1. Policy Makers and Regional Health Institutions Response to NCDs and the Link with Civil Society Healthy Caribbean Coalition Conference Barbados, October 2010 C. James Hospedales Senior Advisor and Coordinator, NCD Prevention & Control Pan American/World Health Organization

2. What’s the role of Civil Society and NGOs in the prevention & control of NCDs? Advocacy, creating mass /popular movements Advocacy, creating mass /popular movements Monitoring/watchdog role Monitoring/watchdog role Providing education and training Providing education and training Research Research Service provision for people with NCDs or risk factors; screening, preventive care, etc. Service provision for people with NCDs or risk factors; screening, preventive care, etc. Health promotion and prevention interventions Health promotion and prevention interventions Other? Other?

3. Burden of NCDs in the Americas, mid-2000s Of a total of 5.2 million deaths, 3.2 million (62%) were due NCDs (51% males, 49% females) Of a total of 5.2 million deaths, 3.2 million (62%) were due NCDs (51% males, 49% females) 97% in high and upper middle-income countries 97% in high and upper middle-income countries Leading causes (per 100,000): Leading causes (per 100,000): –CVD (192), or 1.6M deaths –Cancer (121) –Chronic resp disease (52) –Diabetes (26) In 2004, approximately 598,000 people died prematurely from NCDs before age 60 years In 2004, approximately 598,000 people died prematurely from NCDs before age 60 years

4. MORTALIDAD EN PAISES AGRUPADOS SEGUN INGRESOS REGION DE LAS AMERICAS USA, Can, T&T, Bar, Some OTs Guy, Hai, Hon, Nic, Bol, Guat All others

5. Risk Factors for Chronic Diseases in the Americas region 145 million people >15 years are current smokers 145 million people >15 years are current smokers Prevalence of hypertension: 13-34% Prevalence of hypertension: 13-34% Low fruit & vegetable intake in females >18 years: 56-94%; and 57-92% in males Low fruit & vegetable intake in females >18 years: 56-94%; and 57-92% in males Low physical activity in adults >18 years: 14-46% Low physical activity in adults >18 years: 14-46% Projected that persons >15 years with obesity will increase from 139 million in 2005 to 289 million in 2015! Majority females Projected that persons >15 years with obesity will increase from 139 million in 2005 to 289 million in 2015! Majority females

6. Economic Issues: NCDs reduce the economy of LAC by 2% a year NCDs reduce the economy of LAC by 2% a year Expenditure for diabetes ‘07 = $131 billion Expenditure for diabetes ‘07 = $131 billion 40% of patients with kidney failure pay from their pocket $99/dialysis session, $15,500/year 40% of patients with kidney failure pay from their pocket $99/dialysis session, $15,500/year Treatment/care of NCDs cause catastrophic health expenses because of out-of-pocket expenditure, worsening poverty and increasing health inequities Treatment/care of NCDs cause catastrophic health expenses because of out-of-pocket expenditure, worsening poverty and increasing health inequities Access for low-income persons hindered by 39- 63% of the population having to pay full cost of basic medications for diabetes and hypertension Access for low-income persons hindered by 39- 63% of the population having to pay full cost of basic medications for diabetes and hypertension

7. Some Examples of basic strategies that can help reduce the burden of NCDs Reduce tobacco use by 20%; salt intake by 15%; and use simple multidrug regimens for patients at high-risk of cardiovascular disease to prevent more than 3.4 million deaths from chronic diseases in the Region over 10 years at reasonable cost. Reduce tobacco use by 20%; salt intake by 15%; and use simple multidrug regimens for patients at high-risk of cardiovascular disease to prevent more than 3.4 million deaths from chronic diseases in the Region over 10 years at reasonable cost. Two interventions (20% tobacco and 15% salt intake reduction) would be less than $0.40 per person/year in low- and lower middle-income counties, and $0.50-1.00 in upper middle- income countries. Two interventions (20% tobacco and 15% salt intake reduction) would be less than $0.40 per person/year in low- and lower middle-income counties, and $0.50-1.00 in upper middle- income countries.

8. What are the policy makers doing in countries and regional institutions

9. NCD Progress Indicator Status / Capacity by Country in Implementing NCD Summit Declaration - September 2010

10. ROLES OF CARIBBEAN REGIONAL INSTITUTIONS AND PAHO/WHO IN SUPPORT OF CHRONIC DISEASE PREVENTION AND CONTROL, AND OTHER FINANCING ORGANIZATION (UNICEF, UNFPA, CDC, PHAC, IADB, WORLD BANK)

11. NCD Capacity Survey 2010 - Main Highlights 32 countries; 3 rd survey since 2001 32 countries; 3 rd survey since 2001 Most countries have a capacity installed Most countries have a capacity installed Financial resources mainly allocated for treatment Financial resources mainly allocated for treatment Some have tobacco and alcohol taxes; most not earmarked for NCDs Some have tobacco and alcohol taxes; most not earmarked for NCDs Most countries have not yet developed specific policies on NCDs Most countries have not yet developed specific policies on NCDs However, most have policies on tobacco, diet and physical activity However, most have policies on tobacco, diet and physical activity Most countries have mortality surveillance systems Most countries have mortality surveillance systems But limited information on NCDs incidence and risk factors But limited information on NCDs incidence and risk factors Most countries reported addressing NCDs and risk factors with a primary health care approach Most countries reported addressing NCDs and risk factors with a primary health care approach Most reported having established a partnership/ collaboration Most reported having established a partnership/ collaboration Although most reported having financial resources for health promotion, it seems most not implementing health promotion activities Although most reported having financial resources for health promotion, it seems most not implementing health promotion activities

12. PUBLIC INFRASTRUCTURE Country High Income Upper Middle Income Lower Middle Income Undetermined BARTRTJAMSCNSALSURBELGUYANGBVIMON Per capita health expenditure 1,535785224622360360174185N/AN/AN/A All NCDs mortality rates/100,000 577496N/A519353294225349266280866 There is unit/branch √√√√√√√√√ Includes Planning√√√√√√√√√√ Coordination of implementation √√√√√√√√√√ Monitoring and evaluation √√√√√√√√√√ Funding available: Treatment and control √√√√√√√√√ Prevention and health promotion √√√√√√√√ Surveillance, monitoring an evaluation √√√√√√√ Fiscal interventions to influence behavior change √√√√√ Earmarked taxes on alcohol/tobacco √

13. POLICIES, STRATEGIES AND ACTION PLANS Country High Income Upper Middle Income Lower Middle Income Undetermined BARTRTJAMSCNSALSURBELGUYANGBVIMON Integrated NCD policy/strategy/action plan √√√√√ but not operational/more info needed for current status √ √ √ √ √ Integrated NCD policy/strategy/action plan combines the following: Harmful alcohol consumption √√√√√ Unhealthy diet √√√√√√√√√ Physical activity √√√√√√√√√ Tobacco√√√√√√√√

14. Policies/strategies/action plan combining early detection, treatment and care, rehabilitation Country High Income Upper Middle Income Lower Middle Income Undetermined BARTRTJAMSCNSALSURBELGUYANGBVIMON Cancer√√√√ Cardiovascular diseases √√√√ Chronic respiratory diseases √√ Diabetes√√√√ Hypertension√√√√ Overweight/obesity√√√√ Abnormal blood lipids √√

15. Cont… Policies/strategies/action plan combine early detection, treatment and care, rehabilitation Country High Income Upper Middle Income Lower Middle Income Undetermined BARTRTJAMSCNSALSURBELGUYANGBVIMON Specific policies on: Harmful alcohol consumption √√√√ Unhealthy diets √√√√√√ Physical inactivity √√√√√√ Tobacco consumption √√√√√√

16. Health Information Systems, Surveys and Surveillance; Registry on Risk Factors Country High Income Upper Middle Income Lower Middle Income Undetermined BARTRTJAMSCNSALSURBELGUYANGBVIMON Cause-specific mortality related to NCD √√√√√√√√√√ Morbidity related to NCD √√√ √√ √ √ Existence of disease registry Cancer√√√√ √ √ Diabetes√√ √ √ √ √ √ √ √√ Cardiovascular disease √√ √ √ √ √ Cerebrovascular disease √ √ √ √ √

17. Health Information Systems, Surveys and Surveillance; Risk Factors Country High Income Upper Middle Income Lower Middle Income Undetermined BARTRTJAMSCNSALSURBELGUYANGBVIMON Risk factor surveys on: Harmful alcohol use √√√√ √ Diet√√√ √ Physical inactivity √√√√ Tobacco use √√√√√√√ Raised blood glucose/diabetes √√√√√ Abnormal blood lipids √√√ √ √√ Raised blood pressure/hypertension √√√√√ Overweight/obesity√√√√√

18. Health System Capacity for Prevention, Early Detection, Treatment and Care within the Primary Health Care System Country High Income Upper Middle Income Lower Middle Income Undetermined BARTRTJAMSCNSALSURBELGUYANGBVIMON Primary prevention/health promotion √√√√√√√√√√ Risk factor detection √√√√√√√√√ Risk factor and disease management √√√√√√√√√√√ Support for self help and self-care √√√√√√√√ Home-based care √√√√√ Surveillance reporting √√ √ √ √√√

19. Does your health system have guidelines/protocols or norms for prevention and management of: Guidelines % of Countries (sample size 24) Hypertensión23 Diabetes Mellitus 23 Heart Diseases 17 Cerebrovascular disease 13 Cancer20 Chronic Respiratory Diseases 14 Smoking Cessation 13 Weight Control 12 Nutrition19 Physical Activity 13 Other diseases 9 Source: PAHO. National Capacity for the Management of Chronic Diseases in Latin America & the Caribbean, Washington, 2010

20. Price and access to medicines for chronic diseases NameCost % out of pocket In essential list of meds Insulin$10.3062.323 Aspirin(100 mg) $0.0542.821 Metformin$0.1141.522 Glibenclamide$0.0843.522 Thiazide diuretics $0.0938.622 ACE Inhibitors $0.1438.621 Ca C Blockers $0.8638.621 B Blockers $0.1238.621 Statins$0.5835.216 Tamoxifen$1.2331.614 Chemotherapy$1,188.4418.513 Source: PAHO. National Capacity for the Management of Chronic Diseases in Latin America & the Caribbean, Washington, 2010

21. Health Promotion and Collaboration Country High Income Upper Middle Income Lower Middle Income Undetermined BARTRTJAMSCNSALSURBELGUYANGBVIMON Partnerships/collaborations for implementing key activities √√√√√√√√√√√ Health promotion activities implemented: Fiscal interventions to influence behavior change √√√√√ Implementing 1 or more community/empowerment approaches √√√ √√√√ implementing 1 or more evaluated health promotion campaigns to change individual behaviors √√ √ √ Initiatives that regulate the marketing of foods to children √√

22. Health promotion activities implemented: Type BARTRTDOMJAMSCNSALSURBELGUYANGBVIMON Implementing 1 or more community/empowerment approaches √√√ √√√√√ In Schools √√√ √√√√ In workplace wellness √√√√√√√ In healthy cities / municipalities √√√√√√

23. Conclusions & Next Steps Despite the major gains made by Member States on their national chronic disease programs, the attention and resources devoted to this public health issue are not commensurate with the extent of the disease burden and economic costs. Despite the major gains made by Member States on their national chronic disease programs, the attention and resources devoted to this public health issue are not commensurate with the extent of the disease burden and economic costs. Continue working together to promote inter- sectoral policy changes before, during, and after the high-level meeting of the United Nations on NCDs in September 2011. Continue working together to promote inter- sectoral policy changes before, during, and after the high-level meeting of the United Nations on NCDs in September 2011.

24. Next Steps Member States and PAHO should make a concerted effort to: Member States and PAHO should make a concerted effort to: – build competencies and capacity for comprehensive, integrated prevention and control of chronic diseases at all levels (training), –Improve surveillance, –policy, –tobacco control, –salt reduction, –healthy diets and physical activity, –improved disease management, and –multi-stakeholder engagement mechanisms with a strengthened stewardship role of Ministries of Health.

25. Next Steps Continue to scale up access to medicines and quality health services for screening, early detection, and control of chronic diseases. Continue to scale up access to medicines and quality health services for screening, early detection, and control of chronic diseases. Continue to improve the quality and timeliness of health information designed to guide policy, planning, and evaluation, especially risk factor information, pursue gender-based analysis and novel approaches and technologies Continue to improve the quality and timeliness of health information designed to guide policy, planning, and evaluation, especially risk factor information, pursue gender-based analysis and novel approaches and technologies

26. Next Steps Strengthening national & subregional inter-sectoral efforts, partnerships, and alliances as a key cross- cutting strategy Strengthening national & subregional inter-sectoral efforts, partnerships, and alliances as a key cross- cutting strategy Support the CARMEN Network and Partners Forum as innovative mechanisms to support country efforts to engage private sector and civil society Support the CARMEN Network and Partners Forum as innovative mechanisms to support country efforts to engage private sector and civil society Review their legislation and norms for addressing chronic diseases and tobacco control Review their legislation and norms for addressing chronic diseases and tobacco control Implementation of WHO guidelines on marketing foods and non-alcoholic beverages to children, as approved at the 63rd World Health Assembly. Implementation of WHO guidelines on marketing foods and non-alcoholic beverages to children, as approved at the 63rd World Health Assembly.

27. What’s the role of Civil Society and NGOs in the prevention & control of NCDs? Advocacy, creating mass movements Advocacy, creating mass movements Monitoring/watchdog role Monitoring/watchdog role Providing education and training Providing education and training Research Research Service provision for people with NCDs or risk factors; screening, preventive care, etc. Service provision for people with NCDs or risk factors; screening, preventive care, etc. Health promotion and prevention NGOs Health promotion and prevention NGOs Other Other

28. Thank you