Expenditure is 5.7
Total Health Expenditure is 2.7

68. Stimulating and supporting research
Impact of the diabetes epidemic on TB trends in India (Stevenson et al, 2007)

69. Stimulating and supporting research
Long-term follow-up of the Da Qing diabetes prevention trial cohort (Lancet, May 2008)

70. Cumulative incidence of DM in Da Qing Follow-up Study (Li et al, 2008)

71. Diabetes WHO Collaborating centres

72. With a little help from our friends……