1. NCDs: global situation and response
Dr Nick Banatvala
Senior Adviser to the Assistant Director General
for Noncommunicable Diseases and Mental Health

2. Noncommunicable diseases (NCDs):
Cardiovascular diseases (e.g. heart diseases, stroke)
Cancers
Diabetes
Chronic respiratory diseases (e.g. asthma)
Risk factors for noncommunicable diseases:
Tobacco use
Unhealthy diet
Physical inactivity
Harmful use of alcohol

3. Four types of NCDs are largely preventable by means of effective interventions that tackle shared modifiable risk factors
Chronic
respiratory
diseases
Cardiovascular
disease
Diabetes
Cancer
Mental disorders
Injuries
Noncommunicable diseases and conditions
Physical inactivity
Risk factors
Harmful use of alcohol
Unhealthy
diets
Tobacco

4. World Health Organization
7 April 2019
The top-10 causes of death
Source:
Low-income countries
Middle-income countries
Lower respiratory infections
Coronary heart disease
Diarrhoeal diseases
HIV/AIDS
Stroke and cerebrovascular disease
Chronic pulmonary disease
Tuberculosis
Neonatal infections
Malaria
Premature and low birth weight
Lower respiratory infection
Trachea, bronchus, lung cancers
Road traffic accidents
Hypertensive heart disease
Stomach cancer
Diabetes mellitus

5. World Health Organization
7 April 2019
NCDs are the single biggest cause of death
10%
60 million
5.1 M
50 million
26.9 M (above the age of 60)
40 million
30 million
Source: WHO global estimates 2008
9.1 M
(below the age of 60)
20 million
15.7 M
10 million
Total deaths in the world (2008)
Low-income countries
Group III - Injuries
Group II – Other deaths from NCDs
Group II – Premature deaths from NCDs (below 60 years), which are preventable
Group I – Communicable diseases, maternal, perinatal and nutritional conditions

6. World Health Organization
7 April 2019
Four types of NCDs account for most deaths in all regions
100%
80%
60%
40%
20% 0%
WHO Region
for Africa
WHO Region for the
Eastern Mediterranean
WHO Region
for the Americas
WHO Region
for Europe
WHO Region for
South-East Asia
WHO Region for the
Western Pacific
Diabetes
Respiratory diseases
Cancers
Cardiovascular diseases
Other NCDs

7. 19 13.8 million Deaths in 2011 Age groups
fact 19
In 2011, 13.8 million people died from NCDs between the ages of 30 and 70. Most of these premature deaths from NCDs could have been prevented.
10%
13.8 million
Deaths in 2011
Age groups
Source: WHO Global Burden of Disease (2011)

8. 20 11.8 million Deaths from NCDs age groups
85% of premature deaths from NCDs between the ages of 30 and 70 occur in developing countries, resulting in 11.8 million premature deaths in 2011, which could be prevented
fact 20
11.8 million
Deaths from NCDs
age groups
Source: WHO Global Burden of Disease (2011)

9. World Health Organization
7 April 2019
90% of global premature deaths from NCDs occur in low- and middle-income countries
2.9M
13.6M
25 million
20 million
Total deaths (2008)
15 million
Source: WHO global estimates 2008
5.3M
10 million 1M
8.3M
2.3 M
0.5M
6.6M
0.8M
1.4M
4.4M
5.6M
1.4M 1M
1.2M
0.6M
High-income countries
Upper middle-income
Lower middle-income
Low-income countries
Low-income countries
Group III - Injuries
Group II – Other deaths from NCDs
Group II – Premature deaths from NCDs (below 60 years), which are preventable
Group I – Communicable diseases, maternal, perinatal and nutritional conditions

11. Premature deaths from NCDs
44% of all NCD deaths occur before the age of 70
A higher proportion (48%) of all NCD deaths are estimated to occur in people under the age of 70 in low- and middle income countries, compared with 26% in high income countries

12. World Health Organization
7 April 2019
Causal links
NCDs
Raised blood pressure
Overweight/obesity
Raised blood glucose
Raised lipids
Tobacco use
Unhealthy diet
Physical inactivity
Harmful use of alcohol
Globalization
Urbanization
Population ageing
Metabolic/
physiological
risk factors
Underlying drivers
Behavioural
Social Determinants of Health

13. Attributable Mortality Attributable DALYs
Leading causes of attributable global mortality and burden of disease (2004)
Attributable Mortality
Attributable DALYs %
High blood pressure
Tobacco use 8.7
High blood glucose
Physical inactivity
Overweight and obesity
High cholesterol
Unsafe sex
Alcohol use 3.8
Childhood underweight
Indoor smoke from solid fuels 3.3
59 million total global deaths in 2004 %
Childhood underweight 5.9
Unsafe sex 4.6
Alcohol use 4.5
Unsafe water, sanitation
High blood pressure 3.7
Tobacco use 3.7
Suboptimal breastfeeding 2.9
High blood glucose 2.7
Indoor smoke from solid fuels 2.7
Overweight and obesity 2.3
1.5 billion total global DALYs in 2004

14. Leading risk factors for global mortality
Source: WHO's report on "Global health risks"
60% of global death are due to non communicable diseases;
That includes 15% of the total number of deaths with occurs before the age of 60, and 27% of the total number which occurs before the age of 70.
High blood pressure is ranked 1th on global level
Physical inactivity is ranked 4th on global level (5.5%) – overweight/obesity 4.8% - unsafe sex 7th with 4 %: money to HIV-AIDS enormous.
60% of global deaths due to NCDs

15. Percentage of DALYs attributed to 19 leading risk factors (2004)

16. NCD Risk Factors (2008 estimates)

17. % insufficiently active
% insufficiently active*, WHO estimates, ages 15+ years, 2008, age std, by WHO region and WB income group
*defined as not meeting any of the following criteria: 30 mins of moderate activity on at least 5 days per week OR 20 mins of vigorous activity on at least 3 days per week OR an equivalent combination.

18. % raised blood pressure*, WHO estimates, ages 25+ years, 2008, age std
**defined as SBP ≥ 140 and/or DBP ≥ 90 or on medication for raised blood pressure.

19. High blood pressure continues to go up
40%
30%
High-income countries
Upper Middle-income countries
% of population
Lower middle-income countries
20%
Low-income countries
10%
1980
2008
Raised blood pressure (2008)
Source: WHO NCD Country Profiles (2010)

20. % daily tobacco smoking, WHO estimates, ages 15+ years, 2008, age std, by WHO region and WB income group

21. Overweight continues to increase
Nutrition transition: As incomes rise and populations become more urban, societies enter different stages of what has been called the nutrition transition.
Generally, diets high in complex carbohydrates and fiber give way to diets with a higher proportion of fats, saturated fats, and sugars.
These shifts in diet structure accompany demographic shifts associated with higher life expectancy and reduced fertility rates.
An associated epidemiologic transition also takes place as patterns of disease shift away from infectious and nutrient deficiency diseases toward higher rates of obesity, coronary heart disease, non-insulin dependent diabetes and some types of cancer.
World Health Statistics

22. Overweight continues to increase
70%
60%
50%
High-income countries
40%
Upper Middle-income countries
% of population
Lower middle-income countries
30%
Low-income countries
20%
10% 0%
Overweight (Body mass index _> 25)
Obesity (Body mass index _> 30)
Source: WHO NCD Country Profiles (2010)
1980
2008

23. Overweight and obesity in people over 15 selected countries
Just to provide examples of other risk factors-overweight and obesity are now showing very high rates in both industrialized and developing nations. This shows selected countries with very high rates which are still increasing particularly in LMICs. Around 22 million children under 5 are overweight today. Unlike most adults, children cannot choose the environment in which they live in or the food that they eat. You can see here countries of the regions with the highest rates of overweight and obesity

24. % raised total cholesterol
% raised total cholesterol*, WHO estimates, ages 25+ years, 2008, age std, by WHO region and WB income group
**defined as total cholesterol ≥ 5.0 mmol/L.

25. Global projections (2004 to 2030)12
Cancers 10
Ischaemic HD
Stroke 8
Deaths (millions) 6
Acute respiratory infections 4
Road traffic accidents
Perinatal 2
HIV/AIDS TB
Malaria
2000
2005
2010
2015
2020
2025
2030

26. Poverty contributes to NCDs and NCDs cause poverty
NCDs and Development
Poverty contributes to NCDs and NCDs cause poverty
Poverty at household level
Populations in low- and middle-income countries
Population ageing and Increased exposure to common risk factors
Loss of household income
Noncommunicable diseases
Limited access to effective and equitable health-care services
More than 8 million people die before the age of 60
in developing countries from noncommunicable diseases

27. The poorest people in developing countries are often affected the most
The poorest people smoke the most, often spending more than 10 per cent of their household income on tobacco 45
Smoking prevalence
Lowest household income quintiles 40 35 30 25
Highest household income quintiles % 20 15 10 5
Low-income countries
Lower-middle
Upper-middle-income
High-income
Income

28. The poorest people in developing countries affected the most
The cost of caring for a family member with diabetes can be more than 20 per cent of low-income household incomes in developing countries
The cost per year of diabetes care at household level
Insulin
Syringes
Testing
Consultation
Travel
Total cost
% of per capita Income
Mali (2004)
38%
34% 8% 7%
12%
$339.4
61%
Mozambique (2003) 5%
24% 1% 9%
$273.6
75%
Nicaragua (2007) 0%
73%
27%
$74.4
Zambia (2003)
63% 6%
$199.1
21%
Vietnam (2008)
39% 3%
46%
$427.0
51%

29. Source: Mahal et al 2010
Catastrophic spending >30% HH income in one year; Impoverishment from above poverty line to below during year

30. Economics
The cost of inaction versus action and the costs of scaling up
US$ 7T
cumulative lost output in developing countries associated with NCDs between
US$ 11B
average yearly cost for all LMICs to scale up action by implementing the "best buys"
US$1 per capita in LICs
US$1.5 and US$3 in LMICs and UMICs

31. The macro-economic impact of NCDs
Oil and gas price spike
Retrenchment from globalization
Asset price collapse
NCDs
Fiscal crisis
Flu pandemic
World Economic Forum: Global Risk Assessment 2009
Food crisis
Infectious disease

32. Key messages
NCDs are already leading health problems in almost all countries and their magnitude is still increasing
Shared risk factors
Premature deaths
The poor are disproportionately affected
Negative impact on socioeconomic development
As countries continue to develop, market forces will further promote unhealthy patterns.
Action is urgently needed

33. The 2000 global strategy for the prevention and control of NCDs
4 diseases and 4 risk factors
Goal of reducing morbidity, disability and premature mortality from NCDs
3 objectives
Mapping the epidemic
Reducing individual and population exposure to risk factors
Strengthening health care
Components: surveillance, prevention/health promotion and healthcare management
Clear roles for the three partners

34. World Health Organization
7 April 2019
World Health Assembly in 2000: There is a clear vision on how to address NCDs
*Surveillance*
Mapping the epidemic of NCDs
*Prevention*
Reducing the level of exposure to risk factors
*Management*
Strengthen health care for people with NCDs
We know what we need to do at country level

35. Clear focus on 4 NCDs and 4 common risk factors for NCDs
Tobacco use
Unhealthy diets
Physical inactivity
Harmful use of alcohol
Heart disease and stroke 
Diabetes
Cancer
Chronic lung disease
four groups of NCDs that constitute around 80%of NCD deaths and that share the same risk factors and therefore also the same strategies

36. Global Strategy for the Prevention and Control of NCDs
2000
Global Strategy for the Prevention and Control of NCDs
2003
Global Strategy on Diet,
Physical Activity and Health
2004
Action Plan on the Global Strategy for the Prevention and Control of NCDs
2008
Global Strategy to Reduce the Harmful Use of Alcohol
2009
First WHO Global Status Report on NCDs
2010
2011
UN Task Force on NCDs
UN Political Declaration on NCDs
Moscow Declaration
2013
WHO Global NCD Action Plan , including 9 global targets and 25 indicators
2014
UN General Assembly Comprehensive Review 2014 on NCDs
2015
Country Framework for Action to engage sectors beyond health on NCDS
Adoption of the Post-2015 development agenda
World Health Assembly
2025
Attainment of the 9 global targets for NCDs by 2025
UN General Assembly
2030
Attainment of the 9 global targets for NCDs by 2030 ( as part of the post-2015 development agenda)
ECOSOC

37. NCD Burden
framework for surveillance
Reducing risks and preventing diseases: population approaches
Improving health care: management of NCDs
Capacity

38. Framework for national NCD surveillance
Exposures
Behavior
Physical & metabolic
Social determinants
Outcomes
Health system capacity and response

39. Global Status Report: interventions that work
07/04/2019
Global Status Report: interventions that work
Population-based interventions
addressing NCD
risk factors
Tobacco use
Excise tax increases
Smoke-free indoor workplaces and public places
Health information and warnings about tobacco
Bans on advertising and promotion
Harmful use of alcohol
Excise tax increases on alcoholic beverages
Comprehensive restrictions and bans on alcohol marketing
Restrictions on the availability of retailed alcohol
Unhealthy diet and physical inactivity
Salt reduction through mass media campaigns and reduced salt content in processed foods
Replacement of trans-fats with polyunsaturated fats
Public awareness programme about diet and physical activity
Individual-based interventions
addressing NCDs in primary care
Cancer
Prevention of liver cancer through hepatitis B immunization
Prevention of cervical cancer through screening (visual inspection with acetic acid [VIA]) and treatment of pre-cancerous lesions
Cardiovascular disease and diabetes
Multi-drug therapy (including glycaemic control for diabetes mellitus) for individuals who have had a heart attack or stroke, and to persons at high risk (> 30%) of a cardiovascular event within 10 years
Providing aspirin to people having an acute heart attack 39

40. 19-20 September 2011: UN General Assembly HLM. New York
2nd time in the history of the UN that the GA meets on a health issue
Countries adopted a 13-page action-oriented outcome document to shape global agendas for generations to come.
Articulated roles and responsibilities for Member States and others including WHO

41. The Political Declaration…
A whole-of-government and a whole-of-society effort
Reducing risk factors and create health-promoting environments
Strengthening national policies and health systems
Encouraging international cooperation, including collaborative partnerships
Promoting research and development
Strengthening monitoring and evaluation
Follow up and way forward

42. WHO Global NCD Action Plan > Unites governments, World Bank, UN agencies and WHO around a common agenda
Vision: A world free of the avoidable burden of NCDs Goal: To reduce the preventable and avoidable burden of morbidity, mortality and disability due to NCDs by means of multisectoral collaboration and cooperation at national, regional and global levels

43. The importance of early action on NCD risk factors
Men
Women
Probability of dying between the
ages of 30 years and 70 years
If action on risk factors is taken sooner, the flow on effects will help us get closer to achieving the target 25% reduction in mortality.
Kontis et al. Lancet 2014

44. Priority actions recommended for Member States Accelerating progress at country level
Implement interventions identified by WHO as "best buys" using WHO tools:
Tobacco use
Harmful use of alcohol
Unhealthy diet and physical inactivity
Set national targets for 2025 in 2013, taking into account the 9 global targets
Develop national multisectoral NCD policies and plans to attain national targets for 2025
Strengthen national NCD surveillance systems
Integrate NCD surveillance systems into the national health information systems
Contribute information on trends in NCDs
Implement interventions identified by WHO as "best buys" into the basic primary health care

45. Where do we stand? Progress in Member States: NCD infrastructure
In the Political Declaration (2011), Member States committed to:
Consider the development of national targets (paragraph 63)
Establish national multisectoral plans by 2013 (paragraph 45)
Implement interventions to reduce exposure to risk factors and enable health systems to respond (paragraph 43, 45)
Strengthen surveillance systems (paragraph 60)
 Progress achieved in Member States
2013
2010
Countries with a unit, branch or department in a Ministry of Health with a responsibility for NCDs
95%
89%
Countries with integrated national policies or plans on NCDs
78%
65%
Countries with integrated operational policies or plans on NCDs with a dedicated budget
50%
32%
Countries with cancer registries
81%
80%
Countries which have conducted recent risk factor surveys
63%
30%
Countries providing primary prevention and health promotion
85%
Countries providing risk factor detection
88%
77%
Countries providing risk factors and disease management
82%

46. WHO Global NCD Action Plan 2013-2020 9 global targets to be attained by 2025

47. WHO Global NCD Action Plan > 25 outcome indicators (to measure outcomes in 2015, 2020 and 2025)