Non-Communicable Disease and the future of development

Richard Smith

Director, UnitedHealth Chronic Disease Initiative

Ban Ki-moon on NCDs

• “Non-communicable diseases are a threat to development. NCDs hit the poor and vulnerable particularly hard, and drive them deeper into poverty.”

• Ban Ki-moon

Ban Ki-moon on NCDs

• More than a quarter of all people who die from NCDs succumb in the prime of their lives. The vast majority live in developing countries. Millions of families are pushed into poverty each year when one of their members have become too weak to work. Or when the costs of medicines and treatments overwhelm the family budget. Or when the main breadwinner has to stay home to care for someone else who is sick.

Agenda

• Definitions

• Scale of the problem

• Causes

• The UN meeting

• How best to respond ?

Source: World Health Organization, 2005

Non-communicable disease• WHO defines non-communicable disease (NCD) as

cardiovascular disease, diabetes, chronic respiratory disease, and certain cancers.

• All of these have in common that they are caused predominantly by tobacco use, poor diet, physical inactivity, and the harmful use of alcohol.

• Doesn't include mental health and many other chronic conditions

Burden of disease

8

Leading Causes of Mortality and Burden of Diseaseworld, 2004

%

1. Ischaemic heart disease 12.2

2. Cerebrovascular disease 9.7

3. Lower respiratory infections 7.1

4. COPD 5.1

5. Diarrhoeal diseases 3.7

6. HIV/AIDS 3.5

7. Tuberculosis 2.5

8. Trachea, bronchus, lung cancers 2.3

9. Road traffic accidents 2.2

10. Prematurity, low birth weight 2.0

%

1. Lower respiratory infections 6.2

2. Diarrhoeal diseases 4.8

3. Depression 4.3

4. Ischaemic heart disease 4.1

5. HIV/AIDS 3.8

6. Cerebrovascular disease 3.1

7. Prematurity, low birth weight 2.9

8. Birth asphyxia, birth trauma 2.7

9. Road traffic accidents 2.7

10. Neonatal infections and other 2.7

Mortality DALYs

Deaths from chronic disease are displacing deaths from infectious disease even in rural Bangladesh

NCDs are commonest among the poorest in rural Bangladesh

11

Ten leading causes of burden of disease, world, 2004 and 2030

We can make a difference: death rates in the US, 1900-1996

Decline

Yet only 3% of global health aid ($21 billion)

goes to NCDs and mental health.

Causes of NCDs

In September 2011 the UN held a high level meeting on NCDs

• Only the second high level meeting of the UN on health

• The first in 2001 led to the Global Fund for AIDS, TB, and malaria

• Led to a flurry of activity and a raising of consciousness (although not among ordinary people)

• 130 countries spoke; 200 civil society representatives attended; 40 side meetings

Future commitments with target dates

• 2012: work with WHO and all stakeholders to set targets

– Currently arguments over targets– Can targets be sensibly set?– Will they set some countries up to fail?

• 2013: review of the MDGs; integrate NCDs

• 2014: UN review of progress

What was achieved?

• On global agenda: meeting was a step change

• Understanding that a response must go well beyond health sector: “Whole of society, whole of government”

• Development issue

• Civil society movement important: NCD Alliance

What didn't happen

• Nothing on mental health. Should there be another high level meeting?

• No new funding apart from Russia and Australia

• NCD Alliance had issues with best buys—major omissions

• Alcohol weak

• Little on children

• No champion countries

– China and India not very visible; too few G8 champions

– Not many LMIC stepping forward

• Yet to engage the public—must do by 2014

How best to respond?

Priorities of the UN Secretary General

• Complete government wide action on risk factors

• Sustained primary health care with prioritised packages plus palliative and long term caregivers

• Surveillance and monitoring

• Learning from and integration with AIDS, TB, and malaria programmes

• Governments, private sector, civil society, and international organisations must all work together

How best to respond?

• “We need a whole of government and a whole of society response”

• Margaret Chan, director general, WHO

Which is the best level at which to intervene?

WHO calculations of cost effectiveness of priorities for preventing and controlling NCDs

• Depends on geography and disease patterns in each country/region

• Looked at 500 single or combined interventions

• Costs: resources needed multiplied by unit price (varies widely), in $Int, which takes account of purchasing power

• Benefits: DALYs averted

• “Highly cost effective” if cost per DALY below GDP per person

Interventions that cost less than GDP per head: SubSaharan Africa

• Cardiovascular disease, diabetes and tobacco: 8– Preventive multidrug treatment at 35% risk of CVD event

– Increased taxation on tobacco

– Retinopathy screening, 80% coverage

• Cancer: 6– Cervical cancer, pap smear at age 40, lesion removal plus cancer

treatment, 50% coverage

– Colorectal cancer: surgery/chemotherapy/radiotherapy

• Respiratory disorders: None

• Sensory disorders: 8

• Mental disorder: 8

• Injuries (road traffic): 3

Cost effectiveness of different interventions for preventing and controlling NCDs in Mexico

Interesting question

What might an entirely new system for preventing and controlling NCDs in a low

income country look like?

Best system for responding to NCDs in LMIC

• High level task force that is whole of government and whole of society

• Emphasis on public health and prevention with an emphasis on structural changes

• Patients TRULY in charge

• Extensive use of community health workers

• Extensive standardisation and use of protocols

• Emphasis on primary care

• Few hospitals and specialists—to avoid capture of resources