Low-income countries Group III - Injuries Group II – Other deaths from noncommunicable diseases Group II – Premature deaths from noncommunicable diseases (below the age of 60yrs) which are preventable Group I – Communicable diseases, maternal, perinatal and nutritional conditions

10% NCDs are the biggest cause of death

5.8 M

10 million

20 million

30 million

40 million

50 million

60 million Total number of deaths in the world

18.0 M

(60% of all deaths) •  CVDs, •  Cancer •  Chr Resp Dis •  DM

0 million

1

- 33 Provinces, - 505 districts & towns

+ 52%

2

Causes of Death % Causes of Death % Stroke Tuberculosis Hypertension Injury Perinatal/maternal Diabetes Mellitus Neoplasm/cancer Liver disease Ischemic Heart Dis. Lower resp. tract dis. Heart disease

15,4 7,5 6,8 6,5 6,0 5,7 5,7 5,1 5,1 5,1 4,6

Pneumonia Diarrhea Gastric ulcer Typhoid Malaria Meningitis/Encephalitis Congenital malform Dengue Tetanus Septicemia Malnutrition

3,8 3,5 1,7 1,6 1,3 0,8 0,6 0,5 0,5 0,3 0,2

Causes of Death pattern in Indonesia

Source: BHR, 2007 3

HHS=Household Health Survey BHR =Basic Health Research

Causes of Death, All Ages in Indonesia 1995, 2001, 2007

+ 19% / 6 yrs + 31% /10 yrs

Africa + 27% E. Mediterranean + 25%

4

Source: BHR, 2007 *>10 year old; #>15 year old; ** ≥15 year old (BHR, 2010)

NCDs cases % Hypertension Stroke Heart disease Arthritis Land traffic injuries Asthma DM DM (urban population) Tumor/cancer

31.7 8.3 7.2

30.3 25,9 3.5 1.1 5.7 4.3

5

HYPERTENSION : PREVALENCE & COVERAGE

NO

HYPERTENSION

DIAGNOSED OR UNDER TREATMENT

NO TX

BHR 2007

7

Coverage : Proportion patients diagnosed or under medical treatment

6

Risk Factors Risk factors %

Everyday servings salty foods Everyday servings fatty foods < 5 servings of fruits & vegetables Lack of physical activity Smokers (> 15 yrs of age) Overweight & obese Emotional-mental disorder Alcohol use

24.5*

12.8* 93.6* 48.2*

34.7** 19.1# 11.6# 4.6*

Source: BHR, 2007 *>10 year old; #>15 year old; ** ≥15 year old (BHR, 2010)

8

INDONESIAN SMOKERS BHR 2007

BHR 2010

Smoking Prevalence (>15 Th) 33,4% 34,7% Male Smokers (>15 Th) 65,3% 65,9% Women (>15 Th) 5,06% 4,2% Population exposed to cigarette smoke

84,5 % 76,1%

8

Teenage Trend smoking prevalence

Source: Susenas (1995, 2001, 2004) dan BHR 2007

The prevalence of teenage smokers according to age group 15-19 years, by sex - in Indonesia,

Male Female

Global Youth Tobacco Survey in Indonesia (2007) 20,3 % junior high school student smokes

9

TOBACCO

D I E T

PHYSICAL ACTIVITY

ALCOHOL

10

11

Non-modifiable Risk Factors - Age - Sex - Genes

Socio-Econ, Cultural & Environmental Conditions, and Modernisation, Mechanisation, Urbanisation, Globalisation

- Coronary HD - Stroke - Peripheral Vascular Dis - Several cancers - COPD/ emphysema - Health, wellbeing

End Points

• Hypertension

• Blood lipids • Obesity /

Overweight • Diabetes • Glucose

Intolerance

Intermediate Risk Factors

12

13

Public Health Interventions Epidemiologic Transition

Clinical Interventions

14

GO RED FOR WOMEN

15

Promote Regular Physical Activities

16

No

Smok I ng

Campa I gn 17

Educational talks, seminars, radio and TV talk-shows, exhibitions, free health checks and a variety of competitions (writing, poster drawing, etc)

18

IHF quarterly newsletter

Posters, brochures, leaflets

www.inaheart.or.id

Indonesia Heart Foundation Publications

19

- Assess Capacity

& Coverage - Identify Needs

Essential

Equipmens

Provide Essential Medicines

Essential Recording Tools/

MIS

WHO/ISH Risk

Charts

Protocols for primary

Care

Thermometer Measurement Tape Stethoscope BPMD Weighing Machine Nebulizer Peak Flow Meter Glucometer Urine dipsticks ECG Machine

Aspirin, ISDN, CPG, HCT, Nifedepine, Amlodipin, Captopril, Enalapril, Bisoprolol, Frusemide,Spirono-lacton,Glibenclamide Metformin,Simvstatn Insulin,

Package of Essential NCD (PEN) interventions for primary care

20

Improve CV

care facilities

and referral system

21

POPULATION DISTRIBUTION AND TERTIARY CARDIOVASCULAR SERVICES

Padang

- RSJPD – HK - RSCM - RSHS - Bdg 4

2

Samarinda

12

4

2 9

6

40

11 11 30 36

4

4 3

3.5

3

2

8

2

2 Bengkulu

5 2

•  RS Dr.S •  RS SA - Malang

8.870 PHC, 23.163 sub-centers, 1.556 hospitals, 500 Cardiologist

4

2

3

Existing CV center

22

AGE STANDARDIZED MORTALITY CAUSE BY ISCHEMIC HEART DISEASE/100.000 INHIBITORS

UN data 2008

4

10 more cardiology & vascular medicine dept. was appointed as an education center in 2010

IHA target : 1000 cardiologist in 2020

23

IHA OBJECTIVES OF CVD PREVENTION :

1.  Maintain low risk of CVD population lifelong To help those at increase total CVD risk to reduce it.

2.  To achieve the characteristics of healthy condition : - no smoking - no alcohol - healthy food choices - low salt consumption - physical activity; 30 min of moderate activity/day - BMI < 25 kg/m2 and avoidance of central obesity - BP < 140/90 mmHg - Total cholesterol < 190 mg/dl (< 5 mmol/l) - LDL cholesterol < 115 mg/dl (< 3 mmol/l) - Blood glucose < 110 mg/dl (< 6 mmol/l)

24

IHA OBJECTIVES OF CVD PREVENTION :

3.  To achieve more rigorous risk factor control in high risk subjects; especially those with established CVD or DM :

- BP < 130/80 mmHg if feasible - Total cholesterol < 175 mg/dl (< 4.5 mmol/l) - LDL cholesterol < 100 mg/dl (< 2.5 mmol/l) - Fasting BS < 110 mg/dl (< 6 mmol/l) & HbA1c <6.5%

4.  To consider cardioprotective drug tx in these high risk subjects especially those with established atherosclerotic CVD

25

 CVDs (Hypertension, stroke, HD) the leading cause of death in Indonesia exacerbates poverty

 The prevalence of hypertension is high, not well treated  Parliament : Increase budget for health !  MOH : - Increase NCDs/CVDs prev. & control budget - Integrated National plans of action (for: tobacco control, diet improvement, physical activity, no alcohol)

- Coordination & collaborative action of all sectors: government, medical societies, civil society, private sectors and media

- Scale up packages of effective intervention - Strengthen Primary HC & improve referrals - Universal coverage  Surveillance on the impact of interventions  Promote & support research on CVDs prev & control

Conclusion :

26

20 27