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Noncommunicable

Diseases in the
South-East Asia Region

2011

Situation and Response

Noncommunicable
Diseases in the
South-East Asia Region

2011

Situation and Response

WHO Library Cataloguing-in-Publication data

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

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

ISBN

978-92-9022-413-6

(NLM classification: WT 500)

World Health Organization 2011

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publications@searo.who.int).
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Printed in India

Contents

Acknowledgments
Foreword
Acronyms

ii
iii
iv

1. INTRODUCTION

EXECUTIVE SUMMARY

2. BURDEN OF NONCOMMUNICABLE DISEASES IN WHO SOUTH-EAST ASIA REGION


NCD Mortality
Trends in NCD Mortality and Morbidity
Disease-Specific Burden and Trends
Cardiovascular diseases
Cancers
Diabetes mellitus
Chronic respiratory diseases
Other NCDs

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10
12
13
14
15
17
18
19

IV. DRIVERS OF NCDs


Population ageing
Urbanization
Globalization
Poverty
Illiteracy
Underdeveloped health system

43
43
44
47
47
48
48

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

V. ECONOMIC BURDEN OF NCDs


Economic burden of NCDs at the National Level
Economic burden of NCDs at household level

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24
24
30
31
32
33
33
35
36
37
38

51
51
52

VI. NATIONAL RESPONSE TO NCDs


Institutional Capacity for NCD Prevention and Control at the Central Level
National Policies, Strategies, Plans and Programmes for NCD Prevention and Control
Surveillance and Monitoring
Heath System Capacity for NCD Prevention, Early detection, Treatment and Care
Health Financing
Partnerships and Collaboration

59
59
60
62
65
68
69

VIII. WHO INITIATIVES IN NCD PREVENTION AND CONTROL


Global initiatives
Regional initiatives

75
75
76

VII. MAJOR CHALLENGES IN PREVENTION AND CONTROL OF NCDs


Lack of strong national partnerships for multisectoral actions
Weak surveillance systems
Limited access to prevention, care and treatment services for NCDs
Limited human resources for NCDs
Insufficient allocation of funds
Difficulties in engaging the industry and private sector
Lack of social mobilization

IX. THE WAY FORWARD


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

ANNEXES
Tables
Note on data sources and limitations

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71
71
72
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73

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85
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2011

ii

Acknowledgements
We thank the Member countries of the South-East Asia Region for providing the latest data on risk

factors, morbidity and mortality, as well as updates on national responses and key achievements. We are

grateful to national experts from Member countries of the Region for contributing to selected sections of
the report. We acknowledge the assistance of staff in the World Health Organization country offices for
their contribution in preparing this report. We are grateful to Dr Anton Fric for preparing an earlier

version of the report and Dr Abhaya Indrayan and Dr Niki Shrestha for extensive inputs to the report as
well as data verification, review of literature and references checking. Mr Ravinder Kumar prepared
charts and graphs. Ms Vani Kurup edited and designed the Report.

2011

iii

Foreword

This report describes the current burden of


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

While there is a growing recognition among


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

engaging in regular physical activity to maintain


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

I call upon our Member States to join the


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

Dr Samlee Plianbangchang

Regional Director, World Health Organization


Regional Office for South-East Asia

2011

iv

Acronyms
BMI
BP
CHD
COPD
CRDs
CURES
CVDs
DALYs
DBP
FCTC
GATS
GDP
GYTS
HDL
HDSS
ICMR
IGT
INR
LDL
MDGs
MONICA
NCDs
NFHS
NPHF
NTCC
PEN
SEA-ACHR
SEANET
SEAR
SEARO
TFA
UNHLM
WC
WEF

2011

body mass index


blood pressure
coronary heart disease
chronic obstructive pulmonary disease
chronic respiratory diseases
Chennai Urban Rural Epidemiology Study
cardiovascular diseases
disability adjusted life years
diastolic blood pressure
WHO Framework Convention on Tobacco Control
Global Adult Tobacco Survey
gross domestic product
Global Youth Tobacco Survey
high density lipoprotein
Health and Demographic Surveillance System
Indian Council of Medical Research
impaired glucose tolerance
Indian Rupee
low density lipoprotein
Millennium Development Goals
Multinational Monitoring of Trends and Determinants of Cardiovascular Disease
noncommunicable diseases
National Family Health Survey
Nepal Public Health Foundation
National Tobacco Control Cell
WHO package of essential NCD interventions
South East Asia-Advisory Committee on Health Research
South-East Asian Network of NCD
South-East Asia Region
Regional Office for South-East Asia
trans fatty acids
UN High-level Meeting
waist circumference
World Economic Forum

Executive Summary

Four major noncommunicable diseases


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

Burden of NCDs in the South-East


Asia Region
I

Of the estimated 14.5 million total deaths in


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

An estimated 1.7 million new cases of cancer


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

NCD risk factors and social


determinants
I

The four major behavioural risk factors of


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

2011

2011

The Region has nearly 250 million smokers


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

Approximately 30% of the adult population


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

Economic burden of NCDs


I

There is a two-way link between NCDs and


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

National responses to NCDs


I

All 11 Member countries* initiated a public


health response to NCDs and have
allocation for NCD prevention and control
in the budget of their respective ministries
of health.

Nine Member countries have an integrated


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

All Member countries reported providing at


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

Major challenges in addressing NCDs

Major challenges that need to be overcome


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

Way forward

High level of commitment is needed to


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

2011

Chapter 1

Introduction

Noncommunicable diseases (NCDs) are


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

In 2008, 63% (36 of 57 million) deaths


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

2011

cardiovascular disease mortality will increase by


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

2011

Turkey). A number of low- and middle-income


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

REFERENCES

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

3. World Health Organization. Scaling up action against noncommunicable diseases. How much will it cost? Geneva,
2011 http://whqlibdoc.who.int/publications/2011/9789241502313_eng.pdf. (accessed 28 December 2011).

2011

Chapter 2

Burden of Noncommunicable Diseases


in WHO South-East Asia Region

Noncommunicable diseases (NCDs) are top killers in the South-East


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

Member States in SEAR* are undergoing


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

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

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

This chapter reviews the current burden


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

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10

NCD Mortality

Of the estimated 14.5 million total deaths


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

Region. According to a special survey of deaths


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

Fig 2.1: Estimated percentage of deaths by cause, South-East Asia Region, 2008

Injuries 11%
Cardiovascular
disease 25%

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

Chronic respiratory
diseases 9.6%

Cancers 7.8%
Other
NCDs 10%
Source: Global Health Observatory. World Health Organization 2011.
Note: percentages do not add up to 100% due to rounding off.

2011

Diabetes 2.1%

NCDs are the


leading cause
of death in
the Region

11

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

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

100

Percent

80

60

40

20

0
Ti

te

es

-L

r
mo

ar

nm

a
My

pa

Ne

Ba

sh

de

la
ng

an

ut

Bh

Ind

ia

sia

ne

o
Ind

RK

DP

Sri

nk

La

Communicable diseases/
maternal conditions/
nutritional deficiencies

Noncommunicable
diseases

nd

ila

a
Th

ive

ld
Ma

Injuries

Source: Global Health Observatory. World Health Organization 2011.

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

50

Rest of the world

Percent

40

30

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

20

10

0
All NCDs

Cancer

Diabetes

Cardiovascular
diseases

Chronic
respiratory
diseases

Source: Global Health Observatory. World Health Organization 2011.

NCD deaths account for a massive 70% and


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

Similar observations were noted for all


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

2011

12

38% of deaths were due to NCDs (1). High


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

Trends in NCD Mortality and


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

nutritional conditions would decrease to nearly


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

Fig 2.4: Age-standardized mortality rates per 100 000 population by sex, South-East Asia
Region, 2008
Age-standardized death rates per 100 000

800
700
600
500
400
300
200
100
0
All NCDs

Cardiovascular
diseases

Cancer

Source: Global Health Observatory. World Health Organization 2011.

2011

NCD mortality
rates are
higher in males
than females

Male
Female

Chronic
respiratory
diseases

Diabetes

13

Disease-Specific Burden and


Trends

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

CVDs, cancers, diabetes and CRDs are the


four major NCDs that contribute to more than
80% of NCD deaths in this Region. Significant
differentials exist across Member countries in
the burden of these diseases.

Fig 2.5: Trends in estimated percentage of deaths by cause of death, South-East Asia
Region, 2004 and 2030
2004

80

NCD deaths are


projected to
increase in the
coming years

2030
70
60

Percent

50
40
30
20
10
0
Communicable
diseases/maternal
and perinatal conditions/
nutritional deficiencies

NCDs

Injuries

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

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


70

Increasing
trend in NCD
deaths in
Indonesia

HHS 1995
HHS 2001

60

BHR 2007

Percent

50
40
30
20
10
0
Maternal and
perinatal condition

Communicable
disease

Noncommunicable
disease

Injury

HHS: household survey; BHR: basic health research


Source: Ministry of Health, Indonesia, Country Report, March 2011

2011

14

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

1200

Cases per 100 000

1000

800

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

600

400

200

200708

200406

200103

199800

199597

199294

198991

198688

198385

198082

1997-79

197476

197173

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

Fig 2.8: Trends in hospitalization rates per 100 000 population, by selected diseases,
Thailand, 19852006
700

Significant
increase in
hospitalization
due to NCDs in
Thailand

Diabetes
Heart diseases
Cancer

600

Cases per 100 000

500
400
300
200
100

2005

2003

2001

1999

1997

1995

1993

1991

1989

1987

1985

Source: Thai Health Profile, 2005-2007

Cardiovascular diseases

CVDs are a group of large number of


conditions relating to the heart and blood
vessels. The major CVDs include hypertensive
heart disease, ischaemic heart disease,
rheumatic heart disease and cerebrovascular
disease or stroke.

2011

Of the 7.9 million deaths attributed to


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

15

Types of CVDs vary among countries


(Figure 2.9). The commonest CVDs in the
Region are ischaemic heart disease, stroke and
hypertensive heart disease. Ischaemic heart
disease is the commonest cause of CVD deaths
in all countries except Thailand where deaths
due to cerebrovascular disease (stroke) exceeds
deaths due to ischaemic heart disease.

related death rate increased from 7% to 18%


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

Cancers

CVDs affect younger age-goups in SEAR


than in their counterparts in western countries.
For example, CVD mortality in India in the 30
59 years age-group is twice than that in the US
(9). Nearly 52% of CVD deaths in India occur
below the age of 70 years compared with 23%
in established market economies (10).

Cancers are predicted to become an


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

The trends for CVDs in the Region are of


concern. For example, in Bangladesh, CVDs
were the main cause of death in 2008 27% of
all deaths and are projected to rise to 37% by
2030 (5). DPR Korea reported stroke-related
death rate increase from 3.8% to 25% during a
30-year period (19601991) and heart-disease-

Fig 2.9: Percentage of deaths due to CVDs*, by type of CVD, South-East Asia Region, 2008

Percent

35

Other cardiovascular diseases

30

Hypertensive heart disease

25

Ischaemic heart disease

Cerebrovascular diseases

20
15
10
5

DPRK

Indonesia

Sri Lanka

Bhutan

Bangladesh

Thailand

Maldives

Nepal

India

Myanmar

Timor-Leste

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

* CVDs = cardiovascular diseases


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

2011

16

Based on country reported data, of the


150 000 cancer-related deaths occurring
annually in Bangladesh, more than one half die
within five years of diagnosis (15). In India,
cancers caused a larger percentage of deaths
among females than males in both urban and
rural areas during 20012003 (2).

in the Region. Figure 2.10 shows that among


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

A large proportion of cancer deaths occur


in the economically productive age group. Fiftytwo per cent of cancer deaths among women and
45% of cancer deaths among men occur below
the age of 60 years (1). In a five-city study in
India, nearly 50% of cancer mortality was
reported among those below 55 years of age (16).
In addition to high mortality, SEAR has
high cancer-related morbidity. An estimated
1.7 million new cases of cancer occur each year

Data for the period 19842004 from five


urban and one rural cancer registry in India

Fig 2.10: Incidence of selected cancers per 100 000 population, by sex, South-East Asia
Region, 2008
Incidence/100 000 population
30

20

10

10

20

30

Lung
Breast
Cervix uteri
Lip/oral cavity
Oesophagus
Stomach
Colorectum
Liver
Non-Hodgkin lymph
Larynx
Ovary
Bladder

FEMALES

MALES

Brain/Nervous
Leukaemia
Thyroid
Hodgkins lymphoma
Kidney
Prostate
Corpus uteri
Testis
Gallbladder
Pancreas

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

2011

Lung and oral


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

17

indicated that, cancers of the prostate, colon,


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

Diabetes mellitus

Diabetes is defined as having a fasting


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

Based on results of the STEPS surveys, the


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

2011

18

Fig 2.11: Percentage of adult population with raised blood glucose level*, South-East Asia
Region, 2008
14

Male
Female

12

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

Percent

10
8
6
4
2

Thailand

Sri Lanka

Nepal

Myanmar

Maldives

Indonesia

India

Bhutan

Bangladesh

* Fasting glucose >7.0 mmol/L or on medication for diabetes


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

According to the national Thailand health


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

Chronic Respiratory Diseases

Chronic respiratory diseases narrow air


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

2011

Timor-Leste to 11% in India). Age-standardized


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

19

Other NCDs

Besides the major NCDs, many other


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

disease and 0.15% of stage-V chronic kidney


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

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17. India National Council of Medical Research. IMCR Bulletin, Vol 40, No. 2, February 2010.
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18. Pradhananga KK et al. Multi-institution hospital-based cancer incidence data for Nepal: an initial report.
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19. International Diabetes Federation. http://www.idf.org/ (accessed on 21 September 2011).

20. Katulanda P et al. Prevalence and projection of diabetes and pre-diabetes in adults in Sri Lanka Sri Lanka
Diabetes, Cardiovascular Study (SLDCS). Diabetes Medicine 2008;25:10629.
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Kathmandu valley of Nepal. Nepal Medical College Journal 2009;11:348.
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23. Rahim MA et al. Rising prevalence of type 2 diabetes in rural Bangladesh: A population based study. Diabetes
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25. Ramachandran A. Epidemiology of diabetes in Indiathree decades of research [review]. Journal of the
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26. Pradeepa R, Mohan V. The changing scenario of the diabetes epidemic: implications for India [review]. Indian
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27. Ramachandran A et al. Temporal changes in prevalence of diabetes and impaired glucose tolerance
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Epub 2004 Apr 28.

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28. Porapakkham Y et al. Prevalence, awareness, treatment and control of hypertension and diabetes mellitus among
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29. Liwsrisakun CC, Pothirat C. Actual implementation of the Thai Asthma Guideline. Journal of the Medical Association
of Thailand 2005;88:898-902.

30. Report on Result of National Basic Health Research (RISKESDAS) 2007. The National Institute of Health Research
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7_English.zip / (accessed on 21 September 2011).
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Chronic Kidney Disease 2006, MP281, iv393. http://ndt.oxfordjournals.org/cgi/reprint/21/suppl_4/iv390.pdf
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34. Prodjosudjadi W. Incidence, prevalence, treatment and cost of end-stage renal disease in Indonesia. Ethnicity &
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35. Ong-ajyooth L et al. Prevalence of chronic kidney disease in Thai adults: a national health survey. BMC Nephrology
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2011

Chapter 3

23

Risk Factors

Four behavioural risk factors (tobacco use, unhealthy diet, physical


inactivity and harmful use of alcohol) are largely responsible for
majority of the NCDs.

Behavioural risk factors lead to four key metabolic changes:


overweight/obesity; raised blood pressure; raised blood glucose; and
raised blood cholesterol.
Behavioural and metabolic risk factors are highly prevalent in the
Region and on the rise.

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

The four major NCDs namely CVDs,


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

followed by raised blood glucose (6.8%),


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

2011

24

Noncommunicable diseases

Fig 3.1: Shared risk factors for major noncommunicable diseases

Cardiovascular
diseases
Diabates
(Type II)
Cancers

Chronic
respiratory
diseases

Tobacco
use

Unhealthy
diet

Physical
inactivity

Harmful use
of alcohol

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

Fig 3.2: Estimated number of attributable deaths by risk factor, South-East Asia
Region, 2004

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

Number of attributable deaths (000s)

2000

1500

1000

500

Overweight
and obesity

Harmful use
of alcohol

Suboptimal
breastfeeding

Low fruit and


vegetable intake

Unsafe water,
sanitation, hygiene

Indoor smoke
from solid fuels

High cholesterol

Physical activity

Childhood and
maternal underweight

Tobacco use

High blood glucose

High blood pressure

Risk factors

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

Behavioural Risk Factors


Tobacco use

Tobacco use is the single-most preventable


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

2011

wide range of diseases that impact nearly every


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

25

tobacco-related deaths occur every year (1). It is


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

Both smoking and smokeless types of


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

consumption is now prevalent throughout the


Region. The misconception about tobacco being
good for oral health, has been used as an
advantage by the tobacco industry, which has
produced tobacco products, such as dentifrice,
most common in India and Bangladesh in
different forms such as gul, gudaku, bajjar,
tapkir, lal dantmanjan.
The use of smokeless tobacco products
among children, youth and women has
increased in recent times in the Region, mainly
because of lack of adequate knowledge about
the addictive and harmful effects of smokeless
tobacco. Additionally, aggressive marketing by
the tobacco industry, easy accessibility to and
lower prices of smokeless tobacco products have
contributed to their widespread use in the
Region (8).
Tobacco use among adults

The prevalence of tobacco use varies


significantly across the Member countries of the
Region. Smoking is higher among men while
women usually take to chewing tobacco. The
prevalence of current use of any smoked
tobacco ranges from 26% (India) to 61%
(Indonesia) in males and from less than 1% (Sri
Lanka) to 29% (Nepal) among females. The
prevalence of daily cigarette smoking among
males ranges from 7% (India) to 53% (DPR
Korea). The prevalence of smokeless tobacco
product use among males ranges from 1.3%
(Thailand) to 51.4% (Myanmar); in females
prevalence of smokeless tobacco product use
ranges from 4.6% (Nepal) to 27.9%
(Bangladesh) (Table 3.1). Overall, tobacco use
among males is higher than among their female
counterparts in all Member countries of the
Region.
Tobacco use among students aged 1315
years

The findings of the Global Youth Tobacco


Survey (GYTS) reveal a high prevalence of

2011

26

Table 3.1: Prevalence of tobacco use, among adults by sex, South-East Asia Region, 20062009
Age-standardized prevalence of smoking
DAILY

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

Males
42
53
20
54
38
31
30
21
39
N.A.

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

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

CURRENT

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

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

Prevalence of smokeless
tobacco*
Total
24
15
33
27
24
32
14
24
N.A.

Males

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

Females

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

Total

Year

27.2
19.4**

2009
2007

25.9

2009

29.6
18.6
15.8***
3.9
N.A.

2009
2008
2006
2009

N.A. = Not available


* WHO Report on the Global Tobacco Epidemic, 2011: warning about the dangers of tobacco. http://whqlibdoc.who.int/publications/2011/9789240687813_eng.pdf
**NCD Risk factor Survey, MOH Bhutan, 2007
***NCD Risk factor Survey, MOH Sri Lanka, 2006

tobacco use among youth in the Region. The


current use of any form of tobacco ranges from
8.5% (Maldives) to 55% (Timor-Leste) among
boys and from 3.4% (Maldives) to 30% (TimorLeste) among girls (Figure 3.3). The exceedingly
high tobacco use prevalence among youth in
Timor-Leste underscores their vulnerability to
NCDs in the future. The smoking rate among
students aged 1315 years is higher among boys
than girls (8).
Trends in tobacco use

Increasing smoking prevalence is a


concern in Indonesia where smoking prevalence
among male youths more than doubled from
14% in 1995 to 33% in 2004. Smoking
prevalence among young females in Indonesia,
although low, increased from 0.3% to 1.9%
during the same period (Figure 3.4) (9).
In Sri Lanka, current cigarette smoking
prevalence decreased from 4% in 1999 to 2.4%
in 2003 to 1.2% in 2007 (10). In Myanmar,

2011

current cigarette smoking prevalence showed a


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

Tobacco consumption and educational


level

An inverse relationship has been observed


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

27

Fig 3.3: Prevalence of current tobacco use among students aged 1315 years by sex, SouthEast Asia Region, 20062009
Variable, but
high tobacco
use among
youth in the
Region

60
Boys
Girls

50

Percent

40

30

20

10

2007
Maldives

2007
Bangladesh

2207
Sri Lanka

2007
Nepal

2006
India

2009
Thailand

2007
Myanmar

2009
Bhutan

2009
Indonesia

2006
Timor-Leste

Country and year of survey

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

Fig 3.4: Prevalence of smoking among students aged 1519 years, by sex, Indonesia,
19952004
40
35

Smoking among
Indonesian boys
has more than
doubled over a
decade

Boys
Girls
Both sexes

30

Percent

25
20
15
10
5
0

1995

2001

2004

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

lowest among those who had secondary


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

schooling (68% in males; 33% in females) and


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

2011

28

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

Current cigarette smoker

Current user of other


tobacco products

2001
2007

20

Percent

15

10

Boys

Girls

Boys

Girls

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

Source: Global Youth Tobacco Survey 2001 and 2007, Myanmar

Fig 3.6: Percentage of adults, who are current users of tobacco products, by education,
India, 2009
80

Male
Female

70
60

The less
educated are
more likely to
use tobacco

Percent

50
40
30
20
10
0

No formal
schooling

Less than
primary

Primary but
less than
secondary
Education

Secondary
and above

Source: India Global Adult Tobacco Survey 2009

Thailand GATS (2009) revealed a higher


prevalence of current use of any smoked
tobacco product among those who had less than
primary (24%) and primary (29%) education

2011

than in those who had university level education


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

29

school was 72% compared with 50% among


men who had completed a bachelors degree
(16).
Tobacco consumption and place of
residence

Bangladesh GATS (2009) revealed that a


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

of smoked tobacco products used also differed


between urban and rural smokers; the results
showed a higher prevalence of manufactured
cigarettes use in urban areas than in rural areas
(18% and 14%, respectively) and a higher
prevalence of hand-rolled cigarettes use in rural
areas as against urban areas (18% and 6%
respectively) (14).
Tobacco consumption and poverty

As per Bangladesh GATS (2009), the


prevalence of current use of any smoked
tobacco product and any smokeless tobacco
product decreased with increasing wealth index,
with the highest prevalence in the lowest wealth
index (29% and 36%, respectively) and lowest
prevalence in the highest wealth index (14% and
17%, respectively) (Figure 3.7) (12). Studies
from other sources also revealed consistent
results. Tobacco consumption is now
universally more common among lower
socioeconomic groups (18). In a survey of 471
143 persons of age >10 years in India in the year
19951996, people below the poverty line had

Fig 3.7: Percentage of adults, who are current users of tobacco products, by wealth index,
Bangladesh, 2009
Any smoked tobacco product

40

Any smokeless tobacco product


35
30

Tobacco use is
highest
among the
poorest

Percent

25
20
15
10
5
0

Lowest

Low

Middle

High

Highest

Wealth index
Source: Bangladesh Global Adult Tobacco Survey 2009

2011

30

higher relative odds of chewing tobacco


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

Unhealthy diet

Due to globalization and urbanization,


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

2011

of eating inadequate (less than five servings)


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

31

Table 3.2 Percentage of male and female adults eating less than five
servings of fruits and vegetables, South-East Asia Region, 20042010
Member countries
Bangladesh
Bhutan

Male (%)

Female (%)

Both sexes (%)

Year of survey

65

69

67

2007

94

93

India

NR

NR

Maldives

97

93

Indonesia
Myanmar
Nepal

Sri Lanka
Thailand

Total (Range)

94

94

90

91

61

64

81
83

6597

83
82

6493

93

2010

86

2007-08

97

2004

94
90
62
82
82

6297

2007
2009
2007
2007
2005

Source: National NCD risk-factor surveys in Member countries

Another area of concern is that partially


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

Physical inactivity

Lack of physical activity contributes


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

2011

32

Indonesia was the only exception. No data were


available for DPR Korea and Timor-Leste
(Figure 3.8)

Harmful use of alcohol

Alcohol is a psychoactive and potentially


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

followed by Nepal (17%). In eight countries for


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

Fig 3.8: Percentage of adults with insufficient physical activity*, South-East Asia Region,
2008
70

Males
Females

60

Percent

50
40
30
20
10
0

Bangladesh Bhutan

India

Indonesia Maldives Myanmar

Nepal

Sri Lanka Thailand

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

2011

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

Many people
are not
sufficiently
physically
active

33

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

Alcohol
consumption is
higher in males
than females

Males
Females

Percent

40

30

20

10

Bangladesh Bhutan
2010
2007

DPR Korea
2008

India
2007

Indonesia Myanmar
2007
2009

Nepal
2007

Sri Lanka
2007

Source: National NCD risk-factor surveys in Member countries

People who have consumed alcohol in the past 30 days.

societies are not as apparent here. Until recently


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

Metabolic Risk Factors


Overweight and obesity

Overweight and obesity is defined based


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

with BMI between 25.0 and 29.9 is considered


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

2011

34

Table 3.3 Percentage of adult population that is overweight and obese,


South-East Asia Region, 2008
Member countries
Bangladesh
Bhutan
India

Indonesia
Maldives

Myanmar

Overweight (BMI>25 kg/m2)

Male

Female

Both sexes

25

24

7.6
10
16
29
14

7.8
13
25
53
24

Nepal

9.8

8.9

Thailand

26

36

Sri Lanka

17

27

Overweight (BMI>30 kg/m2)


Male

Female

Both sexes

24

4.7

6.6

5.5

21

2.5

6.9

4.7

7.7
11
41
19

1.0

1.3
6.5
2.0

1.3

2.5
26

16

4.1

7.3

5.0

1.4

1.6

31

4.9

12

2.6

1.9

6.1

22

1.1

1.5
8.5

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

Childhood obesity is an emerging issue. In


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

2011

Among Thai adults, the prevalence of


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

35

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


50

Overweight
2
BMI 25 kg/m

Waist circumference
90.8 cm

2004
2009

40

Percent

30

20

10

Male

Female

Male

Female

Increasing
obesity in
Thailand

Source: National Health Examination Surveys, 2004 and 2009

study that examined data from 26 developing


countries including South-East Asia found a
higher prevalence of overweight than of
underweight among young women living in
rural and urban areas (45).

Raised blood pressure

Raised blood pressure (BP) is a major risk


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

conducted in 2005 in Health and Demographic


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

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

2011

36

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

High blood
pressure is
common in
both sexes

Females

Males

Percent

40

30

20

10

Thailand**

Sri Lanka**

Nepal*

Myanmar**

Maldives*

Indonesia**

India**

DPR Korea*

Bhutan**

Bangladesh*

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

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

Stroke mortality started to increase after


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

2011

sites in Bangladesh, India, Indonesia, Thailand


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

Raised cholesterol

Raised cholesterol (hypercholesterolemia)


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

37

variations in raised cholesterol levels, with the


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

Cluster of risk factors

NCD risk factors are known to result in


accentuated outcomes through synergistic

actions when two or more are simultaneously


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

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

Males

One third to one


half of adults
have raised
cholesterol

Females

50

Percent

40

30

20

Thailand**

Myanmar**

Maldives*

Indonesia**

India**

Bhutan**

10

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

2011

38

study participants in HDSS sites in Bangladesh,


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

Other risk factors

While the risk factors discussed above are


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

About one fifth of the cancer burden is


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

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31. Singh RB et al. Association of trans fatty acids (vegetable ghee) and clarified butter (Indian ghee) intake with higher
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51. Kusuma YS et al. Prevalence of hypertension in some cross-cultural populations of Visakhapatnam District, South
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2011

Chapter 4

43

Drivers of NCDs

NCDs have their origin in the social, cultural, economic and


environmental conditions of societies.

Globalization, unplanned urbanization, poverty, poor health systems


and social inequities are major determinants of NCDs.
Socioeconomic determinants can influence peoples exposure and
vulnerability to NCDs and can also influence health outcomes.

Socioeconomic conditions have an


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

Population Ageing

NCDs have emerged as a public health


problem in SEAR mainly due to epidemiological
transition, characterized by a change in disease

patterns from infectious diseases to NCDs, and


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

2011

44

Fig 4.1. Schematic representation of an iceberg for NCDs

NCDs

Metabolic
risk factors

Behavioural
risk factors

Social
determinants

Urbanization

Urbanization in SEAR is occurring at a


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

2011

Cardiovascular diseases
Cancers
Chronic respiratory diseases
Diabetes

Raised blood pressure


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

Major urban differentials exist in the


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

45

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

Bangladesh, 2011
Male

Bangladesh, 2025
Female

100+
9094
8589

Male

0 0

10

10 8 6 4 2
Population (in millions)

Female

100+
9094
8589

0 0

0 0

Male

10

10 8 6 4 2
Population (in millions)

10

10 8 6 4 2
Population (in millions)

Female

100+
9094
8589

0 0

0 0

10

India, 2050
Male

8084
7579
7074
6569
6064
5559
4549
4044
3539
3034
2529
2529
2529
2024
1519
1014
59
04

Female

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

India, 2025

8084
7579
7074
6569
6064
5559
4549
4044
3539
3034
2529
2529
2529
2024
1519
1014
59
04

10 8 6 4 2
Population (in millions)

Male

8084
7579
7074
6569
6064
5559
4549
4044
3539
3034
2529
2529
2529
2024
1519
1014
59
04

India, 2011
Male

Female

100+
9094
8589

8084
7579
7074
6569
6064
5559
4549
4044
3539
3034
2529
2529
2529
2024
1519
1014
59
04

10 8 6 4 2
Population (in millions)

Bangladesh, 2050

Female

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

2 4

10

10 8 6 4 2
Population (in millions)

0 0

10

Source: US Census Bureau, International Data Base

A study conducted in Sri Lanka showed


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

compared to
categories (5).

medium-

and

high-urban

A study from Tamil Nadu (India) found


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

2011

46

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

Dramatic
increase in
urbanization
expected

2010
2050

80

Percent

60

40

20

Timor-Leste

Thailand

Sri Lanka

Nepal

Myanmar

Maldives

Indonesia

India

DPR Korea

Bhutan

Bangladesh

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

Fig 4.4: Prevalence of NCD risk factors in urban and rural areas, by sex, India, 2003-2006
80

NCD risk
factors are
more prevalent
in urban areas

Urban
Rural

70
60

Percent

50
40
30
20

BMI30

Increased WC

Physical
inactivity at
work

Blood glucose
126 mg/dl

Female

Male

Female

Male

Female

Male

Female

Male

Female

Male

10

Total
cholesterol
200 mg/dl

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

2011

47

inactivity in men and high BMI and physical


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

Globalization

The rapidly growing burden of NCDs in


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

Poverty

A large segment of the population in SEAR


still lives below the poverty line. The NCD
pandemic originates from poverty and
disproportionately affects the poor. Poor people

with NCDs are doubly disadvantaged; on the


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

2011

48

expenditure of over 40% of income on these


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

Illiteracy

Education is a crucial factor for


sustainable development and the most

2011

important underlying determinant of health at


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

Underdeveloped health system

Underdeveloped health systems and maldistribution of health care is also an important


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

49

NCDs are often not available at the primary care


centres.
Annex 7 shows key indicators of the health
workforce in SEAR countries. With the
exception of a few SEAR countries, health care
personnel in every category are understaffed.
The health workforce density in SEAR countries
is low with a regional average of five physicians
and 13 nurses/midwives per 10 000 population,
against 14 and 30, respectively in the global
average. The health infrastructure situation is
also unfavourable with some countries, where
while the number of hospital beds considerably
increased over time, the number of health
centres remain low. This is a major constraint
in sustainable development of the health sector
and in improving access to health care. Health
expenditure ratios in SEAR countries (Annex 6)
indicate a large variation among SEAR

countries. A slight improvement in out-ofpocket expenditure and general government


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

REFERENCES

1. US Census Bureau, International Data Base


http://www.census.gov/population/international/data/idb/region.php?N=%20Region%20Results%20&T=2&A=both&RT
=0&Y=2000,2011,2025&R=123&C=BG,IN,CE (accessed 28 December 2011).
2. World Health statistics 2011. Geneva, World Health Organization 2011.
http://www.who.int/whosis/whostat/EN_WHS2011_Full.pdf (accessed 28 December 2011).

3. Allender S et al. Level of urbanization and noncommunicable disease risk factors in Tamil Nadu, India. Bulletin of
the World Health Organization 2010; 88:297-304.

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

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

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

7. National Institute of Health Research and Development, Ministry of Health. Report on Result of National Basic Health
Research, 2008.
8. de Silva V, Samarasinghe D, Hanwella R. Association between concurrent alcohol and tobacco use and poverty. Drug
and Alcohol Review 2011;30:69-73.

9. Yach D, Hawkes C, Gould CL, et al. The global burden of chronic diseases: overcoming impediments to prevention
and control. Journal of the American Medical Association 2004;291:2616-22.

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

2011

Chapter 5

51

Economic Burden of NCDs

The economic consequences of NCDs are enormous, both at the


micro- and macro-economic levels.

The earnings spent on unhealthy risk behaviours, such as tobacco use


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

The economic burden of NCDs and risk


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

Economic burden of NCDs at the


National Level

The macroeconomic impact of NCDs is


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

Forum (WEF) estimates that over the next 20


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

2011

52

Table 5.1: Projected cost of cardiovascular disease in terms of lost


GDP in selected countries of South-East Asia Region, 2006 and 2015
Foregone GDP*
(US$ billions)

Member countries

2006

2015

Bangladesh

0.08

0.14

Indonesia

0.33

0.53

India

Myanmar
Thailand

1.35

0.03

0.12

2015 as proportion
of 2006 estimates

1.96

175%

1.1

158%

4.2

145%

0.06

200%

0.18

Cumulative GDP loss


(US$ billions) by 2015

150%

17

0.43
1.5

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

As NCDs are chronic in nature and require


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

2011

Average cost of illness per diabetic patient


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

Economic loss in 2008 in Indonesia due to


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

Economic burden of NCDs at


household level

NCDs have a detrimental impact on


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

53

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

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

Total
Rural
Urban

Rupees in million

5000

4000

3000

2000

1000

1996

2001

2006

2011

2016

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

wages (due to disease, disability and premature


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

Tobacco and alcohol use are addictive and


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

In Myanmar, although the actual


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

2011

54

Fig 5.2: Ratio of expenditure on tobacco to education, by household expenditure


group, Bangladesh, 1995-96

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

Tobacco to education expenditure ratio

12
10

1
(poorest)

10 11 12

Household expenditure group

13

14

15 16 17

18
(richest)

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

In Indonesia, the average budget spent in


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

More than one half of health expenditure


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

2011

resourced and there is little social security


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

55

Fig 5.3: Distribution of monthly household expenditure, by expense category,


Indonesia, 2007
Tobacco
expenditure
accounts for a
tenth of the total
household
expenditure in
Indonesia

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

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

long-term effects of NCDs can result in


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

Loss of wages

Most people with NCDs cannot continue


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

2011

56

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

Missed work

Caregiving

NCDs lead to
huge loss in
household
wages

Premature death

Income loss (billion rupees)

120
100
80
60
40
20
0

Cardiovascular
disease

Hypertension

Diabetes

Asthma

Respiratory
illness

Injuries

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

REFERENCES

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

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

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

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

2011

57

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

9. Kyaing NN. Tobacco economics in Myanmar. Health, Nutrition and Population (HNP) Discussion Paper. Economics of
Tobacco Control Paper No. 14. October 2003. http://www.searo.who.int/LinkFiles/NMH_EconomicsMyanmar.pdf
(accessed 28 December 2011).

10. John RM. Crowding out effect of tobacco expenditure and its implications on household resource allocation in India.
Social Science Medicine 2008;66:1356-67. Epub 2008 Jan 9.
11. Saxena S et al. Alcohol and drug abuse. New Age Publishers and National Book Trust, New Delhi, 2003.
12. Karki Y et al. A study on the economics of tobacco in Nepal. Washington, DC:The World Bank; 2003.
13. World Health Organization. World Health statistics 2011. Geneva, 2011.
http://www.who.int/whosis/whostat/EN_WHS2011_Full.pdf (accessed 28 December 2011).

14. Perera M et al. Equity in health carethe case of diabetes in Sri Lanka. Marga Institute
http://www.margasrilanka.org/reading_equity.htm (accessed 28 December 2011).

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

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

2011

Chapter 6

59

National Response to NCDs

NCDs are now recognized as an important health problem in all


Member countries.

Health ministries of Member countries currently lead NCD national


policies and programmes.
Risk factor surveillance has been established in most Member
countries but morbidity and mortality surveillance is generally
ineffective.

Existing primary health-care systems need to be strengthened to


address NCDs at the grass root level.

Member countries in the Region have


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

Institutional Capacity for NCD


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

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

2011

60

countries. The main functions of the NCD


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

National Policies, Strategies, Plans


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

Policies/plans/programmes

There is a high level of national


commitment for tackling NCDs as reflected by
the large number of policies, strategies, plans,

2011

programmes, legislations/regulations and


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

National NCD guidelines

The availability and implementation of


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

Legislative measures on NCD


prevention and control

Legislative measures and effective law


enforcement are key to implementing
comprehensive NCD prevention and control

61

countries except Indonesia have ratified the


WHO FCTC and are implementing the various
elements of MPOWER a package of six
effective tobacco control policies (Table 6.3).

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

In Thailand, the Thai Health Promotion


Foundation (ThaiHealth) has played a crucial
role in NCD prevention and control, particularly
in increasing tobacco taxation. The consistent
increase in taxes over the past several years has
led to a steady decrease in smoking prevalence
among adults. Similar taxation is needed to
reduce the demand for other unhealthy
products such as sugary drinks; conversely,
subsidies should be provided on fruits and
vegetables.

Table 6.1: Number of South-East Asia Region Member countries with


policies, strategies, action plans and programmes for NCD prevention and
control, 2010 (n=11)
Integrated or diseasespecific tools

Policy

Integrated

Strategy

Plan
9

Programme Any of
these
8

11

Heart diseases

Diabetes

Cancer

Chronic respiratory disease

6
5

7
8

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

Table 6.2: Number of countries with national-level NCD guidelines,


South-East Asia Region, 2010 (n=11)
Health conditions/

Availability of national
level guidelines

services

Available

Diabetes

Overweight/obesity

Hypertension
Dyslipidemia

Alcohol dependence

Tobacco dependence
Dietary counselling
Physical inactivity

8
3
5
4
6
4

Implementation

Under
development

Full

Partial

1
1

5
2

1
1
2
1
1

1
3
2
4
3

4
2
2
3
3
1

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

2011

62

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

Ratification of WHO FCTC

Bangladesh Bhutan

DPRK

India Indonesia Maldives

Myanmar Nepal

Sri Lanka

Thailand

Timor-Leste

Monitor tobacco use and prevention policies


Global Adult Tobacco
Survey (GATS)

X
Global Youth Tobacco
Survey (GYTS)

X
X

X
X

X
X
X

X
X

X
X

X
X

X
NA

X
X

X
X

X
X

X
X

X
X

X
X

32%

50%

29%

73%

69%

NIL

Protect people from tobacco smoke


Smoke-free health care facilities
Smoke-free government facilities X
Smoke-free public transport
X
Smoke-free educational institutes
National law requiring fine
for smoking

Fines levied on the establishment X

Offer help to quit tobacco use


Tobacco quit lines available

Warn about dangers of tobacco use


Graphic health warnings
X
Textual health warning

Enforce Bans on tobacco advertising, promotion and sponsorship


Ban on national TV and radio

X
Ban at point of sale

X
Ban on billboards and
outdoor advertising

X
Raise taxes on tobacco
Taxation rate on cigarettes

68%

NA

NA

46%

54%

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

Bangladesh is the first country in the


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

Surveillance and Monitoring


Accurate
information
through
a
sustainable surveillance system is essential for

2011

formulating evidence-based policies, planning


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

Risk factor surveillance

At least one NCD risk-factor survey


(national or subnational) has been completed in

63

Mobile courts, Bangladesh

Box 6.1: Innovative law enforcement using mobile courts, Bangladesh


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

all 11 Member countries. In six countries,


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

6.4). Risk-factor surveys, based on WHO STEPS


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

2011

64

Table 6.4: Type of risk surveys conducted and the latest year, countries of
WHO/SEA Region
Country

STEPS*

Latest

Bangladesh

2010

DPRK

2009

Bhutan
India

Indonesia
Maldives

Myanmar
Nepal

Sri Lanka
Thailand

Timor Leste

2007
2006

2006

2004

2007

2007

2007
NA
NA

No. of
rounds
2

1
3

GATS**

Latest No. of
rounds
2009
NA
NA

NA
NA

NA

2007

NA

NA

NA
NA

NA

2009
NA

NA

2009

NA

NA

NA

NA

2009

NA

2007

Latest

NA

2009-2010
on-going

Latest No. of
rounds

GSHS****

NA

GYTS***

NA
1

NA

2009
2007

2007
2007

2009
2009

No. of
rounds
NA

NA

NA

2009

2010

2006

2007
2003

2008
2009

2009

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

measurement survey. Most countries have


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

Morbidity and mortality surveillance

Disease-specific morbidity data are


generally collected through a routine health

2011

information system in all 11 countries; mortality


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

65

Table 6.5: Number of disease registries reported by Member countries,


South-East Asia Region

Indicator

Cancer

Disease registry present


Scope

National
Sub-national

Source of data
Population-based
Hospital-based

Diabetes

Myocardial
infarction

Stroke

Chronic
respiratory
diseases

9*

5
4

2
3

1
2

2
2

2
1

3
8

1
4

1
2

1
3

1
2

* Number of countries answering in the affirmative.


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

Bangladesh has subnational hospital-based


registries for all listed diseases and DPR Korea
reported having population-based nationallevel registries for several NCDs. Sri Lanka has
registries on cancers and also has a chronic
kidney disease registry. Myanmar and TimorLeste have not yet reported on registries.

system for monitoring response to the NCD


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

A major limitation of mortality and


morbidity surveillance systems in the Region is
that they are largely hospital-based, which
compromises the representativeness of the
information generated. While hospital-based
disease-specific registries are a useful source for
obtaining clinical data, such as disease patterns
and survival rates, population-based disease
registries are needed for estimation of incidence
rates that are currently lacking from the Region.
Moreover, establishment and management of
disease registries need technical expertise and
are resource intensive.

Health System Capacity for NCD


Prevention, Early Detection,
Treatment and Care

Surveillance and monitoring system


for health system response

According to available information, no


country in the Region has a comprehensive

Traditionally, health systems in SEAR are


geared towards providing maternal and child
health care, immunization and deal with
communicable diseases; NCDs have been
generally neglected. With the emergence of
NCDs, it is imperative to reorient health
systems and retrain health personnel to provide
long-term prevention, care and treatment
services to address NCDs.

NCD prevention and control at


primary health-care level

The availability of services at the primary


health-care
level
has
become
more

2011

66

comprehensive over the years. All Member


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

Availability of diagnostic facilities


for NCDs at primary health care
level

A selected set of diagnostic devices to


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

Integrated primary heath care services


Sri Lanka

Box 6.2: Integrating NCD prevention and control into primary health care services, Sri Lanka

2011

The WHO Package of Essential Noncommunicable Diseases Interventions (WHO


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

67

Table 6.6: Availability of NCD tests and procedures (in more than 50% of
facilities) at primary health care level, SEAR, 2010

Health condition Procedure


Overweight
and obesity
Cancer

Diabetes

Cardiovascular
diseases
Chronic
respiratory
diseases

No. of countries
where available

Weight measurement
Height measurement
Waist circumference

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

Blood glucose
Oral glucose tolerance test
Glycosylated haemoglobin
(HbA1c)
Fundal examination
Foot vibration perception
by tuning fork
Foot vascular status by
doppler

9
8
4

Reasons for non-availability


Lack of
Lack of
equipment trained staff
2
2
2

0
0
5

3
8
0
1

2
1
9
7

3
1
1
2

2
1

8
2

0
6

2
1
4

9
3

6
4
3

2
2

3
3
3

0
2

Electrocardiogram
Blood pressure
Lipids including LDL, HDL
and triglycerides

5
11

5
0

0
0

Spirometry

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

countries like Bangladesh, these services are not


included in the primary health-care package
and thus there has been no planning to either
provide these equipments at the primary healthcare level or to train human resources for it.

NCD-related drugs

An uninterrupted and sustained supply of


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

management system is essential. All Member


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

2011

68

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

budget. General government revenue is the


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

Innovative financing,
Thailand

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

25

100

80

20
60
15
40
10
20

5
0

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

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

2011

Excise tax (%)

Regular smokers (%)

30

Excise tax (%)


Regular smokers (%)

Consistent
reduction in
smoking
prevalence
with increase
in
tobacco tax

69

expenditure is the main funding source in India.


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

Partnerships and Collaboration


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

collaboration are important for creating an


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

2011

Chapter 7

71

Major Challenges in Prevention and


Control of NCDs
The South-East Asia Region has a huge
population base with 1.7 billion people and is a
diverse Region with the population size of
Member countries varying from 1.2 billion in
India to less than a million in Maldives and
Bhutan. Additionally, there are enormous
intercountry and intracountry differences in
topography, culture, ethnicity, etc. Addressing
health issues in such large and diverse
populations
poses
many
challenges.
Furthermore, high out-of-pocket expenditure
on health care, poor coverage of health and
social insurance schemes and unregulated role
of the private sector undermines equitable
health care in most countries of this Region. The
specific challenges in NCD prevention and
control are as follows:

Lack of strong national partnerships


for multisectoral actions

The underlying determinants for NCDs


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

brunt of NCDs, ministries of health must carry


out high-level advocacy and take the lead in
bringing together the different stakeholders to
address NCDs. Without effective and strong
partnerships among different sectors, NCD
prevention will remain an elusive goal.

Weak surveillance systems

Lack of availability of robust surveillance


and research data on NCDs is an important
barrier
to
effective
planning
and
implementation of NCD prevention and control
programmes in the Region. There are many
issues with the current surveillance systems.
First, NCD surveillance systems are often not
institutionalized and rarely integrated into the
national health information systems. Although
almost all countries have conducted one or
more NCD risk factor surveys, these are not yet
routine; and are usually dependent on funds
and other factors. Second, there is lack of a
comprehensive framework for surveillance and
monitoring at the national and subnational
levels. Specific indicators and clear targets at the
national and subnational levels and systems for
monitoring are non-existent. Without such a
system, uniform tools for data collection,
systematic data analyses or standard reports to
guide the programme do not exist. Third, most
countries do not report reliable mortality
statistics due to weak civil registration systems.
Fourth,
population-based
cause-specific
morbidity and mortality data collection systems
continue to be poor. While coverage for
2011

72

morbidity data in national information systems


has shown an increase, it is still hospital-based.
Finally, surveillance and research for NCDs are
poorly funded.

Limited access to prevention, care


and treatment services for NCDs

Lack of access to basic prevention and


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

Limited human resources for NCDs

Health systems in the Region are


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

2011

in an inadequate workforce capacity at the


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

Insufficient allocation of funds

Funds allocated for NCD programmes are


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

Difficulties in engaging the industry


and private sector

Profit making industries, such as the food


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

73

Lack of social mobilization

The ministries of health of Member


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

society and government agencies for NCDs. One


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

2011

Chapter 8

75

WHO Initiatives in NCD Prevention and


Control
Over the past decade, WHO has played a
leadership role in addressing the NCD
pandemic at global, regional and country levels.
WHO has raised the priority accorded to NCDs
through high-level advocacy, set norms and
standards, generated the evidence base for
effective policies, strategies and interventions
as well as for surveillance, monitoring and
evaluation. In SEAR, there has been a growing
recognition and commitment to address NCDs.

SEARO is coordinating activities for prevention


and control of NCDs for its 11 Member
countries; providing technical and financial
support to countries in NCD surveillance,
monitoring, evaluation, research, policy and
strategy development; assisting countries in
integrating NCD control in their primary
health-care based health systems, and;
promoting and forging partnerships for NCD
prevention and control in the Region.

Global initiatives

May 2000

The World Health Assembly endorsed the Global strategy on the


prevention and control of NCDs, providing a global vision for
addressing them. The global NCD strategy has three objectives: (i)
mapping the NCD epidemic and its causes; (ii) reducing main risk
factors through health promotion and primary prevention
approaches; and (iii) strengthening health care for people already
afflicted with NCDs.

May 2003

The World Health Assembly endorsed the WHO Framework


Convention on Tobacco Control.

May 2004

The World Health Assembly endorsed the Global strategy on diet,


physical activity and health.

December 2006

The UN General Assembly adopted resolution A/RES/61/225,


encouraged Member States to develop national policies for the
prevention and control of diabetes.

May 2008

The World Health Assembly endorsed the Action Plan for the
Global Strategy for the Prevention and Control of NCDs
(20082013).

2011

76

May 2010

The World Health Assembly endorsed the Global Strategy to


Reduce the Harmful Use of Alcohol.

May 2010

The A/RES/64/265 was adopted unanimously by the UN General


Assembly calling for a High-level Meeting on NCDs.

April 2011

The first global ministerial conference on healthy lifestyles and NCD


control was held in Moscow culminating in the Moscow Declaration.

May 2011

The Sixty-fourth World Health Assembly endorsed resolution WHA


64.11 on Preparation for the UN High-level Meeting (UNHLM) on
noncommunicable diseases.

September 2011

The UNHLM was conducted in New York with participation of heads


of states, ministers and other high-level delegates from Member
countries. The outcome of the UNHLM meeting was the adoption of
a political declaration on NCDs. The political declaration is expected
to galvanize support from governments and international donors
for increased financial resources for NCD interventions; act as a
milestone in advocating for Healthy Public Policies/Health in All
Policies approach to the prevention and control of NCDs; help
produce measurable targets and commitments from governments
and the international community to act against NCDs and provide
an impetus to implement the global strategy for the prevention and
control of NCDs (2000) as well as the action plan (20082013)
endorsed by the World Health Assembly in 2008.

Regional Initiatives

Some of the recent regional events and initiatives for prevention and control of NCDs are listed
below:

2011

November 2005

South-East Asian Network of NCD (SEANET-NCD) was created at


a regional meeting in Bondos, Maldives, to strengthen and formalize
regional partnerships on NCD prevention and control. SEANETNCD meets biennially and greatly facilitates WHO advocacy for
multisectoral approaches in integrated NCD prevention and control.

October 2006

A regional meeting on implementing the global strategy on diet,


physical activity and health in the SEAR was organized in Yangon,
Myanmar to facilitate regional and country-level implementation of
the global strategy.

September 2007

The Regional Framework for Prevention and Control of NCDs was


endorsed at the Sixtieth session of the WHO Regional Committee
for South-East Asia, vide its resolution on Scaling up Prevention
and Control of NCDs in the South-East Asia Region
(SEA/RC60/R4). The key elements of the regional framework
included: epidemiological assessment of NCDs and their

77

determinants; awareness generation and high-level advocacy;


formulation and adoption of policy and strategic plan for integrated
prevention and control of major NCDs; capacity building; resource
mobilization; as well as multisectoral and multilevel actions to
modify determinants.
October 2007

The second meeting of SEANET-NCD was held in Phuket, Thailand.


The inputs for development of a regional and global plan of action for
integrated prevention and control of NCDs were discussed.

June 2009

The third Meeting of SEANET-NCD was held in Chandigarh, India.


The meeting reviewed the progress in scaling up of NCD prevention
and control, particularly the role of SEANET. The meeting also
discussed and contributed to global recommendations on marketing
of food and non-alcoholic beverages to children.

September 2009

The 31st session of South East Asia-Advisory Committee on Health


Research (SEA-ACHR) was held in Kathmandu. The session
discussed research priorities in NCDs and called for intersectoral
collaboration in carrying out research on NCDs.

September 2010

The Sixty-third session of the WHO Regional Committee for SouthEast Asia discussed progress in prevention and control of NCDs in
the Region.

January 2011

A Regional Civil Society Meeting, with support from SEARO was


organized by the Nepal Public Health Foundation (NPHF) in
Kathmandu, during 1923 January, 2011. This meeting resulted in
the Kathmandu Call for Action on NCDs.

March 2011

A regional meeting on health and development challenges of NCDs


was held during 14 March in Jakarta, Indonesia with participation
of all the 11 Member States of the Region. The meeting culminated
in the Jakarta Call for Action on prevention and control of NCDs
and preparation of a report on key messages for UNHLM.

July-September 2011

Country-level multistakeholder meetings were held in 10 of the 11


Member States, along the lines of the regional consultation in
Jakarta, with WHO support. As part of preparations for these
meetings, some countries undertook an assessment of the NCD
situation as well as national capacity and health system response to
address NCDs. The national meetings aimed to discuss inputs to the
UNHLM, build consensus on a multisectoral response to the NCD
epidemic and trigger the development of national multisectoral
medium-term plans for prevention and control of NCDs.

September 2011

The Sixty-third Health Ministers meeting discussed and adopted


ten key messages for the UNHLM from SEAR.

2011

Chapter 9

79

The Way Forward

The UNHLM on NCDs held in New York


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

Guiding Principles for NCD


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

Integrated approach: As the four major


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

2011

80

approach, NCDs and their risk factors are


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

Equity and social justice: NCD


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

Specific strategies and


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

2011

Health promotion and primary


prevention to reduce risk factors for
NCDs using multisectoral approach

The majority of NCDs can be averted


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

Health system strengthening for


early detection and management of
NCDs

In conjunction with primary prevention


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

81

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


Risk factor/disease
Tobacco use

Harmful use of alcohol


Unhealthy diet
Cardiovascular diseases and diabetes

Cancers

Interventions

Protect people from tobacco smoke


Warn about the dangers of tobacco
Enforce bans on tobacco advertising
Raise taxes on tobacco
Enforce bans on alcohol advertising
Restrict access to retailed alcohol
Raise taxes on alcohol

Reduce salt intake in food


Replace trans fat with polyunsaturated fat

Provide counselling and multi-drug therapy (including glycaemic


control for diabetes mellitus) for people with 10-year
cardiovascular risk >30%
Treat acute myocardial infarction (with aspirin)

Hepatitis B vaccination to prevent liver cancer


Detection and treatment of precancerous lesions of the cervix and
early stage cervical cancer

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

project), and are planned in DPR Korea,


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

Surveillance and research

Surveillance and monitoring of NCDs is


essential
to
policy
and
programme
development. A comprehensive national NCD
surveillance system should include surveillance

for risk factors (or measurement of exposure),


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

2011

82

Role of Different Agencies in NCD


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

prevention and control of NCDs as many


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

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


Responsibility of
governments

I
I
I
I
I

Responsibility of
civil society

I
I
I

Responsibility of
academia

I
I
I
I

Responsibility of
media

I
I
I
I

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

2011

I
I
I

I
I
I

Make noncommunicable diseases (NCDs) a national development agenda and include


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

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

83

The NCD epidemic places an enormous


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

scientific evidence need to be designed,


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

2011

Annexes

Females

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

Males

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

Total
54.6
0.3
15.1
312.5
104.8
0.2
24.1
11.1
8.5
35.1
0.2
566.5

48.9
0.3
11.9
321.9
110.7
0.2
21.8
8.9
8.5
35.6
0.3
568.9

Cancers

Females Males

Source: Global Health Observatory, World Health Organization, 2011

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

Country
103.5
0.5
26.9
634.4
215.5
0.4
45.8
20.0
17.0
70.7
0.5
1135.4

Total
9.4
0.0
3.6
80.4
25.7
0.0
4.5
1.6
3.8
22.5
0.0
151.6

Females
10.2
0.1
2.3
96.3
22.6
0.0
4.2
1.6
3.3
13.3
0.0
153.8

Males

Total

19.6
0.1
5.9
176.7
48.3
0.0
8.7
3.2
7.1
35.8
0.1
305.4

Diabetes mellitus
148.9
0.7
36.9
1002.5
235.6
0.1
61.1
20.6
22.8
75.8
0.5
1605.6

Females

166.9
0.9
29.9
1330.6
277.5
0.2
64.2
24.5
30.6
84.4
0.7
2010.3

Males

315.8
1.6
66.8
2333.1
513.1
0.3
125.3
45.1
53.5
160.2
1.2
3615.9

Total

Cardiovascular diseases

31.4
0.1
7.2
472.1
45.5
0.0
12.3
4.1
6.5
10.3
0.1
589.7

Females

37.4
0.2
7.0
618.7
73.8
0.1
14.7
5.6
8.8
30.0
0.2
796.4

Males

Total

68.8
0.3
14.1
1090.8
119.4
0.1
27.0
9.7
15.3
40.3
0.3
1386.1

Chronic respiratory diseases

Annex 1: Estimated number of deaths (in thousands) by major noncommunicable diseases


(NCDs), 2008

85

2011

2011

654.7
667.2
477.4
582.3
547.8
564.5
591.5
543.5
490.5
563.2
476.8

Females

751.2
801.0
644.4
793.0
762.7
621.9
755.6
711.0
781.4
811.3
649.6

Males

All NCDs
701.7
735.2
547.6
684.6
647.0
593.7
667.1
620.2
623.1
675.0
559.7

Total
106.2
119.0
98.9
72.0
109.4
228.8
116.3
118.8
79.0
97.6
95.0

104.5
131.8
122.0
78.9
136.5
290.9
124.5
114.0
91.6
115.6
121.5

Cancers

Females Males

Source: Global Health Observatory, World Health Organization 2011

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

Country
105.0
124.8
106.4
75.0
120.9
261.5
119.8
116.4
84.3
105.9
107.5

Total
22.1
18.7
23.1
21.0
29.0
8.2
23.4
21.0
36.7
64.4
19.3

Females
25.6
26.1
22.6
26.9
29.9
3.7
25.6
24.5
39.8
46.4
21.8

Males

23.8
22.3
23.1
23.8
29.5
5.8
24.4
22.6
38.2
56.3
20.5

Total

Diabetes mellitus
371.0
372.1
245.1
268.7
278.2
214.1
317.8
285.7
220.0
229.7
258.3

Females
424.2
444.7
318.3
366.1
373.9
215.2
398.0
379.6
364.5
304.2
336.6

Males

397.2
409.8
278.6
316.5
323.6
214.1
355.0
329.0
285.7
265.3
296.1

Total

Cardiovascular diseases

73.7
73.0
48.8
128.5
53.6
66.5
63.0
55.8
62.3
30.7
50.0

Females

91.7
93.3
77.2
181.2
103.1
60.2
91.6
87.1
107.1
119.2
77.8

Males

82.5
83.5
59.9
153.6
75.8
63.1
76.0
70.1
82.3
68.6
63.2

Total

Chronic respiratory diseases

Annex 2: Age-standardized death rates due to noncommunicable diseases (NCDs) per 100 000
population in Member countries of SEAR, 2008

86

27.2
8.0
30.5
22.9
36.2
46.0
32.5
23.5
29.1
30.7
29.6

Breast
(females)
29.8
20.4
6.6
27.0
12.6
13.3
26.4
32.4
11.8
24.5
11.4

Cervix uteri
(females)
3.5
4.0
7.2
1.2
3.5
0.0
6.3
1.1
1.0
19.9
2.5

4.1
8.1
15.8
3.2
10.3
0.0
16.5
1.7
2.3
40.6
7.6

4.0
4.4
16.0
3.5
15.6
2.0
12.0
4.8
5.8
13.4
11.2

4.5
7.9
15.0
4.3
19.1
7.8
12.3
5.3
7.5
13.2
17.6

Cancer site
Liver
Colorectum
Females Males
Females
Males

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

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

Country
8.7
10.8
25.8
2.5
10.9
0.0
13.9
18.2
2.7
12.1
7.2

30.4
8.7
34.0
10.9
29.8
20.3
22.9
20.7
12.0
26.8
28.6

Lung
Females
Males

1.9
1.7
2.3
3.7
10.6
3.0
5.8
2.2
5.8
6.5
7.9

Prostate
(males)

Annex 3: Age-standardized incidence per 100 000 persons of common


cancers in Member countries of SEAR, 2008

87

2011

2011

Source: Global health risks, World Health Organization 2009

Childhood and maternal under-nutrition


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

Risk factor

Attributable fraction
(%)
5.4
0.8
1.7
0.7
2.4
9.4
4.9
6.8
2.2
2.9
5.1
6.8
2.3
0.5
2.2
0.5
3.9
1.4
4.1
0.5
0.4
1.8
0.8
0.2

Attributable deaths
(number in thousands)
964
815
301
583
751
405
213
497
366

1 438
756
1 044
343
449 583
781 670
1 037 188
354 481
72 879
331 809
72 526
668
114
336
137
982
000

828
121
252
110
365

598
207
630
70
57
270

121 294
37 998

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

88

162
0.7
24
1200
230
0.3
50
29
20
68
1.1
1 784
6 817

2009

31
31
22
31
27
28
27
37
24
22
45
30
27

2009

6
7
14
7
9
6
8
6
12
11
5
8
11

2009

2.0
0.0
1.3
1.9
1.5
2.5
1.4
2.5
0.9
1.0
1.2
1.8
1.5

1.6
2.5
0.5
1.6
1.3
1.4
0.8
2.1
0.8
0.9
3.3
1.5
1.2

19891999 19992009

Population
Total
Aged
Aged
Annual growth rate (%)
(millions) under 15 (%) over 60 (%)

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

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

Country
20
16
58
26
31
26
25
9
17
29
21
26
43

1990
24
25
60
28
42
28
28
13
16
31
24
29
47

2000
28
36
63
30
53
39
33
18
15
34
28
33
50

2009

Living in urban areas (%)

Annex 5: Regional and global demographic indicators

24
24
34
25
28
24
28
21
30
33
17
26
29

2009

Median
age (years)

89

2011

2011

2.8
6.7

4.6
2
8.7
2.1
5.1
3.7
3.4
8.8
3.9

2000

3.3
5.5

4.2
2.3
13.7
2.3
6
4.1
4.1
13.9
3.8

2008
7.6
12.6

3.9
4.5
11.1
1.2
7.7
6.9
9.9
12.7
4.7

2000

7.4
13

4.4
6.2
13.8
0.7
11.3
7.9
14.2
11.9
5.6

2008

General government
expenditure on health as
percent of total
government expenditure

Source: World Health Statistics 2011, World Health Organization 2011

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

Country

Total expenditure on health


as percent of gross
domestic product
2008

95.1
96.5
free services free services

92.2
74.4
72.9
70.3
73.8
72
99.2
95.7
91.2
72.4
83.3
86.7
76.9
68.1
43.4
37.2
89.4
75.1

2000

Out-of-pocket
expenditure as percent
of private
expenditure on health
22
165
---69
47
242
12
43
101
165
67
64

2000
44
263
---122
91
769
27
66
187
328
112
116

2008

Per capita total


expenditure on health
(PPP int. $)

9
131
---19
17
113
2
11
49
92
48
21

2000

14
217
---40
49
470
2
25
82
244
93
46

2008

Per capita government


expenditure on health
(PPP int. $)

Annex 6: Health expenditure in Member countries of SEAR, 2000 and 2008 comparison

90

43 315
52
74 597
660 801
65 722
552
23 709
5 384
10 279
18 918
79
903 408
9 171 877

Number
3.0
0.2
32.9
6.0
2.9
16.0
4.6
2.1
4.9
3.0
1.0
5.4
14.0

Density*
39 992
545
93 414
1 430 555
465 662
1 539
41 424
11 825
40 678
96 704
1 795
2 224 133
19 379 771

Number

2.7
3.2
41.2
13.0
20.4
44.5
8.0
4.6
19.3
15.2
21.9
13.3
29.7

Density*

Nursing and midwifery


personnel 20002010

Source: World Health Statistics 2011, World Health Organization 2011


* per 10 000 population

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

Country

Physicians 20002010
6 091
80
2 685

6 493

2 013
172
2 411
2 151
22

Number

0.4
0.4
1.2

0.3

0.4
0.1
1.1
0.4
0.3

Density*

Number

Density*

48 692
195

50 715

478
3 247
16 206

10
119 543
1 369 772

3.3
0.9

0.5

13.8
0.6
6.3

0.1
0.9
4.0

Public health workers Community health workers


20002010
20002010

Annex 7: Health workforce in Member countries of SEAR

91

2011

2011

1.

In addition, mortality and morbidity data reported in country


reports were used wherever available. However, these country

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

Mortality data presented in Chapter 2 were obtained primarily


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

Note on data sources and limitations

2.

Methods for risk factor data are presented in the Global status
report on noncommunicable diseases 2010. Briefly, these data are
based on country reported results from national surveys as well as
published and unpublished literature. These data have come from
surveys/studies that fulfilled certain criteria such as: a random
sample of the general population, with clearly indicated survey
methods (including sample size) and risk factor definitions.
Adjustments were made for the following factors so that the same
indicator could be reported for a standard year (in this case 2008)
in all countries: standard risk factor definition, standard set of age
groups for reporting, and representativeness of the population.
Using regression modeling techniques, crude adjusted rates for
each indicator were produced. To further enable comparison

reports contained limited or disparate information and were not


readily accessible. Moreover, country-specific definitions and
methodologies limited comparability of data across countries.
Most country reports used hospital-based data, sometimes only
from one location in the country, thus limiting the
representativeness of the data. Some countries used registration
data that were grossly incomplete and underreported. Extensive
efforts were made to locate regional literature and web documents,
and the same have been used extensively in this report.

92

3. Data presented in Chapter 5 were obtained from a capacity


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

among countries, age-standardized comparable estimates were


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

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

93

2011

94

2011

Noncommunicable Diseases in the South-East Asia Region 2011

Noncommunicable
Diseases in the
South-East Asia Region

diseases in the South-East Asia Region, their underlying risk

factors and socioeconomic determinants. The report also


summarizes the progress countries are making for tackling
the NCD epidemic, provides the base for regional and country

responses, highlights some good country practices and


recommends the way forward in addressing NCDs and risk
factors in a comprehensive and integrated way. The report is

Situation and Response

This report describes the current burden of noncommunicable

intended for policy-makers in health and development,

2011
Situation and Response

health professionals, researchers and academia, and other

key stakeholders involved in prevention and control of NCDs.

WHO
SEARO