Noncommunicable Diseases in the South-East Asia Region

Situation and Response

2011

Noncommunicable Diseases in the South-East Asia Region

Situation and Response

2011

WHO Library Cataloguing-in-Publication data

World Health Organization, Regional Office for South-East Asia.

Noncommunicable diseases in the South-East Asia Region: Situation and response 2011. 1. Mortality. 2. Chronic Disease - prevention and control. 3. Risk Factors. 4. Cost of illness. 5. Risk factors. 6. Epidemiologic surveillance. 7. Delivery of Health Care. 8. Health Care Sector

ISBN

978-92-9022-413-6

(NLM classification: WT 500)

World Health Organization 2011

Requests for publications, or for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution can be obtained from Publishing and Sales, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: publications@searo.who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. This publication does not necessarily represent the decisions or policies of the World Health Organization. Printed in India

Contents

Acknowledgments Foreword Acronyms 1. INTRODUCTION

EXECUTIVE SUMMARY 2. BURDEN OF NONCOMMUNICABLE DISEASES IN WHO SOUTH-EAST ASIA REGION NCD Mortality Trends in NCD Mortality and Morbidity Disease-Specific Burden and Trends Cardiovascular diseases Cancers Diabetes mellitus Chronic respiratory diseases Other NCDs

ii iii iv 1 5 9 10 12 13 14 15 17 18 19 23 24 24 30 31 32 33 33 35 36 37 38 43 43 44 47 47 48 48 51 51 52

3. RISK FACTORS Behavioural Risk Factors Tobacco use Unhealthy diet Physical inactivity Harmful use of alcohol Metabolic Risk Factors Overweight and obesity Raised blood pressure Raised cholesterol Cluster of risk factors Other risk factors

IV. DRIVERS OF NCDs Population ageing Urbanization Globalization Poverty Illiteracy Underdeveloped health system

V. ECONOMIC BURDEN OF NCDs Economic burden of NCDs at the National Level Economic burden of NCDs at household level

VI. NATIONAL RESPONSE TO NCDs Institutional Capacity for NCD Prevention and Control at the Central Level National Policies, Strategies, Plans and Programmes for NCD Prevention and Control Surveillance and Monitoring Heath System Capacity for NCD Prevention, Early detection, Treatment and Care Health Financing Partnerships and Collaboration VII. MAJOR CHALLENGES IN PREVENTION AND CONTROL OF NCDs Lack of strong national partnerships for multisectoral actions Weak surveillance systems Limited access to prevention, care and treatment services for NCDs Limited human resources for NCDs Insufficient allocation of funds Difficulties in engaging the industry and private sector Lack of social mobilization VIII. WHO INITIATIVES IN NCD PREVENTION AND CONTROL Global initiatives Regional initiatives

59 59 60 62 65 68 69 71 71 71 72 72 72 72 73 75 75 76 79 79 80

ANNEXES Tables Note on data sources and limitations

IX. THE WAY FORWARD Guiding Principles for NCD Prevention and Control Health promotion and primary prevention to reduce risk factors for NCDs using multisectoral approach Health system strengthening for early detection and management of NCDs Surveillance and research Specific Strategies for NCD Prevention and Control Role of Different Agencies in NCD Prevention and Control

80 81 81 82 85 85 92

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Acknowledgements
We thank the Member countries of the South-East Asia Region for providing the latest data on risk factors, morbidity and mortality, as well as updates on national responses and key achievements. We are the report. We acknowledge the assistance of staff in the World Health Organization country offices for their contribution in preparing this report. We are grateful to Dr Anton Fric for preparing an earlier charts and graphs. Ms Vani Kurup edited and designed the Report. version of the report and Dr Abhaya Indrayan and Dr Niki Shrestha for extensive inputs to the report as well as data verification, review of literature and references checking. Mr Ravinder Kumar prepared grateful to national experts from Member countries of the Region for contributing to selected sections of

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Foreword

This report describes the current burden of noncommunicable diseases (NCDs) in the SouthEast Asia Region (SEAR), their underlying risk factors and socioeconomic determinants, and summarizes national responses to the epidemic. NCDs are top killers in SEAR, causing 7.9 million deaths annually. One third of these deaths are premature and occur before the age of 60 years, in the economically productive age groups. With the projected number of deaths expected to increase by 21% over the next decade, the scale of the problem we face is clearly serious. Demographic changes (ageing population), rapid unplanned urbanization, negative aspects of global trade and marketing, progressive increase in unhealthy lifestyle patterns, as well as social and economic determinants are accelerating the burden of NCDs.

engaging in regular physical activity to maintain body weight and managing mental stress. Effective legislative policies that promote healthy behaviours by default such as smoke-free zones, restricted sale of alcohol below legal age, regulation of marketing of unhealthy food to children are also required to create a conducive environment where people can adopt healthy lifestyles easily. There is a need to create workplaces, schools, communities and environment that make adoption of healthy lifestyle choices possible. Additionally, health services and systems need to be strengthened to accommodate the needs of NCD prevention and control. Noncommunicable diseases constitute a challenge for socioeconomic development. NCDs contribute to poverty and threaten the achievement of Millennium Development Goals (MDGs). Addressing NCDs requires interventions not only from the health sector but many other sectors, such as agriculture, education, urban development and transport. The United Nations High-Level Meeting on NCDs held in New York, United States of America, earlier this year called upon all Member States to integrate their NCD policies and programmes into the broader health and development agenda and to develop multisectoral national policies and plans to tackle NCDs.

While there is a growing recognition among Member States of the need to tackle NCDs, the current focus is largely on providing medical services to those who have already developed NCDs, rather than on promoting health and eliminating the risk factors for NCDs. In an era of spiralling health-care expenses, NCDs are exacerbating poverty and widening inequities, particularly in SEAR where most health-care costs are met by out-of-pocket expenditures. Thus there is a need for greater emphasis on health promotion and primary prevention of NCDs based on the principles of primary health-care, equity and social justice. Prevention of NCDs is feasible through empowering individuals, families and communities to adopt healthy lifestyles, namely avoiding tobacco and alcohol use, eating a healthy diet including plenty of vegetables and fruits,

I call upon our Member States to join the efforts of WHO and the UN to accord a high priority to prevention and control of NCDs in national health policies and programmes, increase domestic and international resources for NCDs and galvanize a multisectoral response to NCDs. Given the enormous burden of NCDs in the Region and their serious socioeconomic consequences, I urge national governments and all developmental partners to tackle NCDs with a sense of urgency.

Dr Samlee Plianbangchang

Regional Director, World Health Organization Regional Office for South-East Asia

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Acronyms
BMI BP CHD COPD CRDs CURES CVDs DALYs DBP FCTC GATS GDP GYTS HDL HDSS ICMR IGT INR LDL MDGs MONICA NCDs NFHS NPHF NTCC PEN SEA-ACHR SEANET SEAR SEARO TFA UNHLM WC WEF body mass index blood pressure coronary heart disease chronic obstructive pulmonary disease chronic respiratory diseases Chennai Urban Rural Epidemiology Study cardiovascular diseases disability adjusted life years diastolic blood pressure WHO Framework Convention on Tobacco Control Global Adult Tobacco Survey gross domestic product Global Youth Tobacco Survey high density lipoprotein Health and Demographic Surveillance System Indian Council of Medical Research impaired glucose tolerance Indian Rupee low density lipoprotein Millennium Development Goals Multinational Monitoring of Trends and Determinants of Cardiovascular Disease noncommunicable diseases National Family Health Survey Nepal Public Health Foundation National Tobacco Control Cell WHO package of essential NCD interventions South East Asia-Advisory Committee on Health Research South-East Asian Network of NCD South-East Asia Region Regional Office for South-East Asia trans fatty acids UN High-level Meeting waist circumference World Economic Forum

2011

Executive Summary

Four major noncommunicable diseases (NCDs) cardiovascular diseases (including heart disease and stroke), diabetes, cancer and chronic respiratory diseases (including chronic obstructive pulmonary disease and asthma) are the leading cause of illness and death worldwide including the South-East Asia Region (SEAR). In addition to the health burden, NCDs have serious social and economic consequences particularly for poor and disadvantaged populations.

An estimated 1.7 million new cases of cancer occur each year in the Region and claims 1.1 million lives each year. Among males, lung and oral cancers are most common, followed by oral cancer, while among females, the incidence of breast and cervix uteri cancers is the highest. There are an estimated 81 million people living with diabetics in the Region. The prevalence of diabetes is consistently higher in urban than rural areas, and is increasing in both areas. Undiagnosed diabetes is a significant problem in the Region. An estimated 1.4 million people died of chronic respiratory diseases in SEAR in 2008; of these 86% were due to chronic obstructive pulmonary disease and 7.8% due to asthma.

Burden of NCDs in the South-East Asia Region

I

Of the estimated 14.5 million total deaths in 2008 in SEAR, 7.9 million (55%) were due to NCDs. NCD deaths are expected to increase by 21% over the next decade. Of the 7.9 million annual NCD deaths in SEAR, 34% occurred before the age of 60 years compared to 23% in the rest of the world. NCD mortality rates increase with age and are higher in males than females. Of the 7.9 million deaths due to NCDs in 2008, cardiovascular diseases alone accounted for a quarter (25%) of all deaths. Chronic respiratory diseases, cancers and diabetes accounted for 9.6%, 7.8% and 2.1% of all deaths, respectively. Cardiovascular diseases claimed 3.7 million lives in the Region. Ischeamic heart diseases and stroke account for majority of the cardiovascular disease deaths.

NCD risk factors and social determinants

I

The four major behavioural risk factors of NCDs (tobacco use, unhealthy diet, lack of physical activity and harmful use of alcohol) that lead to four major metabolic risk factors (overweight/obesity, high blood pressure, raised blood sugar and raised blood lipids) are highly prevalent in the Region and on the rise. Hypertension, raised blood glucose and tobacco use together account for nearly 3.5 million deaths in the Region every year.

2011

The Region has nearly 250 million smokers and an equal number of smokeless tobacco users. Nearly half of all adult males and two in every five adult females use some form of tobacco. 6.8% of annual deaths in the Region are attributed to tobacco use. The smoking rate among boys is higher than that among girls in the age group 1315 years. However, prevalence of smokeless tobacco use among young girls and women in the Region is on the rise. Three areas of particular concern regarding unhealthy diet in the Region are low intake of fruits and vegetables, high consumption of salt and widespread use of transfats in the food industry. Approximately 80% of the population does not eat sufficient quantities of fruits and vegetables and half a million deaths in the Region are attributed to low intake of fruits and vegetables. Annually, nearly 800 000 deaths in the Region are attributed to inadequate physical activity. The prevalence of insufficient physical activity varies from 3% to 41% among males and from 6.6% to 64% among females; 5.1% of the total annual deaths are attributed to physical inactivity. The prevalence of alcohol consumption varies from 2% to 44% among males and from 0.1% to 26% among females. An estimated 350 000 people died in SEAR of alcohol-related causes in 2004. The prevalence of overweight varied from 8% to 30% among males, and from 8% to 52% among females. The prevalence of overweight and obesity is higher in females than in males. Annually, 350 000 deaths are attributed to overweight and obesity in the Region. Childhood obesity is an emerging issue.

Approximately 30% of the adult population has high blood pressure, which accounts for nearly 1.5 million deaths annually; and 9.4% of the total deaths are attributed to high blood pressure. There are remarkable variations in raised cholesterol levels among adults, with the highest prevalence (above 50% in both sexes) in Maldives and Thailand. Females have a higher prevalence of raised cholesterol than males in several Member countries. 4.9% of the total annual deaths in the Region are attributed to raised cholesterol. In addition to population ageing, which is a non-modifiable determinant of NCDs, poverty, urbanization, globalization, inequity and poor health systems are major drivers of NCDs and their risk factors.

Economic burden of NCDs

I

There is a two-way link between NCDs and household poverty. Poverty exposes populations to risk behaviours and poor health outcomes; NCDs in turn exacerbate poverty due to expenses incurred on unhealthy behaviours, expenses on health care and loss of wages. Similarly, the macroeconomic burden is also enormous and includes health care costs, loss of productivity due to premature deaths and decreased gross domestic product (GDP).

National responses to NCDs

I

All 11 Member countries* initiated a public health response to NCDs and have allocation for NCD prevention and control in the budget of their respective ministries of health.

2011

Nine Member countries have an integrated policy on NCDs. Cancer and diabetes are the most targeted diseases for control and chronic respiratory disease are the least covered. Guidelines on dietary counseling are available in six countries, guidelines on tobacco dependence and physical activity are available in four countries and guidelines on alcohol dependence are available in five countries. Legislative support for tobacco is available in 10 countries; there is alcohol legislation in five countries. Only two countries address diet and nutrition and one country addresses physical activity through legislative measures. At least one NCD risk-factor survey (national or subnational) has been completed in all 11 countries. Surveys for tobacco use have been done more frequently compared to other risk factors. Disease-specific morbidity data are generally collected through the routine health information system in all 11 countries; mortality data are included in nine countries. Disease registries for NCDs have been most commonly established for cancers, followed by diabetes and stroke. Most mortality/morbidity data and disease -specific registries are hospital-based.

All Member countries reported providing at least one NCD-related service at the primary care level in public health facilities. This includes primary prevention and health promotion (11 countries), early diagnosis of NCD risk-factors (9 countries) and risk factor and disease management (10 countries). All Member countries have an essential drugs list and many of the NCDrelated drugs are included in the national essential drugs list.

Major challenges that need to be overcome to effectively address NCDs include lack of strong national partnerships for multisectoral actions, weak surveillance systems, limited access to prevention, care and treatment services for NCDs, limited human resources, insufficient allocation of funds, and lack of engagement of the private sector.

Major challenges in addressing NCDs

High level of commitment is needed to reverse the growing burden of NCDs in the Region. Key priorities for tackling NCDs include: (1) reducing risk factors for NCDs through multisectoral actions; (2) strengthening surveillance systems to map the risk, burden and national response, and (3) integrating NCDs into the primary health care system as a step towards universal coverage.

Way forward

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Chapter 1

Introduction

Noncommunicable diseases (NCDs) are defined as diseases of long duration, and are generally slow in progression. NCDs are the leading cause of adult mortality and morbidity worldwide. Four main diseases are generally considered to dominate NCD mortality and morbidity: cardiovascular diseases (including heart disease and stroke), diabetes, cancers and chronic respiratory diseases (including chronic obstructive pulmonary disease (COPD) and asthma). These four NCDs are caused, to a large extent, by four modifiable behavioural risk factors: tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. NCDs have now reached epidemic proportions in many countries. NCDs hit hardest at the worlds low- and middle-income groups and place a tremendous demand on health systems and social welfare, cause decreased productivity in the workplace, prolong disability and diminish resources within families. Globally, NCDs are estimated to cost more than US$ 30 trillion over the next 20 years, representing 48% of global gross domestic product (GDP) in 2010 (1). NCDs are expected to rise substantially in the coming decades, partly due to a growing ageing global population. Further, as urbanization and globalization increase in the developing world, there is likely to be an increase in the prevalence NCDs. Therefore, unless the NCD epidemic is aggressively confronted, the mounting impact of NCDs will continue unabated.

In 2008, 63% (36 of 57 million) deaths worldwide occurred due to NCDs (2). These deaths are distributed widely among people from high-income to low-income countries. About one-quarter of all NCD deaths were below the age of 60, amounting to approximately 9 million deaths per year. Ninety percent of premature deaths from NCDs occur in developing countries. Nearly 80% of NCD deaths (29 million) occur in low- and middleincome countries. The leading causes of NCD deaths in 2008 were cardiovascular diseases (17 million deaths, or 48% of NCD deaths); cancers (7.6 million, or 21% of NCD deaths); and respiratory diseases, including asthma and COPD (4.2 million). Diabetes caused an additional 1.3 million deaths. Over 80% of cardiovascular and diabetes deaths, and almost 90% of deaths from COPD, occurred in low- and middle-income countries. NCD deaths are projected to increase by 15% globally between 2010 and 2020 (to 44 million deaths) and annual NCD deaths are projected to rise substantially, to 52 million by 2030. The greatest increases will be in the WHO regions of Africa, South-East Asia and the Eastern Mediterranean, where they will increase by over 20%. NCD mortality already exceeds that of communicable diseases, maternal and perinatal conditions, and nutritional deficiencies combined in all Regions with the exception of the African Region. It is projected that over the next 20 years, annual infectious disease deaths will decline by around 7 million, but annual

2011

cardiovascular disease mortality will increase by 6 million, and annual cancer deaths by 4 million. By 2030, in low- and middle-income countries, NCDs will be responsible for three times as many disability adjusted life years (DALYs) and nearly five times the mortality from communicable diseases, as well as from maternal and perinatal conditions, and nutritional deficiencies combined. The good news is that NCDs are largely preventable through interventions and policies that reduce the major risk factors. Many preventive measures are cost-effective, including that for low-income countries. NCD prevention can avert millions of deaths and reduce billions of dollars in economic losses. A recent WHO report underlines that populationbased measures for reducing tobacco and harmful use of alcohol, as well as unhealthy diet and physical inactivity, are estimated to cost US$ 2 billion per year for all low- and middleincome countries, which translates to less than US$ 0.40 per person (3). Numerous options are available to prevent and control NCDs, such asthe WHO identified set of interventions called Best Buys. NCD prevention can be further strengthened by implementing programmes aimed at behaviour change among youth and adolescents, and more cost-effective models of care. Cost-effective nutritional policies, such as salt reduction initiatives in the United Kingdom, Finland, France, Ireland and Japan, have demonstrated positive and measurable results. Declines in tobacco use prevalence are apparent in several high-income countries (e.g. Australia, Canada, Finland, the Netherlands and the United Kingdom). Some low- and middleincome countries have also documented decline in tobacco use prevalence (Mexico, Uruguay and

Turkey). A number of low- and middle-income countries (e.g. Egypt, Pakistan, Turkey and the Ukraine) recently increased taxes on tobacco products, generating substantial revenues and saving lives (2). The South-East Asia Region (SEAR) suffers from a double disease burden, that of communicable diseases that remain an important public health problem, as well as NCDs that have emerged as the leading cause of death. The emergence of NCDs as a public health problem in the Region stems mainly from epidemiological transition, characterized by a change in disease patterns from infectious diseases to NCDs, and from a demographic transition due to increased longevity and a rise in ageing population. The challenges in addressing NCDs in the Region calls for a paradigm shift in approach: from a clinical approach to a more comprehensive approach; from using a biomedical approach to a public health approach and from addressing each NCD separately to collectively addressing a cluster of diseases in an integrated manner. This NCD status report describes the regional burden of NCDs, their risk factors and socio-economic determinants. The report also summarizes the progress countries are making for tackling the NCD epidemic, provides the base for regional and country responses, highlights some good country practices and recommends the way forward in addressing NCDs and risk factors in a comprehensive and integrated way. The report is intended for policy-makers in health and development, health professionals, researchers and academia, and other key stakeholders involved in prevention and control of NCDs.

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REFERENCES

1. The global economic burden of non-communicable diseases. A report by the World Economic Forum and the Harvard School of Public Health. September 2011 http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf (accessed 28 December 2011). 2. World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011 http://whqlibdoc.who.int/publications/2011/9789240686458_eng.pdf. (accessed 28 December 2011). 3. World Health Organization. Scaling up action against noncommunicable diseases. How much will it cost? Geneva, 2011 http://whqlibdoc.who.int/publications/2011/9789241502313_eng.pdf. (accessed 28 December 2011).

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Chapter 2

Burden of Noncommunicable Diseases in WHO South-East Asia Region

Noncommunicable diseases (NCDs) are top killers in the South-East Asia Region (SEAR), causing 7.9 million deaths annually; the number of deaths is expected to increase by 21% over the next decade. NCDs kill people at a relatively younger age in SEAR compared to the rest of the world; one-third (34%) of the 7.9 million deaths in SEAR occur in those below the age of 60 years compared to 23% in the rest of the world. Cardiovascular diseases (coronary heart disease and stroke), cancers, chronic respiratory diseases and diabetes account for the majority of NCD morbidity and mortality. Mortality and morbidity from major NCDs is on the rise and will continue to be so in the future.

Member States in SEAR* are undergoing epidemiological transition. NCDs are replacing communicable diseases, maternal and child health as well as malnutrition (the primary causes of death until some decades ago) as the leading cause of death. NCDs are killing millions and disproportionately affecting people at a younger age and in poorer sections in this Region.

This chapter reviews the current burden and trends of NCDs in SEAR and provides the latest estimates and data as reported by Member countries. Age- and sex-wise estimates of mortality are available; however there is limited availability of disaggregated data by socioeconomic status.

* Bangladesh, Bhutan, Democratic Peoples Republic of Korea, India,

Indonesia, Maldives, Myanmar, Nepal, Thailand, Sri Lanka, Timor-Leste

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Of the estimated 14.5 million total deaths in 2008 in SEAR, 7.9 million (55%) were due to NCDs (1). Cardiovascular diseases (CVDs) alone accounted for 25% of all deaths. Chronic respiratory diseases (CRDs), cancers and diabetes accounted for 9.6%, 7.8% and 2.1% of all deaths, respectively (1) (Figure 2.1). Other NCDs, such as kidney and liver diseases, accounted for most of the remaining NCD burden. In nine of the 11 SEAR Member countries, the estimated percentage of NCD deaths out of the total deaths already exceed 50%, with the highest percentage in Maldives (79%) followed by Thailand (71%) and Sri Lanka (66%). At present, Timor-Leste and Myanmar are the only two countries in this Region where NCDs cause less than 50% deaths (1) (Figure 2.2). In terms of absolute numbers, India and Indonesia together account for 80% of NCD deaths in SEAR (Annex 1), owing to their large population size. NCDs are reported to be the commonest causes of deaths in most countries in the

NCD Mortality

Region. According to a special survey of deaths in India (2), NCDs were common both in urban and rural areas. In urban areas of India, CVDs, cancers and chronic obstructive pulmonary disease (COPD), ranked first, second and fourth respectively, claiming 33%, 11% and 7.7% of the top 10 causes of deaths. In rural areas, CVDs, COPD and cancers ranked first, second and fourth, claiming 23%, 11% and 9% of the top 10 causes of deaths. In Sri Lanka, mortality reports from hospital-based data showed that 86% of deaths were caused due to NCDs (3). According to the Thailand health profile 20052007, just 16% deaths were due to infectious diseases, 12% were due to external causes of injuries and 35% due to diseases of the circulatory system (including stroke) and cancers (4). NCDs are causing deaths among younger age groups in this Region compared to most other parts of the world. Of the 7.9 million annual NCD deaths in SEAR, 34% occurred before the age of 60 years compared to 23% in the rest of the world (Figure 2.3), and nearly twice as much as in the European Region (16%) (1). In age groups 4559 years and 6069 years,

Fig 2.1: Estimated percentage of deaths by cause, South-East Asia Region, 2008 NCDs are the leading cause of death in the Region

Injuries 11% Cardiovascular disease 25%

Communicable diseases, maternal and perinatal conditions, nutritional deficiencies 35%

Chronic respiratory diseases 9.6%

Cancers 7.8% Other NCDs 10%

Source: Global Health Observatory. World Health Organization 2011. Note: percentages do not add up to 100% due to rounding off.

Diabetes 2.1%

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Fig 2.2: Estimated percentage of deaths, by cause, Member countries of the South-East Asia Region, 2008
100

80

NCDs account for more than half of all deaths in most SEAR countries

Percent

60

40

20

0
Ti r mo -L es

te a My

nm

ar

Ne

pa

l la ng

de

sh

Ba

Bh

ut

an

Ind

ia

o Ind

ne

sia

DP

RK

Sri

La

nk

a a Th

ila

nd

ld Ma

ive

Noncommunicable diseases

Communicable diseases/ maternal conditions/ nutritional deficiencies

Injuries

Source: Global Health Observatory. World Health Organization 2011.

Fig 2.3: Estimated percentage of premature deaths (under 60 years of age), by cause, South-East Asia Region vs rest of the world, 2008
50 South-East Asia Region Rest of the world 40

Percent

30

SEAR has a higher proportion of premature NCD deaths than the rest of the world

20

10

0 All NCDs Cancer Diabetes Cardiovascular diseases Chronic respiratory diseases

Source: Global Health Observatory. World Health Organization 2011.

NCD deaths account for a massive 70% and 76%, respectively of all deaths (1). This high NCD mortality among the economically productive age group is premature and largely preventable.

Similar observations were noted for all major NCDs and occur in almost all countries of SEAR (Figure 2.3). The proportion of premature deaths among those below 60 years of age in SEAR was the highest in Bangladesh

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38% of deaths were due to NCDs (1). High premature mortality was noted particularly for cancer deaths 48% of cancer deaths in the Region occurred in those below 60 years of age (Figure 2.3). NCD death rates vary greatly among SEAR Member countries (Annex 2). In 2008, Bhutan had the highest age-standardized death rates per 100 000 population for NCDs among both males and females (801 in males and 667 in females) (1). Age-standardized NCD death rates were higher among males than females for all major NCDs, except for diabetes where males and females had similar death rates (Figure 2.4).

nutritional conditions would decrease to nearly one third from 37% to 14% by 2030 (Figure 2.5) (5). According to the same projections, increase in NCD deaths among males and females would be 22% and 25%, respectively, in just 11 years from 2004 to 2015 (5). National surveys from SEAR countries also observed a steep increase in the proportion of NCDs deaths. In Indonesia, the proportion of NCD deaths increased from 42% in 1995 to 60% in 2007 (6) (Figure 2.6). In Sri Lanka, during the past half-century, the proportion of deaths due to circulatory diseases increased from 3% to 24% while those due to communicable diseases decreased from 24% to 12% (7). Similar trends have been observed in NCDrelated morbidities. The trend in hospitalization of selected diseases in Sri Lanka showed a steady increase in major NCD cases during 19702008, and a reduction in hospitalizations due to infectious diseases (Figure 2.7). A remarkable increase in hospitalizations for the major NCDs during the past two decades has also been documented in Thailand (Figure 2.8).

Trends in NCD Mortality and Morbidity

Based on projections made in 2004, NCD deaths in the Region are likely to increase by nearly 60%, from 7.9 million to 12.5 million by 2030 (5). At the same time, the percentage of total deaths due to communicable diseases, maternal and perinatal conditions as well as

Fig 2.4: Age-standardized mortality rates per 100 000 population by sex, South-East Asia Region, 2008
800 Age-standardized death rates per 100 000 700 600 500 400 300 200 100 0 All NCDs Male Female

NCD mortality rates are higher in males than females

Cardiovascular diseases

Cancer

Chronic respiratory diseases

Diabetes

Source: Global Health Observatory. World Health Organization 2011.

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Bhutan saw a 31% increase in alcoholrelated diseases (from 1217 in 2005 to 1602 cases in 2009); a 20% increase in circulatory system-related diseases (from 21 345 in 2005 to 26 937 cases in 2009); and an alarming 63% increase in diabetes (from 944 in 2005 to 2605 in 2009) (8).

Disease-Specific Burden and Trends

CVDs, cancers, diabetes and CRDs are the four major NCDs that contribute to more than 80% of NCD deaths in this Region. Significant differentials exist across Member countries in the burden of these diseases.

Fig 2.5: Trends in estimated percentage of deaths by cause of death, South-East Asia Region, 2004 and 2030
80 70 60 50 Percent 40 30 20 10 0 Communicable diseases/maternal and perinatal conditions/ nutritional deficiencies NCDs Injuries 2004 2030

NCD deaths are projected to increase in the coming years

Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine 2006, 3(11):e442.

Fig 2.6: Trends in percentage of deaths by cause, Indonesia, 1995-2007

70 60 50 Percent 40 30 20 10 0 Maternal and perinatal condition Communicable disease Noncommunicable disease Injury HHS 1995 HHS 2001 BHR 2007

Increasing trend in NCD deaths in Indonesia

HHS: household survey; BHR: basic health research Source: Ministry of Health, Indonesia, Country Report, March 2011

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Fig 2.7: Trends in hospitalization rates per 100 000 population, by selected diseases, Sri Lanka, 19712008
1200 Intestinal infectious diseases Malaria Hypertensive diseases Ishaemic heart diseases Diabetes mellitus

1000

Cases per 100 000

800

Consistent increase in hospitalization due to NCDs and reduction in infectious diseases

600

400

200

0 1997-79 198688 197476 198082 198385 198991 199294 199597 199800 200406 197173 200103 200708

Source: NCD Profile, Ministry of Health, Sri Lanka, 2010

Fig 2.8: Trends in hospitalization rates per 100 000 population, by selected diseases, Thailand, 19852006
700 600 500 Cases per 100 000 400 300 200 100 0 1989 1993 1987 1991 1995 1997 1999 2003 1985 2001 2005 Diabetes Heart diseases Cancer

Significant increase in hospitalization due to NCDs in Thailand

Source: Thai Health Profile, 2005-2007

CVDs are a group of large number of conditions relating to the heart and blood vessels. The major CVDs include hypertensive heart disease, ischaemic heart disease, rheumatic heart disease and cerebrovascular disease or stroke.

Cardiovascular diseases

Of the 7.9 million deaths attributed to NCDs in SEAR in 2008, 3.6 million (45%) were due to CVDs (1). The proportion of deaths due to CVDs was the lowest in Maldives (34%) and highest in Bhutan (53%). In India, CVDs are the leading cause of death in both males and females and in urban as well as rural areas (2).

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Types of CVDs vary among countries (Figure 2.9). The commonest CVDs in the Region are ischaemic heart disease, stroke and hypertensive heart disease. Ischaemic heart disease is the commonest cause of CVD deaths in all countries except Thailand where deaths due to cerebrovascular disease (stroke) exceeds deaths due to ischaemic heart disease. CVDs affect younger age-goups in SEAR than in their counterparts in western countries. For example, CVD mortality in India in the 30 59 years age-group is twice than that in the US (9). Nearly 52% of CVD deaths in India occur below the age of 70 years compared with 23% in established market economies (10). The trends for CVDs in the Region are of concern. For example, in Bangladesh, CVDs were the main cause of death in 2008 27% of all deaths and are projected to rise to 37% by 2030 (5). DPR Korea reported stroke-related death rate increase from 3.8% to 25% during a 30-year period (19601991) and heart-disease-

related death rate increased from 7% to 18% during the same period (11). In India, the number of new cases of CVDs is projected to increase to 64 million in 2015 (from 29 million in 2000) (12); and stroke cases to increase to an estimated 1.7 million in 2015 (from 1.1 million in 2000) (12).

Cancers are predicted to become an increasingly important cause of morbidity and mortality in the next few decades, all over the world (13). In SEAR, 1.1 million people died of cancers in 2008 (14). Of the 569 000 cancer deaths in males, the commonest sites of cancers were the lungs (17%, including trachea and bronchus), followed by mouth and oropharynx (15%), and liver (7.5%) (14). Among women, cervical and breast cancers accounted for 35% of all cancer deaths (14). The estimated percentage of cancer deaths varied from 6.4% in India to 13% in DPR Korea and Indonesia (1).

Cancers

Fig 2.9: Percentage of deaths due to CVDs*, by type of CVD, South-East Asia Region, 2008
35 30 25 Percent 20 15 10 5 0 Myanmar Bangladesh Thailand Indonesia Nepal India Maldives Timor-Leste Bhutan Sri Lanka DPRK Other cardiovascular diseases Hypertensive heart disease Cerebrovascular diseases Ischaemic heart disease

Ischaemic heart disease is the commonest type of CVD death in most SEAR countries

* CVDs = cardiovascular diseases Source: Global Health Observatory. World Health Organization 2011. http://apps.who.int/ghodata/?region=searo (accessed on 13 May 2011).

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Based on country reported data, of the 150 000 cancer-related deaths occurring annually in Bangladesh, more than one half die within five years of diagnosis (15). In India, cancers caused a larger percentage of deaths among females than males in both urban and rural areas during 20012003 (2). A large proportion of cancer deaths occur in the economically productive age group. Fiftytwo per cent of cancer deaths among women and 45% of cancer deaths among men occur below the age of 60 years (1). In a five-city study in India, nearly 50% of cancer mortality was reported among those below 55 years of age (16). In addition to high mortality, SEAR has high cancer-related morbidity. An estimated 1.7 million new cases of cancer occur each year

in the Region. Figure 2.10 shows that among males, lung cancers are most common followed by oral cancer, while among females, breast and cervix uteri cancers have the highest incidence. There are differences in the incidence of various cancers among Member countries. Among women, the incidence of cervical cancer exceeded that of other cancers in Bangladesh, Bhutan, India and Nepal, whereas in DPR Korea, Indonesia, Myanmar, Sri Lanka and Thailand, breast cancer ranked first. Among men, the incidence of lung cancer was higher than that of other cancers in all Member countries except Thailand, where the incidence of liver cancer was the highest (14). Data for the period 19842004 from five urban and one rural cancer registry in India

Fig 2.10: Incidence of selected cancers per 100 000 population, by sex, South-East Asia Region, 2008
Incidence/100 000 population 30 Lung Breast Cervix uteri Lip/oral cavity Oesophagus Stomach Colorectum Liver Non-Hodgkin lymph Larynx Ovary Bladder Brain/Nervous Leukaemia Thyroid Hodgkins lymphoma Kidney Prostate Corpus uteri Testis Gallbladder Pancreas FEMALES MALES 20 10 0 10 20 30

Lung and oral cancer in males and breast and cervical cancer in females are most common

Source: GLOBOCAN 2008. International Agency for Research on Cancer and World Health Organization

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indicated that, cancers of the prostate, colon, rectum and liver increased significantly among males, while cancers of the breast, corpus uteri and lung increased among females (17). Trends in cancer incidence from seven major hospitals in Nepal revealed that among women breast cancers were common during younger age, cervical cancers were common during middle age and lung cancers during old age. In males, leukaemias and lymphomas occurred more often during youth, lung and stomach cancers occurred during middle age, and cancers of the lung, stomach and larynx were common in old age (18). The present trend suggests that cancer incidence is increasing in most Member countries of the Region. The majority of cases of all cancer types present at a late stage of the disease and with complications, which imposes a heavy burden on the family and health-care system.

Based on results of the STEPS surveys, the highest prevalence of diabetes was in Bhutan (12% in males and 13% in females) and the lowest in Indonesia and Myanmar (6%7% in both sexes) (Figure 2.11). There are an estimated 81 million people living with diabetes in the Region. According to the International Diabetes Federation, estimates were slightly lower ranging from 7.0% in the 2079 years age group in 2010 to a projected rise to 8.4% in 2030 (19). Diabetes prevalence was consistently higher among the urban population than those residing in rural areas. In Bangladesh, diabetes prevalence in urban areas was twice as much as that in rural areas (8% vs. 4%); in Nepal diabetes prevalence was 3% in rural areas and 15% in urban areas (10); in Sri Lanka, diabetes prevalence in urban areas was 16.4% while that in rural areas was 8.7% in 200506 (20). Late diagnosis of diabetes is a major problem in the Region. A Nepal study found high diabetes prevalence among the elderly, the majority of whom were previously undiagnosed (21). In Sri Lanka, one third of those with diabetes were undiagnosed (20). In a national sample of 24 417 persons over 15 years of age in urban Indonesia, undiagnosed diabetes mellitus was present in 4.2% and impaired glucose tolerance (IGT) was present in 10.2%. IGT prevalence was 5.3% in the youngest age group (1524 years) (22). An increasing trend in diabetes prevalence has been reported from several countries. In Bangladesh, prevalence increased threefold, from 2.3% in the 1999 to 6.8% in 2004 (23). Age-standardized diabetes prevalence in a rural area in Sri Lanka increased from 2.5% in 1990 to 8.5% in 2000 (24). In India, diabetes prevalence in urban areas increased tenfold from 1.2% to 12.1% during 19712000 (25,26) while that in rural areas trebled from 2.2% to 6.4% in just 14 years during 19892003 (27).

Diabetes is defined as having a fasting plasma glucose value 7 mmol/l (126 mg/dl) or being on medication for raised blood glucose. Uncontrolled diabetes increases risk of CVD and can lead to retinopathy, nephropathy and gangrene, among other conditions (13). Diabetes is growing significantly in SEAR countries, placing enormous restrictions on those who suffer this lifelong disease. An estimated 305 000 deaths were attributed to diabetes alone in 2008; the number of deaths were slightly more among males than females (1). Diabetes specific death rates vary enormously across countries in SEAR from 56 per 100 000 population in Thailand to 5.8 per 100 000 in the Maldives (1). DPR Korea, Indonesia and Thailand showed substantially higher deaths attributed to diabetes among females than males (Annex 1; 1).

Diabetes mellitus

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Fig 2.11: Percentage of adult population with raised blood glucose level*, South-East Asia Region, 2008
14 12 10 Percent 8 6 4 2 0 Indonesia India Myanmar Bangladesh Sri Lanka Maldives Thailand Bhutan Nepal

Male Female

Nearly one in 10 adults in the Region has raised blood glucose

* Fasting glucose >7.0 mmol/L or on medication for diabetes Source: World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011 Note: Data adjusted for 2008 for comparability

According to the national Thailand health survey, mean fasting blood sugar among those aged 3559 years increased from 87 mg/dl in 1991 to 92 mg/dl in 1996, to 100 mg/dl in 2004 (4,28).

Timor-Leste to 11% in India). Age-standardized death rates of CRDs were lowest in DPR Korea (60 per 100 000 population) and highest in India (154 per 100 000 population) (1). According to national reports from Thailand, asthma prevalence was estimated at 4 million cases affecting 6.8% of the adult population (29). Nation-wide asthma prevalence in Indonesia was reported to be 4% in 2007 (30). For 2011, the projected prevalence rate of chronic asthma in India in the age group 1559 years is 19 per 1000 population in urban areas and 26 per 1000 in rural areas; and the total number of chronic asthma cases is nearly 32 million (31). Statistics on CRDs in SEAR are generally limited. Consequently, the true burden of CRDs is not appreciated. Intensive efforts are required to generate robust data on CRDs.

Chronic respiratory diseases narrow air passages of the lungs and obstruct breathing, thereby severely affecting quality of life. Major chronic respiratory diseases include COPD, asthma and occupational lung disease. These diseases can affect all age groups and are not predominant in old age unlike many other NCDs. Most CRDs are preventable and curable. Yet, an estimated 1.4 million people died of CRDs in SEAR in 2008; of these, 86% deaths were due to COPD and 7.8% due to asthma (1). In the Region, CRDs accounted for an estimated 9.6% of all deaths in 2008 (3.6% in

Chronic Respiratory Diseases

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Besides the major NCDs, many other chronic conditions and diseases contribute significantly to the burden of disease on individuals and families. Particularly significant in the Region are chronic kidney disease, chronic liver disease and thalassaemia. Chronic kidney disease is a slow progressing disease and usually takes many years to manifest clinically. This also is an under-diagnosed disease resulting in lost opportunities for prevention. A significant number of people are affected by chronic kidney disease in the Region. In a Bangladesh slum (n=1000) 16% had chronic kidney disease (32). In a large cross-sectional study (n=3398), of the apparently healthy Indian central government employees 18 years, nearly 15% were in early stages of chronic kidney disease (33). Data obtained from various nephrology centres in Indonesia showed that incidence and prevalence of end-stage renal disease in Java and Bali are increasing over time (34). In Thailand, a nationally representative sample (of 3117 people aged 15 years) showed 8.1% prevalence of stage-III chronic kidney disease in 2004, 0.2% of stage-IV chronic kidney

Other NCDs

disease and 0.15% of stage-V chronic kidney disease (35). The most common liver diseases are hepatitis, cirrhosis and carcinomas. Cirrhosis can affect all age groups but is more commonly seen among men aged 4569 years. The problem is particularly severe in SEAR with about 284 000 cirrhosis deaths constituting nearly 30% of global deaths (1). Hepatitis B virus and Hepatitis C virus are significant contributors to liver disease in this Region. Maldives has the highest prevalence of thalassaemia in the world with a carrier rate of 18% (36). The average frequency of thalassaemia in India is 3%4% although it greatly varies across the country (37). In Indonesia, the carrier frequency of thalassemia in some areas was 6%10% (38). Bangladesh has a 7% thalassemia carrier rate which equals more than 10 million people; and 7000 babies are born each year with thalassemia (39). These data suggest that screening and genetic counseling for haemoglobinopathies should be integrated into the health care system in Member countries of SEAR so as to avert exhorbitant treatment costs as well as human suffering.

REFERENCES 1. 2. 3. 4.

Global Health Observatory. World Health Organization 2011. http://apps.who.int/ghodata/?region=searo (accessed on 13 May 2011). Summary - report on causes of death: 2001-03 in India. Office of Registrar General, Government of India. http://censusindia.gov.in/Vital_Statistics/Summary_Report_Death_01_03.pdf (accessed on 21 September 2011) Sri Lanka health at a glance. Medical Statistics Unit. Ministry of Healthcare and Nutrition, Colombo, Vol 1, 2008.

Thailand health profile 20052007. Bureau of Policy and Strategy, Ministry of Public Health. Ministry of Public Health: 2008. http://www.moph.go.th/ops/thp/index.php?option=com_content&task=view&id=6&Itemid=2&lang=en (accessed on 21 September 2011).

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5.

6. 7. 8. 9.

Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine 2006, 3(11):e442. http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0030442 (accessed on 21 September 2011). Country report to the Regional Meeting on Health and Development Challenges of Noncommunicable Diseases in the South-East Asia Region, Jakarta, Indonesia. Ministry of Health, Indonesia. March 2011 Country report to the Regional Meeting on Health and Development Challenges of Noncommunicable Diseases in the South-East Asia Region, Jakarta, Indonesia. Ministry of Health, Sri Lanka. March 2011 Joshi R et al. Global inequalities in access to cardiovascular care: Our greatest challenge. Journal of the American College of Cardiology 2008;52:181725. Country report to the Regional Meeting on Health and Development Challenges of Noncommunicable Diseases in the South-East Asia Region, Jakarta, Indonesia. Ministry of Health, Bhutan. March 2011

10. Ghaffar A et al. Burden of non-communicable diseases in South Asia. British Medical Journal 2004;328:807 10. http://www.bmj.com/content/328/7443/807.full.pdf (accessed on 21 September 2011). 11. Country Report, Ministry of Health, DPR Korea. March 2011 12. Indrayan A. Forecasting vascular disease cases and associated mortality in India. Background papers: Burden of disease in India. New Delhi: National Commission on Macroeconomics and Health, 2005:198215. 13. World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011. http://www.who.int/nmh/publications/ncd_report2010/en/ (accessed on 21 September 2011). 14. GLOBOCAN 2008. International Agency for Research on Cancer and World Health Organization http://globocan.iarc.fr/ (accessed on 21 September 2011).

15. National cancer control strategy and plan of action 2009-2015. Bangladesh, Ministry of Health and Family Welfare, 2008. http://www.whoban.org/LinkFiles/Publication_Cancer_Strategy.pdf.pdf (accessed on 21 September 2011). 16. Marimuthu P. Projection of cancer incidence in five cities and cancer mortality in India. Indian Journal of Cancer 2008;45:47. 17. India National Council of Medical Research. IMCR Bulletin, Vol 40, No. 2, February 2010. http://www.icmr.nic.in/bulletin/english/2010/ICMR%20Bulletin%20February%202010.pdf (accessed on 9 July 2011).

18. Pradhananga KK et al. Multi-institution hospital-based cancer incidence data for Nepal: an initial report. Asian Pacific Journal of Cancer Prevention 2009;10:25962. http://www.ncbi.nlm.nih.gov/pubmed/19537894 (accessed on 21 September 2011). 19. International Diabetes Federation. http://www.idf.org/ (accessed on 21 September 2011). 20. Katulanda P et al. Prevalence and projection of diabetes and pre-diabetes in adults in Sri Lanka Sri Lanka Diabetes, Cardiovascular Study (SLDCS). Diabetes Medicine 2008;25:10629. http://www.ncbi.nlm.nih.gov/pubmed/19183311 (accessed on 21 September 2011). 21. Chhetri MR, Chopman RS. Prevalence and determinants of diabetes among the elderly population in the Kathmandu valley of Nepal. Nepal Medical College Journal 2009;11:348. http://www.ncbi.nlm.nih.gov/pubmed/19769235 (accessed on 21 September 2011). 22. Mihardja L et al. Prevalence and determinants of diabetes mellitus and impaired glucose tolerance in Indonesia (a part of basic health research/Riskesdas). Acta Medica Indonesia 2009;41:169-74. http://www.inaactamedica.org/archives/2009/20124611.pdf (accessed on 21 September 2011).

23. Rahim MA et al. Rising prevalence of type 2 diabetes in rural Bangladesh: A population based study. Diabetes Research and Clinical Practice 2007;77:3005. 25. Ramachandran A. Epidemiology of diabetes in Indiathree decades of research [review]. Journal of the Association of Physicians India 2005;53:348. 24. Illangasekera U et al. Temporal trends in the prevalence of diabetes mellitus in a rural community in Sri Lanka. Journal of the Royal Society for the Promotion of Health 2004;24:92.

26. Pradeepa R, Mohan V. The changing scenario of the diabetes epidemic: implications for India [review]. Indian Journal of Medical Research 2002;116:12132. 27. Ramachandran A et al. Temporal changes in prevalence of diabetes and impaired glucose tolerance associated with lifestyle transition occurring in the rural population in India. Diabetologia 2004;47:8605. Epub 2004 Apr 28.

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28. Porapakkham Y et al. Prevalence, awareness, treatment and control of hypertension and diabetes mellitus among the elderly: The 2004 National Health Examination Survey III, Thailand. Singapore Medical Journal 2008;49:86873.

30. Report on Result of National Basic Health Research (RISKESDAS) 2007. The National Institute of Health Research and Development, Republic of Indonesia, 2008. http://www.litbang.depkes.go.id/ccount/?http://www.litbang.depkes.go.id/LaporanRKD/Indonesia/Riskesdas_200 7_English.zip / (accessed on 21 September 2011). 31. Murthy KJR, Sastry JG. Economic burden of asthma. Burden of Diseases in India. Background papers: National Commission on Macroeconomics and Health. New Delhi: WHO India, 2005 http://www.whoindia.org/LinkFiles/Commision_on_Macroeconomic_and_Health_Bg_P2_Economic_burden_of_asth ma.pdf (accessed on 21 September 2011). 32. Rahman MM et al. Detection of chronic kidney disease (CKD) in adult disadvantageous population in Bangladesh. Chronic Kidney Disease 2006, MP281, iv393. http://ndt.oxfordjournals.org/cgi/reprint/21/suppl_4/iv390.pdf (accessed on 21 September 2011). 33. Varma PP et al. Prevalence of early stages of chronic kidney disease in apparently healthy central government employees in India. Nephrology Dialysis Transplantation 2010;9: 3011-7; Epub 2010 Mar 15.

29. Liwsrisakun CC, Pothirat C. Actual implementation of the Thai Asthma Guideline. Journal of the Medical Association of Thailand 2005;88:898-902.

34. Prodjosudjadi W. Incidence, prevalence, treatment and cost of end-stage renal disease in Indonesia. Ethnicity & Disease 2006;16 (Suppl 2):S2-14-16. http://www.ncbi.nlm.nih.gov/pubmed/16774003 (accessed on 22 September 2011).

35. Ong-ajyooth L et al. Prevalence of chronic kidney disease in Thai adults: a national health survey. BMC Nephrology 2009;10:35. http://www.biomedcentral.com/content/pdf/1471-2369-10-35.pdf (accessed on 22 September 2011).

36. Maldives. New Delhi: United Nations Office on Drugs and Crime, 2005. http://www.unodc.org/pdf/india/publications/south_Asia_Regional_Profile_Sept_2005/11_maldives.pdf (accessed on 22 September 2011). 38. Timan IS et al. Some hematological problems in Indonesia. International Journal of Hematology 2002;76 (Suppl 1):286-90. 39. Bangladesh Thalassemia Foundation. http://www.thals.org/ (accessed on 22 September 2011). 37. Colah R et al. Epidemiology of beta-thalassaemia in Western India: mapping the frequencies and mutations in subregions of Maharashtra and Gujarat. British Journal of Haematology 2010;149:739-47.

40. The world health report 2006. Geneva: World Health Organization, 2006. www.who.int/whr/2006/en/ (accessed on 22 September 2011).

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Risk Factors

Four behavioural risk factors (tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol) are largely responsible for majority of the NCDs.

Behavioural risk factors lead to four key metabolic changes: overweight/obesity; raised blood pressure; raised blood glucose; and raised blood cholesterol. Behavioural and metabolic risk factors are highly prevalent in the Region and on the rise.

Hypertension, raised blood glucose and tobacco use are the top three risk factors responsible for 3.5 million deaths in the Region every year.

The four major NCDs namely CVDs, diabetes, cancers and CRDs share four common behavioural risk factors that account for the majority of NCD deaths (Figure 3.1) (1). These modifiable behavioural risk factors are tobacco use, unhealthy diets, physical inactivity and harmful use of alcohol. These behaviours in turn lead to four key metabolic changes: overweight/obesity, raised blood pressure, raised blood sugar and raised blood cholesterol (hyper-lipidaemia). The highest number of deaths in SEAR are attributed to raised blood pressure accounting for 9.4% of all deaths,

followed by raised blood glucose (6.8%), tobacco use (6.8%), physical inactivity (5.1%) and raised cholesterol (4.9%) (1) (Figure 3.2). High blood pressure, tobacco use and high blood sugar together account for approximately 3.5 million deaths each year in the Region. This chapter provides evidence that NCD risk factors are widely prevalent in this Region. Data on risk factors are generated from WHOSTEPS surveys (2) and reported as age standardized rates in WHOs Global status report on noncommunicable diseases 2010 (3).

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Fig 3.1: Shared risk factors for major noncommunicable diseases

Tobacco use Unhealthy diet Physical inactivity Harmful use of alcohol

Noncommunicable diseases

Cardiovascular diseases Diabates (Type II) Cancers

   

  

 

 

4 modifiable shared risk factors cause 4 major NCDs which account for 80% of all NCD deaths

Chronic respiratory diseases

Fig 3.2: Estimated number of attributable deaths by risk factor, South-East Asia Region, 2004
2000 Number of attributable deaths (000s)

1500

Hypertension, high blood glucose and tobacco use are top three risk factors for death

1000

500

0 High blood glucose Unsafe water, sanitation, hygiene Childhood and maternal underweight High cholesterol Physical activity Indoor smoke from solid fuels High blood pressure Low fruit and vegetable intake Suboptimal breastfeeding Harmful use of alcohol Tobacco use Overweight and obesity

Risk factors

Source: Global health risks: mortality and burden of diseases attributable to selected major risks. Geneva: World Health Organization, 2009.

Behavioural Risk Factors

Tobacco use is the single-most preventable cause of death in the world today. Tobacco is the only legal consumer product that kills up to half of those who use it (4). Tobacco use causes a

Tobacco use

wide range of diseases that impact nearly every organ of the body. Second-hand smoke also has serious and often fatal health consequences; it has many different chemicals, 50 of which are known to be associated with cancer (5). Tobacco use is a serious public health concern in the Region where about 1 million

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tobacco-related deaths occur every year (1). It is estimated that by 2030 tobacco use will account for more deaths than total deaths from malaria, maternal conditions and injuries combined (6). Tobacco-related illnesses, such as cancers as well as cardiovascular and respiratory diseases are already major problems in most Member countries of the Region. Four countries of SEAR Bangladesh, India, Indonesia and Thailand are among the top 20 tobacco-producing countries in the world (7). The Region also has some of the highest tobacco consuming countries in the world India and Indonesia are among the top ten tobacco consuming countries in the world (8).
Types of tobacco products consumed in the Region

consumption is now prevalent throughout the Region. The misconception about tobacco being good for oral health, has been used as an advantage by the tobacco industry, which has produced tobacco products, such as dentifrice, most common in India and Bangladesh in different forms such as gul, gudaku, bajjar, tapkir, lal dantmanjan. The use of smokeless tobacco products among children, youth and women has increased in recent times in the Region, mainly because of lack of adequate knowledge about the addictive and harmful effects of smokeless tobacco. Additionally, aggressive marketing by the tobacco industry, easy accessibility to and lower prices of smokeless tobacco products have contributed to their widespread use in the Region (8). The prevalence of tobacco use varies significantly across the Member countries of the Region. Smoking is higher among men while women usually take to chewing tobacco. The prevalence of current use of any smoked tobacco ranges from 26% (India) to 61% (Indonesia) in males and from less than 1% (Sri Lanka) to 29% (Nepal) among females. The prevalence of daily cigarette smoking among males ranges from 7% (India) to 53% (DPR Korea). The prevalence of smokeless tobacco product use among males ranges from 1.3% (Thailand) to 51.4% (Myanmar); in females prevalence of smokeless tobacco product use ranges from 4.6% (Nepal) to 27.9% (Bangladesh) (Table 3.1). Overall, tobacco use among males is higher than among their female counterparts in all Member countries of the Region.
Tobacco use among students aged 1315 years Tobacco use among adults

Both smoking and smokeless types of tobacco products are used in the Region. The poorer sections of the population in this Region smoke low-cost indigenous products, such as bidis (Bangladesh, India, Nepal and Sri Lanka), cheroots (Myanmar) and roll-your-own cigarettes (Thailand). Manufactured cigarettes are the preferred choice of the upper class in the Region. Clove cigarettes called kreteks are popular in Indonesia. Other forms of smoking products used in Region are dhumti, chuttas, chillums, hookah, pipes and cigars (8). Smokeless tobacco products are used in various ways chewing, sucking and applying tobacco preparations to the teeth and gums. The commonly used smokeless form of tobacco in the Region is tobacco with betel quid (known as paan in India, Bangladesh and Nepal; kwanya in Myanmar and sirih in Indonesia). Tobacco and lime mixture (known as khaini or surti in India and khoinee in Bangladesh) is another common tobacco product that is either manufactured or prepared by the users themselves. Gutkha, a manufactured tobacco mixed with betel nut and other additives, is popular among youth in India and gutkha

The findings of the Global Youth Tobacco Survey (GYTS) reveal a high prevalence of

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Table 3.1: Prevalence of tobacco use, among adults by sex, South-East Asia Region, 20062009
Age-standardized prevalence of smoking DAILY 42 53 20 54 38 31 30 21 39 N.A. CURRENT Prevalence of smokeless tobacco* Total 24 15 33 27 24 32 14 24 N.A. Males Females Total Year

N.A. = Not available * WHO Report on the Global Tobacco Epidemic, 2011: warning about the dangers of tobacco. http://whqlibdoc.who.int/publications/2011/9789240687813_eng.pdf **NCD Risk factor Survey, MOH Bhutan, 2007 ***NCD Risk factor Survey, MOH Sri Lanka, 2006

Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste

Males

Females 2 3 4 9 6 25 <1 2 N.A.

Total 22 12 29 24 18 28 11 20 N.A.

Males 46 57 26 61 43 40 36 27 45 N.A.

Females 2 4 5 11 8 29 0.4 3 N.A.

26.4 21.1** N.A. 32.9 N.A. N.A. 51.4 31.2 24.9*** 1.3 N.A.

27.9 17.3** N.A. 18.4 N.A. N.A. 16.1 4.6 6.9*** 6.3 N.A.

27.2 19.4** 25.9

2009 2007 2009 2009 2008 2006 2009

29.6 18.6 15.8*** 3.9 N.A.

tobacco use among youth in the Region. The current use of any form of tobacco ranges from 8.5% (Maldives) to 55% (Timor-Leste) among boys and from 3.4% (Maldives) to 30% (TimorLeste) among girls (Figure 3.3). The exceedingly high tobacco use prevalence among youth in Timor-Leste underscores their vulnerability to NCDs in the future. The smoking rate among students aged 1315 years is higher among boys than girls (8). Increasing smoking prevalence is a concern in Indonesia where smoking prevalence among male youths more than doubled from 14% in 1995 to 33% in 2004. Smoking prevalence among young females in Indonesia, although low, increased from 0.3% to 1.9% during the same period (Figure 3.4) (9). In Sri Lanka, current cigarette smoking prevalence decreased from 4% in 1999 to 2.4% in 2003 to 1.2% in 2007 (10). In Myanmar,
Trends in tobacco use

An inverse relationship has been observed between tobacco use and education. Bangladesh GATS 2009 revealed that the prevalence of current use of any smoked tobacco product is highest among those who had no formal education (31%) and lowest among those who had secondary education and above (14%) (12). Similarly, the prevalence of current use of any smokeless tobacco product was highest among those who had no formal education (42%) and

Tobacco consumption and educational level

current cigarette smoking prevalence showed a significant decline from 10.2% in 2001 to 4.9% in 2007. This decline was observed in both boys (19% in 2001; 8.5% in 2007) and girls (3.2% in 2001; 1.3% in 2007). However, prevalence of current use of other tobacco products showed a notable increase from 5.7% in 2001 to 14% in 2007. This increase was observed in both boys (9% in 2001; 20% in 2007) and girls (3.1% in 2001; 7.9% in 2007) (Figure 3.5) (11).

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Fig 3.3: Prevalence of current tobacco use among students aged 1315 years by sex, SouthEast Asia Region, 20062009
60 50 Boys Girls

40 Percent

Variable, but high tobacco use among youth in the Region

30

20

10

0 2009 Thailand 2007 Myanmar 2006 Timor-Leste 2007 Bangladesh 2009 Indonesia 2207 Sri Lanka 2007 Maldives 2009 Bhutan 2007 Nepal 2006 India

Country and year of survey

Source: Global Youth Tobacco Surveys in Member countries of South-East Asia Region

Fig 3.4: Prevalence of smoking among students aged 1519 years, by sex, Indonesia, 19952004
40 35 30 25 Percent 20 15 10 5 0

Boys Girls Both sexes

Smoking among Indonesian boys has more than doubled over a decade

1995

2001

2004

Sources: National Socio-Economic Survey 1995, 2001, 2004. Ministry of Health Indonesia

lowest among those who had secondary education and above (10%). India GATS (2009) revealed the highest prevalence of current use of any tobacco among those who had no formal

schooling (68% in males; 33% in females) and lowest prevalence among those who had secondary education and above (31% in males; 3.6% in females) (Figure 3.6) (13). Similarly,

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Fig 3.5: Prevalence of current tobacco use among students aged 13-15 years, by sex, Myanmar, 2001 and 2007
25

Current cigarette smoker

Current user of other tobacco products

2001 2007

20

15 Percent

10

Boys

Girls

Boys

Girls

Reduction in cigarette smoking but increase in use of other tobacco products

Source: Global Youth Tobacco Survey 2001 and 2007, Myanmar

Fig 3.6: Percentage of adults, who are current users of tobacco products, by education, India, 2009
80 70 60 50 Percent 40 30 20 10 0 Male Female

The less educated are more likely to use tobacco

No formal schooling

Less than primary

Primary but less than secondary Education

Secondary and above

Source: India Global Adult Tobacco Survey 2009

Thailand GATS (2009) revealed a higher prevalence of current use of any smoked tobacco product among those who had less than primary (24%) and primary (29%) education

than in those who had university level education (14%) (14). In Sri Lanka, least-educated males were twice as likely to smoke as most-educated males (15). In Indonesia, smoking prevalence among men who had not completed elementary

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school was 72% compared with 50% among men who had completed a bachelors degree (16).
Tobacco consumption and place of residence

Bangladesh GATS (2009) revealed that a much higher percentage of people in rural areas (14%) smoke bidis than those in urban areas (4.7%) while the prevalence of cigarette smoking was higher in urban areas (18%) than in rural areas (13%) (12). Another study from Bangladesh revealed that 60% men living in slums smoked compared with 46% men living in non-slum areas (17). In India, the prevalence of current tobacco use (smoking and smokeless) is greater in rural areas (38%) than in urban areas (25%). Similarly, the prevalence of current smokeless tobacco use is much higher in rural areas (23%) than urban areas (14%) (13). As per Thailand GATS (2009), the prevalence of any smoked tobacco product among the rural population was slightly higher than that for the urban population (25% and 22%) (14). The type

of smoked tobacco products used also differed between urban and rural smokers; the results showed a higher prevalence of manufactured cigarettes use in urban areas than in rural areas (18% and 14%, respectively) and a higher prevalence of hand-rolled cigarettes use in rural areas as against urban areas (18% and 6% respectively) (14). As per Bangladesh GATS (2009), the prevalence of current use of any smoked tobacco product and any smokeless tobacco product decreased with increasing wealth index, with the highest prevalence in the lowest wealth index (29% and 36%, respectively) and lowest prevalence in the highest wealth index (14% and 17%, respectively) (Figure 3.7) (12). Studies from other sources also revealed consistent results. Tobacco consumption is now universally more common among lower socioeconomic groups (18). In a survey of 471 143 persons of age >10 years in India in the year 19951996, people below the poverty line had
Tobacco consumption and poverty

Fig 3.7: Percentage of adults, who are current users of tobacco products, by wealth index, Bangladesh, 2009
40 35 30 25 Percent 20 15 10 5 0 Any smoked tobacco product Any smokeless tobacco product

Tobacco use is highest among the poorest

Lowest

Low

Middle Wealth index

High

Highest

Source: Bangladesh Global Adult Tobacco Survey 2009

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higher relative odds of chewing tobacco compared to those above the poverty line, and regular tobacco use significantly increased with each diminishing income quintile (19). In Indias National Family Health Survey (NFHS II), prevalence among those in the richest quintile was 16% compared to 40% among the poorest quintile (20). Prevalence of tobacco chewing among women labourers in Dharan, Nepal (22%), was twice as much as the prevalence among service class women (10%) (21). The National Socio-Economic Survey 1995, 2001, 2004 for Indonesia revealed an increased proportion of household expenditure spending on tobacco products across all wealth quintiles (6.4% in 1995; 9.6% in 2001; 12% in 2004). However, a greater percentage of people in the poorest quintile (6.1% in 1995; 9.1% in 2001; 11% in 2004) spent their household expenditure on tobacco products than people in the wealthiest quintile (4.9% in 1995; 7.5% in 2001; 9.7% in 2004).

of eating inadequate (less than five servings) fruits and vegetables ranges from 60% to 97% in males and 64% to 94% in females. In five of eight Member countries for which data are available, the prevalence of inadequate fruits and vegetable consumption was higher among females than males (Table 3.2). Considering the low socioeconomic conditions and poor level of awareness in a large segment of the population in this Region, the findings that the vast majority of the population eats less than five servings of fruits and vegetables a day is not surprising (Table 3.2). A major hindrance in shifting to a healthy diet in this Region could be the high cost of fruits and vegetables relative to the income level of the population. There is evidence of high consumption of salt in many countries. High salt consumption is associated with hypertension and adverse cardiovascular events (23). According to the National Heart Foundation Hospital and Research Institute, Bangladesh, an average Bangladeshi consumes around 16 g of salt per day almost triple the recommended limit (24). In Thailand, the average consumption of salt per day among adults is 10.8 g (25). The Chennai Urban Rural Epidemiology Study (CURES) conducted on 1902 subjects showed that the mean dietary salt intake (8.5 g/d) in the population (26) was higher than that recommended by WHO for adults (5 g or less). Subjects in the highest quintile (mean salt intake=13.8 g/d) of salt intake had a significantly higher prevalence of hypertension than those in the lowest quintile (mean salt intake = 4.9 g/d) of salt intake (48% vs 17%, p<0.0001). Subjects in the highest quintile of salt intake also had significantly higher body mass index (BMI) and waist circumference (WC). The total calories and percentage of calories from fat also increased significantly across increasing quintiles of salt intake.

Due to globalization and urbanization, there is a shift from a healthy traditional highfibre, low-fat, low-calorie diet containing whole grains as well as fruits and vegetables, towards calorie-dense foods that are high in saturated fats, transfats, free sugars or salt. Foods that are high in fats and sugars promote obesity, a major risk factor for CVDs, diabetes and cancers (22). Consumption of adequate servings of food and vegetables on the other hand reduce the risk of heart disease and some cancers. With regards to unhealthy diet, three areas of particular concern in the Region are low intake of fruits and vegetables, high consumption of salt and widespread use of transfat by the food industry. Half a million deaths in the Region are attributed to low intake of fruits and vegetables (1). In SEAR Member countries, the prevalence

Unhealthy diet

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Table 3.2 Percentage of male and female adults eating less than five servings of fruits and vegetables, South-East Asia Region, 20042010
Member countries Bangladesh Bhutan India Male (%) 94 65 Female (%) 93 69 Both sexes (%) 93 67 Year of survey 2010 2007

Indonesia Maldives Nepal Myanmar Sri Lanka Thailand Total (Range)

NR 94 97 90 61 81 6597 83

NR 94 93 91 64 83 6493 82

86 94 97 90 62 82 82

2007-08 2007 2004 2009 2007 2007 2005

6297

Source: National NCD risk-factor surveys in Member countries

Another area of concern is that partially hydrogenated vegetable oils, which are associated with coronary heart disease (27) are commonly used in the preparation of commercially fried, processed, bakery, readyto-eat and street foods in the Region. In India, vanaspati brands, widely available in the market used in the food industry (28), have 512 times higher trans fatty acid (TFA) levels than the 2% limit set by some developed countries (29). In Thailand, samples collected from supermarkets and popular bakery stores showed that shortenings (2.4 g), butter cookies (2.1 g) and margarine (1.7 g) contained highest quantities of TFA per 100 g of food (30). Available regional data confirm current evidence that higher intake of TFA may be associated with increased risk of coronary heart disease. A case-control study (n=3575) carried out in India (1996) showed that ghee (clarified butter) plus TFA in both rural and urban areas were significantly associated with coronary artery disease (31).

Lack of physical activity contributes significantly to overweight and obesity, which is a risk factor for many NCDs. Participation in 150 minutes of moderate to vigourous physical activity per week is estimated to reduce the risk of ischaemic heart disease by 30%, the risk of diabetes by 27%, and the risk of breast and colon cancer by 21%25% (32). In SEAR, 5.1% of deaths are the attributable to physical inactivity (Annex 4) (1). This translates to nearly 800 000 deaths in the Region per year (1). In SEAR countries, the prevalence of insufficient physical activity varied from 3% to 41% among males and from 6.6% to 64% among females. The highest prevalence in both males and females was in Bhutan (41% and 64%, respectively), followed by Maldives (37% and 42%, respectively). In eight of nine SEAR countries for which data are available, prevalence of insufficient physical activity was higher among females than males.

Physical inactivity

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Indonesia was the only exception. No data were available for DPR Korea and Timor-Leste (Figure 3.8)

Alcohol is a psychoactive and potentially dependence-producing substance with severe health and social consequences when taken in excess. Harmful use of alcohol caused 2.5 million deaths each year globally in 2004 and an estimated 350 000 people died in SEAR of alcohol-related causes in 2004 (1). Across countries and cultures men are consistently more likely to consume alcohol frequently and in larger amounts than women (33). The results of the STEPS survey confirm this sex differential. In SEAR Member countries, the prevalence of alcohol consumption varied from 2% to 44% among males and from 0.1% to 26% among females. The highest prevalence among males was in DPR Korea (44%), followed by Nepal (40%) and Bhutan (35%). The highest prevalence among females was in Bhutan (26%),

Harmful use of alcohol

followed by Nepal (17%). In eight countries for which data were available, prevalence of alcohol consumption was higher among males than females. No data were available for Maldives, Thailand and Timor-Leste (Figure 3.9). Evidence suggests that low socioeconomic groups often experience a higher burden of alcohol-attributable diseases despite lower overall consumption levels (34). A recent study from Sri Lanka found that two lowest income categories spent 40% of their income on alcohol and smoking (35). Many poor people in this Region indulged in binge drinking, so much so that almost nothing was left from household expenditure to meet the necessities of life such as food and shelter. Health, particularly the preventive and promotive aspects, always receives low priority in this segment of the population. In Bhutan, little stigma is attached to alcohol use (36) and thus the usual barriers and deterrents to alcohol use inherent in some

Fig 3.8: Percentage of adults with insufficient physical activity*, South-East Asia Region, 2008
70 60 50 Percent 40 30 20 10 0 Males Females

Many people are not sufficiently physically active

Bangladesh Bhutan

India

Indonesia Maldives Myanmar

Nepal

Sri Lanka Thailand

Source: World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011. Data adjusted for 2008 based for comparability

Less than 30 minutes of moderate-to-vigorous activity at least five days a week.

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Fig 3.9: Percentage of adults consuming alcohol*, by sex, South-East Asia Region, 20072010
50 Males Females 40

Alcohol consumption is higher in males than females

Percent

30

20

10

Bangladesh Bhutan 2010 2007

DPR Korea 2008

India 2007

Indonesia Myanmar 2007 2009

Nepal 2007

Sri Lanka 2007

Source: National NCD risk-factor surveys in Member countries

People who have consumed alcohol in the past 30 days.

societies are not as apparent here. Until recently it was not taboo for Bhutanese children to drink at an early age and many women drink beer and wine. Studies in the country have shown that 50% of the grain harvests of households are used to brew alcohol; homemade alcohol production exceeds industrial production. Alcohol production and sale has become a livelihood for a large number of people in Bhutan. In certain areas, homemade alcohol is the only source of cash income to farmers. Alcohol is one of the five leading causes of death in Bhutan (36). Relatively few people in Bangladesh and Indonesia drink alcohol. This may be a due to the cultural setup in these countries.

with BMI between 25.0 and 29.9 is considered overweight and 30.0 is considered obese. Truncal obesity is defined in terms of waisthip (or waistheight) ratio. Raised BMI is among the leading risk factors for NCDs. It accentuates early development of type 2 diabetes and CVDs by triggering metabolic dysfunctions and raising blood pressure, blood glucose and cholesterol levels. Overweight and obesity are the fifth leading risk for global deaths. Globally, at least 2.8 million adults die each year as a result of being overweight or obese (1). Annually, 350 000 deaths are attributed to overweight and obesity in SEAR (1). In SEAR Member countries, overweight prevalence varied from 8% to 30% among males and 8% to 52% among females. The highest prevalence in both males and females was in Maldives (30% and 52%, respectively) followed by Thailand (26% and 36%, respectively). In eight of nine SEAR countries for which data were available, prevalence of overweight and obesity was higher among females. Nepal was the only exception. No data were available for DPR Korea and Timor-Leste (Table 3.3).

Metabolic Risk Factors

Overweight and obesity is defined based on body mass index (BMI). BMI is calculated as (weight in kg)/(height in metres)2. A person

Overweight and obesity

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Table 3.3 Percentage of adult population that is overweight and obese, South-East Asia Region, 2008
Member countries Bangladesh Bhutan India Indonesia Maldives Nepal Myanmar Sri Lanka Thailand Male 7.6 25 10 16 29 9.8 17 26 14 Overweight (BMI>25 kg/m2) Female 7.8 24 13 25 53 8.9 27 36 24 7.7 24 11 21 41 19 22 31 9 Both sexes Overweight (BMI>30 kg/m2) Male 4.7 1.3 2.5 6.5 1.4 2.0 2.6 4.9 1.0 Female 6.6 2.5 6.9 1.6 12 6.1 7.3 26 1.3 1.1 Both sexes 5.5 1.9 4.7 4.1 1.5 5.0 8.5 16

Source: World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011. Data adjusted for 2008 for comparability

Childhood obesity is an emerging issue. In a Mysore (India) study on 43 152 school children, obesity and overweight prevalence was 3.4% and 8.5%, respectively (37). In a school survey of 2156 children aged 1015 years in Khon Kaen (Thailand) 28% were overweight (38). Data from eight Demographic and Health Surveys conducted between 1996 and 2006 (19 211 women in Bangladesh, 19 354 women in Nepal, and 161 755 women in India) showed that between the first to the latest survey, the prevalence of overweight increased from 2.7% to 8.9% in Bangladesh, 1.6% to 10% in Nepal and from 11% to 15% in India. The trend showed significant ruralurban differences with the increase being greater in rural compared with urban areas in all three countries (41). On comparing the first to the latest survey, the prevalence of obesity also increased from 0.5% to 1.4% in Bangladesh, from 0.1% to 1.1% in Nepal, and from 2.2% to 3.4% in India. In all countries, the prevalence of overweight was positively associated with age, increasing relative wealth and urban residence (39).

Among Thai adults, the prevalence of obesity increased from 23% in 2004 to 29% in 2009 among males and from 35% in 2004 to 41% in 2009 among females. Waist circumference also showed an increase among both males and females during the same period (40) (Figure 3.10). In general, obesity is more common in the higher socioeconomic strata of society. Indonesian adolescents from families with high income were three times as likely to be obese (41). In Thailand though obesity was strongly associated with high socioeconomic status in males but inversely in females, particularly for those below 40 years (42). In Jaipur (India), age-adjusted prevalence of obesity among adults of age 2059 years was 9.5% in persons with low education and 17% in persons with high education (43). However, a recent review of relationship between socioeconomic status and obesity in 14 lower- to middle-income countries including India showed that the burden of obesity is shifting towards individuals of lower socioeconomic status as a countrys gross national product increases (44). A recent

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Fig 3.10: Percentage of overweight adult population, by sex, Thailand, 20042009

50 Overweight 2 BMI 25 kg/m Waist circumference 90.8 cm 2004 2009

40

30 Percent

20

10

Male

Female

Male

Female

Increasing obesity in Thailand

Source: National Health Examination Surveys, 2004 and 2009

study that examined data from 26 developing countries including South-East Asia found a higher prevalence of overweight than of underweight among young women living in rural and urban areas (45).

Raised blood pressure (BP) is a major risk factor for coronary heart disease as well as haemorrhagic stroke. Hypertension* is responsible for nearly 1.5 million deaths in SEAR (Annex 4). In a majority of countries of SEAR, more than one third of the adult population is hypertensive. Males have a slightly higher prevalence of raised BP than females in almost all SEAR countries (Figure 3.11). In the 10 countries for which data were available, the prevalence of high BP ranged from 19% in DPR Korea to 42% in Myanmar (Figure 3.11). No data were available from Timor-Leste. Literature review also suggests that high BP is indeed widespread in this Region. A study * Systolic BP>40 mmHg and stroke or diastolic BP>90 mmHg or using medication
to lower BP

Raised blood pressure

conducted in 2005 in Health and Demographic Surveillance System (HDSS) sites from Bangladesh (Matlab, Mirsarai, Abhoynagar, and WATCH), India (Vadu), Indonesia (Purworejo), Thailand (Kanchanaburi) and Viet Nam (Filabavi and Chililab) revealed that a considerable proportion of the study populations, especially those in the HDSS sites from India, Indonesia and Thailand had high BP. The overall prevalence (men and women combined) ranged from around 15% to 28% of the adult population with one exception where prevalence was 9% (one of the HDSS in Bangladesh) (46). In a recent study on 167 331 persons from a rural area of Trivandrum (India), BP 140/90 (either) mmHg was found in 43% men and 45% women of age 3589 years (47). A seven-year average follow-up study showed an accelerated rise of all-cause mortality and ischaemic heart disease mortality in the population with systolic BP110 mmHg and diastolic BP80 mmHg.

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Fig 3.11: Percenatge of adult population with high blood pressure*, South-East Asia Region, 2008
50 Males Females

40

High blood pressure is common in both sexes

Percent

30

20

10

0
DPR Korea* Indonesia** Bangladesh* Myanmar** Sri Lanka** India** Maldives* Bhutan** Nepal* Thailand**

Source: World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011. Data adjusted for 2008 for comparability

Systolic BP>40 mmHg and stroke or diastolic BP>90 mmHg or using medication to lower BP

Stroke mortality started to increase after diastolic BP75 mmHg. Rise in mortality was relatively steeper for incremental systolic BP (2 mmHg) than for incremental diastolic BP (1 mmHg). In a survey of 4616 persons aged 20 or more in Yangon (Myanmar) in 2003, prevalence of hypertension was 34% (48). National data from some countries indicate an increasing trend in the prevalence of raised BP. In Indonesia, percentage of adult population with raised BP increased from 8% in 1995 to 32% in 2008 (49). In Myanmar, the Ministry of Health reported an increase in hypertension prevalence, from 18% to 31% in males and from 16% to 29% in females (50). during 20042009. Rapid urbanization and transition from agrarian life to wage-earning, modern city life are reported as major contributors to increases in elevated BP in urban areas (51). In a study conducted in HDSS

sites in Bangladesh, India, Indonesia, Thailand and Viet Nam, age appeared to be a significant determinant of high BP among both men and women and overweight was positively associated with high BP in all sites (46).

Raised cholesterol (hypercholesterolemia) is widespread in SEAR and accounts for nearly 800 000 deaths annually (Annex 4). Raised cholesterol increases the risk of CVDs (52). This was also noted in studies conducted in the Region. For example, high levels of serum total cholesterol and low density lipoprotein (LDL) cholesterol presented a significantly higher risk of ischaemic stroke in Bangladesh (53) and Indonesia (54). Estimates available from six SEAR Member countries showed remarkable

Raised cholesterol

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variations in raised cholesterol levels, with the highest prevalence (above 50% in both sexes) in Maldives and Thailand. Females had a higher prevalence of raised cholesterol than males in five of six SEAR Member countries (Figure 3.12). In a rural population in Bangladesh, hypercholesterolaemia (total cholesterol 240 mg/dL) was found in 16% and high LDL cholesterol in 20% (55) in the age group 2079 years. Different ethnic groups in Indonesia were found to have varying lipid profiles (56). In a community in eastern Nepal, 13% had hypercholesterolemia in the age group 3586 years (57).

NCD risk factors are known to result in accentuated outcomes through synergistic

Cluster of risk factors

actions when two or more are simultaneously present in the same person. Because of clustering, the term metabolic syndrome is often used to describe the risk factor cluster of large waistline, high BP, raised blood sugar level, low high density lipoprotein (HDL) level and high triglyceride level. When occurring together, they form a risky combination for the development of NCDs. Metabolic syndrome prevalence is high in the Region, e.g. in rural Bangladesh, it was found in 21% women and 18% men (58). Among Indians, metabolic syndrome was prevalent in 19% males with higher educational status and 25% in those with lower educational status (59). Females had higher prevalence of metabolic syndrome and similar trends with respect to education as among men (59). In Sri Lanka, 62% of current smokers were also alcohol consumers (60). Findings from a study conducted among 18 494

Fig 3.12: Percentage of adult population with raised total cholesterol, South-East Asia Region, 2008
60 Males Females

50

One third to one half of adults have raised cholesterol

40

Percent

30

20

10

Indonesia**

Myanmar**

Maldives*

Source: World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011. Data adjusted for 2008 for comparability

Thailand**

Bhutan**

India**

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study participants in HDSS sites in Bangladesh, India, Indonesia, Thailand and Viet Nam, revealed a substantial proportion (>70%) of the largely rural populations having three or more risk factors for chronic NCDs. Chronic NCD risk factor clustering was associated with increasing age, being male and higher educational achievements (46).

While the risk factors discussed above are major contributors to NCDs, other factors also play a role. Prominent among them are infections, environmental factors such as pollution and arsenic, and exposures such as to asbestos. Stress may also act as a trigger for some NCDs.

Other risk factors

About one fifth of the cancer burden is attributable to a few specific chronic infections (61). The principal infectious agents (each responsible for approximately 5% of cancers) are human papillomavirus (cancers of the cervix, anogenital tract and oro-pharynx), hepatitis B virus and hepatitis C virus (primary liver cancers), and Helicobacter pylori (cancers of the stomach). Apart from infectious agents, a wide range of environmental causes, encompassing environmental contaminants or pollutants, occupationally-related exposures and radiation, together make a significant contribution to cancer burden and are often modifiable at low cost (3).

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48. Ko-Ko-Zaw et al. Prevalence of hypertension and its associated factors in the adult population in Yangon Division, Myanmar. Asia Pacific Journal of Public Health 2011;23:496-506. Epub 2010 May 10. 51. Kusuma YS et al. Prevalence of hypertension in some cross-cultural populations of Visakhapatnam District, South India. Ethnicity and Disease 2004;14:250-259.

53. Uddin MJ et al. Association of lipid profile with ischemic stroke. Mymensingh Medical Journal 2009;18:131-5. 54. Kusuma Y et al. Burden of stroke in Indonesia. International Journal of Stroke 2009;4:379-80.

52. Ezzati M et al. Comparative risk assessment collaborating group. Selected major risk factors and global and regional burden of disease. Lancet 2002;360:1347-60.

56. Hatma RD. Lipid profiles among diverse ethnic groups in Indonesia. Acta Medica Indonesiana 2011;43:4-11.

55. Mostafa Zaman M et al. Plasma lipids in a rural population of Bangladesh. European Journal of Cardiovascular Prevention and Rehabilitation 2006;13:444-8.

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57. Kalra S et al. Prevalence of risk factors for coronary artery disease in the community in eastern Nepala pilot study. The Journal of the Association of Physicians of India 2011;59:300-1. 59. Reddy KS et al. Educational status and cardiovascular risk profile in Indians. Proceedings of the National Academy of Sciences United States of America 2007;104:16263-8. Epub 2007 Oct 8. 58. Khanam MA et al. The metabolic syndrome: prevalence, associated factors, and impact on survival among older persons in rural Bangladesh. PLoS One 2011;6:e20259. Epub 2011 Jun 15.

60. Ahmed SM et al. Clustering of chronic non-communicable disease risk factors among selected Asian populations: levels and determinants. Global Health Action 2009;28:2. 61. Parkin DM. The global health burden of infection-associated cancers in the year 2002. International Journal of Cancer 2006;118:3030-3044.

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Drivers of NCDs

NCDs have their origin in the social, cultural, economic and environmental conditions of societies.

Globalization, unplanned urbanization, poverty, poor health systems and social inequities are major determinants of NCDs. Socioeconomic determinants can influence peoples exposure and vulnerability to NCDs and can also influence health outcomes.

Socioeconomic conditions have an enormous impact on population health. Socioeconomic determinants can influence peoples exposure and vulnerability to NCDs and can also influence health outcomes. This chapter reviews the major determinants of NCDs including poverty, illiteracy, poor health infrastructure and social inequities on one side and demographic transition in terms of increasing life expectancy, and urbanization and globalization on the other. These determinants trigger risk factors that increasingly lead to NCDs (Figure 4.1).

NCDs have emerged as a public health problem in SEAR mainly due to epidemiological transition, characterized by a change in disease

Population Ageing

patterns from infectious diseases to NCDs, and from a demographic transition due to increased longevity and a rise in the ageing population. People in this Region are now living longer (Annex 5) and closing the gap with the worlds average life expectancy. This is primarily a result of marked reduction in infant and child mortality and control of communicable diseases in most SEAR Member countries. As a result, typical population pyramids are changing from a pyramid shape to a bell shape to a barrel shape (Figure 4.2). It is projected that from 2000 to 2025, the proportion of population above 65 years will increase from 3.6% to 6.6% in Bangladesh, from 4.4% to 7.7 % in India and from 6.3% to 12.3% in Sri Lanka. Ageing due to this transition will increase the number of NCD cases because prevalence of NCDs increases with age (1).

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Fig 4.1. Schematic representation of an iceberg for NCDs

NCDs

Cardiovascular diseases Cancers Chronic respiratory diseases Diabetes

Metabolic risk factors

Raised blood pressure Raised blood glucose Abnormal blood lipids Overweight/obesity Tobacco use Unhealthy diet Physical inactivity Harmful use of alcohol Illiteracy Poverty Globalization Urbanization

Behavioural risk factors

Social determinants

Urbanization in SEAR is occurring at a rapid rate. It increased from 26% in 1990 to 33% in 2009 (2). The projected percentage of population residing in urban areas will more than double by 2050 in most of the Member countries (Figure 4.3). Urban lifestyles increase the risk of NCDs by reduced opportunities for physical activity, increased exposure to environmental pollutants and stress, and increased availability of processed and unhealthy foods. Increasing urbanization is also causing traditional healthy habits to change to unhealthy habits.

Urbanization

Major urban differentials exist in the prevalence and levels of risk factors and diseases. Studies have shown the correlation of urbanization with an increase in behavioural and metabolic risk factors, i.e. smoking, overweight, raised blood pressure, low physical activity, as well as prevalence of some major NCDs (3). The ICMR (Indian Council of Medical Research) and WHO multi-centric study conducted in six states of India among men and women aged 1564 years shows that behavioural, anthropometric and biochemical risk factors of NCDs are more prevalent in urban than in rural areas (Figure 4.4) (4).

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Fig 4.2: Population projections for Bangladesh and India, 2011, 2025 and 2050

Bangladesh, 2011
Male
100+ 9094 8589 8084 7579 7074 6569 6064 5559 4549 4044 3539 3034 2529 2529 2529 2024 1519 1014 59 04

Bangladesh, 2025
Female Male
100+ 9094 8589 8084 7579 7074 6569 6064 5559 4549 4044 3539 3034 2529 2529 2529 2024 1519 1014 59 04

Bangladesh, 2050
Female Male
100+ 9094 8589 8084 7579 7074 6569 6064 5559 4549 4044 3539 3034 2529 2529 2529 2024 1519 1014 59 04

Female

10 8 6 4 2 Population (in millions)

0 0

10

10 8 6 4 2 Population (in millions)

0 0

10

10 8 6 4 2 Population (in millions)

0 0

10

India, 2011
Male
100+ 9094 8589 8084 7579 7074 6569 6064 5559 4549 4044 3539 3034 2529 2529 2529 2024 1519 1014 59 04

India, 2025
Female Male
100+ 9094 8589 8084 7579 7074 6569 6064 5559 4549 4044 3539 3034 2529 2529 2529 2024 1519 1014 59 04

India, 2050
Female Male
100+ 9094 8589 8084 7579 7074 6569 6064 5559 4549 4044 3539 3034 2529 2529 2529 2024 1519 1014 59 04

Female

10 8 6 4 2 Population (in millions)

0 0

10

10 8 6 4 2 Population (in millions)

0 0

2 4

10

10 8 6 4 2 Population (in millions)

0 0

10

Source: US Census Bureau, International Data Base

A study conducted in Sri Lanka showed that prevalence of diabetes mellitus, overweight and insufficient physical activity was highest among urban men and women compared to those among the middle- and lower-urban categories. The smoking prevalence among men was highest among the low-urban category,

compared to categories (5).

medium-

and

high-urban

A study from Tamil Nadu (India) found that being urban (measured by population size, access to markets, communication, etc.) is associated with smoking, increased body-mass index (BMI), blood pressure and physical

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Fig 4.3: Projected mid-year population, residing in urban areas, South-East Asia Region, 2010-2050
100 2010 2050 80

Dramatic increase in urbanization expected

60 Percent

40

20

0
Bhutan DPR Korea Maldives Bangladesh Sri Lanka Myanmar Nepal Timor-Leste Indonesia India Thailand

Source: World Urbanization Prospects. The 2007 Revision. Highlights. Department of Economic and Social Affairs Population Division. United Nations New York, 2008.

Fig 4.4: Prevalence of NCD risk factors in urban and rural areas, by sex, India, 2003-2006
80 70 60 50 Percent 40 30 20 10
Female

Urban Rural

NCD risk factors are more prevalent in urban areas

Male

Female

Female

Female

BMI30

Increased WC

Physical inactivity at work

Blood glucose 126 mg/dl

Total cholesterol 200 mg/dl

WC = waist circumference; BMI = body mass index; increased WC (Men 90 cm; Women 80 cm) Source: Shah B, Mathur P. Surveillance of cardiovascular disease risk factors in India: the need & scope. Indian Journal of Medical Research 2010;132:634-42.

2011

Female

Male

Male

Male

Male

47

inactivity in men and high BMI and physical inactivity in women (3). However, this study found that being urban is positively associated with increased consumption of fruits and vegetables in both sexes.

The rapidly growing burden of NCDs in low- and middle-income countries is also driven by globalization of trade and market economy. All economies work on the principle of demand and supply, i.e. they influence demand and accordingly modify supply systems manufacturing and service sectors. Moreover, globalization is decreasing trade barriers and populations are now subjected to international marketing and advertising. Globalization has brought processed foods and diets high in total energy, fats, salt and sugar into billions of homes, and people in developing countries are now consuming more processed foods than ever before. Rise in income is increasing the purchasing capacity and may be facilitating consumption of processed food, beverages and tobacco. A significant proportion of global marketing is now targeted at children in developing economies and is a key contributor to unhealthy behaviour. This has resulted in a situation where unhealthy options (be it tobacco, alcohol or food) are more often easily available, cheaper and more attractive. As a result, the level of exposure of individuals and populations to risk factors for NCDs may be higher in the Region than in high-income countries, where people tend to be protected by comprehensive interventions.

Globalization

with NCDs are doubly disadvantaged; on the one hand, low levels of income affect health behaviours and lifestyle choices; healthdamaging behaviours are found to be common among the poor, and low income may affect health directly, for example, due to low purchasing power for a healthy diet. On the other hand, access to health care is low among the poor and NCDs are expensive to treat and may push a family into poverty through out-ofpocket expenditures, thereby limiting their food and health-seeking choices. Poverty in turn is associated with other social determinants of chronic diseases, such as inadequate education, weak social network, social exclusion and longlasting psychological stress. Cardiovascular diseases (CVDs) and their risk factors were originally more common in upper socioeconomic groups in the developed world but have gradually become more common in lower socioeconomic groups (6). In SEAR, many risk factors and NCDs are already equally and more prevalent in the lower socioeconomic strata of society. For example, in Indonesia, hypertension was as common (33%) in the top income quintile as (31%) in the bottom quintile (7). Tobacco and poverty form a vicious circle. Tobacco is a special case of a preventable risk that disproportionately affects the poor. The poorest quintiles are more likely to smoke daily and more likely to smoke larger quantities (see Chapter 3). Expenditure on tobacco consumption displaces income available for the familys food, education and health care. A study conducted in Sri Lanka revealed that the two lowest income categories (monthly income <US$ 76) spent more than 40% of their income on concurrent alcohol and tobacco use while the next income category (US$ 76143) spent 35% of their income on alcohol and tobacco. The poor spent less than those with higher income on alcohol and tobacco but given the mean

A large segment of the population in SEAR still lives below the poverty line. The NCD pandemic originates from poverty and disproportionately affects the poor. Poor people

Poverty

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expenditure of over 40% of income on these substances, the daily survival of the poor is severely constrained (8). Understanding the links between poverty and NCDs would help in developing appropriate policies to address this. One possibility is material deprivation due to poverty that restricts choices and pushes people into highrisk behaviours. This causes not only an early onset of NCDs, but also complications that cannot be averted as access to health care is also limited resulting in early death. The other possibility is that recent developments have generated high incomes for some erstwhile deprived groups in developing countries that has eased choices to indulge in a risky lifestyle thus exacerbating NCDs (9). The outcome of all diseases, particularly of NCDs (since they require prolonged care), is worse in poor countries, particularly where access to health care is dependent on the ability to pay (6). Total expenditure on health in SEAR Member countries is low (Annex 6), with a maximum of 14% GDP in Timor-Leste in 2008 and just 2.3% in Indonesia and Myanmar. In India, total health expenditure as percentage of GDP (4.2%) is about one third that of USA (10). The irony in this impoverished Region is that more than one half (59% in 2008) of health expenditure is met with private resources, mostly out of pocket. This places a disproportionate burden on the poor. Social security is practically non-existent for large segments of the population. In 2008, per capita total expenditure on health was $PPP 116 on average in the Region and government expenditure was just about 33% in populous countries, such as Bangladesh and India, and a dismal 7.5% in Myanmar (Annex 6).

important underlying determinant of health at both individual and community levels. Educated people benefit through increased knowledge of protecting health, a better understanding of health-promoting lifestyles and seeking proper health care. Literacy levels in SEAR have considerably improved from an average of 52% during 199099 to 71% in 2007. However, 30% of the Regions population remains illiterate (11). Low levels of literacy affect health behaviours and lifestyle choices, so that people fall easy and early prey to NCDs. An inverse relationship between tobacco use and education has been observed in the Region. Studies have revealed that both smoking and smokeless tobacco use are more prevalent among the less educated in Bangladesh, India, Indonesia, Sri Lanka and Thailand (see Chapter 2). Illiteracy and a poor level of awareness can also result in high consumption of salt, as well as use of saturated fats and trans fats and thus aggravate development of NCD risk factors.

Education is a crucial factor for sustainable development and the most

Illiteracy

Underdeveloped health systems and maldistribution of health care is also an important determinant of health. Under-developed and under-resourced health-care systems worsen the impact of the NCD epidemic. Current health systems in SEAR have many limitations to tackle NCDs. First, there is unequal distribution of health workers, who particularly concentrate in urban areas. Moreover, there is a disproportionately higher number of health personnel working at the institutional level of medical care vis--vis community level workers including health volunteers delivering public health services. Also, there is insufficient attention to involve the workforce from other sectors or disciplines beyond health. Second, health workers lack training in providing NCD services at the primary care level, particularly, little attention is paid to health promotion and primary prevention. Finally, essential drugs for

Underdeveloped health system

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NCDs are often not available at the primary care centres. Annex 7 shows key indicators of the health workforce in SEAR countries. With the exception of a few SEAR countries, health care personnel in every category are understaffed. The health workforce density in SEAR countries is low with a regional average of five physicians and 13 nurses/midwives per 10 000 population, against 14 and 30, respectively in the global average. The health infrastructure situation is also unfavourable with some countries, where while the number of hospital beds considerably increased over time, the number of health centres remain low. This is a major constraint in sustainable development of the health sector and in improving access to health care. Health expenditure ratios in SEAR countries (Annex 6) indicate a large variation among SEAR

countries. A slight improvement in out-ofpocket expenditure and general government expenditures on health could be observed between 2000 and 2008; however some other crucial indicators show that this Region is well below the global average (Annex 6). In summary, public health infrastructure in most SEAR countries is not adequate and the value of public health is not adequately appreciated. Development of only the institutional health system may not be enough for tackling NCDs; public health interventions (including health promotion and disease prevention as a primary prevention) are also needed. At the same time, curative service cannot be ignored. Public health interventions should reach the poor, un-reached and underprivileged.

1. US Census Bureau, International Data Base http://www.census.gov/population/international/data/idb/region.php?N=%20Region%20Results%20&T=2&A=both&RT =0&Y=2000,2011,2025&R=123&C=BG,IN,CE (accessed 28 December 2011). 2. World Health statistics 2011. Geneva, World Health Organization 2011. http://www.who.int/whosis/whostat/EN_WHS2011_Full.pdf (accessed 28 December 2011). 3. Allender S et al. Level of urbanization and noncommunicable disease risk factors in Tamil Nadu, India. Bulletin of the World Health Organization 2010; 88:297-304.

REFERENCES

6. Equity, social determinants and public health programmes. Geneva, World Health Organization 2010.

5. Allender S et al. Quantifying Urbanization as a Risk Factor for Noncommunicable Disease. Journal of Urban Health 2011;88:906-18.

4. Shah B, Mathur P. Surveillance of cardiovascular disease risk factors in India: the need & scope. Indian Journal of Medical Research 2010;132:634-42. http://icmr.nic.in/ijmr/2010/november/1122.pdf (accessed 28 December 2011).

7. National Institute of Health Research and Development, Ministry of Health. Report on Result of National Basic Health Research, 2008. 9. Yach D, Hawkes C, Gould CL, et al. The global burden of chronic diseases: overcoming impediments to prevention and control. Journal of the American Medical Association 2004;291:2616-22. 8. de Silva V, Samarasinghe D, Hanwella R. Association between concurrent alcohol and tobacco use and poverty. Drug and Alcohol Review 2011;30:69-73.

10. Ilangho RP. Review series: lung disease around the world: lung health in India. Chronic Respiratory Disease 2007;4:107-10. 11. World health statistics 2010. Geneva, World Health Organization 2011.

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Economic Burden of NCDs

The economic consequences of NCDs are enormous, both at the micro- and macro-economic levels.

The earnings spent on unhealthy risk behaviours, such as tobacco use and harmful use of alcohol, leave decreased financial resources for essential items, such as food, education and daily consumables. Expenditure on NCD treatment results in catastrophic health expenditures and impoverishment of affected families.

The economic burden of NCDs and risk factors may be examined in the context of microeconomy (household financing of care, changes in consumption patterns, and foregone earning of individuals and households due to the ill health in the population), and macroeconomy (the expenditure on infrastructure and GDP losses due to ill health in the population). This chapter examines the impact of NCDs and their risk factors on economic development in countries of SEAR, at the national and household level.

Forum (WEF) estimates that over the next 20 years, at the global level, NCDs will cost more than US$ 30 trillion, representing 48% of global GDP in 2010, and will push millions of people below the poverty line (1). According to a macroeconomic analysis, it is estimated that each 10% increase in NCDs is associated with a 0.5% lower rate of annual economic growth (2). At the national level, negative impacts of NCDs also include large-scale loss of productivity as a result of absenteeism and inability to work and loss of lives due to premature deaths (<60 years), and ultimately a decrease in national income. The cumulative projected cost of CVDs in terms of GDP loss by 2015 in five SEAR countries is estimated to amount to more than 20 billion dollars (Table 5.1) (3).

The macroeconomic impact of NCDs is profound as they cause loss of productivity and decrease in GDP. A recent study by Harvard School of Public Health and World Economic

Economic burden of NCDs at the National Level

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Table 5.1: Projected cost of cardiovascular disease in terms of lost GDP in selected countries of South-East Asia Region, 2006 and 2015
Foregone GDP* (US$ billions) Cumulative GDP loss (US$ billions) by 2015

Member countries Bangladesh India Indonesia Myanmar Thailand

2006 0.08 1.35

2015 0.14 1.96

2015 as proportion of 2006 estimates 175% 145%

1.1 0.43 1.5 4.2 17

0.33

0.03

0.53

0.12

0.06

158%

0.18

200%

150%

Source: Abegunde DO, et al. The burden and cost of chronic diseases in low-income and middle-income countries. Lancet 2007;370:1929-38. *GDP: Gross Domestic product

As NCDs are chronic in nature and require long term treatment and care, countries are spending large sums of money for management of people inflicted with NCDs. A major part of these costs is associated with expensive infrastructure, largely at the tertiary level, for investigation technologies and for drugs. Some examples of high expenditure on health care financing in the Region are:
I

Economic loss in 2008 in Indonesia due to tobacco-attributed premature mortality, morbidity and disability was estimated to be 339 trillion Rupiahs (US$ 34 billion). This was much higher than 45 trillion Rupiahs (US$ 4.5 billion) revenue collected by the Government from tobacco in the same year (5). Economic implications of COPD in India reveals that the cost of COPD treatment is increasing in both urban and rural areas (Figure 5.1). It is estimated that more than Rs 48 000 crore will be spent by patients and their families on COPD treatment alone in 2016 (6).

Average cost of illness per diabetic patient in Thailand was US$ 881 in 2008; this represented 21% of per capita GDP of Thailand (4). Total annual health expenditure spent by Indonesian people in 2008 for diseases attributed to tobacco amounted to 15 trillion Rupiahs (~US$ 1.5 billion) for inpatient services and 3.1 trillion Rupiahs (~US$ 0.31 billion) for out-patient services. By applying GDP per capita (in 2008) of US$ 1420, at the macro level, the tobaccoattributed loss of disability adjusted life years (DALYs) caused an economic loss of US$ 19 billion in Indonesia (5).

NCDs have a detrimental impact on individuals and families. Loss of household income among the poor occurs due to high costs incurred because of unhealthy behaviours (tobacco use, harmful use of alcohol), out-ofpocket health-care expenditure (for treatment of NCD and their complications), and loss of

Economic burden of NCDs at household level

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Fig 5.1: Projected cost of treatment for chronic obstructive pulmonary disease (COPD) by residence, India 1996-2016
6000 Total Rural Urban

5000

Rupees in million

4000

COPD treatment cost is expected to increase in urban and rural areas alike

3000

2000

1000

1996

2001

2006

2011

2016

Source: Economic burden of chronic obstructive pulmonary disease, NCMH Background Paper Burden of Disease in India.

wages (due to disease, disability and premature death), thus exacerbating poverty. Risky behaviours, such as smoking and alcohol use, cost a significant proportion of the household income for the poor. Because of prolonged illnesses in NCDs and since NCDs affect the most productive periods of life, the consequent loss of productive capacity affects earnings; and this combined with high health-care costs associated with NCDs, drives poor families further into poverty.
Household expenditure incurred on risky behaviours

Tobacco and alcohol use are addictive and come at a cost that could have a detrimental impact on household budget. In Bangladesh, the poorest spend about 10 times as much on tobacco as on education (Figure 5.2) (7). The average amount spent on tobacco each day would generally be enough to make the difference between at least one family member having just enough to eat to keep from being malnourished (8).

In Myanmar, although the actual household expenditure on tobacco was lower in the low-income groups, the percentage of monthly expenditure for tobacco products was highest among the lowest income groups and fell steadily for higher income groups. Indian households with tobacco users had lower consumption of certain commodities (such as milk, education, clean fuels and entertainment), which may have a more direct bearing on women and children in the household than on men, suggesting that tobacco spending also had negative effects on per capita nutrition intake (10). Families in Delhi (India) with at least one member consuming three or more drinks per week spent almost 14 times more on alcohol each month compared with families where no member consumed more than one drink (11). Excessive drinking also resulted in fewer financial resources for food, education and daily consumables and more debts.

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Fig 5.2: Ratio of expenditure on tobacco to education, by household expenditure group, Bangladesh, 1995-96
12 Tobacco to education expenditure ratio 10

The poorest spend about 10 times as much on tobacco as on education in Bangladesh

1 (poorest)

10 11 12

13

14

15 16 17

Household expenditure group

18 (richest)

Source: Efroymson D et al. Hungry for tobacco: an analysis of the economic impact of tobacco consumption on the poor in Bangladesh. Tobacco Control 2001;10:212-7.

In Indonesia, the average budget spent in 2008 by an individual smoker to purchase tobacco in one month was 216 000 Rupiahs (US$ 22), and the total amount spent by Indonesian smokers on tobacco in one year was 153 trillion Rupiahs (US$ 15.3 billion) (5). In 2007, 11% of monthly household expenditure was on tobacco the second highest expenditure category after food expense and nearly four times than that for education (Figure 5.3). In Nepal the poorest spend 10% of their income on cigarettes against 5% by the wealthiest (12).
Health care expenses incurred at household level

resourced and there is little social security coverage, treatment of NCDs results in catastrophic health expenditures and impoverishment. For example, in Sri Lanka, treatment of diseases such as diabetes is posing a severe burden on households, pushing even non-poor households into poverty (14). A study revealed that the median daily cost of hospital stay due to NCDs in a teaching hospital in Sri Lanka was Rs 340 (15). These turn into enormous costs for the family. Further, in India, the share of out-ofpocket expenditure due to NCDs among the economically better off households increased from 32% in 1995 to 47% in 2004, indicating the growing financial impact of NCDs at the household level (16). In India, diabetes treatment can cost a low-income household, a third of their monthly income (16). Out-ofpocket expenditure associated with acute and

More than one half of health expenditure in SEAR is met by private resources, that too mostly out of pocket (13). As public health-care facilities and services are inadequately

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Fig 5.3: Distribution of monthly household expenditure, by expense category, Indonesia, 2007 Tobacco expenditure accounts for a tenth of the total household expenditure in Indonesia

Health 12% Other expenses 2% Education 3% Tobacco 11% Food 72%

Source: Ministry of Health, National Institute for Health, Research and Development, Indonesia

long-term effects of NCDs can result in catastrophic health expenditure. In India, 25% of families with a member with CVD experience catastrophic expenditure and 10% are driven to poverty (17). The situation is much worse with cancer treatment expenses, where almost 50% of households with a member with cancer experience catastrophic spending and 25% are driven to poverty by health-care expenses. The odds of incurring catastrophic hospitalization expenditure were nearly 160% higher with cancers than when hospitalization was due to a communicable disease (17). In some SEAR countries, up to 40% of household expenditures for treating NCDs are financed through borrowing and sale of assets driving people further into debt and poverty (17).

Most people with NCDs cannot continue working and forego personal and household income. Duration of NCDs is longer compared with other health conditions. In India, duration of illness, defined as days when people could not work, was 5070 days or more for some NCDs (17). The annual income loss from missed work, time given for care taking, and premature deaths are also significant. The total income loss due to chronic diseases in India was between Indian Rupee (INR) 10941113 billion. Of this, income loss due to hypertension was the highest (INR 199 billion), followed by diabetes (INR 163 billion) and CVDs (INR 144158 billion) (Figure 5.4) (17).

Loss of wages

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Fig 5.4: Annual income loss from missed work, time for care giving, and premature death among households with a member suffering from an NCD, India, 2004
140 120

Missed work

Caregiving

Premature death

Income loss (billion rupees)

NCDs lead to huge loss in household wages

100 80 60 40 20 0

Cardiovascular disease

Hypertension

Diabetes

Asthma

Respiratory illness

Injuries

Source: Mahal A et al. The economic implications of non-communicable diseases for India. Health, Nutrition and Population (HNP) Discussion Paper. 2010.

1. The global economic burden of non-communicable diseases. A report by the World Economic Forum and the Harvard School of Public Health. September 2011 http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf (accessed 28 December 2011). 2. Stuckler D. Population causes and consequences of leading chronic diseases: a comparative analysis of prevailing explanations. Milbank Quarterly 2008;86:273326. http://onlinelibrary.wiley.com/doi/10.1111/j.14680009.2008.00522.x/pdf (accessed 28 December 2011).

REFERENCES

3. Abegunde DO et al. The burden and cost of chronic diseases in low-income and middle-income countries. Lancet 2007;370:1929-38. 4. Chatterjee S et al. Cost of diabetes and its complications in Thailand: a complete picture of economic burden. Health and Social Care in the Community 2011;19:289-98.

5. National Institute for Health, Research and Development, Indonesia. Soewarta Kosen. Ministry of Health, Republic of Indonesia, 2009.

6. Murty KJR, Sastry JG. Economic burden of chronic obstructive pulmonary disease. NCMH Background Paper-Burden of disease in India. Mahavir Hospital and Research Centre http://whoindia.org/LinkFiles/Commision_on_Macroeconomic_and_Health_Bg_P2_Economic_burden_of_chronic_obs tructive_pulmonary_disease.pdf (accessed 28 December 2011). 7. Efroymson D et al. Hungry for tobacco: an analysis of the economic impact of tobacco consumption on the poor in Bangladesh. Tobacco Control 2001;10:212-7.

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9. Kyaing NN. Tobacco economics in Myanmar. Health, Nutrition and Population (HNP) Discussion Paper. Economics of Tobacco Control Paper No. 14. October 2003. http://www.searo.who.int/LinkFiles/NMH_EconomicsMyanmar.pdf (accessed 28 December 2011). 11. Saxena S et al. Alcohol and drug abuse. New Age Publishers and National Book Trust, New Delhi, 2003. 12. Karki Y et al. A study on the economics of tobacco in Nepal. Washington, DC:The World Bank; 2003. 14. Perera M et al. Equity in health carethe case of diabetes in Sri Lanka. Marga Institute http://www.margasrilanka.org/reading_equity.htm (accessed 28 December 2011). 13. World Health Organization. World Health statistics 2011. Geneva, 2011. http://www.who.int/whosis/whostat/EN_WHS2011_Full.pdf (accessed 28 December 2011).

8. Ali Z et al. Appetite for nicotine. An economic analysis of tobacco control in Bangladesh. Health, Nutrition and Population (HNP) Discussion Paper. Economics of Tobacco Control Paper No. 16. Nov 2003 http://www.searo.who.int/LinkFiles/NMH_ApetiteforNicotine.pdf (accessed 28 December 2011).

10. John RM. Crowding out effect of tobacco expenditure and its implications on household resource allocation in India. Social Science Medicine 2008;66:1356-67. Epub 2008 Jan 9.

16. Ramachandran A et al. Increasing expenditure on health care incurred by diabetic subjects in a developing country: a study from India. Diabetes Care 2007;30:2526. 17. Mahal A et al. The economic implications of non-communicable diseases for India. Health, Nutrition and Population (HNP) Discussion Paper. 2010. http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/2816271095698140167/EconomicImplicationsofNCDforIndia.pdf (accessed 28 December 2011).

15. Kasturiratne A et al. Morbidity pattern and household cost of hospitalisation for non-communicable diseases (NCDs): a cross-sectional study at tertiary care level. Ceylon Medical Journal 2005;50:109-13.

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National Response to NCDs

NCDs are now recognized as an important health problem in all Member countries.

Health ministries of Member countries currently lead NCD national policies and programmes. Risk factor surveillance has been established in most Member countries but morbidity and mortality surveillance is generally ineffective.

Existing primary health-care systems need to be strengthened to address NCDs at the grass root level.

Member countries in the Region have initiated measures to combat NCDs. WHO Regional Office for South-East Asia (SEARO) conducted a survey in 11 Member countries, using a semi-structured self-administered questionnaire during 2010*, to assess their current capacity to respond to NCDs. This chapter presents the results of this survey and also highlights innovative practices in select countries.

Institutional Capacity for NCD Prevention and Control at the Central Level
The health ministries in all 11 Member countries have formed a separate unit/ department for NCD prevention and control. An NCD focal point for NCD prevention and control, such as the NCD programme manager, is available at the health ministry level in all

* SEAR NCD website: http://www.searo.who.int/en/Section1174/Section1459.htm

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countries. The main functions of the NCD unit/department are to plan, coordinate, implement, monitor and evaluate NCD prevention and control activities in the country. The NCD units scope of work includes the entire spectrum of NCD prevention and control, ranging from health promotion and primary prevention to early diagnosis, treatment and care. The staff at the central level varies widely from 24 persons in Bangladesh, DPR Korea, Nepal, Sri Lanka and Timor-Leste; to 813 persons in Bhutan, India, Maldives and Myanmar; and 5075 in Indonesia and Thailand. However, many countries have identified inadequacies in knowledge and skills among their existing public health workforce to carry out assigned functions of NCD prevention and control at national and subnational levels. Central NCD units support national institutions, such as specialty hospitals and centres, national public health institutions as well as professional associations.

programmes, legislations/regulations and networks that are reported as being implemented or operational in Member countries. Countries are moving from diseasespecific or risk factor-specific approaches towards a more integrated approach. Nine Member countries reported have integrated NCD policies that are largely comprehensive in terms of covering multiple risk factors and diseases. Cancers and diabetes are the most targeted diseases for control and chronic respiratory diseases the least targeted. By 2010, all 11 Member countries had at least one policy/strategy/plan/programme to address NCDs, and these were operational in seven countries (Table 6.1). A dedicated budget for policy/plan/ programme implementation is available in six countries, while seven countries also have a monitoring and evaluation component. All countries have measurable outcome targets as part of the strategy/programme/action plan. While CRD is the least targeted disease, tobacco (its primary cause) is the most targeted risk factor for control, followed by harmful use of alcohol. On the contrary, while diabetes is the most targeted disease, diet and physical activity are the least targeted risk factors.

National Policies, Strategies, Plans and Programmes for NCD Prevention and Control
National NCD policies should be multisectoral in nature and integrated within the national health and development programmes. Further, NCD programmes need to be integrated (and not disease specific) because of common/shared risk factors that are responsible for these NCDs.

The availability and implementation of guidelines is one major way to promote evidence-based care. Disease-specific guidelines that are under development or have been partially implemented in a few countries are given in Table 6.2.

National NCD guidelines

There is a high level of national commitment for tackling NCDs as reflected by the large number of policies, strategies, plans,

Policies/plans/programmes

Legislative measures and effective law enforcement are key to implementing comprehensive NCD prevention and control

Legislative measures on NCD prevention and control

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programmes. Legislation serves to institutionalize NCD control programmes and creates, legitimizes and finances an authority to implement and direct a policy programme for NCD control in a country. In Member countries, tobacco has been addressed almost universally by legislation. Tobacco legislation is available in 10 countries, five countries have alcohol legislation, two countries address legislation on diet and nutrition and only one country has physical activity legislation. Legislative support for other risk factors is yet to be fully developed in Member countries. The WHO Framework Convention on Tobacco Control (FCTC) is the first legally binding international treaty to reduce harm due to tobacco. In SEAR, all

countries except Indonesia have ratified the WHO FCTC and are implementing the various elements of MPOWER a package of six effective tobacco control policies (Table 6.3). In Thailand, the Thai Health Promotion Foundation (ThaiHealth) has played a crucial role in NCD prevention and control, particularly in increasing tobacco taxation. The consistent increase in taxes over the past several years has led to a steady decrease in smoking prevalence among adults. Similar taxation is needed to reduce the demand for other unhealthy products such as sugary drinks; conversely, subsidies should be provided on fruits and vegetables.

Table 6.1: Number of South-East Asia Region Member countries with policies, strategies, action plans and programmes for NCD prevention and control, 2010 (n=11)
Integrated or diseasespecific tools Integrated Policy 4 4 3 2 9 Strategy 6 6 5 4 9 Plan 6 6 6 5 9 Programme Any of these 7 8 7 5 8 11 7 8 8 6

Heart diseases Cancer Diabetes Chronic respiratory disease

Source: World Heath Organization. Assessment of capacity for prevention and control of chronic noncommunicable diseases. New Delhi, 2011.

Table 6.2: Number of countries with national-level NCD guidelines, South-East Asia Region, 2010 (n=11)
Health conditions/ services Diabetes Available 8 8 2 3 5 4 6 4 Availability of national level guidelines 1 1 2 1 1 2 1 1 Implementation Full 5 5 2 1 3 2 4 3 Under development Partial 4 4 1 2 2 3 3 1

Hypertension Dyslipidemia

Overweight/obesity Alcohol dependence Dietary counselling Physical inactivity Tobacco dependence

Source: World Heath Organization. Assessment of capacity for prevention and control of chronic noncommunicable diseases. New Delhi, 2011.

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Table 6.3: Status of implementation of Framework Convention on Tobacco Control in South-East Asia Region, 2011
Ratification of WHO FCTC FCTC Implementation
Bangladesh Bhutan

Monitor tobacco use and prevention policies Global Adult Tobacco Survey (GATS) X Global Youth Tobacco Survey (GYTS) Protect people from tobacco smoke Smoke-free health care facilities Smoke-free government facilities X Smoke-free public transport X Smoke-free educational institutes National law requiring fine for smoking Fines levied on the establishment X X X X

DPRK

India Indonesia Maldives

Myanmar Nepal

Sri Lanka

Thailand

Timor-Leste

X X X X X X NA

X X X X 32%

X X X X X X X 50%

X X X X X X 29%

X X X X 73%

69%

X X X X X X X X X X X X NIL

X X X X X

Offer help to quit tobacco use Tobacco quit lines available

Enforce Bans on tobacco advertising, promotion and sponsorship Ban on national TV and radio X X Ban at point of sale X X Ban on billboards and outdoor advertising X X Raise taxes on tobacco Taxation rate on cigarettes 68% NA NA 46%

Warn about dangers of tobacco use Graphic health warnings X Textual health warning

54%

Source: Narain, et al. Noncommunicable diseases in the South-East Asia Region: strategies and opportunities. NMJI 2011 (in press) Implemented X not implemented NA information not available

Bangladesh is the first country in the Region to establish a National Tobacco Control Cell (NTCC) under the Bloomberg Initiative. Bangladesh is exemplary in the developing world as it conducts mobile courts drives across the country to enforce tobacco control law and take cognizance of violations of the law (Box 6.1).

Surveillance and Monitoring

Accurate information through a sustainable surveillance system is essential for

formulating evidence-based policies, planning appropriate interventions and services, and monitoring progress towards desired goals. There are three essential elements of a comprehensive NCD surveillance system, namely: (1) surveillance for exposure to behavioural and metabolic risk factors; (2) surveillance for disease outcomes (morbidity and mortality); and (3) surveillance/monitoring of health system response.

At least one NCD risk-factor survey (national or subnational) has been completed in

Risk factor surveillance

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Box 6.1: Innovative law enforcement using mobile courts, Bangladesh

The mobile court drives is a unique feature of the judicial system in Bangladesh for hastening the dispensation of justice in non-criminal cases. It is being used for enforcing anti-tobacco laws. Violation of tobacco products advertisement bans is one of the offences try-able by a mobile court. An empowered magistrate tries the case on the spot, ensures immediate removal of the advertisement and punishes the perpetrator as per the law. Members of law enforcing agencies including the police, provide the magistrate with necessary support. Onthespot actions have been taken by removing billboards containing advertisement of tobacco products and also by removing other promotional materials from places such as fast-food corners, snooker-playing places and restaurants. The youth of the country have shown active involvement during the drives of mobile courts by voluntarily participating in removing billboards, signboards and other promotional objects. The mobile court drives have also played an exceptionally important and exemplary role in the enforcement of smoke-free laws in the country. The mobile court drives have received tremendous support from the civil society. The initiative has received huge media coverage and contributed in creating awareness about the law among the public. As a result of the enthusiastic effort of the Government, local administration and development partners, and particularly due to the unique efforts by mobile courts, tobacco advertisements on billboards or signboards have become almost non-existent in Bangladesh.

Mobile courts, Bangladesh

all 11 Member countries. In six countries, surveys were done at the national level. In India, the process of national-level surveys is under way. In most countries, risk factor surveys are carried out as special or vertical surveys. Indonesia and Thailand are the only two countries that integrated risk-factor questions into the general health survey or behavioural risk-factor surveys. Tobacco use surveys have been done more frequently compared to other risk factors. Four countries conducted at least one round of GATS. Ten countries completed at least one round of GYTS and all 10 countries conducted more than one round of GYTS (Table

6.4). Risk-factor surveys, based on WHO STEPS approach that aims to collect information on risk behaviours (tobacco and alcohol use, physical inactivity and unhealthy diet), physiological variables (weight and height and blood pressure), and biochemical variables (blood sugar and blood lipids), have now been conducted in all countries (Table 6.4). While behavioural variables were collected in all 10 countries, physiological risk factors (BMI and hypertension) have been measured in nationallevel surveys in four countries, and blood sugar has been measured in three countries. No country has yet reported a national-level lipid

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Table 6.4: Type of risk surveys conducted and the latest year, countries of WHO/SEA Region
Country Latest 2010 2007 2009 2006 2006 2004 STEPS* No. of rounds 2 1 3 2 3 1 Latest No. of rounds 2009 NA NA NA NA NA 1 1 1 GATS** Latest No. of rounds 2009 2009 2009 2007 2007 NA 2007 NA 3 7 3 2 2 GYTS*** Latest NA 1 1 NA GSHS**** No. of rounds NA NA NA

Bangladesh Bhutan DPRK India

Indonesia Maldives Nepal Myanmar Sri Lanka Thailand Timor Leste

2009-2010 on-going NA NA NA NA NA

NA 1

2009

2006

2007 NA NA

2007

2007

NA NA

NA 1

NA NA NA

2007 2007 2009 2009

2010

2009

2007 2003 2008 2009 2009

Sources: * STEPS Country reports http://www.who.int/chp/steps/reports/en/index.html ** http://www.searo.who.int/en/Section2666/Section2670_15825.htm#GATS *** http://www.searo.who.int/LinkFiles/TFI_FCTC-2009.pdf; http://www.searo.who.int/en/Section2666/Section2670_15825.htm#GYTS **** World Heath Organization. Assessment of capacity for prevention and control of chronic noncommunicable diseases. New Delhi, 2011. NA = Not available GYTS: Global Youth Tobacco Survey GSHS :Global School-based Student Health Survey GATS : Global Adult Tobacco Survey STEPS: Stepwise approach to NCD risk factor surveillance

measurement survey. Most countries have completed only one round of STEPS survey; therefore, sufficient information for trends estimation for diseases and risk factors on a nationally representative sample is not available in the Region. In most Member countries, the health ministry is the lead agency for planning and implementing risk factor surveys. However, a major limitation of risk factor surveys is that they are not institutionalized and are done on an ad hoc basis depending on the availability of funds rather than on a regular periodic basis at fixed intervals.

information system in all 11 countries; mortality data are included in nine countries. However, most mortality and morbidity data are hospitalbased. Many countries are using a standardized protocol for data collection and quality control procedures are reportedly in place. Morbidity and mortality data obtained from routine health information systems are being used for target setting in NCD prevention and control in many Member countries. Disease-specific registries are an important source of morbidity and mortality data. The disease registries for NCDs have been most commonly established for cancer, followed by diabetes and stroke. About half of these are national-level disease registries and most are hospital-based (Table 6.5). Maldives has no disease registry except for thalassemia.

Disease-specific morbidity data are generally collected through a routine health

Morbidity and mortality surveillance

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Indicator

Table 6.5: Number of disease registries reported by Member countries, South-East Asia Region
Cancer Diabetes 5 2 3 1 4 Myocardial infarction 3 1 2 1 2 Stroke 4 2 2 1 3

Disease registry present Scope National Sub-national

9* 5 4 3 8

Chronic respiratory diseases 3 2 1 1 2

Source of data Population-based Hospital-based

* Number of countries answering in the affirmative. Source: World Heath Organization. Assessment of capacity for prevention and control of chronic noncommunicable diseases. New Delhi, 2011.

Bangladesh has subnational hospital-based registries for all listed diseases and DPR Korea reported having population-based nationallevel registries for several NCDs. Sri Lanka has registries on cancers and also has a chronic kidney disease registry. Myanmar and TimorLeste have not yet reported on registries. A major limitation of mortality and morbidity surveillance systems in the Region is that they are largely hospital-based, which compromises the representativeness of the information generated. While hospital-based disease-specific registries are a useful source for obtaining clinical data, such as disease patterns and survival rates, population-based disease registries are needed for estimation of incidence rates that are currently lacking from the Region. Moreover, establishment and management of disease registries need technical expertise and are resource intensive.

system for monitoring response to the NCD epidemic. At the global level, indicators and targets are currently being developed to monitor the global and national response to the NCD epidemic. Developing monitoring systems for the future is a major priority for countries.

Health System Capacity for NCD Prevention, Early Detection, Treatment and Care
Traditionally, health systems in SEAR are geared towards providing maternal and child health care, immunization and deal with communicable diseases; NCDs have been generally neglected. With the emergence of NCDs, it is imperative to reorient health systems and retrain health personnel to provide long-term prevention, care and treatment services to address NCDs.

According to available information, no country in the Region has a comprehensive

Surveillance and monitoring system for health system response

The availability of services at the primary health-care level has become more

NCD prevention and control at primary health-care level

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comprehensive over the years. All Member countries provide at least one NCD-related service at the primary health-care level in public health facilities. This includes mainly risk factor and disease management (10 countries), primary prevention and health promotion (11 countries) and early diagnosis of NCD riskfactors (9 countries). However, not much progress has been achieved in promoting homebased care. In SEAR countries, pilot projects for integrating NCDs within the primary healthcare system are under way in Bhutan and Sri Lanka (Box 6.2), and are planned in Maldives and Indonesia.

A selected set of diagnostic devices to detect risk factors is essential at the primary health-care level. All Member countries have blood pressure measurement facility available at the primary health-care level. Blood glucose and weight measurement facilities are available in nine countries. Cancer detection services are the least available, possibly due to their high technical requirements (Table 6.6). The major reason reported for lack of these services has been the non-availability of equipment. In some

Availability of diagnostic facilities for NCDs at primary health care level

Box 6.2: Integrating NCD prevention and control into primary health care services, Sri Lanka
The WHO Package of Essential Noncommunicable Diseases Interventions (WHO PEN) for primary care is an innovative response to the NCD challenge. PEN is a prioritized set of cost-effective interventions, tools and aids that help deliver acceptable quality of care even in resource-poor settings. It includes the entire spectrum of services from health promotion to prevention of risk factors and NCDs to management, care, treatment and referral. The essential components of PEN include: assessment of health system capacity; use of standard protocols for diagnosis and treatment of major NCDs at primary level; use of WHO/ISH risk charts for assessing an individuals risk; essential medicines and essential equipments; and essential recording and reporting tools. A pilot PEN project was initiated in Badulla district in Sri Lanka in 2009. A baseline assessment of all health facilities was done using a structured questionnaire. Most of the essential equipment recommended in the PEN were already available in the primary care centres; additional equipment, namely blood glucometers, urine protein test strips and peak flow meters were procured and supplied to all institutions. The essential list of medicines proposed for PEN was reviewed by expert groups in the country and steps were taken to include these into the essential list of medicines at the primary health care level. A striking feature of this project is the use of non health workers at the community level, for mobilizing the community members especially for systematic screening at primary care level. All persons over 40 years of age were requested to visit their nearest health facility to undergo a medical check-up including an assessment of cardiovascular risk by checking BMI, blood pressure and blood sugar. To maintain proper records, several data collection formats were developed including screening cards, patient health records, OPD registers and clinic registers.

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Integrated primary heath care services Sri Lanka

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Health condition Procedure Overweight and obesity Cancer

Table 6.6: Availability of NCD tests and procedures (in more than 50% of facilities) at primary health care level, SEAR, 2010
No. of countries where available 9 8 4 2 1 4 3 8 0 1 9 3 2 1 2 5 11 3 1 0

Weight measurement Height measurement Waist circumference

Reasons for non-availability Lack of Lack of equipment trained staff 2 2 2 6 4 3 2 1 9 7 2 2 8 2 3 5 0 6 6 8 0 0 5 3 3 3 3 1 1 2 0 2 0 6 3 0 0 0 2 1

Diabetes

Cervical cytology Acetic visualization Faecal occult blood test Digital examination for bowel cancer Breast cancer by palpation Mammogram Colonoscopy

Cardiovascular diseases Chronic respiratory diseases

Blood glucose Oral glucose tolerance test Glycosylated haemoglobin (HbA1c) Fundal examination Foot vibration perception by tuning fork Foot vascular status by doppler Electrocardiogram Blood pressure Lipids including LDL, HDL and triglycerides Spirometry

Source: World Heath Organization. Assessment of capacity for prevention and control of chronic noncommunicable diseases. New Delhi, 2011.

countries like Bangladesh, these services are not included in the primary health-care package and thus there has been no planning to either provide these equipments at the primary healthcare level or to train human resources for it.

An uninterrupted and sustained supply of quality-assured essential drugs for NCDs is fundamental to NCD control. For this purpose, an effective drug procurement supply and

NCD-related drugs

management system is essential. All Member countries have an essential drugs list and many of the NCD-related drugs are in the national essential drugs lists. Most of these drugs are generally available at public sector health facilities. The least available are nicotine replacement therapy and oral morphine. Highend technology for the management of NCDs like renal dialysis, radiotherapy and chemotherapy are available in public health systems of seven of 11 Member countries.

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Health Financing
The commitment of Member countries to NCD prevention and control is reflected in NCD programmes being funded largely by regular government budgets. All 11 Member countries have allocated for NCD prevention and control in their respective regular health ministry

budget. General government revenue is the main source of funding for NCD prevention and control activities in all Member countries except Maldives and Sri Lanka. For these two countries, international donors are a significant source of funding. In Thailand, sin tax from tobacco and alcohol is used to finance health promotion activities (Box 6.3). Out-of-pocket

Box 6.3: Innovative financing for NCD prevention and control, Thailand
The Thai Health Promotion Foundation (ThaiHealth), established in 2001, is the first organization of its kind in Asia and has been created under the Health Promotion Foundation Act B.E. 2544 (2001). ThaiHealth gets funded from sin taxes. These 'sin taxes' are a revenue source for innovative projects and activities to promote public health. ThaiHealth receives 2% of total national tax revenue on alcohol and tobacco products equivalent to about US$ 35 million per year. There are 12 programmes funded by ThaiHealth which include tobacco consumption control, alcohol consumption control, physical activity and sports for health, as well as health risk factors control such as nutrition, traffic injuries and disaster prevention. In 2008, ThaiHealth financed tobacco control campaigns (105 million baht or US$ 3 million), smoke-free projects (38 million baht or US$ 1.08 million) and other tobacco control projects, as well as research (40 million baht or US$ 1.14 million). Sin tax has helped generate additional funds for health promotion and led to a significant reduction in smoking prevalence. During the Funds ten years of existence, the percentage of regular smokers was reduced by 10%, with an 30% increase in excise tax. Trends in smoking prevalence and excise tax, Thailand, 1990-2010
Excise tax (%) Regular smokers (%)

Innovative financing, Thailand

30 25 20 15

100

Regular smokers (%)

80

40 10 5 0 20

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Source: National Statistics Office 2010; Excise Department, Ministry of Finance, Thailand.

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Excise tax (%)

60

Consistent reduction in smoking prevalence with increase in tobacco tax

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expenditure is the main funding source in India. In all countries, funding covered all activities/functions related to treatment and control (except in Timor-Leste), prevention and health promotion (except in Sri Lanka), and surveillance, monitoring and evaluation (except in Bhutan and Sri Lanka). Health insurance is not a major source of funding in this Region. NCD-related services and treatment are covered by health insurance in five countries. Of these, two countries (Sri Lanka and Thailand) have full populationlevel coverage by insurance. In India, less than 20% of the population is covered by insurance, while in Indonesia and Maldives, insurance coverage is estimated to be 20%50%. Community/home care for people with endstage diseases like cancers are available in three countries DPR Korea, Myanmar, Thailand.

collaboration are important for creating an enabling environment where people can make appropriate choices that promote their health. Interventions for NCD prevention and control have to be multisectoral and multidisciplinary and should act at multiple levels. In addition, the private sector has a major role to play in determining the consumption of tobacco, alcohol and dietary items. Its involvement needs to be regulated through appropriate mechanisms. Governments of Member countries are moving towards establishing mechanisms for intersectoral coordination. All countries reported having partnerships/collaborations between various departments/sectors in place for implementing key activities related to NCDs. The key mechanisms used for such collaborations are cross-departmental or ministerial committees in 10 countries; interdisciplinary committees in nine countries and a joint task force in six countries. The key stakeholders involved are government ministries (in all countries); UN agencies (all countries except Indonesia); other international agencies (nine countries); academic institutions and nongovernmental organizations (10 countries); and private sector (eight countries).

Partnerships and Collaboration

The involvement of sectors other than health has a major impact on shaping physical and social environments that determine health behaviours. Intersectoral coordination and

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Major Challenges in Prevention and Control of NCDs

The South-East Asia Region has a huge population base with 1.7 billion people and is a diverse Region with the population size of Member countries varying from 1.2 billion in India to less than a million in Maldives and Bhutan. Additionally, there are enormous intercountry and intracountry differences in topography, culture, ethnicity, etc. Addressing health issues in such large and diverse populations poses many challenges. Furthermore, high out-of-pocket expenditure on health care, poor coverage of health and social insurance schemes and unregulated role of the private sector undermines equitable health care in most countries of this Region. The specific challenges in NCD prevention and control are as follows: brunt of NCDs, ministries of health must carry out high-level advocacy and take the lead in bringing together the different stakeholders to address NCDs. Without effective and strong partnerships among different sectors, NCD prevention will remain an elusive goal.

The underlying determinants for NCDs mainly exist in non-health sectors, such as agriculture, urban development, education and trade. Intersectoral collaboration is therefore essential to create an enabling environment, which promotes healthy lifestyles. Intersectoral partnerships are however not easy to forge as it means coming together of many sectors with competing interests and priorities. Lack of effective partnerships among different development sectors at the national level is one of the major weaknesses in the Member countries. Because the health sector bears the

Lack of strong national partnerships for multisectoral actions

Lack of availability of robust surveillance and research data on NCDs is an important barrier to effective planning and implementation of NCD prevention and control programmes in the Region. There are many issues with the current surveillance systems. First, NCD surveillance systems are often not institutionalized and rarely integrated into the national health information systems. Although almost all countries have conducted one or more NCD risk factor surveys, these are not yet routine; and are usually dependent on funds and other factors. Second, there is lack of a comprehensive framework for surveillance and monitoring at the national and subnational levels. Specific indicators and clear targets at the national and subnational levels and systems for monitoring are non-existent. Without such a system, uniform tools for data collection, systematic data analyses or standard reports to guide the programme do not exist. Third, most countries do not report reliable mortality statistics due to weak civil registration systems. Fourth, population-based cause-specific morbidity and mortality data collection systems continue to be poor. While coverage for
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Weak surveillance systems

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morbidity data in national information systems has shown an increase, it is still hospital-based. Finally, surveillance and research for NCDs are poorly funded.

Lack of access to basic prevention and treatment in the primary health care setting including access to affordable medicines and health-care services are major causes of premature deaths due to NCDs. Limited emphasis on public health and primary care results in inefficient and unsustainable NCD programmes and poor health outcomes. In most countries, the major investment on NCD prevention and control is for tertiary care services, which are available to a limited number of people living in urban areas. A general lower resource allocation to health does not allow for the development of an adequate primary health care infrastructure. As a result, opportunities for early diagnosis are lost and NCDs are diagnosed in late stages as heart attacks, strokes and diabetes complications which require tertiary care. Moreover, community- and home-based palliative care are nonexistent. The health system in the Member countries of SEAR should provide a continuum of NCD care for NCDs and their risk factors from prevention and early diagnoses through to treatment and care.

Limited access to prevention, care and treatment services for NCDs

in an inadequate workforce capacity at the primary care level. Moreover, health workers particularly at the primary care level are trained traditionally in communicable diseases and maternal and child health issues, and have limited training in addressing NCDs and their risk factors. There is a need to develop effective tools for training health workers in NCD prevention, early diagnosis, treatment and care.

Funds allocated for NCD programmes are disproportionately lower than the disease burden. A low allocation of government budget on health and for NCDs in particular, persists in many Member countries of the Region. Moreover, available health funds are stretched thin to meet the acute demands of addressing communicable diseases as well as maternal and child health issues, leaving minimal funds for NCDs. Some countries are generating funds through innovative financing schemes such as sin tax on tobacco and alcohol. There is a need to increase both domestic and international resources to address NCDs.

Insufficient allocation of funds

Health systems in the Region are characterized by inadequate human resources capacity to address NCDs both in terms of number of health workers and their training. Existing health professionals are concentrated in urban areas at the tertiary care level, resulting

Limited human resources for NCDs

Profit making industries, such as the food and beverage industry, are a major contributor to NCDs. Dialogue is needed with the industry to influence them to voluntarily reformulate products with lower sodium, lower sugar and eliminate trans fats. While the need to engage the industry is acknowledged, the mechanisms are not easy, given their profit-making interests. Strong government regulations, both fiscal and legislative, need to be enforced to ensure compliance of the industry with health policy norms.

Difficulties in engaging the industry and private sector

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The ministries of health of Member countries run NCD programmes and policies. There is inadequate community mobilization and weak coordination among the few existing civil society agencies, as well as between the civil

Lack of social mobilization

society and government agencies for NCDs. One of the lessons to be learned and applied from HIV control programmes in the Region is to organize social mobilization to increase the demand for investments for NCD control programmes.

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WHO Initiatives in NCD Prevention and Control

Over the past decade, WHO has played a leadership role in addressing the NCD pandemic at global, regional and country levels. WHO has raised the priority accorded to NCDs through high-level advocacy, set norms and standards, generated the evidence base for effective policies, strategies and interventions as well as for surveillance, monitoring and evaluation. In SEAR, there has been a growing recognition and commitment to address NCDs. SEARO is coordinating activities for prevention and control of NCDs for its 11 Member countries; providing technical and financial support to countries in NCD surveillance, monitoring, evaluation, research, policy and strategy development; assisting countries in integrating NCD control in their primary health-care based health systems, and; promoting and forging partnerships for NCD prevention and control in the Region.

May 2000

The World Health Assembly endorsed the Global strategy on the prevention and control of NCDs, providing a global vision for addressing them. The global NCD strategy has three objectives: (i) mapping the NCD epidemic and its causes; (ii) reducing main risk factors through health promotion and primary prevention approaches; and (iii) strengthening health care for people already afflicted with NCDs. The World Health Assembly endorsed the WHO Framework Convention on Tobacco Control. The World Health Assembly endorsed the Global strategy on diet, physical activity and health. The UN General Assembly adopted resolution A/RES/61/225, encouraged Member States to develop national policies for the prevention and control of diabetes. The World Health Assembly endorsed the Action Plan for the Global Strategy for the Prevention and Control of NCDs (20082013).

Global initiatives

May 2003 May 2004 December 2006

May 2008

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May 2010 May 2010 April 2011 May 2011

The World Health Assembly endorsed the Global Strategy to Reduce the Harmful Use of Alcohol. The A/RES/64/265 was adopted unanimously by the UN General Assembly calling for a High-level Meeting on NCDs. The first global ministerial conference on healthy lifestyles and NCD control was held in Moscow culminating in the Moscow Declaration. The Sixty-fourth World Health Assembly endorsed resolution WHA 64.11 on Preparation for the UN High-level Meeting (UNHLM) on noncommunicable diseases. The UNHLM was conducted in New York with participation of heads of states, ministers and other high-level delegates from Member countries. The outcome of the UNHLM meeting was the adoption of a political declaration on NCDs. The political declaration is expected to galvanize support from governments and international donors for increased financial resources for NCD interventions; act as a milestone in advocating for Healthy Public Policies/Health in All Policies approach to the prevention and control of NCDs; help produce measurable targets and commitments from governments and the international community to act against NCDs and provide an impetus to implement the global strategy for the prevention and control of NCDs (2000) as well as the action plan (20082013) endorsed by the World Health Assembly in 2008.

September 2011

Some of the recent regional events and initiatives for prevention and control of NCDs are listed below: November 2005 South-East Asian Network of NCD (SEANET-NCD) was created at a regional meeting in Bondos, Maldives, to strengthen and formalize regional partnerships on NCD prevention and control. SEANETNCD meets biennially and greatly facilitates WHO advocacy for multisectoral approaches in integrated NCD prevention and control. A regional meeting on implementing the global strategy on diet, physical activity and health in the SEAR was organized in Yangon, Myanmar to facilitate regional and country-level implementation of the global strategy. The Regional Framework for Prevention and Control of NCDs was endorsed at the Sixtieth session of the WHO Regional Committee for South-East Asia, vide its resolution on Scaling up Prevention and Control of NCDs in the South-East Asia Region (SEA/RC60/R4). The key elements of the regional framework included: epidemiological assessment of NCDs and their

Regional Initiatives

October 2006

September 2007

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determinants; awareness generation and high-level advocacy; formulation and adoption of policy and strategic plan for integrated prevention and control of major NCDs; capacity building; resource mobilization; as well as multisectoral and multilevel actions to modify determinants. October 2007 The second meeting of SEANET-NCD was held in Phuket, Thailand. The inputs for development of a regional and global plan of action for integrated prevention and control of NCDs were discussed. The third Meeting of SEANET-NCD was held in Chandigarh, India. The meeting reviewed the progress in scaling up of NCD prevention and control, particularly the role of SEANET. The meeting also discussed and contributed to global recommendations on marketing of food and non-alcoholic beverages to children. The 31st session of South East Asia-Advisory Committee on Health Research (SEA-ACHR) was held in Kathmandu. The session discussed research priorities in NCDs and called for intersectoral collaboration in carrying out research on NCDs. The Sixty-third session of the WHO Regional Committee for SouthEast Asia discussed progress in prevention and control of NCDs in the Region. A Regional Civil Society Meeting, with support from SEARO was organized by the Nepal Public Health Foundation (NPHF) in Kathmandu, during 1923 January, 2011. This meeting resulted in the Kathmandu Call for Action on NCDs. A regional meeting on health and development challenges of NCDs was held during 14 March in Jakarta, Indonesia with participation of all the 11 Member States of the Region. The meeting culminated in the Jakarta Call for Action on prevention and control of NCDs and preparation of a report on key messages for UNHLM. Country-level multistakeholder meetings were held in 10 of the 11 Member States, along the lines of the regional consultation in Jakarta, with WHO support. As part of preparations for these meetings, some countries undertook an assessment of the NCD situation as well as national capacity and health system response to address NCDs. The national meetings aimed to discuss inputs to the UNHLM, build consensus on a multisectoral response to the NCD epidemic and trigger the development of national multisectoral medium-term plans for prevention and control of NCDs. The Sixty-third Health Ministers meeting discussed and adopted ten key messages for the UNHLM from SEAR.

June 2009

September 2009

September 2010

January 2011

March 2011

July-September 2011

September 2011

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The Way Forward

The UNHLM on NCDs held in New York during 1920 November was a turning point in the global struggle against NCDs. This was the second time in the history of the United Nations that the General Assembly met with the participation of heads of state and government on a health issue with a major socioeconomic impact. The HLM was attended by 113 Member States, including 34 presidents and prime ministers, three vice presidents and deputy prime ministers, 51 ministers of foreign affairs and health, 11 heads of UN agencies, and hundreds of representatives from civil society. From SEAR, heads of states from Bangladesh (Prime Minister) and Maldives (Deputy), health ministers from India, Indonesia, Maldives, Thailand and Sri Lanka, and high-level delegates from other countries participated in the UNHLM. The outcome of the meeting was a Political Declaration of commitment, which was adopted by the General Assembly on 19 September 2011 as resolution A/RES/66/2. It acknowledges the rapidly growing magnitude of NCDs in developing countries and its increasingly devastating health and socioeconomic impacts and calls for concrete and comprehensive action by Member States and the international community.

Guiding Principles for NCD Prevention and Control

The following guiding public health concepts should be used for NCD prevention and control measures in the Region:
I

Integrated approach: As the four major NCDs causing 80% of NCD deaths result from shared risk factors, there is a need for an integrated approach to address NCDs together as a cluster of diseases instead of addressing each NCD separately as an individual disease. Multisectoral actions: Major determinants of NCDs lie outside the scope of the health sector. Therefore control of NCDs requires effective multisectoral actions and adoption of Health in All policies. This means that sectors outside health must consider health issues while formulating policies, strategies and standards. With the exception of the tobacco industry, the private sector can immensely contribute to addressing NCD prevention and control. Life course approach: Individuals are influenced by factors acting at all stages of their life span and risk of developing NCDs increases with age. Using the life course

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approach, NCDs and their risk factors are best addressed throughout the course of peoples lives, through promotion of healthy behaviours and early diagnosis and treatment that begins before pregnancy and continues through childhood, adolescence, adult life to old age.
I

Equity and social justice: NCD prevention and control measures should be affordable, appropriate and accessible to diverse groups programmes should be gender sensitive and gender specific. Priority should be given to the poorest and the socially disadvantaged sections of society. Evidence-based and culturally appropriate interventions: NCD intervention strategies need to be based on sound scientific evidence. A coordinated agenda for NCD surveillance and research is essential to strengthen the evidence base for cost-effective and culturally appropriate NCD prevention and control measures.

The majority of NCDs can be averted through interventions and policies that reduce major risk factors. Population-wide primary prevention approaches are cost-effective and interventions that combine a range of evidencebased approaches have better results. Priority should be given to implementation of practical and affordable Best Buys interventions. A best buy is an intervention that is not only highly cost-effective but also feasible and culturally acceptable to implement. The recommended Best buys are given in Box 9.1.

Health promotion and primary prevention to reduce risk factors for NCDs using multisectoral approach

Specific strategies and Interventions for NCD Prevention and Control

The vision and framework for reversing the NCD epidemic is articulated in WHOs global strategy for prevention and control of NCDs, 20082013 Action plan for the global strategy for the prevention and control of noncommunicable diseases and the Regional framework for the prevention and control of noncommunicable diseases. The key strategies recommended by WHO and endorsed by Member countries are as follows:

In conjunction with primary prevention interventions, improved access to early detection and providing essential standards of care for those with major NCDs at the primary health-care level, will have the greatest potential for reversing the progression of disease, preventing complications, reducing hospitalizations and health care as well as outof-pocket expenditures. The WHO package of essential NCD interventions (PEN), which includes standardized tools for health facility assessment, essential diagnostic equipment, essential drugs, counseling of patients, recording and reporting, and community mobilization is an innovative package for increasing access to high-quality, low-cost care for people at high risk for NCDs. In SEAR Member countries, pilot projects for integrating NCDs within the primary health-care system are under way in Bhutan and Sri Lanka (The PEN

Health system strengthening for early detection and management of NCDs

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Box 9.1: Cost-effective interventions (best buys) for preventing NCDs

Risk factor/disease
Tobacco use Protect people from tobacco smoke Warn about the dangers of tobacco Enforce bans on tobacco advertising Raise taxes on tobacco Enforce bans on alcohol advertising Restrict access to retailed alcohol Raise taxes on alcohol

Interventions

Harmful use of alcohol Unhealthy diet Cardiovascular diseases and diabetes

Cancers

Provide counselling and multi-drug therapy (including glycaemic control for diabetes mellitus) for people with 10-year cardiovascular risk >30% Treat acute myocardial infarction (with aspirin)

Reduce salt intake in food Replace trans fat with polyunsaturated fat

Source: World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011.

Hepatitis B vaccination to prevent liver cancer Detection and treatment of precancerous lesions of the cervix and early stage cervical cancer

project), and are planned in DPR Korea, Indonesia, Maldives, Myanmar and Nepal in the near future. The delivery of effective NCD interventions is determined by the capacity of health-care system. The existing organizational and financial arrangements surrounding health care need to be reoriented to address the longterm needs of people suffering from and vulnerable to NCDs. Broad-based initiatives to achieve equity in health-care financing are vital protections against the risk of catastrophic NCD-related health-care costs. Additionally, initiatives aimed at health systems reform should include specific NCD related endpoints in universal coverage goals.

for risk factors (or measurement of exposure), disease morbidity or mortality (or measurement of outcomes), and assessment of health system capacity and response. Measurable core indicators for each have to be adopted and used to monitor trends and progress. Emphasis should be placed on surveillance of both behavioural and metabolic risk factors. To ensure an effective surveillance system, countries should make efforts to integrate and institutionalize NCD surveillance into the national health information system, for longterm sustainability. Countries also need to have a prioritized research agenda and carry out formative and operational research with major focus on primary prevention and early diagnosis of NCDs, addressing social and economic determinants as well as developing and testing multisectoral approaches to NCD prevention and control. Allocation of budget for research and building up of research work force should also be a priority.

Surveillance and monitoring of NCDs is essential to policy and programme development. A comprehensive national NCD surveillance system should include surveillance

Surveillance and research

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Role of Different Agencies in NCD Prevention and Control

A multisectoral approach and involvement of different agencies is key to addressing

prevention and control of NCDs as many determinants of NCDs lie outside the health sector. Significant roles can be played by governments, development partners, civil society, academia, media and the private sector (see Box 9.2).

Box 9.2: Role of partners in prevention and control of NCDs

Responsibility of governments
I I I I I

Responsibility of civil society

Make noncommunicable diseases (NCDs) a national development agenda and include health in all policies. Set and effectively enforce health promoting norms, standards and strategies. Set up surveillance and monitoring to track the NCD epidemic and its control. Mobilize and coordinate multisectoral responses and strengthen the engagement of all sectors in NCD prevention and control. Provide equitable access to affordable, effective health care for the prevention and management of NCDs. Mobilize political and social awareness and support for prevention and control of NCDs. Act as a counterbalance to commercial and private sector interests against healthy policies. Provide prevention and health care services to fill gaps in public and private sector services. Hold governments accountable for delivering on NCD commitments. Build capacity of human resources in NCD prevention and control. Independently monitor and evaluate progress in achieving outcomes by both the government and private sector. Generate evidence and ensure an evidencepolicy interface.

I I I I I I I

Responsibility of academia

Responsibility of media

I I I I

Raise public awareness among the general population about prevention of risk factors for NCDs. Create an enabling environment for behaviour change. Sensitize political leadership about the importance of multisectoral actions for NCD prevention and control. Act as a watchdog to offset commercial interests against healthy policies. Work closely with the government to promote healthy lifestyles, for example by reformulation to reduce salt, trans fats and sugar in their products. Improve health of their employees through workplace wellness programmes. Ensure responsible marketing by helping to make essential medicines more affordable and accessible. Prioritize NCD prevention and control in aid programmes. Strengthen support for full and effective implementation of global strategies to address NCDs. Coordinate and pool technical expertise to strengthen normative guidance to achieve the best results at the country level.

Responsibility of private sector (except the tobacco industry) Reponsibility of development partners

I I I

I I I

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The NCD epidemic places an enormous toll in terms of disease morbidity and mortality and inflicts serious damage to human development in both social and economic spheres. Actions based on best available

scientific evidence need to be designed, implemented and monitored. A multisectoral approach that mobilizes all stakeholders is essential for long-term progress. Efforts and involvement of all partners will contribute to sustained improvement in public health.

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Annexes

Annex 1: Estimated number of deaths (in thousands) by major noncommunicable diseases (NCDs), 2008
Total 54.6 0.3 15.1 312.5 104.8 0.2 24.1 11.1 8.5 35.1 0.2 566.5 48.9 0.3 11.9 321.9 110.7 0.2 21.8 8.9 8.5 35.6 0.3 568.9 103.5 0.5 26.9 634.4 215.5 0.4 45.8 20.0 17.0 70.7 0.5 1135.4 9.4 0.0 3.6 80.4 25.7 0.0 4.5 1.6 3.8 22.5 0.0 151.6 10.2 0.1 2.3 96.3 22.6 0.0 4.2 1.6 3.3 13.3 0.0 153.8 19.6 0.1 5.9 176.7 48.3 0.0 8.7 3.2 7.1 35.8 0.1 305.4 148.9 0.7 36.9 1002.5 235.6 0.1 61.1 20.6 22.8 75.8 0.5 1605.6 166.9 0.9 29.9 1330.6 277.5 0.2 64.2 24.5 30.6 84.4 0.7 2010.3 Females Males Cancers Total Females Males Total Females Males 315.8 1.6 66.8 2333.1 513.1 0.3 125.3 45.1 53.5 160.2 1.2 3615.9 Total Diabetes mellitus Cardiovascular diseases Chronic respiratory diseases Females 31.4 0.1 7.2 472.1 45.5 0.0 12.3 4.1 6.5 10.3 0.1 589.7 37.4 0.2 7.0 618.7 73.8 0.1 14.7 5.6 8.8 30.0 0.2 796.4 Males 68.8 0.3 14.1 1090.8 119.4 0.1 27.0 9.7 15.3 40.3 0.3 1386.1 Total

Country 598.8 3.1 132.9 5241.4 1063.9 0.9 242.5 91.7 117.9 418.4 2.4 7913.9

Bangladesh 285.5 Bhutan 1.4 DPR Korea 71.4 India 2273.8 Indonesia 481.7 Maldives 0.4 Myanmar 116.6 Nepal 42.8 Sri Lanka 51.1 Thailand 191.3 Timor-Leste 1.0 SEAR total 3517.2

Females

All NCDs

313.3 1.7 61.5 2967.6 582.3 0.5 125.8 48.8 66.8 227.1 1.4 4396.7

Males

Source: Global Health Observatory, World Health Organization, 2011

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Annex 2: Age-standardized death rates due to noncommunicable diseases (NCDs) per 100 000 population in Member countries of SEAR, 2008
Total 701.7 735.2 547.6 684.6 647.0 593.7 667.1 620.2 623.1 675.0 559.7 106.2 119.0 98.9 72.0 109.4 228.8 116.3 118.8 79.0 97.6 95.0 104.5 131.8 122.0 78.9 136.5 290.9 124.5 114.0 91.6 115.6 121.5 105.0 124.8 106.4 75.0 120.9 261.5 119.8 116.4 84.3 105.9 107.5 22.1 18.7 23.1 21.0 29.0 8.2 23.4 21.0 36.7 64.4 19.3 25.6 26.1 22.6 26.9 29.9 3.7 25.6 24.5 39.8 46.4 21.8 23.8 22.3 23.1 23.8 29.5 5.8 24.4 22.6 38.2 56.3 20.5 371.0 372.1 245.1 268.7 278.2 214.1 317.8 285.7 220.0 229.7 258.3 424.2 444.7 318.3 366.1 373.9 215.2 398.0 379.6 364.5 304.2 336.6 Females Males Cancers Total Females Males Total Females Males Diabetes mellitus Cardiovascular diseases 397.2 409.8 278.6 316.5 323.6 214.1 355.0 329.0 285.7 265.3 296.1 Total Chronic respiratory diseases Females 73.7 73.0 48.8 128.5 53.6 66.5 63.0 55.8 62.3 30.7 50.0 91.7 93.3 77.2 181.2 103.1 60.2 91.6 87.1 107.1 119.2 77.8 Males 82.5 83.5 59.9 153.6 75.8 63.1 76.0 70.1 82.3 68.6 63.2 Total

Country

Source: Global Health Observatory, World Health Organization 2011

Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste

Females

All NCDs

654.7 667.2 477.4 582.3 547.8 564.5 591.5 543.5 490.5 563.2 476.8

Males

751.2 801.0 644.4 793.0 762.7 621.9 755.6 711.0 781.4 811.3 649.6

Annex 3: Age-standardized incidence per 100 000 persons of common cancers in Member countries of SEAR, 2008
Breast (females) 27.2 8.0 30.5 22.9 36.2 46.0 32.5 23.5 29.1 30.7 29.6 29.8 20.4 6.6 27.0 12.6 13.3 26.4 32.4 11.8 24.5 11.4 3.5 4.0 7.2 1.2 3.5 0.0 6.3 1.1 1.0 19.9 2.5 4.1 8.1 15.8 3.2 10.3 0.0 16.5 1.7 2.3 40.6 7.6 4.0 4.4 16.0 3.5 15.6 2.0 12.0 4.8 5.8 13.4 11.2 4.5 7.9 15.0 4.3 19.1 7.8 12.3 5.3 7.5 13.2 17.6 8.7 10.8 25.8 2.5 10.9 0.0 13.9 18.2 2.7 12.1 7.2 30.4 8.7 34.0 10.9 29.8 20.3 22.9 20.7 12.0 26.8 28.6 Cervix uteri (females) Cancer site Liver Colorectum Females Males Females Males Lung Females Males 1.9 1.7 2.3 3.7 10.6 3.0 5.8 2.2 5.8 6.5 7.9 Prostate (males)

Country

Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste

Source: GLOBOCAN 2008. International Agency for Research on Cancer and World Health Organization

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Annex 4: Estimated attributable deaths by major risk factor, SEAR, 2004

Attributable deaths (number in thousands) 828 121 252 110 365 1 438 756 1 044 343 449 583 781 670 1 037 188 354 481 72 879 331 809 72 526 598 207 630 70 57 270 668 114 336 137 982 000 121 294 37 998 405 213 497 366 9.4 4.9 6.8 2.2 2.9 5.1 6.8 2.3 0.5 2.2 0.5 3.9 1.4 4.1 0.5 0.4 1.8 0.8 0.2 964 815 301 583 751 5.4 0.8 1.7 0.7 2.4 Attributable fraction (%)

Risk factor

Source: Global health risks, World Health Organization 2009

Childhood and maternal under-nutrition Underweight Iron deficiency Vitamin A deficiency Zinc deficiency Sub-optimal breastfeeding Other nutrition-related risk factors and physical activity High blood pressure High cholesterol High blood glucose Overweight and obesity Behavioural risk factors Low fruit and vegetable intake Physical inactivity Addictive substances Tobacco use Alcohol use Illicit drug use Sexual and reproductive health Unsafe sex Unmet contraceptive need Environmental risks Unsafe water, sanitation, hygiene Urban outdoor air pollution Indoor smoke from solid fuels Lead exposure Global climate change Occupational risks Other selected risks Unsafe health care injections Child sexual abuse

Annex 5: Regional and global demographic indicators

Population Total Aged Aged Annual growth rate (%) (millions) under 15 (%) over 60 (%) Living in urban areas (%) 1990 20 16 58 26 31 26 25 9 17 29 21 26 43 24 25 60 28 42 28 28 13 16 31 24 29 47 28 36 63 30 53 39 33 18 15 34 28 33 50 2000 2009 24 24 34 25 28 24 28 21 30 33 17 26 29 162 0.7 24 1200 230 0.3 50 29 20 68 1.1 1 784 6 817 2009 2009 31 31 22 31 27 28 27 37 24 22 45 30 27 2009 6 7 14 7 9 6 8 6 12 11 5 8 11 19891999 19992009 2.0 0.0 1.3 1.9 1.5 2.5 1.4 2.5 0.9 1.0 1.2 1.8 1.5 1.6 2.5 0.5 1.6 1.3 1.4 0.8 2.1 0.8 0.9 3.3 1.5 1.2 2009 Median age (years)

Country

Source: World Health statistics 2011. World Health Organization 2011.

Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR Global

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Annex 6: Health expenditure in Member countries of SEAR, 2000 and 2008 comparison
General government expenditure on health as percent of total government expenditure 2000 95.1 96.5 free services free services 92.2 74.4 72.9 70.3 73.8 72 99.2 95.7 91.2 72.4 83.3 86.7 76.9 68.1 43.4 37.2 89.4 75.1 22 165 ---69 47 242 12 43 101 165 67 64 44 263 ---122 91 769 27 66 187 328 112 116 7.6 12.6 3.9 4.5 11.1 1.2 7.7 6.9 9.9 12.7 4.7 2008 7.4 13 4.4 6.2 13.8 0.7 11.3 7.9 14.2 11.9 5.6 2000 2008 2000 2008 Out-of-pocket expenditure as percent of private expenditure on health Per capita total expenditure on health (PPP int. $) Per capita government expenditure on health (PPP int. $) 2000 9 131 ---19 17 113 2 11 49 92 48 21 2008 14 217 ---40 49 470 2 25 82 244 93 46

Total expenditure on health as percent of gross domestic product

Country

Source: World Health Statistics 2011, World Health Organization 2011

Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR

2000

2.8 6.7 4.6 2 8.7 2.1 5.1 3.7 3.4 8.8 3.9

2008

3.3 5.5 4.2 2.3 13.7 2.3 6 4.1 4.1 13.9 3.8

Annex 7: Health workforce in Member countries of SEAR

Physicians 20002010 43 315 52 74 597 660 801 65 722 552 23 709 5 384 10 279 18 918 79 903 408 9 171 877 Number 3.0 0.2 32.9 6.0 2.9 16.0 4.6 2.1 4.9 3.0 1.0 5.4 14.0 39 992 545 93 414 1 430 555 465 662 1 539 41 424 11 825 40 678 96 704 1 795 2 224 133 19 379 771 2.7 3.2 41.2 13.0 20.4 44.5 8.0 4.6 19.3 15.2 21.9 13.3 29.7 6 091 80 2 685 6 493 2 013 172 2 411 2 151 22 0.4 0.4 1.2 0.3 0.4 0.1 1.1 0.4 0.3 48 692 195 50 715 478 3 247 16 206 10 119 543 1 369 772 Density* Number Density* Number Density* Number Density* 3.3 0.9 0.5 13.8 0.6 6.3 0.1 0.9 4.0 Nursing and midwifery personnel 20002010 Public health workers Community health workers 20002010 20002010

Country

Source: World Health Statistics 2011, World Health Organization 2011 * per 10 000 population

Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR Global

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Note on data sources and limitations

1.

Mortality data presented in Chapter 2 were obtained primarily from estimates presented in the Global Health Observatory (GHO) Data Repository 2011, provided in the following website link http://www.who.int/gho/mortality_burden_disease/global_bur den_disease_DTH6_2008.xls.

reports contained limited or disparate information and were not readily accessible. Moreover, country-specific definitions and methodologies limited comparability of data across countries. Most country reports used hospital-based data, sometimes only from one location in the country, thus limiting the representativeness of the data. Some countries used registration data that were grossly incomplete and underreported. Extensive efforts were made to locate regional literature and web documents, and the same have been used extensively in this report. 2. Methods for risk factor data are presented in the Global status report on noncommunicable diseases 2010. Briefly, these data are based on country reported results from national surveys as well as published and unpublished literature. These data have come from surveys/studies that fulfilled certain criteria such as: a random sample of the general population, with clearly indicated survey methods (including sample size) and risk factor definitions. Adjustments were made for the following factors so that the same indicator could be reported for a standard year (in this case 2008) in all countries: standard risk factor definition, standard set of age groups for reporting, and representativeness of the population. Using regression modeling techniques, crude adjusted rates for each indicator were produced. To further enable comparison

The data presented on the website are for the year 2008 and are updates on estimates of deaths by cause, age and sex using the same general methods as previous revisions carried out by WHO for 2002 and 2004. Mortality estimates are based on analysis of latest available national information on levels of mortality and cause distributions as at the end of 2010 together with latest available information from WHO programmes, International Agency for Research on Cancer (IARC) and Joint United Nations Programme on HIV/AIDS (UNAIDS) for specific causes of public health importance and using the 2008 revision of the population estimates for WHO Member States prepared by the UN Population Division. Further details of the methods, sources of data and the reference year are provided in Annex xx at the end of this document and on the website http://apps.who.int/ghodata/ ?vid=2490.

In addition, mortality and morbidity data reported in country reports were used wherever available. However, these country

continued...

among countries, age-standardized comparable estimates were produced by adjusting crude estimates to an artificial population structure that closely reflected the age and sex structure of most low- and middle-income countries.

3. Data presented in Chapter 5 were obtained from a capacity assessment survey using a structured tool. An important limitation is that data were reported by the national NCD focal persons and may be prone to reporting bias. While the countries had been asked to provide supportive documents for verification, these documents were not always provided, or they were not always in English. Thus, little verification was possible on the reported information. Another limitation is that while the survey

focused largely on quantitative indicators, the qualitative aspects were not adequately covered. For example, while the survey focuses on the availability of guidelines, equipments and services in the countries with a yes or no response, it does not elicit crucial aspects related to coverage or quality of services. Third, since this was a self-administered questionnaire, it was not possible to explain or clarify the questions or use probes. Thus, it is possible that the respondents may not have understood clearly some questions or differentiated distinctly between policies, strategies, programmes or plans. Therefore responses related to some of the questions may not have been accurate. Finally, data on the role of the private sector, which manages a major share of NCDs, could not be obtained in the survey.

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This report describes the current burden of noncommunicable diseases in the South-East Asia Region, their underlying risk factors and socioeconomic determinants. The report also summarizes the progress countries are making for tackling the NCD epidemic, provides the base for regional and country recommends the way forward in addressing NCDs and risk factors in a comprehensive and integrated way. The report is intended for policy-makers in health and development, health professionals, researchers and academia, and other responses, highlights some good country practices and

key stakeholders involved in prevention and control of NCDs.