SEA/RC60/7 - Scaling up prevention and control of chronic noncommunicable diseases in the South-East Asia region

REGIONAL COMMITTEE Sixtieth session Thimphu, Bhutan 31 August – 3 September 2007

Provisional Agenda item 9 SEA/RC60/7 13 July 2007

SCALING UP PREVENTION AND CONTROL OF CHRONIC NONCOMMUNICABLE DISEASES IN THE SOUTH-EAST ASIA REGION Chronic noncommunicable diseases (NCDs) are assuming alarming proportions in the SouthEast Asia (SEA) Region. Almost half of the 89 million NCD-related deaths projected in the Region during the next 10 years will occur prematurely, thus hindering social and economic development of Member countries. There is strong evidence that significant reduction in NCDs can be achieved by the introduction of simple public health interventions addressing major NCD risk factors and their socioeconomic determinants at population, community and individual levels. Member countries of the SEA Region are in the process of strengthening their public health response to ongoing epidemics of NCDs by initiating national policies, plans and programmes for prevention and control of NCDs. The Health Secretaries of Member countries of the SEA Region, at their Eleventh Meeting held in June 2006, endorsed the WHO Regional Framework for Prevention and Control of NCDs. The Joint Meeting of Health Secretaries and the Consultative Committee for Programme Development and Management (CCPDM) held in the Regional Office, New Delhi from 2–6 July 2007 further considered and endorsed the Framework. The priorities for its implementation were also identified. The Joint Meeting made the following recommendations: Action by Member States (1) To set up mechanisms to promote multilateral, multisectoral, multidisciplinary and multilevel collaboration in applying evidence-based and cost-effective interventions for prevention and control of NCDs. (2) To ensure that the integration of NCD programmes should correspond to the stage of epidemiological transition and existing health infrastructure, and meet the health needs of the population. Action by WHO-SEARO (1) To submit to the Sixtieth session of the Regional Committee the draft resolution on the Regional Framework for Prevention and Control of Noncommunicable Diseases, identifying priorities for its implementation. (2) To support the establishment of the Regional NCD Network (SEANET-NCD). The Sixtieth session of the Regional Committee is invited to consider the Regional Framework for Prevention and Control of NCDs and provide guidance on strategies for its implementation.

Contents Page Scope of the problem ............................................................................................................... 1 National capacity ..................................................................................................................... 2 Setting up NCD surveillance ..................................................................................................... 3 Strengthening health workforce ................................................................................................ 6 Networking for integrated prevention and control of NCDs....................................................... 7 Regional Framework for Prevention and Control of NCDs......................................................... 7 Priorities for prevention and control of NCDs............................................................................ 8 Priorities for Member States ................................................................................................................. 8 Priorities for WHO .............................................................................................................................. 9

Points for consideration .......................................................................................................... 10 References .............................................................................................................................. 10

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Scope of the problem 1. Chronic, noncommunicable diseases (NCDs) are the major cause of death and disability in the South-East Asia (SEA) Region of the World Health Organization (WHO) [1]. They account for 54% of all deaths in the Region (see Figure) [2]. Table 1 compiles national life expectancy data together with WHO estimates of NCD-related mortality and disease burden in the Member States of the SEA Region as presented in WHO’s World Health Statistics 2007 [3]. Rapidly progressing epidemiological transition and globalization will lead to an unrelenting increase in the health, social and economic burden inflicted by NCDs in the Region. If appropriate public health action is not initiated, disability and premature deaths from heart disease, cancer, diabetes and chronic respiratory diseases will grow by more then 21% over the next 10 years in the SEA Region. Figure: Projected deaths by cause, all ages, WHO South-East Asia Region, 2005 Injuries 11%

Cardiovascular disease 28%

Communicable, maternal and perinatal, nutritional deficiencies 35%

Cancer 9% Chronic respiratory disease 7% Other chronic diseases 8% Diabetes 2%

2. The worrying aspect of the epidemiological transition observed in the SEA Region is that middle-aged adults (35-60 years) show disproportionately high death rates due to NCDs in comparison with those living in more developed countries. People in countries of the Region tend to contract disease at younger ages, suffer longer and die sooner than people of high-income countries. According to WHO projections, almost half of the estimated 89 million NCD-related deaths that are likely to occur in the SEA Region over the next 10 years will be premature [4].

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Table 1: NCD-related mortality statistics in the countries of the SEA Region Life expectancy at birth (years) Male 2005 Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste 62 62 65 62 66 67 56 61 68 67 63 Female 2005 63 65 68 64 69 69 62 61 75 73 68 2002 762 771 691 750 727 864 796 796 711 559 814 Age-standardized mortality rate by cause (per 100 000 population) NCD CVD Both sexes 2002 428 441 371 428 361 484 432 436 314 199 441 2002 111 112 102 109 132 123 115 118 118 129 118 2002 60 65 44 58 41 55 60 64 19 43 63 Cancer Distribution of Years of Life Lost (YLL) by broader causes (%) CD NCD Both sexes 2002 28 25 46 29 44 36 29 25 61 40 26 2002 12 10 11 13 15 9 11 11 20 17 11 Injuries

Member State

NCD – noncommunicable diseases; CVD – cardiovascular diseases; CD – communicable diseases. Source: ref. 3

3. NCDs are increasingly becoming common among the poor and marginalized population groups. Contrary to common perception, 80% of chronic disease deaths occur in low and middle income countries. In fact, in developing countries the poor population is likely to bear the brunt of chronic diseases, mostly due to lack of awareness of risk factors, inability to modify lifestyles, and other economic reasons. The invisible epidemic of NCDs hinders the social and economic development of countries and perpetuates chronic poverty at the household level. 4. The causes of NCDs are known and are by and large modifiable. There is an increased emphasis on targeting the main risk factors common to several NCDs and heightened commitment to apply integrated approaches to deal with all major NCDs in an integrated way. The existing knowledge on effective, efficient and affordable interventions to modify common NCD risk factors such as unhealthy diet, physical inactivity and tobacco consumption at the individual, community and national level is largely underutilized [5]. 5. Beyond the risk factors, there are also major socioeconomic determinants that cause NCDs. These lie outside the domain of the health sector. Incorporating comprehensive NCD prevention and control interventions into existing mainstream public health programmes as well as socio-economic programmes outside the health sector have the potential to prevent at least 80% of all cases of heart disease, stroke and diabetes and 40% of cancers.

National capacity 6. There is a growing commitment of Member States towards the integrated prevention and control of NCDs and considerable progress has been achieved in this regard. A number of countries have taken strong action to control tobacco and alcohol consumption.

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7. Thailand, India and Indonesia have achieved notable progress in framing and implementing national NCD prevention and control policies, plans and programmes. Indonesia formulated its National Policy and Strategy for NCD Prevention and Control in 2004. Bangladesh developed the Strategic Plan of Action on Surveillance and Prevention of Noncommunicable Diseases in 2006 and India launched a National Programme for Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke the same year. National policies and action plans for NCD prevention and control are being developed in Maldives, Nepal and Sri Lanka. 8. The programmes for the control of NCDs in the Region need to be reviewed, strengthened and consolidated. Having appropriate mechanisms in place for regular programme assessment is considered an important prerequisite for scaling up NCD work. To facilitate the review of the current status of national capacities for prevention and control of NCDs a standard survey using an instrument adapted by the South-East Asia Network for NCD Prevention and Control (SEANET-NCD) was conducted in all Member States of the Region. 9. The WHO document “Capacity for Noncommunicable Disease Prevention and Control in the Countries of the South-East Asia Region” (SEA/RC60/15 Inf. Doc.1) compiles the results of the Capacity Assessment Survey 2006-2007 and provides comprehensive information on the current status of NCD prevention and control efforts in the Region. The survey helped in identifying the gaps and formulating priorities for collaborative programmes. 10. Table 2 documents the progress achieved in the Region since the first similar capacity assessment survey was conducted in 2001. By and large, the repeat survey revealed an increase in capacity and that all countries have made some progress in developing different components of NCD prevention and control. However, there has been limited progress in some areas such as development of treatment guidelines and programme target setting. As Timor-Leste, born in 2002, was not covered by the 2001 survey, the information presented in the table pertains to the 10 countries of the SEA Region that had participated in both surveys i.e. Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. Table 2: Progress in prevention and control of NCDs in the SEA Region (2001–2006) Area Infrastructure Financial allocation Policy/ programmes Indicator Presence of an NCD unit or department in MoH Allocation for NCDPC in regular budget of MoH National health policy addresses NCDs National health strategy addresses NCDs National integrated NCD programme/plan Area-specific policies/programme/plan Quantifiable targets set for the country in the area of NCDPC Tobacco Food and nutrition (related to NCDs) Inclusion of NCDs in national HMIS Routine or regular surveillance for NCDs/risk factors Availability of national guidelines for disease/risk management (for all major NCDs) No. of countries 2001 4 6 4 3 3 9 4 7 9* 10 6 1 2006 7 7 5 6 5 9 5 10 5 10 6 2

Target setting Legislation/ regulation Surveillance National guidelines

* Includes legislation not directly relevant to NCDs; MoH – ministry of health; NCDPC – NCD prevention and control Source: Capacity for NCD Prevention and Control in the Countries of the South-East Asia Region (SEA/RC60/15 Inf. Doc.1)

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Setting up NCD surveillance 11. Generating core information and linking it to policy and programme development, monitoring and evaluation is the domain of public health surveillance. All countries of the SEA Region include information on NCDs in their national health information systems. 12. In order to improve the availability, validity and accessibility of core information on major NCDs, a Regional Strategy for NCD Surveillance was adopted in the Region in 2003 [6]. The strategy aimed to strengthen the capacity of Member States in the implementation of NCD surveillance at the national level and promoted utilization of standardized tools and methods to facilitate tracking time trends and making inter-country comparisons. 13. In the case of NCDs, while information on disease burden is useful for advocacy, the distribution of risk factors among the population is the key information required for planning of prevention programmes. The information on risk factors predicts the future burden of the diseases and is also useful to measure the effectiveness of interventions. 14. Consensus building and capacity strengthening efforts facilitated by WHO have resulted in the development and adoption of a standard STEPS approach for NCD risk factor surveillance [7]. In line with the Regional Strategy for NCD Surveillance the countries of the SEA Region are making continued progress towards developing systems for NCD risk factor surveillance and effectively using the information generated to strengthen their programmes for integrated prevention and control of NCDs. 15. The number of countries reporting risk factor surveys and surveillance has increased since 2000-2001 when the WHO STEPS approach was introduced in the Region. While most countries have already conducted surveys using the STEPS approach, there is a need now to move from sub-national surveys to national-level surveys and to develop sustainable national NCD risk factor surveillance systems. 16. Between 2002 and 2006, nine Member States of the SEA Region conducted NCD risk factor surveys that adopted and/or adapted the standard WHO promoted STEPS approach. The WHO document “Risk Factors for Noncommunicable Diseases: Results from Surveys Using the WHO STEPS Apporach” (SEA/RC60/15 Inf. Doc.2) summarizes information on the current levels of major modifiable risk factors for NCDs in the South-East Asia (SEA) Region collected through these surveys. The document displays and shares the information collected with the purpose to strengthen the case for developing and applying common approaches and standard tools for NCD risk factor surveillance. 17. The report demonstrates that the levels of risk factors are unacceptably high in the countries of SEA Region (Table 3). The major NCD risk factors are common to both sexes and increasingly affect younger segments of populations. There is extensive variability of major NCD risk factor levels within and between Member countries. Whereas unhealthy diet, physical inactivity and tobacco consumption are well recognized as major NCD risks, poor maternal nutrition, stress and air pollution should also be included in that category. 18. NCD Infobase was set up in the SEA Region and select countries are being supported in deploying NCD Infobase at the national level [8]. The Infobase helps in bringing the evidence closer to the policy-makers and programme managers and contributes to the planning process.

Table 3: Summary results of NCD risk factor surveys using STEPS approach conducted in the SEA Region; 25-64 years; both sexes

Country/site

Year of survey

Current smokers (%) 21.9 25.3 31.1 15.7 17.8 32.0 22.7 22.9 24.4 20.6 19.6 18.6 16 – 32 3 – 41 40.1 40.5 96.8 85.0 81 - 99 40.5 99.1 18.0 98.2 3.5 NR 14.9 NR 4 - 24 18.4 99.1 7.3 NS 84.6 NR 3.2 94.5 7.8 22.3 44.2 36.5 23.3 16.5 28.8 37.5 9 - 44 26.4 84.6 10.0 13.3 20.7 81.4 23.8 39.4 24.3 20.3 35.9 NR 25.0 11.9 42.0 7.8 22.4 8 - 42 NS NS NS NR 16.3 NS NR NR 8.6 NR NS NR NR 36.5 NR NS NS NS NR NR 5.2 NR 7.7 3.8 NS NS 8.6 4-9

Current consumers of alcohol (%) % physicall y inactive

% eating <5 servings of fruits and vegetables/ day % overweight or obese BMI ? 25

% with blood pressure ? 140/90 mm Hg

% with fasting blood sugar ? 7 mmol/l

% with blood cholesterol ? 5.2 mmol/l NS NS NS NR NR 13.1 54.4 25.8 18.7 NS NS 48.1 13-54

Bangladesh – U Dhaka 2003 2005 2004-5 2004-5 2004 2004 2004 2004 2005 2003 2004-5 2003-5

2003

Bangladesh – R Dhamrai upzilla

DPR Korea Pyongyang City

India – U ( six sites)

India – R ( six sites)

Indonesia – national

Maldives – Malé

Myanmar – U (Yangon)

Myanmar – R (Yangon)

Nepal – Lalitpur Ilam & Tanahu

Sri Lanka – Dehiwala

Thailand – national

TOTAL (range)

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BMI – body mass index; F & V – fruits and vegetables; NS – not studied; NR – not reported; R – rural; U – urban. Source: Risk Factors for Noncommunicable Diseases in the SEA Region (SEA/RC60/15 Inf. Doc.2)

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Strengthening health workforce 19. A competent health workforce is the backbone of the public health system. The Fifty-ninth session of the Regional Committee endorsed the Regional Strategic Plan for Human Resource Development and highlighted the need for continuous professional development of the public health workforce both within and beyond the health sector [9]. The capacity of the health workforce needs to be strengthened and appropriate resources allocated to deal effectively with the prevention and control of NCDs. 20. Application of existing knowledge in imparting health promotion and disease prevention and control-oriented NCD programmes requires involvement of empowered communities and committed partners outside the health sector. Human resources for health in the context of NCD prevention and control comprise many stakeholders outside the formal health sector. This includes a number of other governmental sectors (such as education, trade, agriculture, finance, urban development and others), general public, communities, families and individuals, NGOs, civil society, international organizations, etc. 21. Support in framing policies and plans for prevention and control of NCDs is one of the top priorities for WHO technical assistance to Member States. At the same time there is a growing demand to strengthen the capacity and capability of the public health workforce at the national and sub-national level to the extent that would empower them to review, revise, update, implement, monitor and evaluate programmes for integrated prevention and control of NCDs. 22. In this context a project to strengthen capacity of programme managers from the health and other sectors has been initiated in the Region. A series of knowledge updating and skillsenhancing regional modules compiling evidence-based information required for developing, reviewing and revising national (and sub-national) NCD policies and programmes have been developed and pilot-tested in the Region. National capacity strengthening workshops utilizing these modules are being implemented in Member countries of the SEA Region. 23. NCDs are of a chronic nature. Scarce resources can be saved and public health outcomes enhanced by promoting the development and use of simple, evidence-based guidelines and standards that endorse the application of cost-effective interventions, including use of basic medicines. WHO should facilitate the development of such standards and guidelines and their dissemination to health-care providers. 24. While an increasing number of people with chronic diseases require long-term treatment major gaps in access to even basic clinical and diagnostic services persist. Member States are demanding increased support to develop essential capacity for implementing interventions for integrated management (treatment and care) of NCDs in tandem with full utilization of the existing primary health-care system capacity. 25. The availability and affordability of basic medicines used to treat major NCDs in the public health sector of low income countries is inadequate [10]. Educating professionals and consumers to use generic, low-cost products enhanced by context-specific policies has the potential to improve access to essential medicines.

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Networking for integrated prevention and control of NCDs 26. The 2007 World Health Assembly Resolution on Prevention and Control of NCDs (WHA 60.23) urges Member States to establish and strengthen national coordinating mechanisms and local coalitions for the same [11]. The resolution requests WHO to facilitate the coordination of NCD prevention and control and to support NCD networking activities as an effective means of cooperation at global, regional and national levels. 27. Regional networks for NCD prevention and control have been established with WHO support in Europe (CINDI), the Americas (CARMEN), and also recently in Africa (NANDI), the Eastern Mediterranean Region (EMAN) and the Western Pacific Region (MOANA). 28. National networking activities for integrated NCD prevention have been initiated in several countries of the SEA Region including India, Indonesia, Maldives, Nepal, Sri Lanka and Thailand. Building on the momentum generated by the national networks, the WHO Regional Office had initiated a regional network for integrated prevention and control of NCDs (SEANET-NCD) in 2004 [12]. 29. According to the recommendations of the network’s meeting held in November 2005 (Document SEA-NCD-71) [13], SEANET-NCD has formally been established. 30. The goal of the SEANET-NCD is to stimulate, strengthen and sustain efforts in the SEA Region to reduce the health and economic burden of major NCDs through coordinated and integrated multisectoral programmes of health promotion and disease prevention. The general objective of the network is to strengthen regional cooperation among Member States to develop and implement policies and programmes for the prevention and control of NCDs. 31. It has been agreed that the networking should focus on information sharing, capacity building, advocacy, policy development and research. The network creates an important advocacy and capacity-building platform for regional implementation of important global WHO commitments such as the Framework Convention on Tobacco Control and Global Strategy on Diet, Physical Activity and Health [14, 15]. The functioning of the network will be coordinated by a board of directors of national networks and facilitated by a secretariat located at the WHO Regional Office for SE Asia.

Regional Framework for Prevention and Control of NCDs 32. The Eleventh Meeting of Health Secretaries of Member States of the SEA Region held in New Delhi, India, in June 2006 reviewed and unanimously endorsed the Regional Framework for Prevention and Control of Noncommunicable Diseases (Document SEA/HSM/Meet.11/2) [16] (SEA/RC60/15 Inf. Doc.3). 33. The Framework draws from the national, regional and global consensus on policy and technical actions for prevention and control of NCDs and their primary risk factors. It aims to assist governments in balancing diverse priorities related to prevention and control of NCDs while promoting implementation of simple, evidence-based interventions. It applies an

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ecological perspective and is based on public health principles. The implementation of the framework necessitates intersectoral, multidisciplinary and multilevel approaches focused on awareness generation, health promotion and disease prevention through reduction of common risk factors. This is enabled by combining a population-wide approach with clinical intervention at the individual, family and community levels. 34. The Framework provides a step-wise construction that offers a flexible and practical approach taking into consideration available resources and local needs. Three planning steps proposed by the Framework include: (1) Estimating population needs and advocating for action; (2) Formulating and adopting policy, and, (3) Identifying the policy implementation process. 35. The Framework also reaffirms WHO’s continuous commitment to provide technical support and facilitate national capacity building, resource mobilization and the development of tools, norms and standards. It will contribute to fostering partnerships and promoting intercountry cooperation and networking in the context of the Charter of SEANET-NCD. 36. The health secretaries of the countries of the SEA Region appreciated the step-wise approach proposed and the focus of the Regional Framework on health promotion and disease prevention through identifying and addressing major risk factors for NCDs and their socioeconomic determinants. They pointed out that treatment and care aspects are also important as Member States have the responsibility to provide cost-effective management for people with NCDs. 37. The health secretaries of Member States of the SEA Region requested the Regional Office to facilitate the submission of a draft resolution to endorse and provide guidance for implementation of the Regional Framework for Prevention and Control of NCDs for the Regional Committee’s consideration.

Priorities for prevention and control of NCDs Priorities for Member States 38. Based on the Regional Framework for Prevention and Control of NCDs – endorsed by the Eleventh Meeting of Health Secretaries of Member States of the SEA Region held in New Delhi, India, in June 2006 – there is a priority need to initiate appropriate steps to formulate, update and strengthen national policies, plans and programmes for integrated prevention and control of NCDs. 39. Since Member States are faced with a triple burden of disease (NCDs, injuries and communicable diseases) and only a small proportion of their health budget is available for implementing public health-oriented programmes for integrated prevention and control of NCDs, there is a need to establish a suitable infrastructure and appropriate funding mechanism for this purpose. 40. Since existing capacities and capabilities of national health systems do not meet current challenges and expectations, there is a need to enhance the knowledge and skills of the health

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workforce at all levels for planning and implementation of comprehensive programmes for integrated prevention and control of NCDs. 41. Appropriate coordinating mechanisms to promote multilateral, multisectoral, multidisciplinary and multilevel collaboration for integrated prevention and control of NCDs need to be set up. In particular, Member States should consider supporting the establishment of national and international networks for NCD prevention and control and facilitate such networks joining the regional NCD network (SEANET-NCD). 42. The persistent gaps in equitable access to basic clinical and diagnostic services for NCDs need to be bridged through the strengthening of capacity for integrated management (treatment and care) of major NCDs with full utilization of the existing primary health-care capacity and, where appropriate, engaging traditional systems of medicine.

Priorities for WHO 43. Having recognized the growing commitment of Member States to scale up their responses to growing public health challenges posed by NCDs, WHO should provide technical assistance in developing and implementing national policies, plans and programmes for prevention and control of NCDs. 44. Noting the need to bolster the capacity of national health systems to strengthen prevention and control of NCDs, WHO should provide technical assistance to Member States for human resource development at all levels. 45. In view of the perceived need to strengthen coordinating mechanisms and local coalitions for the prevention and control of NCDs, WHO should foster partnerships and create platforms for dialogue and cooperation among Member States and, in particular, support the organization and coordination of the regional NCD prevention and control network. 46. Noting the progress achieved in setting up national NCD prevention and control programmes and bearing in mind the need for sustainable collection of core information to enable further policy development, planning effective interventions and measuring performance and outcomes, WHO needs to technically support national efforts aimed at the development of appropriate monitoring and evaluation approaches including those for surveillance of NCDs and their risk factors. 47. As cost-effective and simple interventions for NCDs are available but largely underutilized, WHO should facilitate the development and implementation of evidence-based standards and guidelines for prevention and management of major NCDs and their risk factors and promote their broad utilization at all levels in general and the primary health-care level in particular. 48. Keeping in mind the huge existing funding gap that hinders application of the currently available knowledge on cost-effective public health interventions for prevention and control of NCDs, WHO should strengthen efforts to facilitate mobilization of resources for this purpose and coordinate international support through development partners.

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Points for consideration 49. The Sixtieth session of the Regional Committee is invited: •

To endorse and provide guidance, as per the recommendations of the Eleventh Meeting of Health Secretaries of Member States of the SEA Region, for the implementation of the Regional Framework for Prevention and Control of NCDs.

References 1. World Health Organization (2002). Noncommunicable diseases in South-East Asia Region – A profile. New Delhi, World Health Organization, Regional Office for South-East Asia. 2. World Health Organization. Impact of chronic disease (http://www.who.int/chp/chronic_disease_report/media/searo.pdf in regions. Available from:

3. World Health Organization (2007). World Health Statistics 2007. Geneva, World Health Organization. 4. World Health Organization (2005). Preventing chronic diseases, a vital investment. Geneva, World Health Organization. 5. World Health Organization (2002). The World Health Report 2002. Reducing risks, promoting healthy life. Geneva, World Health Organization, 2002. 6. World Health Organization (2003). Regional strategy for NCD surveillance. New Delhi, World Health Organization, Regional Office for South-East Asia. 7. World Health Organization (2005). WHO STEPS Surveillance Manual: The WHO STEPwise approach to chronic disease risk factor surveillance. Geneva, World Health Organization. 8. World Health Organization. Regional http://www.searo.who.int/ncd/index1.asp NCD Infobase. Available from:

9. World Health Organization (2006). WHO Regional Committee for South-East Asia, Report of the Fiftyninth Session, Dhaka, Banglades, 22-25 August 2006. New Delhi, World Health Organization, Regional Office for South-East Asia. 10. Mendis S, Fukino K, Cameron A, Laing R, Khatib O, Leowski J, at al. The availability and affordability of selected essential medicines for chronic diseases in six low- and middle income countries. Bulletin of the World Health Organization 2007;85:279-88 11. Resolution WHA60.23. Prevention and control of noncommunicable diseases: implementation of the global strategy. In: Fifty-third World Health Assembly, Geneva, 23 May 2007. 12. World Health Organization (2004), Networking for integrated prevention and control of Noncommunicable Diseases in the SEA Region, New Delhi, India, 30 March – 2 April 2004. New Delhi, World Health Organization, Regional Office for South-East Asia. 13. World Health Organization (2006). South-East Asia Network for Noncommunicable Disease Prevention and Control, report of the WHO meeting Bandos, Maldives, 7-10 November 2005. New Delhi, World Health Organization, Regional Office for South-East Asia. (SEA-NCD-71) 14. Resolution WHA56.1. WHO Framework Convention on Tobacco Control. In: Fifty-sixth World Health Assembly, Geneva, May 2003. 15. Resolution WHA57.17. WHO Global Strategy on Diet, Physical Activity and Health. In: Fifty-seventh World Health Assembly, Geneva, May 2004. 16. World Health Organization (2006). Report of the Eleventh Meeting of Health Secretaries of Member States of the South-East Asia Region, WHO Regional Office, New Delhi, 12-13 June 2006. New Delhi, World Health Organization, Regional Office for South-East Asia.



REGIONAL COMMITTEE Sixtieth session Thimphu, Bhutan 31 August − 3 September 2007

Provisional Agenda item 9 SEA/RC60/7 Inf. Doc.1 13 July 2007

SCALING UP PREVENTION AND CONTROL OF CHRONIC NONCOMMUNICABLE DISEASES IN THE SEA REGION Capacity for Noncommunicable Disease Prevention and Control in Countries of the South-East Asia Region Results of a 2006-2007 survey

Country focal points that provided the information contained in this document. Bangladesh Dr Syeda Badrun Nahar Director ( Disease Control) Directorate General of Health Services Dhaka Bhutan Dr Sonam Ugen CPO,NCDD DOPH Thimpu, DPR Korea Dr Choe Tong Chol Deputy Director, Treatment & prevention Dept. Pyongyang, India Dr Atul K. Tiwary Deputy Secretary Ministry of Health & Family welfare New Delhi. Indonesia Dr Achmad Hardiman Director , Non Communicable Diseases Control Jakarta Maldives Mrs. Sheena Moosa Director of Health Services, Ministry of Health, Male Myanmar Dr Tin Min Director (Medical Care) Department of Health Yangon Nepal Dr Nirakar Man Shrestha Chief Specialist, Ministry of Health and Population Kathmandu Sri Lanka Dr Lakshmi Somatunga Director, Non communicable Diseases Colombo Thailand Dr Chaisri Supornsilaphachai Director, Bureau of Noncommunicable diseases Nonthaburi Timor- Leste Mr Rafael Dos Santos Xiemenes Head, Department of NCDs Directorate of Health Services Delivery Ministry of Health Dili

Contents Introduction ................................................................................................................................ 1 Objectives ................................................................................................................................... 2 Methods ...................................................................................................................................... 2 Results......................................................................................................................................... 3 Epidemiological Assessment ................................................................................................3 National Policies and Plans..................................................................................................4 Legislative and Regulatory Framework .................................................................................6 Programme Infrastructure and Funding................................................................................9 Public Health Interventions ...............................................................................................10 National protocols and guidelines for management ...........................................................11 Progress since 2001 ...................................................................................................................13 Implications for Action...............................................................................................................14 Annexes 1. 2. Questionnaire ...................................................................................................................16 Abbreviations and Acronyms .............................................................................................25

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Introduction 1. The continuous rise in the incidence of noncommunicable diseases (NCDs) represents one of the major public health challenges in the new century. It threatens economic and social development of countries as well as the lives and health of millions of people in the South-East Asia (SEA) Region of WHO. 2. Since the landmark Global Strategy for the Prevention and Control of Noncommunicable Diseases adopted by WHO in 2000, numerous important global, regional and national initiatives have been launched to address the challenge. The Framework Convention on Tobacco Control (FCTC) was introduced in 2003, and the WHO Global Strategy on Diet, Physical Activity and Health was launched in 2004. The most recent global WHO resolution on NCDs adopted in 2007 urges Member States to strengthen political will, coordinating mechanism, regulatory functions and primary health care system involvement in prevention and control of NCDs. 3. A Global Survey on Assessment of National Capacity for NCD Prevention and Control was undertaken by WHO in 2001. The findings of the survey indicated that although a high percentage of countries reported having national health policies in general, less than half had specific policies for NCDs and their risk factors. The information obtained from key informants indicated that NCDs were regarded as high priority but health systems lacked the capacity to take effective action. 4. At the regional level, several countries such as India, Indonesia and Thailand have made notable progress in framing and implementing national NCD prevention and control policies, plans and programmes. Indonesia formulated its National Policy and Strategy for NCD Prevention and Control in 2004, and India launched a National Programme for Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke in late 2006. The SEAR Framework for Prevention and Control of NCDs was also formulated in 2006 to facilitate the development and implementation of comprehensive national policies, plans and programmes in the Region. Since then, national policies and action plans for NCD prevention and control have been developed in Bangladesh, Maldives and Nepal. 5. WHO is assisting Member States in strengthening their capacities in dealing with NCDs. In order to carry out this mandate in a more fruitful way, it is important to periodically assess the status of NCD prevention and control in a standard manner. Having appropriate mechanisms in place for regular programme assessment is considered an important requirement for scaling up NCD prevention and control work in the Region. Setting up efficient monitoring and evaluation systems involves identification of relevant indicators, periodical collection of data and their timely analysis and interpretation. 6. Adoption of an instrument for monitoring progress in preventing and controlling NCDs at regional and national levels was among the major objectives of the WHO Meeting of the SouthEast Asia Network for NCD Prevention and Control (SEANET-NCD) conducted in Maldives in November 2005. The proposed WHO tool was presented and subsequently discussed in detail by working groups. Several modifications of the questionnaire were suggested by these groups

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and discussed again at the plenary session, which adopted the instrument for use in the Region. It was agreed that the survey would be carried out through national NCD focal points by the respective ministries of health. 7. In line with the recommendations of the SEANET-NCD meeting, a survey was conducted in all 11 Member States of the SEA Region in 2006-2007. The publication compiles the results of these national surveys and documents the progress achieved in the Region in the NCD area since the first survey conducted in 2001.

Objectives 8. The specific objectives of this report are to: • • •

share information on national capacity for NCD prevention and control in the SEA Region; assess the progress achieved in NCD prevention and control between 2001 and 2006, and identify the existing constraints and needs for NCD prevention and control in the Region.

Methods 9. Information was collected through application of a structured questionnaire. The survey questionnaire contained nine sections each covering a separate aspect of NCD prevention and control at national level. The major NCDs covered by the survey were cardiovascular disease, cancer, diabetes and chronic respiratory diseases. The risk factors included were tobacco use; unhealthy diet; physical inactivity; alcohol consumption; elevated blood pressure; obesity; elevated blood glucose, and dyslipidemia. The survey comprised the following elements: • • • • • • • • •

national focal point, unit/department; national act, law, legislation, ministerial decree; policy, strategy, action plan, programme; national target; national health reporting system, survey and surveillance; national community-based demonstration programme; implementation of the Framework Convention on Tobacco Control and Global Strategy on Diet, Physical Activity and Health; national protocols/guidelines/standards, and financial resources.

10. The full text of the questionnaire is available at Annex 1. The questionnaire was sent to ministries of health of countries of the SEA Region. All 11 Member countries of the Region i.e. Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste participated in the survey. The respondents were national NCD focal points which are listed at the beginning of the document. The responses were collected by the

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Regional Office through the WHO country offices between February 2006 and March 2007. The compilation and analysis of information were done manually by the SEA Regional Office. The SEA Regional Framework for Prevention and Control of NCDs, endorsed by the Secretaries of Health of the Member States in June 2006 (Fig 1), guided the way data on different facets of NCD prevention and control are grouped and presented in this publication. Figure 1: SEAR Framework for Prevention and Control of NCDs Epidemiological assessment

Awareness generation and high-level advocacy

Development of policy and strategic plan

Capacity strengthening, resource mobilization and infrastructure development Multisectoral and multilevel action to modify environment (physical, social and economic)

Health sector interventions

Decrease in NCD risk factor level and reduced adverse health events

Reduced health and economic burden of NCD

11. It should be noted that: • •

Some developments might have occurred in Member States since this survey was conducted which might not get reflected in the current analysis. The results are as provided by the national focal points. While all efforts have been made to be faithful to the respondents, the process of interpretation and summarization could have, in some cases, failed to capture the intention of the respondent.

Results Epidemiological Assessment 12. The first step in addressing any health problem is to assess its magnitude and define population needs. The information on population needs must be synthesized and disseminated in a way that encourages policy action. This is the domain of public health surveillance – to generate information and link it to people in position to take action. For NCDs, while

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information on disease burden is useful for advocacy, the distribution of risk factors among the population is the key information required for planning of prevention and control programmes. The information on risk factors predicts the future burden of diseases and is also useful to measure the effectiveness of prevention programmes. For the surveillance activity to be sustainable, it has to be an inherent part of the national health information system and use valid and standardized tools. Table 1: Status of NCD surveillance activities in countries of the SEA Region, 2006-2007 Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste Inclusion of NCDs in national HIS RF √ – – √ √ – √ – – – – Morbidity √ √ √ – – – √ √ √ √ √ Mortality √ √ √ – – √ √ – √ √ √ Regular surveillance for NCDs/RF – – √ √ √ – √ – √ √ – STEPS survey conducted √ – √ √ √ √ √ √ √ √ –

13. The survey found that all countries had included NCDs in their national health information systems (HIS). Of these, eight countries included both mortality and morbidity data. Only four countries reported including NCD risk factors into the national health information systems. All countries were conducting national/provincial-level surveys for any one or more of the NCD risk factors, notably tobacco. Four countries were conducting disease surveys at national or provincial level – especially for diabetes, cancer or heart disease. 14. Six countries had a regular NCD surveillance system with one more country likely to join it in the near future. All countries with two exceptions had carried out NCD risk factor surveys using the WHO-promoted standardized and validated STEPS approach.

National Policies and Plans 15. An NCD policy sets out the vision and provides the basis of action for the next five to ten years. It is accompanied by plans and programmes that provide the means of implementing the policy. Governments need to create a comprehensive health policy and regulatory environment in which all sectors that influence health can operate successfully. In all countries, a national policy and planning framework is essential to give NCDs appropriate priority and allocate sufficient resources. Comprehensive and integrated policies are vital as they minimize overlap and fragmentation of the health system. Programme implementation should also be integrated.

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In the absence of strong coordinating mechanisms, having multiple vertical programmes for individual NCDs often leads to loosing opportunities for optimizing public health outcomes through exploiting multiple synergies. Table 2: Status of NCD-related policies and programmes in countries of the SEA Region, 2006-2007 Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste Health policy addresses NCDs – – √ – √ √ √ – – √ √ Health strategy addresses NCDs – – √ – √ √ √ – √ √ √ Integrated NCD prevention and control programme – – √ √ – – √ – √ √ – Area-specific policies/programmes/plans Tobacco, alcohol, cancer, diabetes – All inclusive # Tobacco, nutrition, cancer All inclusive # Tobacco, nutrition, health promotion All inclusive # Tobacco, nutrition, alcohol, health promotion Tobacco All inclusive # Health promotion

# - all inclusive means that policies/plans/programmes (whichever appropriate) exist for all risk factors and diseases listed in the introduction

16. Since the commitment to address NCDs is a relatively recent phenomenon among health policy- makers in the Region, this may not yet be adequately reflected in national policies and strategies. Nevertheless, six countries reported including NCDs in their national health policies, while seven countries reported that they specifically targetted NCDs in their national health strategies. National health policies are usually reviewed / revised periodically in most countries. Application of an integrated approach to NCD prevention and control was reported by five countries with Thailand leading the way. Tobacco, diet, physical activity and health promotion were the areas where specific programmes were being implemented in the countries. Specific targets 17. Targets are needed for monitoring the progress of the programme and for its evaluation. They need to be set carefully and in broad consultation with and among major stakeholders. Targets need to be realistic and matched with resources allocated. 18. Six of the 11 Member countries of the Region reported setting of targets for NCD prevention and control (NCDPC). These pertained to case finding targets for diseases, increase in knowledge of the community, and health care infrastructure development, etc.

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Table 3: Status of NCD-related programme targets in countries of the SEA Region, 2006-2007 Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Targets set √ – √ – – √ √ not specified – not specified – – Comprehensive - including mortality and morbidity burden, risk factor levels and health system issues Knowledge of own BP – 45% , awareness of CVD risk factors – 70% , mean total cholesterol of population – 200 mg/dl, establishment of central diabetic registry, provision of effectively and timely treatment for diabetes in four diabetes clinics – – Screening for diabetes and hypertension of 60% of the population above 40 years, 90% of all air-conditioned restaurants and cafeterias to be to non-smoking areas. not specified Types of targets

Nepal Sri Lanka Thailand

– – √

Timor-Leste

√

Legislative and Regulatory Framework 19. National and local legislation, regulation and ordinances, international laws and treaties and other legal frameworks are fundamental components of effective public health policy and practice. Historically, laws have played a crucial role in some of the greatest achievements in public health, such as environmental laws, and seat-belt laws, etc. Having specific legislative and regulatory strategies is imperative for development of successful NCD prevention and control programmes. It is equally important to scrutinize the provisions of existing legislative acts, developed for purposes other than enhancing health, in order to determine their public health implications for prevention and control of NCDs. 20. The status of NCD-related legislation and regulation in countries of the SEA Region is summarized in Table 4. Tobacco control is an area where legislation and regulation are most practised in the Region. Though this approach precedes the WHO Framework Convention on Tobacco Control (FCTC) in this Region, there is no doubt that the Framework Convention has given a major stimulus to reinforce the national efforts. In the area of alcohol, five countries reported having legislation including one with religious proscription (Shariat law in Maldives). Food and nutrition can clearly be identified as an area requiring much more attention. This area has been emphasized in the past mostly for purposes other than NCD control, such as maternal and child health and food safety. For physical activity, little has been done by the way of legislation with exception of regulatory measures to ensure compulsory physical exercise in schools for children.

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Table 4: NCD-related legislation and regulation in countries of the SEA Region, 2006-2007 Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste Tobacco √ √ √ √ √ √ √ √ √ √ Food and nutrition √ √ √ √ √ Food in school/ workplace settings √ √ Alcohol control √ √ √ √ √ Physical activity √ √ √ -

Framework Convention on Tobacco Control 21. The WHO’s Framework Convention on Tobacco Control endorsed in 2003, is the first global health treaty negotiated under the auspices of WHO. This evidence-based treaty reaffirms the right of all people to the highest standard of health. It represents a paradigm shift in developing a regulatory strategy to address addictive substances. In contrast to previous drug control treaties, the WHO Framework Convention asserts the importance of demand-reduction strategies as well as of supply-reduction issues. Tables 5: Status of the Framework Convention’s implementation in countries of the SEA Region, 2006-2007 Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste Framework Convention Signed √ √ √ √ √ √ √ √ √ √ Ratified √ √ √ √ √ √ √ √ √ Action plan for Framework Convention √ √ √ √ √ √ √ Areas where assistance needed Information, education and communication (IEC), cessation, monitoring, capacity building Tobacco cessation programmes Technical assistance Alternative cropping and rehabilitation of tobacco growers and associate sectors Capacity building, product regulation and testing, IEC Technical and financial assistance, IEC, product regulation Technical and financial assistance, drafting laws Product regulation Crop substitution, countering smuggling and cross-border advertising, laboratory set-up, sub-national law Technical support

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22. In the SEA Region, all countries except Indonesia have signed and ratified the Framework Convention demonstrating a very high regional commitment to tobacco control. Six countries reported development of an action plan for its implementation. The countries also indicated a need for technical and financial support for further implementing the provisions of the Framework Convention. The two tobacco producing countries i.e. India and Thailand needed help in crop substitution. Global Strategy on Diet, Physical Activity and Health 23. The WHO’s Global Strategy on Diet, Physical Activity and Health (DPAS) was adopted in 2004. It delineates the role of Member States, UN agencies, civil society and the private sector in reducing the occurrence of NCDs trough promoting healthy diets and physical activity. It also stresses the importance of addressing NCD prevention in health services, food, agriculture, school and fiscal policies; surveillance systems; nd consumer education and marketing as they affect food and physical activity choices. The document emphasizes the need for countries to develop national strategies with the long-term perspective to make the healthy options the preferred choices at the individual, community and population level. The strategy provides Member States and other stakeholders with a range of recommendations and policy options to promote healthier diets and more physical activity. 24. In the SEA Region, DPAS is being implemented in three countries with five more countries in the process of initiating its implementation. The existing mechanisms in the Region for interaction with private industry are weak. Countries implementing DPAS also requested for more technical assistance to strengthen capacity especially in relation to development of guidelines and formulating appropriate legislation. Table 6: Issues related to DPAS’ implementation in countries of the SEA Region, 2006-2007 Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Implementation of DPAS Proposed Proposed Proposed Proposed Proposed Proposed Mechanism to interact with private sector √ √ Nongovernmental Organizations √ Aspects where assistance needed To conduct baseline survey Technical assistance Development of nutrition standards, land use planning, drafting laws and legislation Technical assistance Technical and financial assistance Capacity building Developing strategic plan, promoting research, monitoring health policy, tools for operational implementation Conduct assessment surveys

Myanmar Nepal Sri Lanka Thailand

√ √ √ -

Timor-Leste

-

-

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Programme Infrastructure and Funding 25. In order to ensure that government’s policy for prevention and control of NCDs is implemented, it is essential to have appropriate mechanisms in place. This calls for sufficient technical and human resource capacity development and is well reflected in the presence of a team of dedicated staff dealing with NCD prevention and control at the Ministry of Health (MoH). It is encouraging to find that all Member countries of the SEA Region have focal points for NCD prevention and control in their ministries of health. Eight countries also reported having NCD units or departments with one more country about to initiate the same. Only six countries had national-level institutes of public health (not necessarily dealing with NCDs alone), which could provide technical support in the area of NCD policy and programme development and its implementation. 26. Establishing sustainable funding mechanisms is among the important prerequisites for successful implementation of policies and plans. As a first step, a line item for NCD prevention and control should be included in the annual health budget. Additional funding mechanisms such as introducing fiscal measures to generate resources like taxation could be considered. 27. In the SEA Region eight countries reported specific allocation of resources for NCDs in their budgets, six of which were in the regular national budget. Tax on tobacco and alcohol, international and private donations, and WHO support were listed as other sources of funding. This budgetary support was allocated for management of diseases, their risk factor (in particular tobacco) control, and health promotion. The information generated through the survey indicates that financing mechanisms for NCD prevention and control, though still weak, are being established in the Region. Table 7: Programme infrastructure for NCDs in countries of the SEA Region, 2006-2007 Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor- Leste NCD focal point √ √ √ √ √ √ √ √ √ √ √ NCD unit or dept. in MoH √ √ @ √ √ √ √ √ √ No of staff in the NCD unit* 10 3 25 1 8 3 59 6 Presence of national public health institute for NCDs √ √ √ √ √ √ -

* Professional and managerial staff only; @ NCD cell in MoH on the anvil

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Table 8: Funding and resource allocation for NCD programmes in countries of the SEA Region, 2006-2007 Specific budget allocated by government √ √ √ √ √ √ √ Budgetary support to specific components Tobacco, nutrition, alcohol, diabetes, health promotion All diseases and risk factors Tobacco, diabetes, heart disease, stroke, cancer All diseases and risk factors Tobacco, nutrition, physical activity, health promotion Tobacco, nutrition and cancer All diseases and risk factors

Country

Source of funding

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

RB, IA RB, IA RB, IA RB, IA RB, WHO Tax on cigarettes and alcohol Health sector development project Tax on cigarettes, alcohol and unhealthy imported food, RB, IA, WHO, private donors RB, IA, WHO, private donors

Timor- Leste

√

Health promotion

RB – Regular budget; IA – International aid

Public Health Interventions Demonstration projects 28. Community-based projects for NCD prevention and control target a specified community. They are a good way to build local capacity. They can also serve as the starting point for national initiatives. Integrated community-based programmes aim to reach the general population as well as target high-risk and priority population groups in schools, workplaces and health care settings, etc. The success of community-based interventions depends on establishing effective partnerships between community, policy-makers, businesses, health providers and other stakeholders. The positive health impact of community-based interventions for NCD prevention documented in many developed countries, indicates considerable potential for achieving major public health gains in developing countries too. Seven countries of the SEA Region reported having a demonstration project for NCD prevention and control. These were mainly settingsbased projects implemented in schools, workplace, hospitals and community. Accordingly, adolescents and adults were the primary target groups.

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Table 9: Demonstration projects for NCD prevention in countries of the SEA Region, 2006-2007 Country Bangladesh Bhutan DPR Korea Integrated NCDPC √ √ Individual risk factor Tobacco Population groups 25-64 years Women, adolescents, 25-64 years, Settings Community Hospitals, community/ family Workplace, schools, hospitals, community Workplace, schools, hospitals, community/family Schools, hospitals, community Schools All Children, 25-64 years, women Schools, hospitals, community/family Workplace, schools, hospitals, community/ family

India

√

-

Indonesia

√

√

Women, adolescents, 25-64 years, elderly Adolescents, 25-64 years -

Maldives Myanmar Nepal Sri Lanka Thailand Timor- Leste √ √ -

√ √ -

Tobacco -

National protocols and guidelines for management 29. Adjusting health systems to provide equitable and cost–effective management for major NCDs, especially at primary health care level, continues to be a major challenge in low–resource settings. The introduction of integrated management guidelines is one of the important methods for promoting evidence-based care. Treatment guidelines should be tailored to fit local contexts and resource constraints, endorsed by local professional societies, approved at the national level and made accessible to the users. 30. In the SEA Region, Indonesia and Thailand had guidelines for all major NCDs whereas Nepal and Timor-Leste did not have any. These guidelines were more commonly available for diseases especially diabetes, heart disease and less commonly for NCD risk factors.

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Table 10: Availability of treatment guidelines for management of major NCDs in countries of the SEA Region, 2006-2007 Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor- Leste Diabetes √ √ √ √ √ √ √ √ Heart diseases √ √ √ √ √ Stroke √ √ √ Cancer √ √ √ √ Chronic obstructive pulmonary disease (COPD) √ √ √ √ -

Table 11: Availability of treatment guidelines for management of NCD risk factors in countries of the SEA Region, 2006-2007 Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor- Leste Smoking cessation √ √ High blood pressure √ √ √ √ Obesity √ √ Dietary √ √ √ Physical activity √ √ -

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Progress since 2001 31. A survey on assessment of national capacity for NCD prevention and control was carried out by WHO for the first time in 2001. All 10 countries which were Members of the SEA Region in 2001 responded to the standard questionnaire. The survey conducted in 2006 had several topics common with the 2001 survey. These included information on NCD units/departments; national legislation; national policies, strategies, plans and programmes; national health reporting systems, surveys and surveillance; guidelines, and financial resources. 32. The results of the 2006 survey are described in detail in chapter 4. This chapter compares areas common to both surveys. It needs to be mentioned that, although similar, the two survey instruments were not fully equivalent. Some discrepancies noted in the comparison are therefore likely to be artifacts due to differences in interpretation of the questions between the first and the second round. Nevertheless, the commonalities of the surveys conducted in 2001 and 2006 permit estimation of the progress achieved in the period between the two surveys (Table 12). As Timor-Leste, formed in 2002, was not covered by the 2001 survey, the information presented in the table pertains to ten countries of the SEA Region that participated in both surveys i.e. Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. Table 12: Progress in the prevention and control of NCDs in the SEA Region (2001 – 2006) Area Infrastructure Financial allocation Policy/programmes Indicator Presence of a NCD unit or department in MoH Allocation for NCDPC in regular budget of MoH National health policy addresses NCDs National health strategy addresses NCDs National integrated NCD programme/plan Area-specific policy/programme/plan Target-setting Legislation/regulation Quantifiable targets set for the country in the area of NCDPC Tobacco Food and nutrition (related to NCDs) Surveillance Inclusion of NCDs in national HIS Routine or regular surveillance for NCDs / risk factors National guidelines Availability of national guidelines for disease / risk management (for all major conditions) No. of countries 2001 4 6 4 3 3 9 4 7 9@ 10 6 1 2006 7 7 5 6 5 9 5 10 5 10 6 2

@ includes legislation not directly relevant to NCDs

33. By and large, the repeat survey showed an increase in the capacity of Member States of the SEA Region. All countries have made some progress in strengthening different components of NCD prevention and control. The presence of NCD units within the ministries of health has

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shown an increase and more countries have developed NCD policies, strategies and programmes. The progress was also evident in the area of tobacco control. There was limited progress, however, in developing treatment guidelines and target-setting.

Implications for Action 34. The results of the capacity assessment surveys provide comprehensive information on the current status of the NCD prevention and control efforts in the SEA Region, help in identifying gaps and in formulating priorities for collaborative programmes implemented by WHO and other developmental partners operating in public health. The following are the major areas that require further strengthening: (1) Advocacy: There is a growing commitment in the Region to the cause of NCDs. At the same time, there is a considerable knowledge gap on the health and socioeconomic burden of NCDs and on the cost-effective interventions to prevent them. In particular, the involvement of sectors other than health, which have a major impact on shaping the physical and social environments that determine health behaviours, remains insignificant. Enhanced multisectoral, multidisciplinary and multi-level collaboration is required to ensure better implementation of the Framework Convention on Tobacco Control, and Global Strategy on Diet, Physical Activity and Health. (2) Policy and programme development: An increasing number of countries have policies, action plans and programmes for prevention and control of major NCDs and their common risk factors in place. Nevertheless, even with higher priority assigned to the prevention and control of NCDs, implementation of NCD prevention and control remains a major challenge and there is a need to convert commitments to decisive implementation of plans and programmes. (3) Human resource development: While support in developing policies and plans continues to be among top priorities for WHO assistance to Member States, there is a growing demand to strengthen the capacity and capability of public health workforce at national level to the extent that would empower them in reviewing, revising, updating and implementing the national programmes for integrated prevention and control of NCDs. In most Member States, there is a lack of public health institutes having adequate capacity for technical leadership and expertise required for planning and implementing integrated NCD prevention and control programmes at national and subnational level. (4) Programme infrastructure and financing: Although majority of Member States report presence of an NCD unit or department in the MoH and financial allocation for NCD prevention and control in its regular budget, most often the number of staff is small and funding far from adequate. While there is a need to increase the overall allocation to health sector and strengthen advocacy to improve funding through regular budget, innovative ways to fund NCD programmes may need to be found. (5) Legislation: This is clearly an identified gap. It would be important for WHO to provide technical assistance to countries in this area. There is a need to review existing legislations in other countries and share these national experiences between countries.

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WHO can also frame guidelines and provide technical support in formulating and implementing laws, acts and regulations. (6) Surveillance: Health management information systems in countries include information on morbidity and mortality due to NCDs. Currently this information has serious limitations in terms of coverage, representativeness and validity. There is a need to strengthen national capacity to collect core information required for planning, monitoring and evaluation of NCD prevention and control programmes. For risk factor surveillance, while most countries have already conducted surveys using WHO STEPS approach, there is a need now to move from sub-national surveys to national-level surveys and to develop sustainable national NCD risk factor surveillance systems. (7) Disease management: NCDs are chronic in character. Scarce resources can be saved and public health outcomes enhanced by promoting development and use of simple evidence-based guidelines and standards that endorse application of low cost and the most cost-effective interventions, including the use of basic medicines, implemented preferentially at primary health care level. WHO should facilitate the development of such standards and guidelines and facilitate their dissemination to health care providers. (8) Monitoring and evaluation: In order to monitor the progress achieved by programmes, a set of simple, achievable, and measurable indicators and targets for both processes and outcomes needs to be developed. While the indicators may be common to all countries, the targets would be country-specific. The capacity assessment survey reported in this publication may also serve the purpose of monitoring progress in NCD prevention and control in the SEA Region.

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Annex 1

Questionnaire National Noncommunicable Disease (NCD) Prevention and Control Questionnaire Thank you for agreeing to complete this questionnaire. The objectives of the survey are to: • • • • Assess national capacity for development and implementation of national NCD prevention and control policy, strategy, action plan and programme; Identify constraints and needs; Assist in evaluation of NCD programmes, and Promote sharing of information, experiences and best practices.

COUNTRY NAME: This is a current profile of NCD prevention and control in this country. We understand that it will be used in a regional and global analytic report. NAME OF PRINCIPAL PERSON FILLING IN THE QUESTIONNAIRE: Surname: DESIGNATION /TITLE: CONTACT DETAILS: Please provide contact details in case further information or clarification is needed. Address: Tel: SIGNATURE: Note: This questionnaire is accompanied by two documents to assist you in completing the questionnaire: the Preamble which explains the background to this survey, and the Objectives, Terms and Definitions. 1. If you have any difficulty or need to discuss this in any way, please contact the WHO Regional Office for South-East Asia; Dr Jerzy Leowski, at leowskij@whosea.org. 2. We prefer that you complete the questionnaire in an electronic version. 3. Some of the questions require that you provide supplementary material (e.g. documents, reports and published papers). We would prefer to receive an electronic copy of each (WORD, PDF etc) and the website where the document is located. If an electronic version is unavailable, please send two hard (paper) copies of each. If the original document is in another language, we would be grateful to receive a short abstract in English. 4. We recommend that you discuss this questionnaire with the relevant people or focal points at the national level prior to completion to ensure as full a response as possible. ** Date of completion generated automatically Fax Email: DATE OF COMPLETION: ** (dd/mm/yyyy) First Name:

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A. A1

National Focal Point, Unit / Department Is/are there a focal point(s) for overall prevention and control of NCDs in the Ministry of Health? Yes Surname: Designation /Title: Address: Tel: Fax: Email: Please attach list of all NCD National Focal Points (if more than one) No First Name: Unit /Department: If yes, please give contact details of lead person as follows:

A2

Is there a unit (or department) for prevention and control of NCDs in the Ministry of Health? Yes No If Yes, what is the total number of professional / managerial staff: Total number of clerical / ground staff:

A3

Are there national institutes for public health or NCD prevention and control – or equivalent (Other)? Yes No Other If Yes, please provide us with the name and website of the institute, where this exists

B

National Act, Law, Legislation, Ministerial Decree for NCD Prevention and Control These are nationally approved acts, laws, legislations or ministerial decrees for prevention and control of NCDs.

B1

Does your country have an act, law, legislation, ministerial decrees developed on the following areas a. Tobacco control

Tick box, if yes

Type

Year, Title and website (or PDF file), if exists

b. Food and nutrition • • c. Specific food product e.g. fat consumption, salt control Settings: school, workplace Alcohol control

d. Physical activity e. Any other regulatory instruments of relevance to NCD prevention and control? (please indicate)

Any other comments you wish to add regarding section B?:

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C C1

Policy, Strategy, Action plan, Programme These are nationally approved policies, strategies, action plans, programmes for the prevention and control of NCDs. Does your country have a national health policy relevant to NCD prevention and control? Yes No If yes, please give: Effective Year: Title (original and English): website (or PDF file), if exists: Please provide hard (paper) copy, if electronic version does not exist.

C2

Does your country have a national health strategy relevant to prevention and control of NCDs? Yes No If yes, please give: Effective Year: Title (original and English):: website (or PDF file), if exists: Please provide hard (paper) copy, if electronic version does not exist.

C3

Does your country have national integrated programme for NCD prevention and control which covers all or some of the major risk factors (tobacco use, nutrition, physical inactivity, alcohol consumption), or main NCDs (heart diseases, stroke, cancer, chronic respiratory diseases, hypertension, diabetes)? Yes No

If yes, please give details: Effective Year: Title (original and English): website (or PDF file), if exists: Please provide hard (paper) copy, if electronic version does not exist. C4 Does your country have individual national policies developed on the following areas a. Tobacco Control b. Nutrition/diet c. Physical Activity d. Alcohol Control e. f. g. Hypertension Diabetes Heart Diseases If yes, please tick Year, Title (original and English) and website (or PDF file), if exists

h. Stroke i. Cancer j. Chronic respiratory disease k. Other NCDs of importance l. Health promotion

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C C5

Policy, Strategy, Action plan, Programme These are nationally approved policies, strategies, action plans, programmes for the prevention and control of NCDs. Does your country have individual national action plans developed on the following areas a. Tobacco Control b. Nutrition/diet c. Physical Activity d. Alcohol Control e. f. g. Hypertension Diabetes Heart Diseases If yes, please tick Year, Title (original and English) and website (or PDF file), if exists

h. Stroke i. Cancer j. Chronic respiratory disease k. Other NCDs of importance l. Health promotion C6 Does your country have individual national programmes developed on the following areas a. b. c. d. e. f. g. h. i. j. k. l. Tobacco Control Nutrition/diet Physical Activity Alcohol Control Hypertension Diabetes Heart Diseases Stroke Cancer Chronic respiratory disease Other NCDs of importance Health promotion Yes No If yes, please tick Year, Title (original and English) and website (or PDF file), if exists

C7. Are there any relevant policies / plans in preparation?

If yes, please give details Any other comments you wish to add regarding section C?

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D

National Target Setting of quantitative health indicators for NCD prevention and control

D1

Has your country set quantitative targets for NCD Yes No prevention and control? If Yes, please provide us with a copy of the document or Web site and electronic file (in word, PDF). Please complete the table below on the areas of NCDs or major risk factors where National targets for prevention and control have been set. Area/aspect of NCDs ( or risk National targets factors, health determinants)

D2

Which organizations were involved in setting population targets for NCD prevention and control? (Please tick) Associations for specific population Ministry of Health groups e.g. Men’s, Women’s or Youth Organizations Ministry of Education Consumer Organizations Medical /Health Professional Ministry of Finance Associations Disease-specific Associations e.g. Other Ministries (Specify) Cancer Society, Diabetes Associations International Nongovernmental Subnational Government Organizations Other Bilateral / Multilateral World Health Organization Organizations National NGOs Academic institutions Citizen or community Others ( please specify) representatives

Any other comments you wish to add regarding section D? E. Implementation of the Framework Convention on Tobacco Control (FCTC) and the Global Strategy on Diet, Physical activity and Health (DPAS) E1. Has your country become a contracting Party to the WHO FCTC? FCTC signed Yes No FCTC ratified Yes No If Yes, does your country have an action plan for the implementation of the FCT, in addition to any Tobacco Control action plan already mentioned in section C? Yes No If Yes, please provide us with a copy of the document or Web site and electronic file (in word, PDF). E2. Are there aspects of FCTC implementation you need assistance with from WHO? Yes No If Yes, in what aspects?

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E3. Does your country implement the DPAS?

Yes

No

If Not, Does your country have plans for the implementation of the DPAS? Yes No If Yes, please provide us with links to the website where the plans is and the electronic copy (word, PDF, etc), or provide us with a hard copy. E4. Does your country have a mechanism in place for discussion/interaction between national authorities and private sector related to the DPAS? Yes No If yes, what is the mechanism? E5. Are there aspects of DPAS implementation you need assistance with from WHO? Yes No If Yes, in what aspects? F National health reporting system, survey and surveillance National health reporting system refers to annual or regular health report system of MoH; Survey refers to regular, fixed or unfixed time interval national health survey; Surveillance refers to the ongoing monitoring and reporting/analysis of NCDs / risk factors, morbidity and mortality due to NCDs in a population. F1 a. Does your country have a health information system in which NCDs and/or major risk factors are part of system? Yes No If yes, b. Are NCDs included in the annual health report system? c. Please specify the data included: 1) Risk factors 2) Cause-specific mortality 3) Morbidity d. How are the results made available e.g. website? e. How has the information been used for decision-making or policy-making? F2 During the past 5 years (2000-2005), were national/provincial studies/surveys carried out on: (Please tick) Tobacco use Raised blood glucose Unhealthy diet Raised blood pressure Physical inactivity Dyslipidaemia Alcohol consumption Heart diseases Hypertension Stroke Diabetes Cancer Overweight and obesity Chronic respiratory diseases Other Does your country have a routine or regular surveillance system for NCDs / risk factors? Yes No If Yes, please state: year initiated Periodicity date last completed: age groups covered: Yes No If yes,

F3

and provide us with a Web site and electronic file (in word, PDF)of the most recent report

SEA/RC60/7 Inf. Doc.1 Page 22

F4

Which of the following NCDs / risk factors does your country’s NCD surveillance system cover? (Please tick) Tobacco use Overweight and obesity (Body Mass Index) Unhealthy diet e.g. low fruit and Dyslipidaemia (cholesterol) vegetable intake Physical inactivity Heart diseases Alcohol consumption Stroke Diabetes (Elevated blood glucose) Cancer Hypertension (Elevated blood Chronic respiratory diseases pressure)

F5. Has the WHO Stepwise approach to surveillance for risk factors been implemented in your country? Yes G No Any other comments you wish to add regarding section F?

National community-based demonstration programme for NCD prevention and/or health promotion Refers to national demonstration community-based NCD prevention and control and/or health promotion programmes targeting major risk factors, group of population or settings. Does your country have health promotion and prevention and control demonstration site(s) for integrated NCD prevention and control? Yes No If yes, where Please provide a website and electronic evaluation report, if these exist?

G1

G2

Does your country have health promotion and NCD prevention and control demonstration site(s) for tackling individual risk factors? Yes No If yes, where? Please provide a website and electronic evaluation report, if these exist?

G3

Does your country have health promotion and NCD prevention and control demonstration project(s) for individual population groups? (Please tick all that apply). Please provide a website and electronic evaluation report, if these exist? Children 15 years and under Young people and adolescents, 15 –24 years Adults, 25 – 64 years Elderly, 65 years and over Women Others (please indicate)

Yes

No

SEA/RC60/7 Inf. Doc.1 Page 23

G4

Does your country have health promotion and NCD prevention and control demonstration project(s) for individual settings? (Please tick all that apply). Please provide a website and electronic evaluation report, if these exist? Workplace School Hospitals and clinics Community Family Others(please indicate)

Yes

No

Any other comments you wish to add regarding section G?

H

National Protocols/Guidelines/Standards for NCDs and Conditions Refers to the prevention, treatment or management services that deal with an already existing NCD or risk factor aiming to prevent, treat and control the condition, prevent complications, improve outcomes and quality of life of the patients.

H1

Does your country have national protocols/guidelines/standards developed and implemented for the prevention, treatment or management of the following NCDs or risk factors? If yes, please provide a website and electronic document, if these exist? a. b. c. d. e. f. g. h. i. j. k. Hypertension Diabetes Mellitus Heart diseases Stroke/CVA (Cardiovascular Accidents) Cancer Chronic Respiratory Diseases Smoking cessation Obesity control Dietary Physical activity Other NCDs of importance in your country

Tick box, if yes

Type

Any other comments you wish to add regarding section H?

SEA/RC60/7 Inf. Doc.1 Page 24

I

Financial Resources Specific budgetary and other financial resources allocated for NCD prevention and control.

I1

Has your country allocated specific resources or a dedicated budget for implementation of a national policy or strategy for the prevention and control of NCDs and for health promotion? Does your country allocate specific/dedicated budgets for prevention and control in any of the following NCD components? a. b. c. d. e. f. g. h. i. j. k. l. m. Tobacco use Nutrition/diet Physical activity Alcohol consumption Obesity control Hypertension Diabetes Mellitus Heart diseases Stroke Cancer Chronic respiratory diseases Health promotion Other Yes No

I2

I3

What is the source of financial support for NCD prevention and control? (Please tick). Government appropriation from: Regular government budget allocation Increase tax on Cigarette Increase tax on Alcohol Increase Tax on unhealthy imported food International Financial Aids Fund Raising Activities Donations from Health Interested Private Groups Unspecific resources of financial budget Others ( please indicate)

Any other comments you wish to add regarding section I?

SEA/RC60/7 Inf. Doc.1 Page 25

Annex 2

Abbreviations and Acronyms COPD DPAS FCTC HIS IA IEC MoH NCDPC NCDs NGOs RB RF SEA SEAR SEANET-NCD STEPS WHO Chronic obstructive pulmonary disease WHO’s Global Strategy on Diet, Physical Activity and Health WHO’s Framework Convention on Tobacco Control Health information system International aid Information, education, communication Ministry of Health Noncommunicable disease prevention and control Noncommunicable diseases Nongovernmental organizations Regular budget Risk factors (for NCDs) South-East Asia South-East Asia Region South-East Asia Network for Noncommunicable Disease Prevention and Control WHO’s STEPwise approach to NCD risk factor surveillance World Health Organization



REGIONAL COMMITTEE Sixtieth session Thimphu, Bhutan 31 August – 3 September 2007

Provisional Agenda item 9 SEA/RC60/7 Inf. Doc.2 13 July 2007

SCALING UP PREVENTION AND CONTROL OF CHRONIC NONCOMMUNICABLE DISEASES IN THE SEA REGION: Risk Factors for Noncommunicable Diseases: Results in the South-East Asia Region (Results from Surveys using the WHO STEPS Approach)

Contributors Dr Tint Swe Latt Department of Medicine, Institute of Medicine 2, Yangon, Myanmar. Dr Nirakar Man Shrestha Chief Specialist, Ministry of Health & Population Kathmandu, Nepal Dr Lakshmi C. Somatunga, Director, Noncommunicable Diseases, Ministry of Health, Nutrition & Welfare, Colombo, Sri Lanka, Dr Gun Chernrungroj Chief, NCD Information Center, Bureau of NCD, Department of Disease Control Ministry of Public Health, Bangkok, Thailand

Dr Mahmudur Rahman, PhD Director, Institute of Epidemiology, Disease Control & Research, Dhaka, Bangladesh Dr Choe Tong Chol Assistant Director, Department of Treatment and Prevention, NCD Programme Manager, Ministry of Public Health, Pyongyang, DPR Korea Dr Bela Shah Sr. Deputy Director General & Chief Division of Noncommunicable Diseases, Indian Council of Medical Research New Delhi, India Dr Suhardi Health Researcher, National Institute of Health Research & Development, Ministry of Health, Jakarta, Indonesia Ms Maimoona Aboobakuru Health Information & Research Section Ministry of Health Male, Republic of Maldives

Contents Page Introduction ................................................................................................................................ 1 Risk factor surveys ....................................................................................................................... 2 Risk factor profiles ....................................................................................................................... 5 Tobacco use .................................................................................................................................... 5 Alcohol consumption ....................................................................................................................... 8 Inadequate fruit and vegetable intake............................................................................................. 11 Physical inactivity........................................................................................................................... 13 Overweight and obesity ................................................................................................................. 16 High blood pressure....................................................................................................................... 18 Raised blood glucose and cholesterol ............................................................................................. 21 Summary results ............................................................................................................................ 26

Conclusions ...............................................................................................................................29 References.................................................................................................................................29 Annexes 1. 2. 3. Sources of Information ......................................................................................................32 Definition of Indicators......................................................................................................34 Abbreviations and Acronyms .............................................................................................35

SEA/RC60/7 Inf. Doc.2

Introduction 1. Noncommunicable diseases (NCDs), such as heart diseases, stroke, cancer, chronic respiratory diseases and diabetes, are the leading cause of mortality in the South-East Asia (SEA) Region of World Health Organization (WHO). Out of the total estimated number of deaths in SEA Region for 2005, 7.9 million (54%) were NCD-related [1]. NCDs are increasingly becoming a disease of poor and younger segments of the population. WHO projects that in the SEA Region, over the next 10 years: 89 million people will die from NCDs. While deaths from infectious diseases, maternal and perinatal conditions, and nutritional deficiencies combined will decrease by 16%, deaths from NCDs will increase by 21%. 2. For NCDs, the information on the population levels of several common, well known, modifiable and easily measurable risk factors could be reliably used to predict the future burden of the diseases and to measure the effectiveness of public health interventions. According to World Health Report, 2002, Reducing Risks, Promoting Healthy Life the leading NCD risk factor is raised blood pressure, followed by tobacco use, raised total cholesterol, and low fruit and vegetable consumption [2]. The major risk factors together account for around 80% of deaths from heart disease and stroke. It was estimated for the year 2000 that in SEA Region at least: • • • • • •

1.5 million people died as a result of raised blood pressure; 1.1 million people died as a result of tobacco use; 1.1 million people died as a result of raised total cholesterol levels; 0.8 million people died as a result of low fruit and vegetable consumption; 0.5 million people died as a result of physical inactivity, and 0.25 million people died as a result of being overweight or obese.

3. Recognizing the need for a reliable and sustainable information system on risk factors, WHO developed the STEP-wise approach to NCD risk factor surveillance (STEPS). The aim was to provide standard yet simple and flexible tool and support collection of core data on the eight key modifiable risk factors, which predict the major NCDs [3]. 4. As depicted in Fig. 1, STEPS is a sequential process starting with gathering information on key risk factors by the use of questionnaire (Step 1) then moving to simple physical measurements (Step 2), and then collection of blood samples for biochemical assessment (Step 3). At each step, mandatory core information is collected, with the potential to collect expanded information, and also information on discretionary optional variables. For surveillance to be sustainable, the STEP-wise approach advocates that small amount of comparable, good quality data is more valuable than large amount of poor quality data. Sustainable collection of quality information on Step 3 might be beyond the current capacity of the surveillance systems in majority of developing countries.

SEA/RC60/7 Inf. Doc.2 Page 2

Figure 1: WHO STEPwise approach to NCD risk factor surveillance.

5. In order to improve the availability and accessibility of core information on major NCDs, a Regional Strategy for NCD Surveillance was adopted by SEAR Member States in 2003 [4]. Collection of standardized data on NCD risk factors was an important target of this strategy. The target four of the strategy reads as “Collection of standardized data on NCD risk factors to be initiated at national/sub-national level using WHO STEP-wise approach in at least eight Member Countries by 2005.” 6. In line with the strategy the capacity for conducting epidemiological surveillance of NCDs with particular focus on collection of standardized information on major risk factors has been strengthened in the SEA Region. Member States have been supported in adapting and implementing NCD surveillance approach promoted by WHO. Surveys using WHO STEPS approach have been carried out in nine countries of the SEA Region between 2002-2006. The results of these surveys are compiled and presented below.

Risk factor surveys 7. Between 2002 and 2006 nine Member States of SEA Region conducted NCD risk factor surveys that used WHO promoted STEPS approach. While some countries conducted national

SEA/RC60/7 Inf. Doc.2 Page 3

level surveys (Indonesia and Thailand), others have carried out sub-national surveys. All surveys were implemented with support of respective national governments. In some countries (India, Nepal) the surveys were conducted at multiple sites to capture risk factor data which reflects the diverse situations. Table 1 displays the basic information about these surveys. In countries where more than one survey was done, the most recent or the most representative survey is shown. The information provided in this document is extracted from the reports submitted to WHO by the principal investigators. The sources of information used for preparation of this document are listed at Annex 1. 8. As a part of the STEPS approach documentation, WHO has produced templates for brief as well as the full report to present the results of NCD risk factor surveys. These templates were shared with Member States. At the Inter-country Workshop on NCD Risk Factor Data Management, Analysis and Reporting held in Kathmandu, Nepal in July 2006, participants were trained to analyze data in this format [5]. 9. Except for Indonesia and Thailand, these surveys are not national level surveys and therefore do not represent national figures. They only represent the population of the sites where the surveys were conducted. It is known that there are wide differences between different parts of the same country especially in large countries. Thus cross-country comparisons based on tables presented in the document should not be attempted. 10. The WHO STEPwise approach, recommends surveying a core age group of 25-64 years with the flexibility to add additional ten years age groups below and above this range. Four countries i.e. DPR Korea, India, Nepal and Sri Lanka chose to extend their age range to include the 15 to 24 year olds. Myanmar and Sri Lanka increased the upper age limit to 74 years. Both Indonesia and Thailand, as a part of their national survey, did not have any upper age limit. Most of the sites have sampled for equal (around 250 each) representation in each 10 year age and sex groups. Therefore, in order to make the data to represent an actual population age structure, the age-specific rates have been applied to respective national population structures. In order to maintain uniformity, the tables below present the data only for the 25-64 years age group. 11. In the reported surveys, the sample size varied from around two thousand in Maldives, Myanmar and Nepal to more than fifty thousand in Indonesia and Thailand. The response rate of the subjects was usually high around 90%. 12. While all the surveys followed the same approach, countries made necessary adaptations of the survey instrument to suit local context. For example some countries such as India and Nepal included questions on oral tobacco use while others such as Bangladesh and Maldives excluded questions on alcohol consumption. Flexibility of the approach to suit local context and needs is a well appreciated feature of STEPS approach. The countries which did not study a particular risk factor have been identified as NS (not studied) in the subsequent tables.

SEA/RC60/7 Inf. Doc.2 Page 4

Important points for interpreting data presented in tables 1. The subsequent tables present the data only for the 25-64 years age group after adjustment to the national age structure. 2. Surveys other than those conducted in Indonesia and Thailand are not national level surveys and do not represent national figures. They only represent the sites where the surveys were conducted. It is inappropriate to make inter-country comparisons based on these results. 3. The countries which did not study a particular risk factor have been identified as NS (not studied) in the tables. 4. If during the surveys, investigators collected the said information, but did not present data in the required format or used definitions other than that recommended by WHO, these have been labeled as not reported (NR) in the tables.

Table 1: NCD risk factor surveys using STEPS approach conducted in SEA Region Country Bangladesh Survey site Rural - Dhamrai Upazilla Urban - Mohammadpur, Dhaka District DPR Korea India Moranbong District, Pyongyang Rural - Ballabgarh, Dibrugarh, Nagpur, Trivandrum, Chennai Urban - Ballabgarh, Dibrugarh, Delhi, Nagpur, Trivandrum, Chennai Indonesia National NSES NHHS NHHS Maldives Myanmar Nepal Sri Lanka Thailand Urban - Male’ Urban - Yangon Rural - Yangon District Combined - Lalitpur, Ilam and Tanahu Dehiwala National BRFSS NHES-III Year of survey 2003 2003 2005 2004 2004 Age group 25-64 25-64 15-64 15-64 15-64 Sample size M 2,087 3,535 1,316 6,668 7,557 F 2,040 3,743 1,339 6,849 7,666 Response rate (%) NR NR 91 98.2* 96.3*

2004 2001 2004 2004 2004 2004 2005 2003 2005 2004

15+ 10+ 15+ 25-64 25-74 25-74 15-64 15-74 25+ 25+

24,363 4,153 3,083 934 979 1,015 3,674 1,500 45,754 11,276

22,349 4,800 3,499 1,092 1,306 1,148 4,118 1,500 47,150 12,160

NR 97.2 90.1 100 91.4 86.5 92 100 NR 93.5

BRFSS – Behavioural Risk Factor Surveillance Survey; NHES – National Health Examination Survey; NHHS – National Household Health Survey; NSES – National Socio-economic Survey; NR – not reported; * – response rate for Ballabgarh

SEA/RC60/7 Inf. Doc.2 Page 5

Risk factor profiles 13. The chapter presents the most important findings of the surveys for each major NCD risk factor. Individual risk factors’ sub-chapters start with basic facts about the concerned factor. This is followed by tables and figures highlighting the results of the STEPS approach-based surveys conducted in countries of the SEA Region. As already mentioned, the surveys, except for Indonesia and Thailand, are sub-national and do not represent the country situation. The set of indicators selected to present results related to individual NCD risk factors reflects their perceived appropriateness to capture the most important information, suitability to the regional context and the availability and completeness of the information in the survey reports. The definitions of the indicators are given at Annex 2. Each sub-chapter ends with presentation of the key messages and comments reflecting the implications of the results.

Tobacco use Basic Facts •

Smokers have markedly increased risk of multiple cancers, particularly lung cancer, and are at far greater risk of heart disease, stroke, and chronic obstructive pulmonary disease (COPD). People who chew tobacco risk cancer of the lip, tongue and mouth [6]. Intra uterine growth retardation, spontaneous miscarriages and low birth weight babies are known outcomes of smoking during pregnancy [6]. Non-smokers exposed to second hand smoke have a 25 to 35% increased risk of suffering acute coronary diseases, and increased frequency of chronic respiratory conditions [7]. It is estimated that productive assets equal to 1% or more of global GDP are lost each year due to smoking. Applying this to global GDP for 2005 suggests that over US$ 600 billion in productive assets may be lost annually [8]. In the poorest households in some low-income countries as much as 10% of total household expenditure is on tobacco. In addition to its direct health effects, tobacco leads to malnutrition, and increased health care costs [9, 10]. The World Bank estimates that in high-income countries, smoking-related healthcare accounts for between 6 and 15 percent of all annual health-care costs [11]

• •

•

•

•

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Survey Results Table 2: Prevalence of smoking and smokeless tobacco use Country Bangladesh – R Bangladesh – U DPR Korea India – R India – U Indonesia* Maldives Myanmar – R Myanmar – U Nepal Sri Lanka Thailand* All (range) % current daily smokers Men 49.3 42.6 62.1 30.2 29.8 57.7 35.8 39.5 39.8 26.9 37.6 31.8 27 - 62 Women 0.2 0.3 0.0 4.7 0.7 3.7 8.8 9.9 6.6 14.9 0.2 1.2 0 - 15 Both sexes 25.3 21.9 31.1 17.8 15.7 32.0 22.7 24.4 22.9 20.6 19.6 18.6 16 - 32 % current daily smokeless tobacco user Men NR NR NS 38.8 21.5 NS 35.2 39.7 34.6 34.0 NS NS 22 - 40 Women NR NR NS 21.2 7.7 NS 8.5 12.1 8.5 12.0 NS NS 8 - 21 Both sexes NR NR NS 30.2 14.8 NS 22.2 25.7 21.3 22.4 NS NS 15 - 30

* - only national surveys, others are sub-national surveys; NR – not reported; NS – not studied

Table 3: Select characteristics of smokers Mean age at starting regular smoking (yrs.) Men Bangladesh – R Bangladesh – U DPR Korea India – R India – U Indonesia * Maldives Myanmar – R Myanmar – U Nepal Sri Lanka Thailand * All (range) 21.2 19.9 NS 21.8 21.7 19.7 18.3 19.4 20.1 19.5 20.8 17.8 18 -22 Women 25.0 20.9 NS 31.3 32.7 21.3 18.2 22.1 24.0 18.7 # 20.5 18 - 33 Both sexes 21.2 19.9 NS 23.0 21.9 19.8 18.3 19.9 20.7 19.2 20.8 18.0 18 - 23 Mean duration of smoking (yrs.) Men 18.6 17.5 NS 20.4 19.5 20.4 # 21.6 18.2 22.8 20.7 23.8 18 - 24 Women 22.5 18.8 NS 15.5 15.8 19.6 # 26.7 21.2 27.9 # 25.5 16 - 28 Both sexes 18.6 17.5 NS 19.8 19.5 20.3 # 22.7 18.7 24.8 20.7 23.9 18 - 25

Country

* - only national surveys, others are sub-national surveys; # - not included due to sample size < 25

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Figure 2: Prevalence of current smoking among men by age 80 70 60 Proportion (%) 50 40 30 20 10 0 15-24 25-34 35-44 45-54 55-64 65-74 Age group ( Yrs.) 17.6 20 25.2 33.6 40 42.8 33.6 56.6 60.8 65.6 70.8

DPR Korea

Sri Lanka

Figure 3: Rural-urban differences in prevalence of current smoking among men

Indonesia

53.3 61.3

Bangladesh

40 50.3

0

10

20

30

40

50

60

70

Proportion (%) Rural Urban

Key Messages •

All surveys reported a high consumption of smoked tobacco among men with the highest rates in DPR Korea and Indonesia. The smoking was less prevalent among females, with Nepal reporting highest current daily smoking rates among women.

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• • •

All the countries, which studied smokeless tobacco use, reported a high usage. In contrast to smoking, smokeless tobacco use was more common among women. The regular use of tobacco starts by 18-22 years among males and much later among females. The usage rates rise sharply in the 25-34 years age group. Rural areas reported a higher tobacco use than urban areas. The tobacco use rates were higher in lower income groups as reported in Bangladesh and Indonesia.

Comments • •

The high prevalence, low age at initiation and long duration of tobacco use indicate that the behaviour is a well established social norm in the Region. Lower tobacco usage in younger age groups, urban areas and higher socio-economic groups are possible signs heralding the positive changes in the social perception of tobacco use occurring in these sections of the population. These positive changes need to be reinforced by appropriate policy, legislative and behavioural interventions at multiple levels.

•

Alcohol consumption Basic Facts • Besides the direct toxic effects and addiction, alcohol use causes about 20% to 30% of each of oesophageal cancer, liver disease, homicide, epileptic seizures, and motor vehicle accidents worldwide [12]. Alcohol consumption is among the leading risk factor for disease burden [12]. The proportion of disease burden attributable to alcohol use in the developing world is between 2.6% to 9.8% of the total burden for males and 0.5% to 2.0% of the total burden for females [13]. Excessive alcohol consumption can severely impair an individual's functioning in social roles such as parent or spouse [12]. Heavy alcohol use increases the risk of cardiovascular disease and stroke [14]. In contrast to the declining trends in alcohol consumption in other regions, the SEA Region shows a continuing increase [15]. The alcohol consumption pattern in the SEA Region is changing as follows [15]: − more “binge” drinking; − increase in drinking among women; − greater acceptability of drinking as a social norm; − early experimentation and decreasing age at initiation, and − emergence of wine and beer drinking.

• •

• • • •

SEA/RC60/7 Inf. Doc.2 Page 9

Survey Results Table 4: Prevalence of alcohol consumption Country DPR Korea India – R India – U Indonesia* $

% lifetime abstainers Men NS 55 54 94.0 53.1 54.9 44.2 20.1 37.0 20 – 77 Women NS 90.5 96.4 99.1 98.5 97.9 71.3 72.6 80.9 71 – 98 Both sexes NS 72.2 74.6 96.7 76.2 76.7 58.5 45.4 59.9 45 - 89

% current consumers of alcohol (in last 12 months) Men NS 46.7 38.5 6.0 31.4 35.8 54.7 67.0 63.0 6 – 67 Women NS 4.9 1.8 0.9 1.0 1.6 27.8 12.1 19.1 1 – 28 Both sexes NS 26.4 20.7 3.3 18.0 18.4 40.5 40.5 40.1 3 - 41

Myanmar – R Myanmar – U Nepal Sri Lanka Thailand*@ Al (range)

* – only national surveys, others are sub-national surveys; NS – not studied; $ – current consumer defined as consuming alcohol in last one week; @ – abstainer defined as not consuming alcohol in last year.

Table 5: Alcohol consumption patterns among current consumers of alcohol Country DPR Korea India – R India – U Indonesia* Myanmar – R Myanmar –U Nepal Sri Lanka Thailand* All (range) @

Mean number of standard drinks in last 7 days Men NS 3.3 2.3 2.7 1.3 2.8 3.6 0.8 NS 1–4 Women NS 0.7 1.5 2.0 * 0.4 1.9 1.5 NS 0.4 - 2 Both sexes NS 3.1 2.3 2.6 1.3 2.7 3.0 0.9 NS 1–3

Proportion taking > 5 standard drinks a day Men 23.3 31.6 33.2 16.5 @

Women 0 1.3 8.1 12.5 * * 9.8 9.0 NS 1 – 10 @

Both sexes 11.7 28.8 32.1 16.6@ 35.3 27.9 21.3 8.5 NS 11 - 35

35.3 28.6 27.7 8.0 NS 23 – 35

* – only national surveys, others are sub-national surveys; ** – not included due to sample size <25; – during one week

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Figure 4: Prevalence of current consumers of alcohol among men by age 80 70 Proportion (%) 60 50 40 30 20 10 0 25-34 35-44 Age Group (Yrs.) Thailand Nepal 45-54 55-64 21 21.6 23.5 20.5 68.1

66.9

60.5 46.5

Key Messages • • •

Large sections of the population, especially among females, abstain from alcohol use. Bangladesh and Maldives did not include questions on alcohol in their instruments. Among males, high alcohol use has been reported from all countries that collected data. Higher rates of alcohol use among females were reported from Nepal, Thailand and Sri Lanka. One quarter to one third of current consumers of alcohol among men consumed more than five drinks per day. The prevalence of alcohol use is similar in rural and urban areas. After a steep rise in the second decade of life, the alcohol usage rates are more or less stable across ages after 25 years with a minimal decline beyond 55 years.

• • •

Comments • •

Continuing high abstinence rates indicate that traditionally and culturally regular alcohol use is not widely accepted in the Region. However alcohol drinking, including that among females, is finding social acceptance in some countries of the Region. Other available data supports a loosening of social mores, norms and customs related to alcohol. There is a need to reverse this trend by addressing issues related to marketing and promotion of alcohol.

•

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Inadequate fruit and vegetable intake Basic Facts • • • • •

Overall 2.7 million lives could be saved each year worldwide if fruit and vegetable consumption were increased [1]. Of the burden attributable to low fruit and vegetable intake, about 85% was from cardiovascular diseases [2]. Adequate consumption of fruit and vegetables reduces the risk for cardiovascular diseases, stomach cancer and colorectal cancer [16, 17]. The consumption of at least 400g of fruit and vegetables per day is recommended to prevent diet-related chronic diseases [2]. Due to the cooking and dietary habits, measurement of fruits and vegetables intake is difficult in the Region. Consumption of raw vegetables is much less than cooked vegetables.

Survey Results Table 6: Fruit and vegetable consumption pattern Days in a week fruit consumed Men India – R India – U Indonesia* Maldives Myanmar – R Myanmar –U Nepal Sri Lanka Thailand* All (range) 1.6 2.9 2.2 3.6 2.7 3.1 NR 3.6 4.3 1.6 – 4.3 Women 1.2 2.8 2.2 3.3 3.2 3.3 NR 3.8 4.8 1.2 – 4.8 Both sexes 1.4 2.9 2.2 3.5 2.9 3.2 NR 3.7 4.6 1.4 – 4.6 Days in a week vegetables consumed Men 5.6 5.8 5.0 3.5 5.5 5.4 NR 6.6 5.9 3.5 – 6.6 Women 5.5 5.9 5.1 3.3 5.6 5.5 NR 6.6 6.1 3.3 – 6.6 Both sexes 5.6 5.9 5.1 3.4 5.6 5.4 NR 6.6 6.0 3.4 – 6.6

Country

* - only national surveys, others are sub-national surveys; NR – not reported

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Table 7: Prevalence of inadequate fruit and vegetable consumption % consuming < 5 servings of fruits & vegetable per day Men India – R India – U Indonesia* Maldives Myanmar – R Myanmar – U Nepal Sri Lanka Thailand* All (range) 82.3 80.0 94.6 85.4 98.6 98.7 98.5 97.1 86.3 80 – 99 Women 87.0 83.0 94.3 83.7 97.8 99.5 99.5 96.5 83.8 83 – 100 Both sexes 84.6 81.4 94.5 84.6 98.2 99.1 99.1 96.8 85.0 81 – 99 % consuming < 1 servings of fruits & vegetable per day Men 15.6 7.0 32.2 NR NR NR NR NR 75.4 7 – 75 Women 21.2 9.8 28.6 NR NR NR NR NR 71.3 10 – 71 Both sexes 18.3 8.3 30.5 NR NR NR NR NR 73.5 8 - 73

Country/site

* - only national surveys, other are sub-national surveys; NR – not reported

Figure 5: Rural-urban differences in consumption of fruits and vegetables - Indonesia

Mean days/week of Fruits intake

1.88 2.67

Mean days/week of Vegetables intake

4.92 5.24

0

1

2 Urban

3 Rural

4

5

6

SEA/RC60/7 Inf. Doc.2 Page 13

Key Messages • • •

While vegetable consumption appears to be a daily habit in most countries (except Maldives), fruit consumption is, on an average, only every alternate day. Almost the entire population of the Region consumes inadequate amount of fruits and vegetables. There were only little age-wise differences in fruit and vegetable intake. Rural population had poorer intake of fruits and vegetables especially that of fruits.

Comments • •

Traditionally, regional diets include fruits and vegetables. Insufficient consumption of fruits and vegetables is primarily an issue of availability and affordability. Given the fact that the population of the Region is universally and well short of the minimum recommended intake of 400g of fruits and vegetables, this target needs to be re-examined in the regional context. Efforts are needed to increase production of fruits and vegetables, improve their storage, transport and marketing.

•

Physical inactivity Basic Facts • •

Physical inactivity causes about 1.9 million avoidable deaths per year worldwide [2]. Physically inactive persons have a 20% to 30% increased risk of all-cause mortality as compared to those who adhere to 30 minutes of moderate intensity physical activity on most days of the week [18]. Globally, physical inactivity accounts for 21.5% of ischemic heart disease, 11% of ischemic stroke, 14% of diabetes, 16% of colon cancer and 10% of breast cancer [19]. Physical inactivity is a major risk factor for obesity, which itself is a risk factor for other chronic diseases [18]. Physical activity prevents osteoporosis and related fractures [18].

• • •

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Survey Results Table 8: Levels of physical inactivity % of population Country Men India – R $

physicaly inactive in any domain Women 13.6 25.2 7.9 NR 3.4 8.2 NR 17.3 NR 3 – 25 Both sexes 10.0 23.8 7.8 NR 3.5 7.3 NR 14.9 NR 3 – 24

Mean time spent in sedentary activities (in minutes per day) Men 172 303 247 NR 190 237 NR 216 NR 172 – 304 Women 159 203 276 NR 192 234 NR 216 NR 159 – 276 Both sexes 166 255 258 NR 191 236 NR 216 NR 166 – 255

6.6 22.4 7.7 NR 3.6 6.3 NR 12.7 NR 4 – 22

India – U $ Indonesia * Maldives Myanmar – R Myanmar – U Nepal Sri Lanka Thailand * All (range)

* - only national surveys, other are sub-national surveys; NR – not reported; $ - time spent in sedentary activities is only for those who were sedentary

Table 9: Proportion (%) of population inactive in various domains Work related Country India – R India – U Indonesia* Maldives Myanmar – R Myanmar – U Nepal Sri Lanka Thailand* All ( range) Men 35.4 65.6 NS 87.2 20.9 43.2 41.7 51.4 NR Women 32.9 58.8 NS 94.8 17.5 40.3 54.6 55.8 NR Both sexes 34.2 62.3 NS 90.9 19.2 41.8 48.5 53.5 NR Transport related Men 13.5 39.4 NS NR 11.8 15.4 12.0 NR NR Women 28.3 46.3 NS NR 10.9 15.7 26.4 NR NR Both sexes 20.7 42.7 NS NR 11.4 15.5 19.6 NR NR Men 82.1 78.8 NS NR 88.8 86.9 85.1 93.5 NR 79 – 94 Recreational Women 90.6 86.6 NS NR 97.6 95.1 88.2 95.4 NR 87 – 98 Both sexes 86.2 82.5 NS NR 93.3 91.1 86.7 94.4 NR 83 – 94

21 – 87 18 – 95 19 – 91 12 – 39 11 – 46 11 – 43

* – only national surveys, other are sub-national surveys; NR – not reported

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Figure 6: Proportion of population inactive by domain and age in Nepal, both sexes 100 90 80 Proportion (%) 70 60 50 40 30 20 10 0 Work Transport Physical activity domains 15-24 25-34 35-44 45-54 55-64 Recreation 14.4 18.5 19.4 19.1 24.5 56.8 46.2 46 58.8 50.2 81 85.4 86.7

87.9 89.1

Figure 7: Proportion of population doing inadequate physical activity (< 150 min/wk) by sex and area of residence 70 60 50 Proportion (%) 40 30 20 10 0 India Rural Males Rural Females Urban Males Myanmar Urban Females 36.8 38.1 39.3 32.2 63.6

60.7 51.4 46.8

Key Messages •

Measuring physical activity by STEPS approach is comprehensive, though complicated and time consuming. This makes it difficult for inclusion into integrated national health surveys. Adaptations of the approach hinder comparability across countries / sites/ surveys.

SEA/RC60/7 Inf. Doc.2 Page 16

•

While the proportion of population reporting physical inactivity in all domains was low (except urban India), the people mainly indulged in light or sedentary activities. Adequate moderate or vigorous physical activity was being practiced only by a small proportion of people. In terms of frequency, most of the people were doing physical activity in the transport domain followed by work and then during leisure time. However, in terms of duration, this was highest at work, followed by transport domain and least again in leisure time. Urban areas reported higher rates of physical inactivity in India and Myanmar. The male – female differences were marginal; in general, females were more likely to be physically active.

•

• •

Comments: • •

As countries move towards integrating NCD risk factor surveillance a simpler tool for measuring physical activity is required. Increasing urbanization, motorization and mechanization is leaving less and less space and time for physical activity at work and transport. The leisure time physical activity is yet to pick up to compensate for the loss of physical activity in the other two domains.

Overweight and obesity Basic Facts •

Overweight and obesity adversely affects blood pressure, cholesterol and triglyceride level and insulin sensitivity. Risks of coronary heart disease, ischemic stroke and type 2 diabetes mellitus increase with increasing body mass index (BMI) [2]. Raised BMI also increases the risks of cancer of the breast, colon, prostate, endometrium, kidney and gall bladder [2]. Mortality rates increase with increasing degrees of overweight, as measured by BMI [2]. To achieve optimum health, the median BMI for adult population should be in the range of 21 to 23 kg/m2, while the goal for individuals should be to maintain BMI in the range 18.5 to 24.9 kg/m2. There is slightly increased risk of co morbidities for BMI 25.0 to 29.9, and moderate to severe risk of co morbidities for BMI greater than 30 [20]. Waist circumference serves as a proxy indicator of intra-abdominal fat mass and total body fat. Changes in waist circumference reflect changes in risk factors for cardiovascular disease and other NCDs [16]. Waist circumference or waist-to-hip ratio are more powerful determinants of subsequent risk of type 2 diabetes than BMI [21]. Central Obesity is defined as waist circumference > 102 cm. for men and 88 cm for women OR as Waist Hip Ratio (WHR) > 1 in men and > 0.8 in women

• • •

•

• •

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Survey Results Table 10: Mean body mass index and waist circumference Country Bangladesh – R Bangladesh – U DPR Korea India – R India – U Indonesia* Maldives Myanmar – R Myanmar – U Nepal Sri Lanka Thailand * All (range) Mean body mass index (BMI) Men 20.6 23.0 22.7 20.7 23.7 21.8 24.3 21.1 22.6 22.8 22.6 23.4 21 -24 Women 21.0 24.4 22.3 21.0 24.6 23.1 25.5 23.0 24.2 22.6 23.7 24.8 21 – 26 Both sexes 20.8 23.7 22.5 20.9 24.1 22.5 24.9 22.0 23.4 22.7 23.1 24.2 21 – 25 Mean waist circumference Men 74.0 83.0 NS 78.4 86.0 75.1 84.4 NR NR 78.3 75.1 80.8 74 – 86 Women 70.0 81.4 NS 72.1 83.6 74.2 83.5 NR NR 75.0 79.8 78.9 70 – 84 Both sexes 72.1 82.2 NS 76.8 84.9 74.6 84.0 NR NR 76.6 77.4 79.8 75 - 85

* - only national surveys, other are sub-national surveys; NR – not reported; NS – not studied;

Table 11: Prevalence of overweight and obesity % overweight or obese (≥ 25 BMI)$ Men Bangladesh – R Bangladesh – U DPR Korea India – R India – U Indonesia* Maldives Myanmar – R Myanmar – U Nepal@ Sri Lanka Thailand* All (range) 6.5 32.6 NR 11.0 35.4 14.8 39.2 15.3 30.8 21.2 22.7 30.8 7 – 35 Women 10.8 41.2 NR 15.7 43.6 28.7 49.5 30.9 42.0 12.3 35.3 43.5 11 – 50 Both sexes 8.6 36.5 NR 13.3 39.4 22.3 44.2 23.3 36.5 16.5 28.8 37.5 9 – 44 % obese (≥ 30 BMI) Men 0.2 3.5 NR 1.2 6.1 1.7 8.2 1.9 6.3 NR 2.6 5.2 Women 0.8 10.7 NR 2.9 12.3 6.1 16.6 7.8 11.5 NR 7.1 11.3 Both sexes 0.5 7.0 NR 2.0 9.1 4.1 12.3 4.9 9.0 NR 4.8 8.4 Central obesity # Men NR NR NR 12.7 31.7 0.8 NR 5.0 5.4 NR NR NS 5 – 32 Women NR NR NR 31.0 61.7 9.8 NR 21.6 26.7 NR NR NS Both sexes NR NR NR 21.6 46.2 5.6 NR 13.5 16.3 NR NR NS

Country

0.2 – 8 0.8 – 17 0.5 – 12

22 – 62 16 – 46

* - only national surveys, other are sub-national surveys; NR – not reported; $ - BMI, body mass index; # - central obesity was defined as waist circumference > 102 cm for men and 88 cm for women except for Myanmar which defined it as WHR > 1 in men and > 0.8 in women; @ - for Nepal, BMI 25-29.99 is reported

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Figure 8: Prevalence of Overweight (BMI >25) by age, Maldives 70 60 Proportion (%) 50 40 30 20 10 0 25-34 35-44 Men 45-54 Women 55-64 Age group (Yrs.) 31.5 38.6 42.6 43.1 55.2 58.4 60.9

53.6

Key Messages • • • •

The populations of many countries in the Region are approaching or have already crossed the public health action point of mean BMI of 23. The prevalence of overweight is high with about one third of the population being overweight. Overweight and obesity rates are generally higher among females and lower in rural areas. The overweight and obesity rates are high even in the younger age groups.

Comments • • •

While under-nutrition, especially among children is still a major problem, obesity among adults has emerged as an important public health challenge in the Region. Decreasing levels of physical activity and rising consumption of energy dense foods seems to fuel increase in obesity rates. Countries need to recognize the challenge of nutritional transition and respond to it timely and effectively.

High blood pressure Basic Facts • • • •

Raised blood pressure is a major risk factor for coronary heart disease and ischemic as well as hemorrhagic stroke [16]. The risk of cardiovascular disease doubles for each increment of 20/10 mm Hg of blood pressure, starting as low as 115/75 [22]. Complications of raised blood pressure include heart and renal failure, peripheral vascular disease, and blindness [23]. Treating hypertension adequately (to less than 140/90) is associated with a decrease in cardiovascular complications [24

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Survey Results Table 12: Mean systolic and diastolic blood pressure Country Bangladesh – R Bangladesh – U DPR Korea India – R India – U Indonesia* Maldives Myanmar – R Myanmar – U Nepal Sri Lanka Thailand * All (range) Mean systolic blood pressure Men 113.8 119.8 128.6 125.9 130.5 132.0 126.0 123.2 123.1 132.5 125.6 120.0 114 – 133 Women 115.2 119.6 127.7 123.9 126.6 133.0 121.9 120.2 118.6 126.0 123.9 117.6 115 – 133 Both sexes 114.4 119.6 128.1 124.9 128.6 132.5 124.0 121.7 120.9 129.1 124.8 118.7 114 – 133 Mean diastolic blood pressure Men 76.2 77.9 87.5 78.2 81.3 81.1 77.7 73.4 76.9 82.1 74.0 78.5 74 – 88 Women 74.9 76.7 85.9 77.2 79.1 83.2 77.1 75.4 75.8 79.5 74.6 76.4 75 – 86 Both sexes 75.5 77.3 86.7 77.7 80.2 82.2 77.4 74.5 76.4 80.7 74.3 77.4 74 – 87

* - only national surveys, other are sub-national surveys

Table 13: Prevalence of raised blood pressure Country Bangladesh – R Bangladesh – U DPR Korea @ India – R India – U Indonesia* Maldives Myanmar – R Myanmar – U Nepal Sri Lanka Thailand* All (range) % with raised blood pressure ≥=140/90 or on treatment Men NR NR 16.7 20.9 27.2 32.9 NR 10.9 26.0 49.7 6.8 24.4 7 – 50 Women NR NR 15.9 19.6 21.1 38.6 NR 12.6 23.7 35.1 9.0 20.5 9 – 39 Both sexes NR NR 16.3 20.3 24.3 35.9 NR 11.9 25.0 42.0 7.8 22.4 8 – 42 % with raised blood pressure ≥ =160/100 or on treatment Men NR NR NR 5.5 7.4 10.2 NR 7.5 13.1 11.7 5.5 8.1 6 – 13 Women NR NR NR 5.8 6.5 13.9 NR 9.1 15.0 8.4 7.9 5.8 6 – 15 Both sexes NR NR NR 5.7 7.0 12.1 NR 8.3 14.2 10.0 6.7 6.9 6 – 14

* - only national surveys, other are sub-national surveys; NR – not reported; NS – not studied; @ - did not collect information on those under treatment

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Table 14: Prevalence of known hypertension and its treatment Proportion with known hypertension in last 12 months Men India – R India – U Indonesia* Maldives Myanmar – R Myanmar – U Nepal Sri Lanka Thailand* All (range) 5.7 13.2 NS 8.0 10.8 14.1 6.9 NR NR 6 – 14 Women 8.8 18.7 NS 9.0 17.3 22.2 7.2 NR NR 7 – 22 Both sexes 7.2 15.8 NS 8.5 14.2 18.3 7.0 NR NR 7 – 16 % of known hypertensives currently on medication Men NR 68.7 NS NR 9.0 17.3 45.2 NR NR 9 – 69 Women NR 67.6 NS NR 10.1 20.7 46.7 NR NR 10 – 68 Both sexes NR 68.1 NS NR 9.7 19.4 46.0 NR NR 10 - 68

Country

* - only national surveys, other are sub-national surveys; NR – not reported; NS – not studied

Figure 9: Prevalence of raised blood pressure by age, Sri Lanka 18 16 14 Proportion (%) 12 10 8 6 4 2 0 0.4 0 15-24 0.4 0.4 25-34 2 35-44 45-54 55-64 65-74 5.6 7.2 7.6

Males

Females 11.6

14.8

16

12.4

Age group (yrs.)

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Figure 10: Distribution of systolic blood pressure by area of residence, India 3500 3000 No. of subjects 2500 2000 1500 1000 500 0 100-109 110-119 120-129 130-139 140-149 150-159 160-169 170-179 180-189 190-199 200-209 210-219 220-229 230-239 240-249 90-99 >250 <90 Urban Rural

Systolic Blood Pressure (mm Hg)

Key Messages • •

The surveys document a high proportion of the population having increased arterial blood pressure. There is a wide variation in the prevalence of raised blood pressure among the population – Nepal and Indonesia reported very high prevalence in contrast to Sri Lanka. Rural areas reported lower prevalence of raised blood pressure Differences among the sexes were not consistent, even though males were more likely to have raised blood pressure. The proportion of people diagnosed with hypertension was much less than the estimated prevalence and high proportion of those diagnosed were not on treatment. The prevalence of raised blood pressure increased after 34 years.

• • • •

Comments • •

There is a need to reduce the blood pressure across the entire population by adopting population based intervention strategies. There is a treatment gap for hypertension, due to both inadequate diagnosis as well as treatment. This calls for efforts to strengthen the health systems to improve identification and treatment of individuals with hypertension. The availability and affordability of drugs for the treatment of hypertension needs to be improved.

•

Raised blood glucose and cholesterol 14. Owing to the logistic complexity and cost of collecting data on biochemical risk factors only five countries had conducted surveys that included collection of blood samples for measuring fasting glucose and total cholesterol. Indonesia and Thailand did this at national level where as

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other countries generated this information at sub-national level. Unlike other countries, which did all the three steps in one go, in India, the biochemical measurements were done on a subsample of the individuals surveyed for behavioural risk factors after one year. 15. Thailand and Indonesia conducted national level surveys for biochemical risk factors using capillary blood and dry chemistry. In the remaining three countries venous blood was collected and wet chemistry was used to measure blood glucose and total cholesterol levels at sub-national levels. The quality control procedures adopted in the surveys were insufficiently documented. Table 15: Surveys reporting data on blood glucose and cholesterol Country India – R India – U Indonesia* Maldives Myanmar – R Myanmar – U Thailand* Year of survey 2005 2005 2004 2004 2004 2004 2004 Method of testing Venous blood using wet chemistry Venous blood using wet chemistry Capillary blood using dry chemistry Venous blood using wet chemistry Venous blood using wet chemistry Venous blood using wet chemistry Capillary blood using dry chemistry Sample size M 1,255 1,255 7,594 696 1,015 979 11,224 F 1,305 1,317 7,923 823 1,148 1,303 12,117 Response rate (%) 82.5 @ 80.8 @ 70/45** 75 87 91 94

* - only national surveys, other are sub-national surveys; ** - respectively for glucose/cholesterol; @ - response rate for Ballabgarh

Raised blood glucose Basic Facts •

The age-adjusted mortality, mostly due to coronary heart disease, is 2-4 times higher in diabetics in comparison with the non-diabetic population. People with diabetes have a twofold increase risk of stroke [25]. Diabetes is the leading cause of renal failure in both developed and developing countries [26]. The risk of lower limb amputation is 10 times higher in people with diabetes than in nondiabetic individuals; more than half of all non-traumatic lower limb amputations are due to diabetes [27]. Diabetes is one of the leading causes of visual impairment and blindness [28]. People with diabetes require at least 2-3 times the health care resources than people who do not have diabetes; diabetes care accounts for up to 15% of national healthcare budgets [29, 30].

• •

• •

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Survey Results Table 16: Fasting blood glucose distribution % with raised blood glucose≥ 7.0 mmol/l Men India – R India – U Indonesia * Maldives Myanmar – R Myanmar – U Thailand * All (range) 6.9 11.1 5.8 NR 2.8 7.4 7.8 2.8 – 7.8 Women 6.2 10.8 4.7 NR 4.7 7.8 9.2 4.7 – 9.2 Both sexes 6.6 10.9 5.2 NR 3.8 7.7 8.6 3.8 – 8.6 Mean fasting blood glucose (mmol/l ) Men 5.2 5.6 4.8 5.0 4.6 5.3 5.4 4.6 – 5.4 Women 5.3 5.6 4.6 4.9 4.8 5.3 5.3 4.5 – 5.3 Both sexes 5.3 5.6 4.7 5.0 4.7 5.3 5.4 4.6 – 5.4

Country

* - only national surveys, other are sub-national surveys; NR – not reported

Table 17: Prevalence of known diabetes and its treatment Proportion with known diabetes in last 12 months Men India – R India – U Indonesia * Maldives Myanmar – R Myanmar – U Nepal Sri Lanka Thailand * All (range) 3.5 7.1 1.2 NR 4.8 3.8 1.8 NR NR 1–7 Women 2.6 6.7 1.1 NR 3.4 4.5 1.8 NR NR 1–7 Both sexes 3.1 6.9 1.2 NR 4.1 4.2 1.8 NR NR 1– 7 % on medication for raised blood sugar in last 12 months Men 66.6 73.1 79.5 NR 6.4 22.2 NR NR 36.2 6 – 92 Women 69.3 80.1 67.5 NR 9.0 25.2 NR NR 52.2 9 – 80 Both sexes 67.7 74.7 72.5 NR 7.5 23.8 NR NR 45.3 24 – 75

Country

* - only national surveys, other are sub-national surveys; NR – not reported

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Figure 11: Prevalence of raised fasting blood glucose (> 7 mmol) by age and sex in Myanmar 20.0 18.0 16.0 Proportion (%) 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 1.5 2.2 4.4 0.0 35-44 45-54 Age Group (Yrs.) Rural Males Rural Females Urban Males Urban Females 55-64 64-74 5.9 6.7 5.0 4.1 10.2 17.7 14.5

16.5 14.2 12.8 9.9 8.3 5.5 7.0 13.6

25-34

Key Messages • • • •

The prevalence of raised fasting blood glucose (> 7 mmol/l), in the population was high. The rural areas had lower prevalence. No consistent difference was seen among males and females. The prevalence rates show a rise after the age of 45 years, especially in urban areas. The proportion of diagnosed diabetics was much less than the estimated prevalence and many of those diagnosed were not on treatment.

Comments •

Measuring blood glucose by wet chemistry as a part of the NCD surveillance requires technical expertise and logistics arrangements for collecting and transporting blood samples. Using dry chemistry methods pushes up the cost and makes quality control difficult. Developing countries deciding to include biochemical risk factors as a part of the national NCD surveillance should proceed with caution. There is a need to reduce the blood sugar levels across the entire population by adopting population based intervention strategies. The rising prevalence of diabetes and its treatment gap call for efforts to strengthen the health systems to improve detection and treatment of individuals with diabetes.

• •

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Raised total cholesterol Basic Facts • • •

Cholesterol is a key component in the development of atherosclerosis. High cholesterol is estimated to cause 18% of global cerebrovascular disease and 56% of global ischaemic heart disease [2]. A 10% reduction in serum cholesterol in men aged 40 results in a 50% reduction in heart disease within 5 years, while a 20% reduction in heart disease occurs within 5 years in men aged 70 years [31]. A 4.6% reduction of population mean of total cholesterol had the greatest impact of all risk factors in decreasing CHD mortality in Ireland; a full 30 % reduction in mortality was attributable to this reduction alone [32].

•

Survey Results Table 18: Blood cholesterol level distribution % with raised total cholesterol (≥ 5.2 mmol/l Men India – R India – U Indonesia* Maldives, Myanmar – R Myanmar – U Thailand* All (range) 18.5 33.3 9.0 53.6 12.2 21.9 46.6 9 – 54 Women 25.6 33.2 16.0 55.0 24.7 29.2 49.5 16 – 55 Both sexes 22.1 33.2 13.1 54.4 18.7 25.8 48.1 13 – 54 Mean total cholesterol(mmol/l) Men 4.2 4.7 4.4 5.4 4.1 4.5 5.2 4.1 – 5.4 Women 4.4 4.8 4.6 5.4 4.5 4.7 5.3 4.5 – 5.4 Both sexes 4.3 4.7 4.5 5.4 4.3 4.6 5.2 4.3 – 5.4

Country

* - only national surveys, other are sub-national surveys

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Figure 12: Prevalence of raised blood cholesterol levels by age and sex, Maldives 90 80 70 Proportion (%) 60 50 40 30 20 10 0 25-34 35-44 45-54 55-64 Age group ( Yrs.) Men Women 54.0 46.8 42.9 61.6 58.7 62.3 64.5 80.7

Key Messages • • •

High rates of raised blood cholesterol levels were observed in India, Maldives and Thailand. The rates were generally higher among females and lower in rural areas. A continuous rise of blood cholesterol level was seen with age.

Comments •

Inappropriate quantity and quality of fat intake is a well recognized dietary phenomenon in the region. Measuring blood cholesterol levels provide valuable information on this aspect as other wise this issue is not addressed in STEPS approach. The high burden of hypercholesterolemia, availability of effective treatment and potential for prevention by policy level interventions make a good case for health sector intervention.

•

Summary results 16. The data generated through the NCD risk factor surveys using the STEPS approach conducted in the countries of SEA Region illustrate that: 1. All countries report high prevalence and levels of major NCD risk factors; 2. There is extensive variability within the countries and between countries; 3. High prevalence of NCD risk factors occurs not only in urban but also in rural areas;

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4. Both men and women share high burden of NCD risk factors although there is considerable difference in the relative importance of individual risk factors; 5. High levels of NCD risk factors are noted in the second and third decades of life and increase thereafter; 6. Low consumption of fruit and vegetable, especially fruits, is a widespread phenomenon; 7. Consumption of tobacco (smoked and smokeless) and alcohol are highly prevalent especially among males in most of countries; 8. Overweight, especially in urban areas are now a public health problem that needs to be addressed; 9. The prevalence of raised blood pressure shows variability but is sufficiently high in most settings to warrant a public health response; 10. The extensive variability in the prevalence of individual NCD risk factors between countries, within countries, between urban and rural areas as well as between sexes reflects the complexity of the situation and points to the need for designing targeted public health interventions customized to national, sub-national and local needs.

Table 19: Summary results of NCD risk factor surveys using STEPS approach in the SEA Region; both sexes; 2003-5

SEA/RC60/7 Inf. Doc.2 Page 28

Country/site

Current smokers (%) 25.3 21.9 31.1 17.8 15.7 32.0 22.7 24.4 22.9 20.6 19.6 18.6 16 – 32 3 – 41 81 – 99 4 – 24 40.1 85.0 NR 40.5 96.8 14.9 28.8 37.5 9 – 44 40.5 99.1 NR 16.5 18.4 99.1 7.3 36.5 18.0 98.2 3.5 23.3 NS 84.6 NR 44.2 NR 11.9 25.0 42.0 7.8 22.4 8 – 42 3.3 94.5 7.8 22.3 35.9 20.7 81.4 23.8 39.4 24.3 26.4 84.6 10.0 13.3 20.3 6.6 10.9 5.2 NR 3.8 7.7 NS NS 8.6 4–9 NS NS NS NR 16.3 NS NS NR NR 36.5 NR NS NS NR NR 8.6 NR NS NS NS NS 22.1 33.2 13.1 54.4 18.7 25.8 NS NS 48.1

Current consumer of alcohol (%) % physically inactive % overweight and obese % with raised blood pressure % with raised fasting blood sugar

% eating < 5 servings of F&V

% with raised blood cholesterol

Bangladesh – R

Bangladesh – U

DPR Korea

India – R

India – U

Indonesia -

Maldives – Malé

Myanmar – R

Myanmar – U

Nepal

Sri Lanka

Thailand

TOTAL (range)

13 – 54

* - only national surveys, other are sub-national surveys; F & V – fruit and vegetable; NS – not studied; NR – not reported; R – rural; U – urban

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Conclusions 1. The better availability of NCD risk factor data has led to increased awareness among policy makers and programme managers. The results are being extensively used to build commitment to upscale and integrate national NCD prevention and control programmes. 2. Indonesia and Thailand are already conducting national level NCD risk factor surveys. Other countries such as India, Nepal and Sri Lanka are in the process of moving from initial subnational surveys towards more representative large scale surveys as the first step in instituting regular national NCD risk factor surveillance systems. 3. The shift from sub-national to national level surveys requires amplified technical support. One option to develop a sustainable NCD risk factor surveillance is to integrate it with other health surveys as done in Indonesia and Thailand. This often affects scope and content of NCD risk factor component of the survey and can compromise inter country and global comparability of results. Another approach adopted recently by India, Nepal and Sri Lanka, is to use core STEPS instrument with appropriate adjustments suiting national context and needs. 4. The STEPS approach-based NCD risk factor surveys conducted in countries of SEA Region furnish baseline data for trend assessment in future. In some of survey sites integrated community-based intervention (CBI) projects for prevention of NCDs have been initiated. The repeated surveys are being used in these sites for evaluation of the impact of CBI efforts. 5. SEA Regional Strategy for NCD surveillance guides development of risk factor surveillance in the Region. The sharing of the information, expertise and resources among countries as envisaged in the strategy and facilitated by WHO leads to generation of considerable amount of new and useful information on NCDs. 6. In the last five years, the national capacity for setting up systems for NCD surveillance in the countries of SEA Region has been strengthened.

References 1. World Health Organization. Preventing Chronic Diseases: A Vital Investment: WHO Global Report. Geneva: World Health Organization, 2005. 2. World Health Organization. The World Health Report: 2002: Reducing risks, promoting healthy life. Geneva: World Health Organization; 2002. 3. World Health Organization. WHO STEPS Surveillance Manual: The WHO STEPwise approach to chronic disease risk factor surveillance. Geneva, World Health Organization; 2005. 4. World Health Organization. Establishment of a South-East Asia Regional Network for Noncommunicable Disease Surveillance. Report of an Inter-country Workshop. New Delhi: World Health Organization; 2002.

5. World Health Organization NCD Risk Factor Data Management, Analysis and Reporting Report of an Intercountry Workshop. New Delhi, World Health Organization 2006. 6. Building blocks for tobacco control. Geneva, World Health Organization, 2004. 7. He, J. Vupputuri, S. Allen, K. et al. Passive Smoking and the Risk of Coronary Heart Disease-A MetaAnalysis of Epidemiologic Studies. New England Journal of Medicine 1999; 340: 920-6.

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8. "Estimating the costs of tobacco use". In Chaloupka, F. and P. Jha, eds., Tobacco control in developing countries. Oxford University Press. p. 97 9. Tobacco and Poverty: A vicious cycle. World Health Organization, 2004. 10. Karki Y B et al. A study on the economics of tobacco in Nepal. HNP Discussion Paper, Economics of tobacco control. Paper no: 13, 2003. 11. Curbing the epidemic. Governments and the Economics of Tobacco Control. Washington DC, The World Bank, 1999. 12. Global Status Report on Alcohol 2004. Geneva, World Health Organization, 2004. 13. Rehm J et al. Alcohol. In: Ezzati M et al., eds. Comparative Quantification of Health Risks:Global and Regional Burden of Disease Due to Selected Major Risk Factors. Geneva, World Health Organization, 2004. 14. Friedman H S. Cardiovascular effects of alcohol. In: Galanter M ed. The Consequences of Alcoholism. New York, Plenum Press, 1998:135-166. 15. World Health Organization. Public Health Problems caused by harmful use of alcohol: Alcohol control series No.2. New Delhi, World Health Organization 2006. 16. Diet, Nutrition and the Prevention of Chronic Diseases. Report of a joint WHO/FAO expert consultation. Geneva, World Health Organization, 2003. 17. Palli D. Epidemiology of gastric cancer: an evaluation of available evidence. Journal of Gastroenterology, Vol 35 (suppl 12), 2000:S84-S89. 18. Vuori I. Physical inactivity as a disease risk and health benefits of increased physical activity. In: Oja P, Borms J (eds) Perspectives-The multidisciplinary series of physical education and sport science: Health enhancing physical activity. Vol 6, 2004:29 - 73. 19. Bull F, Armstrong T, Dixon T, Ham S, Neiman A, Pratt M. Physical inactivity. In: Ezzati M, Lopez A, Rodgers A, Murray C (eds) Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva, World Health Organization, 2004:729–881 20. Obesity: preventing and managing global epidemic. Report of a WHO consultation. Geneva, World Health Organization, 2000. 21. Boyko E J et al. Visceral adiposity and risk of type 2 diabetes: a prospective study among Japanese Americans. Diabetes Care, Vol 23, 2000:465-471. 22. Williams B, Poulter N R, Brown M J et al. British Hypertension Society guidelines for hypertension management 2004: summary. British Medical Journal, 2004; 328: 634-640. 23. 2003 World Health Organization / International Society of Hypertension statement on management of hypertension. Journal of Hypertension 2003; 21: 1983-1992. 24. Chobanian A V, Bakris G L, Black H R et al. The Seventh Report of the National Committee on Prevention, Detection, Evaluation, and Treatment of high blood pressure. Journal of American Medical Association, 2003; 289(19): 1206-1252. 25. Bell D S. Stroke in the diabetic patient. Diabetes Care, Vol 17, 1994:213-219. 26. American Diabetes Association. Diabetic Nephropathy. Diabetes Care Vol 25, 2002:S85-S89. 27. Siitonen O I, Niskanen L K, Laakso M, Siitonen J T, Pyorala K. Coger extremity amputations in diabetic and non diabetic patients. Diabetes Care, Vol 16, 1993:16. 28. Anonymous. From the Centers for Disease Control and Prevention. Blindness caused by diabetes. Journal of American Medical Association, Vol 276, 1996:1865-1866.

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29. American Diabetic Association. Economic consequences of Diabetes Mellitus in the US in 1997. Diabetes Care, Vol 21, 1998:296-309. 30. International Diabetes Federation, World Health Organization. The economics of diabetes and diabetes care. Brussels: International Diabetes Federation, 1996. 31. Law M R, Wald N J, Thompson S G. By how much and how quickly does reduction in serum cholesterol concentration lower risk of ischemic heart disease? British Medical Journal, Vol 308, 1994:367-372. 32. K Bennett, Z Kabir et al. Explaining the recent decrease in Coronary Heart Disease Mortality rates in Ireland, 1985 to 2000. J of Epidemiology Community Health, Vol 60, 2006:322-327.

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Annex 1

Sources of Information Bangladesh Behavioural Risk Factors of Non-communicable Diseases in Bangladesh. Tobacco Usage, Dietary Pattern and Physical Activity Status. National Institute of Preventive and Social Medicine, Mohakhali, Dhaka, 2004. DPR Korea Department of Treatment and Prevention and NCD Programme, MoPH. Final Report of Noncommunicable Disease Risk Factor Survey in Moranbong District of Pyongyang, DPR Korea, 2006. India Development of Sentinel Health Monitoring Centres for Surveillance of Risk Factors of Noncommunicable Diseases in India. Collated results of six centres. Division of Noncommunicable Diseases, Indian Council of Medical Research, New Delhi, 2005. Sentinel Health Monitoring Centers in India: Biochemical Risk Factor Survey for Noncommunicable Diseases. Collated results of six centres. Division of Non-communicable Diseases, Indian Council of Medical Research, New Delhi, 2006. Indonesia National Socio-Economic Survey 2004. Monograph for SEA Regional Infobase. National Institute of Health Research and Development, Ministry of Health, Republic of Indonesia, 2006. National Household Health Survey 2001. Monograph for SEA Regional Infobase. National Institute of Health Research and Development,Ministry of Health, Republic of Indonesia, 2006. National Household Health Survey 2004. Monograph for SEA Regional Infobase STEP 2 & 3. National Institute of Health Research and Development, Ministry of Health, Republic of Indonesia, 2006. Maldives Ministry of Health. Survey on Noncommunicable Disease Risk Factors, Maldives. Health Information and Research Section, Ministry of Health Maldives, 2004. Myanmar Ministry of Health Union, Myanmar. WHO STEPwise Approach to NCD Surveillance, Myanmar, Disaggregation of Urban and Rural Data (Urban) 2005. Ministry of Health Union, Myanmar WHO STEPwise Approach to NCD Surveillance, Myanmar, Disaggregation of Urban and Rural Data (Rural) 2005.

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Nepal SOLID Nepal. Surveillance of Risk Factors for Non-Comnmunicable Diseases in Nepal. Report of Survey in Ilam, Lalitpur and Tanahu, 2006. Sri Lanka NCD Risk Factor Survey in Sri Lanka (STEPS Survey) Report, Ministry of Health, Sri Lanka 2004. Thailand Behavioral Risk Factor Surveillance Survey 2005. National Health Examination Survey III 2004. Thailand Health Survey Office.

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Annex 2

Definition of Indicators • • • • • • • • • • • • • • • • • • •

Response rate (%): the proportion of eligible people contacted who participate in the study expressed as percentage. Current daily smokers: people who smoke daily currently. Current daily smokeless tobacco users: people who use smokeless tobacco daily currently. Mean age at starting regular smoking (yrs.): among those who are current daily smokers, average age (in years) at starting this habit regularly (not necessarily the age of initiation). Mean duration of smoking (yrs.): among those who are current daily smokers, average duration (in years) of regular smoking. Alcohol abstainers: people who have not consumed alcohol in the last 12 months. Current consumer of alcohol: people who have consumed alcohol in last 12 months. Standard drink: contains around 10g of ethanol. Serving of fruit or vegetable: one serving is equivalent to about 80g of fruit or vegetable or a medium sized fruit like an apple. Physical inactivity: doing very little or no physical activity in all three domains – work, transport and recreation (leisure). Inadequate physical activity: doing less than the recommended physical activity of 30 minutes a day for at least five days in a week (< 150 minutes per week). Body mass index (BMI): a measure of obesity equal to weight in kilograms divided by square of height in meters. Overweight: individuals with a BMI ≥ 25 kg/m2 but less than 30 kg/m2 . Obese: individuals with a BMI ≥ 30 kg/m2 . Waist circumference: the circumference of the abdomen at the mid-point between last rib and iliac crest. Central obesity: waist circumference > 102 cm for men and 88 cm for women or as waist hip ratio (WHR) > 1 in men and > 0.8 in women. Raised blood pressure: blood pressure levels ≥140/90 mm Hg or if the subject is on treatment for hypertension. Raised fasting blood glucose: fasting plasma glucose level ≥ 7.0 mmol/l. Raised total cholesterol: fasting blood cholesterol levels ≥ 5.2 mmol/l.

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Annex 3

Abbreviations and Acronyms BMI BRFSS CBI COPD F GDP HDL LDL M NCDs NHES NHHS NR NS NSES R RF SEA SIDS STEPS U WHO WHR Body Mass Index Behavioural Risk Factor Surveillance System Community Based Intervention Chronic Obstructive Pulmonary Disease Female Gross Domestic Product High Density Lipoproteins Low Density Lipoproteins Males Non-communicable Diseases National Health Examination Survey National Household survey Not reported Not Studied National Socio-economic Survey Rural Risk Factors South-East Asia Sudden Infant Death Syndrome Step-wise Approach to NCD Risk Factor Surveillance Urban World Health Organization Waist-Hip Ratio



REGIONAL COMMITTEE Sixtieth session Thimphu, Bhutan 31 August – 3 September 2007

Provisional Agenda item 9 SEA/RC60/7 Inf. Doc.3 13 July 2007

SCALING UP PREVENTION AND CONTROL OF CHRONIC NONCOMMUNICABLE DISEASES IN THE SEA REGION: Regional Framework for Prevention and Control of Noncommunicable Diseases

Contents Page Introduction ............................................................................................................................... 1 Evidence-base for public health action........................................................................................ 2 Risk factors ......................................................................................................................... 2 Socioeconomic determinants ............................................................................................. 3 Public health interventions ................................................................................................. 4 Framework for prevention and control........................................................................................ 4 Purpose.............................................................................................................................. 4 Guiding principles .............................................................................................................. 5 The framework................................................................................................................... 5 Planning steps .................................................................................................................... 6 National NCD programme development and management ................................................ 7 The private sector and civil society ..................................................................................... 8 The role of WHO ............................................................................................................... 8 Monitoring and evaluation.......................................................................................................... 9 Conclusions .............................................................................................................................. 10

Annexes 1. 2. Framework for Prevention and Control of Noncommunicable Diseases ............................ 11 Selected population-wide interventions feasible for implementation within the existing or realistically increased resources in the short- and medium-term ...................... 12

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Introduction 1. Noncommunicable Diseases (NCDs) have emerged as a major public health challenge in WHO's South-East Asia Region (SEAR), accounting for 54% of all deaths and 44% of the disease burden (see Figure 1). The epidemiological and demographic transition further increases the NCD-related mortality, morbidity and disability. NCDs threaten the lives and health of millions of people as well as socioeconomic development of Member States. The dominant feature of the epidemics of NCDs in SEAR countries is that young and middle-aged adults are increasingly being affected. Major NCDs include cardiovascular diseases (CVDs), cancers, chronic respiratory diseases and diabetes mellitus, which are being targeted for integrated prevention and control during the next few decades in the Region. Figure 1: Projected deaths by cause, all ages, in WHO South-East Asia Region, 2005 Injuries 11%

Cardiovascular disease 28%

Communicable, maternal and perinatal, nutritional deficiencies 35%

Cancer 9% Chronic respiratory disease 7% Other chronic diseases 8% Diabetes 2%

Source: WHO-CHP, Geneva (http://who.int/chp/chronic_disease_report/en/)

2. The South-East Asia Network for NCD Prevention and Control (SEANET-NCD), consisting of experts and institutions dealing with national NCD control, met in November 2005 at Bandos, Maldives, and recommended that the Region should have a regional framework for Prevention and Control of NCDs. They recommended that the Framework should aim to highlight the change in policy and programmes to address the increasing challenges for prevention and control of NCDs, contribute to strengthening high-level commitment, and facilitate the

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development of effective national policies, strategies and programmes for integrated prevention and control of NCDs in the Region. 3. Countries have to promote collaborative and multisectoral actions focused on health promotion and primary prevention and control of NCDs. These involve integrated epidemiological surveillance and comprehensive environmental, policy and programme interventions on major risk factors. At the same time, equitable and cost-effective management of major NCDs with optimal utilization of existing capacity of health systems needs to be promoted.

Evidence-base for public health action 4. According to WHO estimates, NCDs account for 54% of all deaths and 44% of the disease burden in SEAR. Major NCDs targeted for integrated prevention and control are cardiovascular diseases (CVDs), cancers, chronic respiratory diseases and diabetes. Almost half of NCD-related deaths occur prematurely in people below 70 years of age. The notable and worrying aspect of epidemiological transition observed in SEAR countries is that middle-aged adults (35-60 years) show disproportionately high death rates due to NCDs in comparison with those living in more developed countries. This premature morbidity and mortality in the most productive phase of life is posing a serious challenge to societies and to their economies. 5. One of the major challenges is that the information on morbidity and mortality and trends of risk factors for NCDs are neither adequately collected and compiled nor analyzed systematically in most countries of the Region. The available information also has many shortcomings in terms of coverage, representativeness, quality and validity. Existing national and international information indicates considerable diversity and disparity between countries and within countries. The burden of NCDs differs between age groups, sexes, and between the ruralurban, socio-economic and ethnic strata of populations in the Region. Nevertheless, existing evidence from various sources indicates that NCDs pose a major and growing public health and economic challenge to all countries of SEAR, to the young and old, women and men, the rural and urban population, to the poorer as well as the more affluent sections of society.

Risk factors 6. The main risk factors that cause major NCDs are well known and are common in all countries of the Region. These risk factors which are amenable to modification by simple health promotion and preventive measures include: (a) tobacco and alcohol use, (b) unhealthy diet (high in total energy, fat, salt and sugar, low in fruit and vegetables) and (c) physical inactivity. These risk factors are also closely related to intermediate risks such as high blood pressure (hypertension), overweight and high blood levels of glucose and cholesterol. The high level of risk factors among the population explains the current epidemiological situation, and points to future increases in NCD prevalence and deaths. 7. According to WHO estimates, at least 1.4 million people die annually in SEAR countries as a result of high blood pressure (hypertension) and another 2.2 million die as a result of tobacco

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use and high cholesterol level. Low intake of fruits and vegetables as well as lack of physical activity claim an additional 1.3 million lives every year. A few SEAR countries have adopted WHO’s standardized approach to surveillance of risk factors to help strengthen evidence and provide valid indicators for planning and monitoring of intervention strategies for NCDs.

Socioeconomic determinants 8. Beyond the risk factors, there are major socioeconomic determinants that cause NCDs. These lie outside the domain of the health sector. The application of a holistic, multidisciplinary and multisectoral perspective to address these determinants in the context of complex interrelations between individuals, communities and populations and their environment becomes increasingly important. Underlining social, economic, cultural and political determinants of health such as those related to rapid globalization and trade liberalization, uncontrolled urbanization, improved communication and technology, and population ageing need to be clearly understood so that appropriate policy and programme interventions can be initiated. WHO established a Commission on Social Determinants of Health (CSDH) in 2005, to study these aspects carefully and to develop a global agenda beyond the health sector and to improve equity in health care through action on social and economic determinants. 9. The increasing prevalence of risk factors and the consequent growth of NCDs in SEAR is the result of the progressively “harmful” evolution of physical, socioeconomic and technological environment rather than the “voluntary” adoption of unhealthy lifestyles by well informed individuals who have multiple and equally accessible choices. Since human behaviour occurs in a specific milieu, policy interventions that improve the physical and economic environments and modify social norms have proven to be far more effective in reducing the burden due to NCDs and improving health, rather than focussing mainly on behaviour change at the individual level and promoting unregulated growth of expensive specialized health care services focused on managing people in advanced stages of disease. Modification of unhealthy behaviour through social, economic and environmental interventions by adopting appropriate policy interventions is less expensive and more permanent than individual-level lifestyle change. 10. Evidence clearly shows that NCDs are also becoming common among the poor and marginalized people. Contrary to popular belief that NCDs are problems of the urban rich, people belonging to lower socioeconomic strata are becoming increasingly vulnerable. Material deprivation and psychosocial stress are linked to a high frequency of risky behaviours. There is evidence to show that the poor population has a high prevalence of hypertension and high level of cholesterol and sugar in blood. They are also at a higher risk of NCDs due to high tobacco and alcohol consumption and lower consumption of fruits and vegetables. Compounded with unhealthy living conditions and limited access to good quality healthcare, the poor are more likely to suffer complications and other adverse consequences of NCDs. This is more so among women, since they are often more vulnerable to the effects of social inequality and poverty, and less able to access resources including healthcare. Chronic diseases inflict an enormous direct economic burden on the poor, and push many people and their families further into poverty.

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Public health interventions 11. Available knowledge on simple health promotion and preventive measures could be used effectively to address the threats posed by NCDs. Policy interventions aimed to change the physical and socioeconomic environment, when implemented with comprehensive health promotion and integrated disease prevention programmes could significantly reduce the incidence of NCDs and decrease overall morbidity and mortality. Population-wide interventions to reduce tobacco consumption and to promote physical activity and healthy eating habits coupled with interventions targeting high-risk groups and individuals could greatly improve public health outcomes. When applied in an integrated way at population, community and individual levels, available public health interventions have the potential to prevent at least 80% of cardiovascular diseases and diabetes, and 40% of cancers. 12. The cost of care and treatment of NCDs is increasingly stressing the health systems and the budget of immediate families. It could be considerably reduced by application of available costeffective interventions. For example, a combination of behavioural and low-cost pharmacological interventions has considerable potential in improving outcomes in people at high risk and in those with CVDs and diabetes. Establishment of basic health facilities and community-based rehabilitative and palliative services could also contribute significantly in improving the quality of life of people with disabilities and those in the terminal stages of chronic diseases.

Framework for prevention and control Purpose 13. Currently, prevention and control of NCDs is marginal to the mainstream of public health action in countries of the Region. Public health resources allocated for prevention and control of NCDs are disproportionately low in relation to their public health burden. WHO has stated that a target of an annual reduction by 2% of the deaths due to NCDs is achievable if appropriate actions are taken now by Member States.1 Over the next 10 years, it would result in preventing more than 8 million premature deaths with huge economic gains, in the SEA Region. 14. The Regional Framework for Prevention and Control of Noncommunicable Diseases has been developed to: •

Facilitate the process of updating and strengthening national policies, strategies and programmes for integrated prevention and control of NCDs (for countries which have already established national policies, strategies and programmes); and Propose the policy development framework and provide technical inputs for consideration in the process of developing national policies, strategies and programmes for integrated prevention and control of NCDs (for countries that have not yet adopted national policies, strategies and programmes).

•

1

WHO, Preventing Chronic Diseases: a vital investment, 2005

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Guiding principles 15. The Regional Framework has the following guiding principles: • • • • • • •

Integrated action based on comprehensive national health policy and strategy; Application of public health perspective; Stepwise implementation taking into consideration available resources and local needs; Focus on awareness generation, health promotion and disease prevention through reduction of common risk factors; Intersectoral, multidisciplinary and multilevel approaches; Combining a population-wide approach with clinical intervention at the individual, family and community levels; Addressing health disparity and minimizing health inequality related to socioeconomic, cultural and political factors.

The framework 16. The Regional Framework is based on national, regional and global consensus on policy and technical actions for prevention and control of NCDs and their primary risk factors. In particular, the following policy guidance was used in the process of developing the Framework: • • • • •

World Health Assembly Resolution – WHA53.17 on Prevention and Control of Noncommunicable Diseases; World Health Assembly Resolution – WHA56.1 on WHO Framework Convention on Tobacco Control; World Health Assembly Resolution – WHA57.17 on WHO Global Strategy on Diet, Physical Activity and Health; National NCD prevention and control policies and strategies of SEAR Member States; The Regional Strategy for NCD Surveillance developed by Member States at the Intercountry Workshop on Establishing South-East Asia Regional Network for NCD Surveillance, 2003 (Document SEA-NCD-58); The WHO Report “Preventing Chronic Diseases: a vital investment", 2005 and, WHO Country Cooperation Strategies of SEAR Member States.

• •

17. The Regional Framework (see Annex 1) applies the socioeconomic and ecological perspective, draws on public health principles, and is based on existing evidence. It provides a stepwise construction that offers a flexible and practical approach to assist governments in balancing diverse needs and priorities while implementing evidence-based interventions. The Framework includes three main planning steps and three major implementation steps.

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Planning steps Step 1 – Estimate population need through assessing the current risk profile and advocate for action 18. The first step is to assess the epidemiological situation by identifying the distribution of risk factors among different population groups in a country. In particular, the development of a national risk factor profile for NCDs provides key information required for planning prevention and control activities. The information on risk factor profile could help predict the future burden of disease. This, in turn, would help in making a strong case for high-level advocacy and constitutes an evidence base for planning interventions at policy, environmental and health system levels. 19. WHO has promoted the STEPwise approach to NCD risk factor surveillance in countries of the Region. The regional NCD InfoBase, available at http://w3.whosea.org/ncd with a link to WHO/HQ NCD InfoBase, contains the NCD risk factor profiles of each Member State, which are being updated periodically. Within the context of existing health information systems, an integrated NCD surveillance system incorporating a minimum set of NCD surveillance indicators with the focus on NCD risk factors has to be developed. There is a need to have sustainable mechanisms to collect basic NCD risk factor information regularly (every 3 to 5 years), wherever appropriate. Step 2 – Formulate and adopt NCD policy 20. After estimating population needs and advocating for action, the second planning step is to formulate and adopt a national NCD policy. Effective and efficient responses to NCDs require the development and adoption of comprehensive public health policies that set out the vision for prevention and control of NCDs for the next 10-15 years. This would give appropriate priority to integrated prevention and control of major NCDs. It should be accompanied by plans and programmes for implementing the policy. 21. National policies and programmes related to NCDs have to cut across specific NCDs and focus on common risk factors. They should also encompass health promotion, disease prevention and case management strategies, trying to reach as much of the population as possible. The programmes are implemented across multiple levels and require the involvement of multiple sectors. The process of formulation and adoption of comprehensive policy needs to involve numerous stakeholders from within and beyond the health sector. In this process, making use of available economic evaluations and understanding the local political, cultural, and epidemiological context is very important. 22. India is formulating a National Programme for Prevention and Control of Diabetes, CVD and Stroke, for the next 10-15 years. Since 1975, India is implementing a comprehensive National Cancer Control Programme. Indonesia, in 2003, launched a national programme with the adoption of the National NCD Policy and Strategy by the Ministry of Health. Maldives adopted national prevention and control strategies in 2005 for reducing NCDs. Thailand also adopted a strategy to control NCDs within the Healthy Thailand initiative in 2004.

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Step 3 – Identify policy implementation steps 23. The third planning step is to identify the best means by which the policy can be implemented, especially in the areas of health financing, legislation and regulations, advocacy, community-based interventions, and health services delivery. Given the wide ethnic, cultural and economic diversity in the Region, the ‘one-size-fits-all’ approach is not appropriate. Therefore, the implementation steps developed at national and subnational levels need to be context- and culture-specific, as well as resource-sensitive. Resources required for effective implementation need to be ensured. Some actions will be within the domain of health ministries, for example, realigning health systems to cater for prevention and management of chronic diseases. Developing or enforcing legislation may be in the domain of other ministries, such as the Ministry of Home Affairs and Local Administration. Taxation may be the responsibility of the finance ministry. 24. Implementation of the national programmes may also go along step-by-step, choosing interventions from the core to a higher desired level: (a) Core Programme: Interventions which are feasible to implement with existing resources in the short term; (b) Expanded Programme: Interventions that are possible to implement with a realistically projected increase in, or reallocation of, resources in the medium term; and (c) Desired Programme: Evidence-based interventions which are beyond the reach of existing resources. 25. A majority of effective public health interventions in the area of NCDs are primarily beyond the direct control of the health ministry. The application of multisectoral approaches in planning and implementing policies for prevention and control of NCDs is mandatory. Generation of public awareness, community mobilization and high level advocacy need to be strengthened. 26. Comprehensive policies and programmes to control NCDs should include: development and modification of health legislation, regulations and financing mechanisms, modification of the physical environment, and resource-sensitive organization and delivery of health services. National programmes need to select interventions potentially feasible for implementation within existing or realistically increased resources in the short and medium term. The possible interventions are listed in Annex 2 for easy reference. Further information on specific core, expanded and desirable implementation steps, together with suggested milestones, are proposed in Part Four of the WHO Report - “Preventing Chronic Diseases: a vital investment".

National NCD programme development and management 27. National prevention and control policies and programmes for NCDs need to be developed with national governments leading the way. The pivotal role of the government in identifying and addressing basic public health priorities can not be overemphasized. The basic task for the government is to develop a comprehensive policy for the prevention and control of NCDs within the framework of the overall national public health policy and set up appropriate legislative,

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regulatory and financing mechanisms to ensure implementation. This unifying framework creates an appropriate milieu for multisectoral, multidisciplinary and multilevel actions involving all major stakeholders. 28. The ministry of health takes the leadership role in coordinating action and in promoting partnerships that involve stakeholders from the government, the private sector, civil society groups and international agencies. Planning, implementation, monitoring and evaluation of national NCD prevention and control programmes requires the development of an appropriate organizational infrastructure within the health sector, for example, a dedicated NCD unit within the Ministry of Health and establishing a budget line for financing NCD programmes. 29. Governments have a central leadership role to play in establishing appropriate health financing mechanisms and models. Equitable redistribution of available resources with priority given to financing predefined basic public health services including health promotion, primary and secondary prevention and cost-effective curative services should be emphasized. Investing in health workforce development through education and training, establishing basic health infrastructure and improving the availability of essential drugs and technologies that take into consideration the legitimate needs of people at risk and with established NCDs need to be given adequate priority. Applied research in prevention and control of NCDs and in evaluating different policies and interventions should be promoted.

The private sector and civil society 30. Multisectoral interventions for integrated prevention and control of NCDs will have maximum effect if key partners from the private sector and civil society are identified and involved in the process of NCD policy development and in the implementation of its different components. Stakeholders from outside the government sector add human and financial resources and bring different perspectives to public debate on priorities and the best ways to address them. 31. The private sector, such as the food industry and retailers, advertising and recreation businesses, pharmaceutical companies, the media and others have an important role to play in promoting healthy behaviour. Assuming public health accountability by partners from the private sector through developing and adopting health enhancing self-regulations could bring considerable health benefits to the people. 32. Civil society and nongovernmental organizations are instrumental in wide dissemination of information and in influencing behaviour in individuals. They lead grass-roots mobilization, organize campaigns and events that raise awareness, plan and implement community-based activities and contribute to improving health care delivery.

The role of WHO 33. WHO has assisted in developing national policies and intervention strategies for prevention and control of major NCDs, based on evidence. It will continue to develop norms and standards and demonstrate feasible models for the implementation of such strategies.

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34. WHO will fulfill its role in providing technical support and facilitating capacity building for integrated surveillance, prevention and control of NCDs. It will assist in resource mobilization for NCD activities at all levels within and outside WHO and assist in developing tools for monitoring national efforts. 35. WHO plays an important role in coordinating action among UN system organizations, intergovernmental bodies, nongovernmental organizations, professional associations, research institutions and the private sector. It aims to foster partnerships and promote intercountry cooperation and networking of NCD programmes and initiatives. The South-East Asia Network for Noncommunicable Disease Prevention and Control (SEANET-NCD) has been initiated and national NCD networks are being established.

Monitoring and evaluation 36. Developing a system for monitoring and evaluation of NCD programmes is essential in order to provide data for policy development, planning effective interventions, and subsequently measuring performance and outcomes. Setting up a sustainable monitoring and evaluation system requires allocation of appropriate human and financial resources. Monitoring and evaluation should be inbuilt in the NCD programme and linked with the national health management information system. 37. The steps in setting up an effective monitoring system include: (i) identifying information needs and key interventions and services; (ii) selecting and defining key indicators for inputs, process and outcomes and their respective sources; (iii) collecting and storing data; (iv) analyzing and interpreting data; and (v) using information in identifying problems and in decision making. Clear definitions of indicators, establishing responsibilities of personnel for data collection and analysis and ensuring timely flow of information are important aspects of an effective monitoring system. 38. Recognizing the need to strengthen monitoring and evaluation, a simplified instrument assessing the progress in national NCD prevention and control was developed through regional adaptation of the global survey tool in 2005. The survey documents the status of national commitment, capacity and capability, and identifies the constraints and the needs. Information on the status of national acts, decrees and legislation, existence of national policies, strategies, action plans and programmes, implementation status of the WHO FCTC, and the Global Strategy on Diet, Physical Activity and Health, existence of demonstration projects, availability of health care services and financial resources for NCD prevention and control have been compiled, analysed and disseminated. 39. The broad adoption of the WHO STEPwise approach is a major measure contributing to strengthening national capacity for collecting standardized information on major risk factors of NCDs in the Region. The establishment of integrated NCD surveillance, based on periodic collection of information on NCD risk factors, at the national level, could contribute to assessing the impact of programmes for NCD prevention and control.

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Conclusions 40. Noncommunicable diseases are a major and growing public health problem in the Region. The current threat of NCDs can be addressed effectively and efficiently with available knowledge and experience. A comprehensive public health response to NCDs that applies a public health perspective and integrates multisectoral strategies of health promotion, disease prevention and cost-effective management is required. The progress achieved by Member States in addressing prevention and control of NCDs needs to be monitored and evaluated. Regional networking of NCD programmes and initiatives is important to share experiences and provide a framework for collaborative action for the prevention and control of noncommunicable diseases.

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Annex 1

Framework for Prevention and Control of Noncommunicable Diseases Epidemiological assessment

Awareness generation and high-level advocacy

Planning STEP 1 Estimate population need and advocate for action Planning STEPS 2 and 3 Formulate and adopt policy Identity policy implementation steps

Development of policy and strategic plan

Capacity strengthening, resource mobilization and infrastructure Implementation STEPS Multisectoral and multi-level action to modify environment (physical, social and economic) Health sector interventions

Population decrease in NCD risk factor level and reduced adverse health events Outcome and Impact Reduced health and economic burden of NCD

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Annex 2

Selected population-wide interventions feasible for implementation within the existing or realistically increased resources in the short- and medium-term Policy Levers Health financing • • Legislation and Regulation • Interventions Prevention and control of NCDs budgeted in national health plan; Tobacco taxes implemented and revenue earmarked for interventions to reduce risk and promote health;* Tobacco control legislation consistent with FCTC enacted and enforced; (ban/restriction on smoking in public places, and increased price of tobacco products through raising taxes)*; Food standards and food labelling legislation enacted; Marketing and advertising food to children regulated; Transportation policy developed; Improved access to infrastructure/places for physical activity (urban planning)*; Increasing physical education hours in schools*; Improved processing and manufacturing of foods; Assessing and creating awareness on the impact of the environment and transportation system on health; Advocacy initiatives and campaigns to promote healthy foods and physical activity; NCD prevention networks established; Community-based programmes on major NCD risk factors*; Health workforce informed and provided skills for NCD prevention and control; Simple, integrated prevention and treatment guidelines developed; Clinical prevention for people with estimated risk of cardiovascular events above 30% over next 10 years*; Tobacco cessation services*; Access to affordable first-line medication for NCDs (such as aspirin, drugs for hypertension and high lipids)*.

• • • Physical environment • • • • Advocacy and community mobilization • • • Health services • • • • •

* specific interventions that are proved to be highly effective.