Chronic Diseases and Health Promotion – Gojka Roglic World Health Organization, Geneva,...

Chronic Diseases and Health Promotion – www.who.int/chp/en

Gojka RoglicWorld Health Organization, Geneva,

Switzerland

What can WHO do to control the epidemic of diabetes?


The World Health Organization

• United Nations specialized agency for health

• Governed by 192 Member States

• Headquarters in Geneva• Six regional offices• Numerous country offices

Support to member states to enhance the health of their populations


The World Health Organization• First World Health Assembly 1948

• Priorities for the organization:• Malaria

• Tuberculosis

• Venereal diseases

• Maternal and child health

• Sanitary engineering

• NutritionSupport to member states to enhance the health of their populations


Examples of WHO activities

• Successful: Smallpox eradication 1977

Campaigns against yaws, endemic syphilis, leprosy, trachoma, malaria in Europe

Control of cholera pandemic



• Moderately successful, ongoing:

Polio eradication (since 1988)

Expanded programme on Immunization (since 1974)

"3 by 5" initiative (antiretroviral therapy for 3 million people in low and middle-income countries by end of 2005)



• Unsuccessful: Safe Motherhood Initiative (aim in 1987: reduce maternal morbidity & mortality by 50% by the year 2000)


The comparative advantages of WHO are:

- Neutral status- Nearly universal membership- Impartiality- Strong convening power- Normative and technical roles


Three sources of funding

WHOProgramme

budget

Assessed Contributions and Miscellaneous Income

(Regular budget )

Assessed Contributions and Miscellaneous Income

(Regular budget )

Negotiated core voluntary

contributions

Negotiated core voluntary

contributions

Project-type voluntary contributions

Project-type voluntary contributions


81 Member States

103 Member States at less than

0.01%10 major contributors

77 %

22 %

<1 %

Assessed contributions to Regular Budget - 10 member states pay 77 %

Assessed contributions to Regular Budget - 10 member states pay 77 %


Top 10 Country contributions to WHO's Regular Budget 2008-09 in %

1- USA 22 % 2- Japan 16.6% 3- Germany 8.57%4- UK + Northern

Ireland 6.64%5- France 6.30%

6- Italy 5.07%7- Canada 2,97%8- Spain 2,96%9- China 2.66%10- Mexico 2.25%

Following countries: Republic of Korea 2.17% Netherlands 1.87% Australia 1.78% / Brazil 0.87%

Switzerland 1.21%


81 Member States

103 Member States at less than

0.01%10 major contributors

77 %

22 %

<1 %

Source of voluntary contributions 2006-2007Source of voluntary contributions 2006-2007


0

1,000

2,000

3,000

4,000

5,000

6,000

1994-1995

1996-1997

1998-1999

2000-2001

2002-2003

2004-2005

2006-2007

2008-2009

2010-2011

2012-2013

2014-2015

US

$ (

mil

lio

ns

)

Voluntary Contributions

Regular Budget

72%

83%

28% 17%

Without action the imbalance between voluntary contributions and regular budget will continue to increase


What about chronic, noncommunicable diseases (NCDs)?


Adult mortality


2005 2006-2015 (cumulative)

Geographical regions (WHO classification)

Total deaths

(millions)

NCD deaths (millions)

NCD deaths

(millions)

Trend: Death from infectious

disease

Trend: Death from NCD

Africa 10.8 2.5 28 +6% +27%

Americas 6.2 4.8 53 -8% +17%

Eastern Mediterranean 4.3 2.2 25 -10% +25%

Europe 9.8 8.5 88 +7% +4%

South-East Asia 14.7 8.0 89 -16% +21%

Western Pacific 12.4 9.7 105 +1 +20%

Total 58.2 35.7 388 -3% +17%

Noncommunicable diseases

WHO projects that over the next 10 years, the largest increase in deaths from cardiovascular disease, cancer, respiratory disease and diabetes will occur in Sub-Saharan Africa (+27%)


• 57 Million Total Deaths

• 35 Million due to Chronic Disease

• 16 Million Deaths less than 70 yrs

Importance of Chronic DiseasesImportance of Chronic Diseases


Expenditure within WHO HQ

ONLY US$ 0.50 SPENT ON LEADING CHRONIC

DISEASES PER DEATH COMPARED WITH $7.50

FOR LEADING COMMUNICABLE DISEASES

World Health OrganizationDepartment of Chronic Diseases and Health PromotionDepartment of Chronic Diseases and Health Promotion

Funding for Noncommunicable Chronic Diseases at WHO

Other NCDs

Injuries

CVD

DM

CD

Global NCD disease burden Total WHO expenditure on NCDs

In 2002, 3.5% of total budget of US$ 43.6 million on NCDs

Source: WHO long-term strategy for prevention and control of leading chronic diseases© World Health Organization [2004]


Official Overseas Development Aid to the health sector in 2002

Donor aid for the health sector

Increased health support by donors mostly directed towards HIV/AIDS, not NCDs

allocated toNCDs

(including mental health)



World Bank and Regional Development Banks

of their $4.2 billion total to health, population and nutritionbetween 1997 and 2002

World Bank loans for chronic diseases



33 %mental health

30 %tobacco

37 %unspecified chronic disease components

WHO is the largest source of funding for chronic diseases

WHO provides tenfold more funds than all bilateral agencies combined

Nevertheless…..

Overall US$ 16 million

WHO expenditure for chronic disease 1998 2002

Tobacco

Mental disorders

Other chronic disease activities

US$ 383,000

US$ 7.1 million

US$ 9.4 million

US$ 13.2 million

US$ 13.3 million

US$ 14.3 million

US$ 43.6 million


What about chronic, noncommunicable diseases?

1998 – Tobacco Free Initiative to coordinate a global response to the Tobacco epidemic



2000 World Health Assembly adopts the Global Strategy for the Prevention and Control of Noncommunicable diseases



2003 – World Health Assembly adopts the Framework Convention on Tobacco Control – first treaty negotiated under the auspices of WHO (in force since 2005)



2004 – World Health Assembly adopts the Global Strategy on Diet, Physical activity and Health



2005 – First WHO report on chronic,noncommunicable diseases


• February – Informal consultations with Member States, International Partners and the business community

• April – Final draft of Action Plan available online

• May – adoption by the World Health Assembly

2008: Action Plan for the Global Strategy


Scope of the Action Plan

• The major noncommunicable diseases: • Cardiovascular disease• Cancer• Respiratory disease• Diabetes

• The main causes are 4 shared preventable risk factors: • Tobacco use• Unhealthy diet• Physical inactivity • Harmful use of alcohol


What about diabetes?


Noncommunicable Diseases and Mental Health Cluster

Cardiovascular diseases: 1 person

Cancer: 2 persons

Asthma and COPD: 2 persons

Diabetes: 1 person


The beginnings of the WHO Diabetes Programme in the 1980s…….

Dr Hilary King


The WHO Diabetes Programmeat its strongest (early 2000s) …..


The core functions of WHO

• Providing leadership and engaging in partnerships where joint action is needed

• Shaping the research agenda, stimulating the generation and translation of knowledge

• Setting norms and standards• Articulating ethical and evidence-based policy

options• Providing technical support• Monitoring the health situation and assessing health

trends• High-level advocacy and awareness raising on

matters critical to health


WHO core function: Partnership where joint action is needed

International Diabetes Federation (IDF)

•A natural ally and partner to WHO

•In official relations since 1957


Partnership where joint action is needed

WHO

• Works with governments

• Strong public health voice

• WHO offices in almost every country

• Global reference centre for health statistics

• Has prestige among governments/health ministries

IDF

• Works through member associations

• Strong lay and professional advocacy voice

• Network of member associations

• Well-developed secretariat to respond to calls for information

• Has prestige among NGOs and private sector


WHO-IDF Collaboration• Norms and standards

• Capacity building (Cambridge Seminar)

• Global estimates

• Management of diabetes in crises and humanitarian settings

• Awareness raising

• Access to essential medicines/equipment


WHO core function : Awareness- raising and advocacy

• Rationale for investing in chronic diseases that share the same risk factors

• Evidence for dispelling myths on chronic diseases


Joint WHO-IDF project, supported by the World Diabetes Foundation


• To achieve a major increase in the awareness of the impact of diabetes in low and middle income countries

Main aim of Diabetes Action Now…..


Chronic noncommunicable diseases effectively excluded from Millennium Development Goals

Chronic diseases excluded from UNICEF Action Plan for "A World Fit for Children" and from WHO/UNICEF high

level consultation

Chronic diseases excluded from UNFPA initiatives, and from WHO/UNFPA high-level consultations


Diabetes is an obstacle to achieving the Millennium Development Goals……

• Diabetes is likely to be responsible for 15% of all new tuberculosis cases in India

(AIDS accounts for 3-4%)


Diabetes Action Now – Diabetes Awareness in Chennai (Murugesan et al, 2007)

Policy makers (n=20)

General public (n=3681)

Do not know what diabetes is 35% 60%

Think diabetes is preventable by meditation

61% 6.3%

Correctly identify healthy body size

15% 25%

Correctly identify healthy body shape

0% 25%

Analysis of articles on diabetes in India (2005)

Online newspapers:

The Hindu – 39 articles The Hindustan Times – 21 articles The Indian Express – 2 articles The Times of India – 17 articles

WHO/IDF key messages in newspaper articles (India, 2005)

Diabetes is a life threatening illness: 10%

Diabetes is a common condition and its frequency is increasing dramatically: 40%

A full and healthy life is possible with diabetes: 30%, but only a clear statement in a few articles

In many cases, diabetes can be prevented: 40%


Raising awareness….


UN Resolution on Diabetes…..


WHO Region 2000 2006

AFR 17 25

AMR 46 63

EMR 46 69

EUR 53 67

SEAR 50 67

WPR NA NA

TOTAL 41 56

Percentage of countries with specific action plan for diabetes control (WHO, 2007)


WHO core function: Setting norms and standards

• What is diabetes?Definition, Diagnosis and Classification of

Diabetes Mellitus

WHO report 1965WHO report 1980WHO report 1985WHO report 1999


• Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycaemia

WHO/IDF consultation report 2006

Norms and standards


Definition,Diagnosis and Classification of Diabetes Mellitus, 2009

• HbA1c for diagnosis• "Pre-diabetes"• Refinement of etiological classification

Norms and standards


The metabolic syndrome: useful concept or clinical tool?

2009

Norms and standards


WHO core function: Monitoring the health situation

Surveillance of chronic, noncommunicable diseases

• STEPS – stepwise methodology for monitoring risk factor prevalence in countries

• Global InfoBase – data warehouse that collects, stores and displays information on chronic diseases and risk factors by country (country profiles, comparison of countries)

http://www.who.int/ncd_surveillance/infobase


Monitoring the health situation• Is diabetes a public health problem?

King et al, 2000 Wild et al, 2004

Global estimates and projections of diabetes prevalence


Monitoring the health situation

• Number of deaths attributable to diabetes in the world in 2000

= 2.9 million

(routine health statistics estimate ~1 million deaths)

Roglic et al, 2005

• Is diabetes a public health problem?


Update: Global Burden of Diseases, Injuries, and Risk Factors Study 2005

Harvard Initiative for Global Health

Institute for Health Metrics and Evaluation, University of Washington

Johns Hopkins University

University of Queensland

WHO

• Prevalence• Incidence• Mortality• Complications


WHO core function: Articulating evidence-based policy options

Global Strategy on Diet, Physical Activity and Health

2004

What can countries do to prevent diabetes?

WHO Global Strategy on Diet, Physical Activity and Health (DPAS) - a public health tool to support countries fight the increasing burden of NCDs by

reducing major risk factors through public health actions

Increasing awareness of importance of healthy diet and physical activity

Developing, strengthening and implementing policies and plans on healthy diet and physical activity and engaging all sectors

Monitoring science and promoting research

DPAS

Implementation should be coordinated by governments

Based on multisectoral action involving the private sector and civil society

Makes specific recommendations for governments, civil society groups, international agencies and the private sector

WHO has initiated dialogue with the food and non-alcoholic beverages industry on issues of food labelling, salt content and marketing

DPAS implementation at country levels

Several countries have developed national diet & PA strategy / plans /materials / platform, modelled after DPAS, e.g.

Spain

Chile

Diet, PA & tobacco guide

CAN WE PUT SWISS BALANCE HERE ?

Healthy Eating - Healthy Action Oranga Kai - Oranga Pumau

Stategic Framework andImplementation Plan

New Zealand


WHO Region 2006

AFR 8

AMR 26

EMR 0

EUR 45

SEAR 50

WPR NA

TOTAL 26

Percentage of countries implementing the Global Strategy on Diet and Physical Activity

(WHO, 2007)


Articulating evidence-based policy options

Prevention of diabetes mellitus (1994)

Update 2009

What is the evidence for prevention of diabetes and prevention of its complications?


Articulating evidence-based policy options

Screening for Type 2 Diabetes

2003

To screen or not to screen?


WHO core function: Stimulating and supporting research

• 1975 Multinational Study of Vascular Disease in Diabetes

• Follow-up


Stimulating and supporting research

• 1991 DiaMond study of global incidence of type 1 diabetes (coordinated by Helsinki and Pittsburgh)



• Health beliefs and awareness of diabetes in Chennai (Murugesan et al, 2007)

• Health beliefs and awareness of diabetes in Cameroon (ongoing)

• Cost of diabetes in Shanghai (China) and Tanzania


In China, the DM/nonDM ratio of

• Direct Health Expenditure is 2.4

• Indirect Health Expenditure is 5.7

• Total Health Expenditure is 2.7




• Impact of the diabetes epidemic on TB trends in India (Stevenson et al, 2007)



Long-term follow-up of the Da Qing diabetes prevention trial cohort (Lancet, May 2008)


Cumulative incidence of DM in Da Qing Follow-up Study (Li et al, 2008)

0102030405060708090

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Follow-up (years)

% w

ith

dia

be

tes

Control groupIntervention group


Diabetes WHO Collaborating centres


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