1. Joseph Perriëns MD, PhD Dept of HIV/AIDS World Health Organization
The Growing Global Burden of Non-Communicable Diseases – Implications for Health Systems
Joseph Perriëns MD, PhD
Dept of HIV/AIDS
World Health Organization
Good afternoon.
As you know from the introduction by Kevin De Cock, I work for the HIV Dept of the World Health Organization. But this afternoon I will present on non-communicable diseases, and their implications for health systems. I will close with a few ideas about how people working on HIV might look at both.

2. Leading Causes of Mortality and Burden of Disease - World, 2004%
Ischaemic heart disease
Cerebrovascular disease
Lower respiratory infections
COPD
Diarrhoeal diseases
HIV/AIDS
Tuberculosis
Trachea, bronchus, lung cancers 2.3
Road traffic accidents
Prematurity, low birth weight %
Lower respiratory infections 6.2
Diarrhoeal diseases 4.8
Depression 4.3
Ischaemic heart disease 4.1
HIV/AIDS 3.8
Cerebrovascular disease
Prematurity, low birth weight
Birth asphyxia, birth trauma 2.7
Road traffic accidents
Neonatal infections and other 2.7
This slide shows the 10 leading causes of death, and of burden of disease, in the world. Burden of disease is measured in Disability Adjusted Life Years – or DALYs – which is calculated as the sum of life years lost because of premature death, and the years of healthy life lost to disability.
HIV infection is in the top ten of each classification. But other causes of death are more frequent. The top 4 causes of death are non-communicable diseases.
In the burden of disease classification the list is topped by respiratory infections. Of the non-communicable diseases, depression and ischaemic heart disease precede HIV. However, the burden of cardiovascular disease - ischemic heart disease and cerebrovascular disease combined – overshadows all other causes of burden of disease – with 7.2% of the total.
Source: slides 2-8:

3. DALYs lost/1000 inhabitants, by cause and by region, 2004
Of course, diseases don't affect everyone in the same way. Environmental factors, lack of sanitation, poor access to transport, low education levels, poverty, and wealth, gender – are powerful determinants of health. The health care system mitigates what influence they have on survival.
These things play out differently according to where one lives. In SSA life expectancy is much less than in other regions, because of an extraordinary burden of communicable diseases. Among those HIV (in red) and TB (in brown) feature prominently. However, SSA also carries the highest burden of maternal, perinatal and nutritional conditions.
In SE Asia and the Eastern Mediterranean region those conditions also demand a heavy toll.
But the common denominator is that in all regions cardiovascular, cancer, and other non communicable diseases – on the left side in the bars of this graph - demand a heavy toll.

4. Global projections for selected causes, 2004 to 2030
Cancers
Ischaemic HD
Stroke
Acute respiratory infections
Road traffic accidents
Looking into to future, this slide shows the projected evolution of burden of disease from 2004 to 2030, from a study commissioned by the World Health Organization. It was published in 2006, and updated in 2008.
Between now and 2030 we will see a massive increase in the burden of non communicable diseases. Cancer, ischemic heart disease, stroke, and neuropsychiatric conditions – in particular depression - will demand a heavier toll.
In 2008, non-communicable diseases accounted for 51% of the burden of disease. They will be responsible for 56% of the burden of disease in 2015, and for 76% in 2030 – an exponential increase.
Part of this evolution can be explained by the better control of infectious diseases. Demographic change, economic development and technology change are also major drivers.
Perinatal
HIV/AIDS TB
Malaria
Updated from Mathers and Loncar, PLoS Medicine, 2006

5. Responding to the increasing concern about non communicable diseases, the World Health Organization launched a Global Strategy for the Prevention and Control of Noncommunicable diseases in 2008.
The main actions in this strategy are 6. My shorthand for them is
1: Advocate
2: National strategic planning
3: Tackle risk factors: - tobacco use, unhealthy diets, physical inactivity, and alcohol abuse
4: Promote research
5: Promote partnerships, and
6: Monitor and evaluate the state, progress and determinants of non communicable diseases.
This strategy is remarkably similar to current HIV strategies – except for its near exclusive emphasis on prevention.
Progress has been made – the Framework Convention on Tobacco Control is having impact already, and many member states are starting to deal with the risk factors mentioned in the strategy.
Now, how does this strategy link to health systems?

6. Health systems: $ 186 billion – 74%
Incremental costs to reach the MDGs in 49 low income countries –
Answering this question requires that we take a look at what investments are needed to address different health needs.
This slide comes from the World Health Organization report to high level working group on Innovative Financing for Health of the International Health Partnership. It shows the incremental cost required to reach the MDGs and provide a package of essential health services in the 49 low income countries of the world, over and above the 31 billion they spent on health in the year 2008.
From 2009 to 2015, a total of 251 billion $ of fresh funds would be needed.
The right hand pie shows that 26% of the incremental cost is required to scale up specific programmes and services. This includes 6% for essential HIV/AIDS interventions, and 4% for preventing and treating non-communicable diseases and neglected parasitic diseases.
However, almost 3 quarters of the incremental cost is needed for health systems strengthening: more than a third for infrastructure, equipment and vehicles, almost a quarter for health workers, and 6% for supply chain and logistics.
Health systems: $ 186 billion – 74%
Health services: $ 66 billion – 26%

7. Incremental costs to reach the MDGs in 49 low income countries – 2009-2015 – by year
This slide shows the same projected costs, year by year. I'm showing this because the enormous need to invest in infrastructure, equipment and transport is so obvious. Along with the health workforce this is a component of the health system that has suffered from years of neglect.
In their attempts to sustain service delivery for major health concerns, HIV, NCDs and other priority health concerns share a common need: a strong system - a foundation made of infrastructure, people and supply management, governed well, and supported by functioning information systems.
This - and the relative present and future importance of causes of burden of disease in different parts of the world - should inform the way we operate.

8. Looking forward In public health, HIV has become a major force
The expectation is now that other health outcomes should also benefit from HIV
HIV should deliver on this expectation
National Health Planning offers the opportunity to maximize both output and synergies between HIV, other MDGs and NCD
Now, working on HIV, how do we deal with this?
First, we must realize that In public health, HIV has risen from a small stakeholder to a major force.
Even if the funding for HIV is not enough, the expectation is now that other health outcomes should also benefit from investment in HIV. People working on HIV can ignore this expectation, but this will do their cause no good.
Therefore, HIV should deliver on this expectation – to the extent possible. By supporting a more inclusive health agenda, HIV can continue to be the game changer in global public health that it has been and is still now. This will deliver:
- Better governance: with the involvement of clients, civil society, and private sector,
A strong focus on values: human rights and equity
Service delivery reform – with the chronic disease management and people centred care in low income countries
Universal coverage, and last, but not least:
Continued attention to HIV
The least risk and highest yield approach to reconcile the aspirations for HIV with those of other health outcomes, is supporting national health planning.
National health planning offers the opportunity to maximize both the output for HIV and its synergy with the other MDGs, non communicable diseases, and other health concerns.
It is where the bridge between HIV and NCDs can be built.

9. Distribution of DAH in low income countries in 2006

10. Ten leading causes of burden of disease, world, 2004 and 2030
First – AIDS will be with us – but decrease somewhat in importance.
But the diseases and conditions that will increase in importance include, in that order, unipolar depressive disorders, ischemic heart disease, cerebrovascular disease, COPD, hearing loss, and refractive disorders – which will all be more important than HIV, as will be road traffic accidents. Of note is also the increase in diabetes.

11. Causes of burden of disease among 15 to 59 year olds, 2004
Other factors also affect what burden of disease one will need to face. Age counts, and income too. This slide shows how gender determines burden of disease.
Women are the only ones to suffer from maternal conditions. They also face a higher burden of cancer, of AIDS, and of depression than men.
Men are more exposed to TB, injuries, and cardiovascular causes.
So far I did only show you what the present situation is. Planning for health should also take into account what the future will look like.
How burden of disease will evolve over time in the future has been the subject of 2 major burden of disease assessments by the World Health Organization. In addition, refined forecasts were published in 2006, from a study commissioned by the World Health Organization, and updated in 2008.
What do these assessments tell us?

12. Projected deaths by cause and income
2004 to 2030
Intentional injuries
Other unintentional
Road traffic accidents
Other NCD
Cancers
CVD
The increase in non communicable diseases is a global trend. This slide shows its evolution in high, middle or low income countries.
Quite striking is the projected increase in cardiovascular burden of disease in middle income countries, but neither low nor high income countries escape this trend.
This evolving epidemic of non communicable diseases is an increasingly serious concern for health planning globally.
Mat//peri/nutritional
Other infectious
HIV, TB, malaria