Noncommunicable

Diseases in the
South-East Asia Region

2011
Situation and Response
 Noncommunicable
Diseases in the
South-East Asia Region

2011
Situation and Response
WHO Library Cataloguing-in-Publication data

World Health Organization, Regional Office for South-East Asia.

Noncommunicable diseases in the South-East Asia Region: Situation and response 2011.

1. Mortality. 2. Chronic Disease - prevention and control. 3. Risk Factors. 4. Cost of illness. 5. Risk factors.
6. Epidemiologic surveillance. 7. Delivery of Health Care. 8. Health Care Sector

ISBN 978-92-9022-413-6 (NLM classification: WT 500)

World Health Organization 2011

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Printed in India
 i

Contents
Acknowledgments ii
Foreword iii
Acronyms iv
EXECUTIVE SUMMARY 1
1. INTRODUCTION 5
2. BURDEN OF NONCOMMUNICABLE DISEASES IN WHO SOUTH-EAST ASIA REGION 9
NCD Mortality 10
Trends in NCD Mortality and Morbidity 12
Disease-Specific Burden and Trends 13
Cardiovascular diseases 14
Cancers 15
Diabetes mellitus 17
Chronic respiratory diseases 18
Other NCDs 19
3. RISK FACTORS 23
Behavioural Risk Factors 24
Tobacco use 24
Unhealthy diet 30
Physical inactivity 31
Harmful use of alcohol 32
Metabolic Risk Factors 33
Overweight and obesity 33
Raised blood pressure 35
Raised cholesterol 36
Cluster of risk factors 37
Other risk factors 38
IV. DRIVERS OF NCDs 43
Population ageing 43
Urbanization 44
Globalization 47
Poverty 47
Illiteracy 48
Underdeveloped health system 48
V. ECONOMIC BURDEN OF NCDs 51
Economic burden of NCDs at the National Level 51
Economic burden of NCDs at household level 52
VI. NATIONAL RESPONSE TO NCDs 59
Institutional Capacity for NCD Prevention and Control at the Central Level 59
National Policies, Strategies, Plans and Programmes for NCD Prevention and Control 60
Surveillance and Monitoring 62
Heath System Capacity for NCD Prevention, Early detection, Treatment and Care 65
Health Financing 68
Partnerships and Collaboration 69
VII. MAJOR CHALLENGES IN PREVENTION AND CONTROL OF NCDs 71
Lack of strong national partnerships for multisectoral actions 71
Weak surveillance systems 71
Limited access to prevention, care and treatment services for NCDs 72
Limited human resources for NCDs 72
Insufficient allocation of funds 72
Difficulties in engaging the industry and private sector 72
Lack of social mobilization 73
VIII. WHO INITIATIVES IN NCD PREVENTION AND CONTROL 75
Global initiatives 75
Regional initiatives 76
IX. THE WAY FORWARD 79
Guiding Principles for NCD Prevention and Control 79
Health promotion and primary prevention to reduce risk factors for NCDs 80
using multisectoral approach
Health system strengthening for early detection and management of NCDs 80
Surveillance and research 81
Specific Strategies for NCD Prevention and Control 81
Role of Different Agencies in NCD Prevention and Control 82
ANNEXES 85
Tables 85
Note on data sources and limitations 92

2011
ii

Acknowledgements
We thank the Member countries of the South-East Asia Region for providing the latest data on risk
factors, morbidity and mortality, as well as updates on national responses and key achievements. We are
grateful to national experts from Member countries of the Region for contributing to selected sections of
the report. We acknowledge the assistance of staff in the World Health Organization country offices for
their contribution in preparing this report. We are grateful to Dr Anton Fric for preparing an earlier
version of the report and Dr Abhaya Indrayan and Dr Niki Shrestha for extensive inputs to the report as
well as data verification, review of literature and references checking. Mr Ravinder Kumar prepared
charts and graphs. Ms Vani Kurup edited and designed the Report.

2011

Foreword
This report describes the current burden of
noncommunicable diseases (NCDs) in the South-
East Asia Region (SEAR), their underlying risk
factors and socioeconomic determinants, and
summarizes national responses to the epidemic.
NCDs are top killers in SEAR, causing 7.9
million deaths annually. One third of these deaths
are premature and occur before the age of 60
years, in the economically productive age groups.
With the projected number of deaths expected to
increase by 21% over the next decade, the scale of
the problem we face is clearly serious.
Demographic changes (ageing population), rapid
unplanned urbanization, negative aspects of global
trade and marketing, progressive increase in
unhealthy lifestyle patterns, as well as social and
economic determinants are accelerating the
burden of NCDs.
While there is a growing recognition among
Member States of the need to tackle NCDs, the
current focus is largely on providing medical
services to those who have already developed
NCDs, rather than on promoting health and
eliminating the risk factors for NCDs. In an era of
spiralling health-care expenses, NCDs are
exacerbating poverty and widening inequities,
particularly in SEAR where most health-care costs
are met by out-of-pocket expenditures. Thus there
is a need for greater emphasis on health
promotion and primary prevention of NCDs based
on the principles of primary health-care, equity
and social justice.
Prevention of NCDs is feasible through
empowering individuals, families and
communities to adopt healthy lifestyles, namely
avoiding tobacco and alcohol use, eating a healthy
diet including plenty of vegetables and fruits,
iii
engaging in regular physical activity to maintain
body weight and managing mental stress. Effective
legislative policies that promote healthy
behaviours by default such as smoke-free zones,
restricted sale of alcohol below legal age,
regulation of marketing of unhealthy food to
children are also required to create a conducive
environment where people can adopt healthy
lifestyles easily. There is a need to create
workplaces, schools, communities and
environment that make adoption of healthy
lifestyle choices possible. Additionally, health
services and systems need to be strengthened to
accommodate the needs of NCD prevention and
control.
Noncommunicable diseases constitute a
challenge for socioeconomic development. NCDs
contribute to poverty and threaten the
achievement of Millennium Development Goals
(MDGs). Addressing NCDs requires interventions
not only from the health sector but many other
sectors, such as agriculture, education, urban
development and transport. The United Nations
High-Level Meeting on NCDs held in New York,
United States of America, earlier this year called
upon all Member States to integrate their NCD
policies and programmes into the broader health
and development agenda and to develop
multisectoral national policies and plans to tackle
NCDs.
I call upon our Member States to join the
efforts of WHO and the UN to accord a high
priority to prevention and control of NCDs in
national health policies and programmes, increase
domestic and international resources for NCDs
and galvanize a multisectoral response to NCDs.
Given the enormous burden of NCDs in the
Region and their serious socioeconomic
consequences, I urge national governments and
all developmental partners to tackle NCDs with a
sense of urgency.
Dr Samlee Plianbangchang
Regional Director, World Health Organization
Regional Office for South-East Asia
2011
iv

Acronyms
BMI body mass index
BP blood pressure
CHD coronary heart disease
COPD chronic obstructive pulmonary disease
CRDs chronic respiratory diseases
CURES Chennai Urban Rural Epidemiology Study
CVDs cardiovascular diseases
DALYs disability adjusted life years
DBP diastolic blood pressure
FCTC WHO Framework Convention on Tobacco Control
GATS Global Adult Tobacco Survey
GDP gross domestic product
GYTS Global Youth Tobacco Survey
HDL high density lipoprotein
HDSS Health and Demographic Surveillance System
ICMR Indian Council of Medical Research
IGT impaired glucose tolerance
INR Indian Rupee
LDL low density lipoprotein
MDGs Millennium Development Goals
MONICA Multinational Monitoring of Trends and Determinants of Cardiovascular Disease
NCDs noncommunicable diseases
NFHS National Family Health Survey
NPHF Nepal Public Health Foundation
NTCC National Tobacco Control Cell
PEN WHO package of essential NCD interventions
SEA-ACHR South East Asia-Advisory Committee on Health Research
SEANET South-East Asian Network of NCD
SEAR South-East Asia Region
SEARO Regional Office for South-East Asia
TFA trans fatty acids
UNHLM UN High-level Meeting
WC waist circumference
WEF World Economic Forum

2011

Executive Summary
Four major noncommunicable diseases
(NCDs) cardiovascular diseases (including
heart disease and stroke), diabetes, cancer and
chronic respiratory diseases (including chronic
obstructive pulmonary disease and asthma)
are the leading cause of illness and death
worldwide including the South-East Asia Region
(SEAR). In addition to the health burden, NCDs
have serious social and economic consequences
particularly for poor and disadvantaged
populations.
Burden of NCDs in the South-East
Asia Region
I Of the estimated 14.5 million total deaths in
2008 in SEAR, 7.9 million (55%) were due
to NCDs. NCD deaths are expected to
increase by 21% over the next decade. Of the
7.9 million annual NCD deaths in SEAR,
34% occurred before the age of 60 years
compared to 23% in the rest of the world.
I NCD mortality rates increase with age and
are higher in males than females. Of the 7.9
million deaths due to NCDs in 2008,
cardiovascular diseases alone accounted for
a quarter (25%) of all deaths. Chronic
respiratory diseases, cancers and diabetes
accounted for 9.6%, 7.8% and 2.1% of all
deaths, respectively.
I Cardiovascular diseases claimed 3.7 million
lives in the Region. Ischeamic heart diseases
and stroke account for majority of the
cardiovascular disease deaths.
1
I An estimated 1.7 million new cases of cancer
occur each year in the Region and claims 1.1
million lives each year. Among males, lung
and oral cancers are most common, followed
by oral cancer, while among females, the
incidence of breast and cervix uteri cancers
is the highest.
There are an estimated 81 million people
I
living with diabetics in the Region. The
prevalence of diabetes is consistently higher
in urban than rural areas, and is increasing
in both areas. Undiagnosed diabetes is a
significant problem in the Region.
I An estimated 1.4 million people died of
chronic respiratory diseases in SEAR in
2008; of these 86% were due to chronic
obstructive pulmonary disease and 7.8% due
to asthma.
NCD risk factors and social
determinants
The four major behavioural risk factors of
I
NCDs (tobacco use, unhealthy diet, lack of
physical activity and harmful use of alcohol)
that lead to four major metabolic risk
factors (overweight/obesity, high blood
pressure, raised blood sugar and raised
blood lipids) are highly prevalent in the
Region and on the rise. Hypertension,
raised blood glucose and tobacco use
together account for nearly 3.5 million
deaths in the Region every year.
2011
2

I The Region has nearly 250 million smokers
and an equal number of smokeless tobacco
users. Nearly half of all adult males and two
in every five adult females use some form of
tobacco. 6.8% of annual deaths in the
Region are attributed to tobacco use. The
smoking rate among boys is higher than
I Approximately 30% of the adult population
has high blood pressure, which accounts for
nearly 1.5 million deaths annually; and 9.4%
of the total deaths are attributed to high
blood pressure.
There are remarkable variations in raised
I

cholesterol levels among adults, with the

that among girls in the age group 1315
highest prevalence (above 50% in both sexes)
years. However, prevalence of smokeless
in Maldives and Thailand. Females have a
tobacco use among young girls and women
higher prevalence of raised cholesterol than
in the Region is on the rise.
males in several Member countries. 4.9% of
I Three areas of particular concern regarding the total annual deaths in the Region are
unhealthy diet in the Region are low intake attributed to raised cholesterol.
of fruits and vegetables, high consumption
In addition to population ageing, which is a
of salt and widespread use of transfats in
I

non-modifiable determinant of NCDs,

the food industry. Approximately 80% of
poverty, urbanization, globalization,
the population does not eat sufficient
inequity and poor health systems are major
quantities of fruits and vegetables and half
drivers of NCDs and their risk factors.
a million deaths in the Region are attributed
to low intake of fruits and vegetables.
Economic burden of NCDs
Annually, nearly 800 000 deaths in the
There is a two-way link between NCDs and
I
I
Region are attributed to inadequate
household poverty. Poverty exposes
physical activity. The prevalence of
populations to risk behaviours and poor
insufficient physical activity varies from 3%
health outcomes; NCDs in turn exacerbate
to 41% among males and from 6.6% to 64%
poverty due to expenses incurred on
among females; 5.1% of the total annual
unhealthy behaviours, expenses on health
deaths are attributed to physical inactivity.
care and loss of wages.
The prevalence of alcohol consumption
Similarly, the macroeconomic burden is
I
I
varies from 2% to 44% among males and
also enormous and includes health care
from 0.1% to 26% among females. An
costs, loss of productivity due to premature
estimated 350 000 people died in SEAR of
deaths and decreased gross domestic
alcohol-related causes in 2004.
product (GDP).
The prevalence of overweight varied from 8%
National responses to NCDs
I

to 30% among males, and from 8% to 52%

among females. The prevalence of
overweight and obesity is higher in females
than in males. Annually, 350 000 deaths are
attributed to overweight and obesity in the
Region. Childhood obesity is an emerging
issue.
I All 11 Member countries* initiated a public
health response to NCDs and have
allocation for NCD prevention and control
in the budget of their respective ministries
of health.

2011

I Nine Member countries have an integrated
policy on NCDs. Cancer and diabetes are
the most targeted diseases for control and
chronic respiratory disease are the least
covered. Guidelines on dietary counseling
are available in six countries, guidelines on
tobacco dependence and physical activity
are available in four countries and
guidelines on alcohol dependence are
available in five countries.
I Legislative support for tobacco is available
in 10 countries; there is alcohol legislation
in five countries. Only two countries
address diet and nutrition and one country
addresses physical activity through
legislative measures.
I At least one NCD risk-factor survey
(national or subnational) has been
completed in all 11 countries. Surveys for
tobacco use have been done more
frequently compared to other risk factors.
Disease-specific morbidity data are
I
generally collected through the routine
health information system in all 11
countries; mortality data are included in
nine countries. Disease registries for NCDs
have been most commonly established for
cancers, followed by diabetes and stroke.
Most mortality/morbidity data and disease
-specific registries are hospital-based.
3
I All Member countries reported providing at
least one NCD-related service at the
primary care level in public health facilities.
This includes primary prevention and
health promotion (11 countries), early
diagnosis of NCD risk-factors (9 countries)
and risk factor and disease management (10
countries). All Member countries have an
essential drugs list and many of the NCD-
related drugs are included in the national
essential drugs list.
Major challenges in addressing NCDs
Major challenges that need to be overcome
to effectively address NCDs include lack of
strong national partnerships for multisectoral
actions, weak surveillance systems, limited
access to prevention, care and treatment
services for NCDs, limited human resources,
insufficient allocation of funds, and lack of
engagement of the private sector.
Way forward
High level of commitment is needed to
reverse the growing burden of NCDs in the
Region. Key priorities for tackling NCDs
include: (1) reducing risk factors for NCDs
through multisectoral actions; (2) strengthening
surveillance systems to map the risk, burden
and national response, and (3) integrating
NCDs into the primary health care system as a
step towards universal coverage.
2011
Chapter 1

Introduction
Noncommunicable diseases (NCDs) are
defined as diseases of long duration, and are
generally slow in progression. NCDs are the
leading cause of adult mortality and morbidity
worldwide. Four main diseases are generally
considered to dominate NCD mortality and
morbidity: cardiovascular diseases (including
heart disease and stroke), diabetes, cancers and
chronic respiratory diseases (including chronic
obstructive pulmonary disease (COPD) and
asthma). These four NCDs are caused, to a large
extent, by four modifiable behavioural risk
factors: tobacco use, unhealthy diet, physical
inactivity and harmful use of alcohol.
NCDs have now reached epidemic
proportions in many countries. NCDs hit
hardest at the worlds low- and middle-income
groups and place a tremendous demand on
health systems and social welfare, cause
decreased productivity in the workplace,
prolong disability and diminish resources
within families. Globally, NCDs are estimated
to cost more than US$ 30 trillion over the next
20 years, representing 48% of global gross
domestic product (GDP) in 2010 (1). NCDs are
expected to rise substantially in the coming
decades, partly due to a growing ageing global
population. Further, as urbanization and
globalization increase in the developing world,
there is likely to be an increase in the prevalence
NCDs. Therefore, unless the NCD epidemic is
aggressively confronted, the mounting impact
of NCDs will continue unabated.
5
In 2008, 63% (36 of 57 million) deaths
worldwide occurred due to NCDs (2). These
deaths are distributed widely among people
from high-income to low-income countries.
About one-quarter of all NCD deaths were
below the age of 60, amounting to
approximately 9 million deaths per year. Ninety
percent of premature deaths from NCDs occur
in developing countries. Nearly 80% of NCD
deaths (29 million) occur in low- and middle-
income countries. The leading causes of NCD
deaths in 2008 were cardiovascular diseases (17
million deaths, or 48% of NCD deaths); cancers
(7.6 million, or 21% of NCD deaths); and
respiratory diseases, including asthma and
COPD (4.2 million). Diabetes caused an
additional 1.3 million deaths. Over 80% of
cardiovascular and diabetes deaths, and almost
90% of deaths from COPD, occurred in low- and
middle-income countries. NCD deaths are
projected to increase by 15% globally between
2010 and 2020 (to 44 million deaths) and
annual NCD deaths are projected to rise
substantially, to 52 million by 2030. The
greatest increases will be in the WHO regions of
Africa, South-East Asia and the Eastern
Mediterranean, where they will increase by over
20%. NCD mortality already exceeds that of
communicable diseases, maternal and perinatal
conditions, and nutritional deficiencies
combined in all Regions with the exception of
the African Region. It is projected that over the
next 20 years, annual infectious disease deaths
will decline by around 7 million, but annual
2011
6

cardiovascular disease mortality will increase by Turkey). A number of low- and middle-income
6 million, and annual cancer deaths by 4 countries (e.g. Egypt, Pakistan, Turkey and the
million. By 2030, in low- and middle-income Ukraine) recently increased taxes on tobacco
countries, NCDs will be responsible for three products, generating substantial revenues and
times as many disability adjusted life years saving lives (2).
(DALYs) and nearly five times the mortality
from communicable diseases, as well as from The South-East Asia Region (SEAR)
maternal and perinatal conditions, and suffers from a double disease burden, that of
nutritional deficiencies combined. communicable diseases that remain an
important public health problem, as well as
The good news is that NCDs are largely
NCDs that have emerged as the leading cause of
preventable through interventions and policies
death. The emergence of NCDs as a public
that reduce the major risk factors. Many
health problem in the Region stems mainly
preventive measures are cost-effective,
from epidemiological transition, characterized
including that for low-income countries. NCD
by a change in disease patterns from infectious
prevention can avert millions of deaths and
diseases to NCDs, and from a demographic
reduce billions of dollars in economic losses. A
transition due to increased longevity and a rise
recent WHO report underlines that population-
in ageing population. The challenges in
based measures for reducing tobacco and
addressing NCDs in the Region calls for a
harmful use of alcohol, as well as unhealthy diet
paradigm shift in approach: from a clinical
and physical inactivity, are estimated to cost
approach to a more comprehensive approach;
US$ 2 billion per year for all low- and middle-
from using a biomedical approach to a public
income countries, which translates to less than
health approach and from addressing each NCD
US$ 0.40 per person (3). Numerous options are
separately to collectively addressing a cluster of
available to prevent and control NCDs, such
diseases in an integrated manner.
asthe WHO identified set of interventions called
Best Buys. NCD prevention can be further
This NCD status report describes the
strengthened by implementing programmes
regional burden of NCDs, their risk factors and
aimed at behaviour change among youth and
socio-economic determinants. The report also
adolescents, and more cost-effective models of
summarizes the progress countries are making
care. Cost-effective nutritional policies, such as
for tackling the NCD epidemic, provides the
salt reduction initiatives in the United Kingdom,
base for regional and country responses,
Finland, France, Ireland and Japan, have
highlights some good country practices and
demonstrated positive and measurable results.
recommends the way forward in addressing
Declines in tobacco use prevalence are apparent
NCDs and risk factors in a comprehensive and
in several high-income countries (e.g. Australia,
integrated way. The report is intended for
Canada, Finland, the Netherlands and the
policy-makers in health and development,
United Kingdom). Some low- and middle-
health professionals, researchers and academia,
income countries have also documented decline
and other key stakeholders involved in
in tobacco use prevalence (Mexico, Uruguay and
prevention and control of NCDs.

2011
 7

REFERENCES
1. The global economic burden of non-communicable diseases. A report by the World Economic Forum and the Harvard
School of Public Health. September 2011
http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf
(accessed 28 December 2011).
2. World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011
http://whqlibdoc.who.int/publications/2011/9789240686458_eng.pdf. (accessed 28 December 2011).
3. World Health Organization. Scaling up action against noncommunicable diseases. How much will it cost? Geneva,
2011 http://whqlibdoc.who.int/publications/2011/9789241502313_eng.pdf. (accessed 28 December 2011).

2011
Chapter 2
 9

Burden of Noncommunicable Diseases

in WHO South-East Asia Region

I Noncommunicable diseases (NCDs) are top killers in the South-East

Asia Region (SEAR), causing 7.9 million deaths annually; the number
of deaths is expected to increase by 21% over the next decade.
I NCDs kill people at a relatively younger age in SEAR compared to the
rest of the world; one-third (34%) of the 7.9 million deaths in SEAR
occur in those below the age of 60 years compared to 23% in the rest
of the world.
I Cardiovascular diseases (coronary heart disease and stroke), cancers,
chronic respiratory diseases and diabetes account for the majority of
NCD morbidity and mortality.
I Mortality and morbidity from major NCDs is on the rise and will
continue to be so in the future.

Member States in SEAR* are undergoing
epidemiological transition. NCDs are replacing
communicable diseases, maternal and child
health as well as malnutrition (the primary
causes of death until some decades ago) as the
leading cause of death. NCDs are killing millions
and disproportionately affecting people at a
younger age and in poorer sections in this
Region.
This chapter reviews the current burden
and trends of NCDs in SEAR and provides the
latest estimates and data as reported by
Member countries. Age- and sex-wise estimates
of mortality are available; however there is
limited availability of disaggregated data by
socioeconomic status.

* Bangladesh, Bhutan, Democratic Peoples Republic of Korea, India,

Indonesia, Maldives, Myanmar, Nepal, Thailand, Sri Lanka, Timor-Leste
2011
10
NCD Mortality
Of the estimated 14.5 million total deaths
in 2008 in SEAR, 7.9 million (55%) were due to
NCDs (1). Cardiovascular diseases (CVDs) alone
accounted for 25% of all deaths. Chronic
respiratory diseases (CRDs), cancers and
diabetes accounted for 9.6%, 7.8% and 2.1% of
all deaths, respectively (1) (Figure 2.1). Other
NCDs, such as kidney and liver diseases,
accounted for most of the remaining NCD
burden. In nine of the 11 SEAR Member
countries, the estimated percentage of NCD
deaths out of the total deaths already exceed
50%, with the highest percentage in Maldives
(79%) followed by Thailand (71%) and Sri Lanka
(66%). At present, Timor-Leste and Myanmar
are the only two countries in this Region where
NCDs cause less than 50% deaths (1) (Figure
2.2). In terms of absolute numbers, India and
Indonesia together account for 80% of NCD
deaths in SEAR (Annex 1), owing to their large
population size.
NCDs are reported to be the commonest
causes of deaths in most countries in the
Fig 2.1: Estimated percentage of deaths by cause, South-East Asia Region, 2008
Injuries 11%
Communicable diseases,
maternal and perinatal
conditions, nutritional
deficiencies 35%
Diabetes 2.1%
Other
NCDs 10%
Source: Global Health Observatory. World Health Organization 2011.
Note: percentages do not add up to 100% due to rounding off.
2011
Region. According to a special survey of deaths
in India (2), NCDs were common both in urban
and rural areas. In urban areas of India, CVDs,
cancers and chronic obstructive pulmonary
disease (COPD), ranked first, second and fourth
respectively, claiming 33%, 11% and 7.7% of the
top 10 causes of deaths. In rural areas, CVDs,
COPD and cancers ranked first, second and
fourth, claiming 23%, 11% and 9% of the top 10
causes of deaths. In Sri Lanka, mortality reports
from hospital-based data showed that 86% of
deaths were caused due to NCDs (3). According
to the Thailand health profile 20052007, just
16% deaths were due to infectious diseases, 12%
were due to external causes of injuries and 35%
due to diseases of the circulatory system
(including stroke) and cancers (4).
NCDs are causing deaths among younger
age groups in this Region compared to most
other parts of the world. Of the 7.9 million
annual NCD deaths in SEAR, 34% occurred
before the age of 60 years compared to 23% in
the rest of the world (Figure 2.3), and nearly
twice as much as in the European Region (16%)
(1). In age groups 4559 years and 6069 years,
NCDs are the
leading cause
Cardiovascular of death in
disease 25% the Region
Chronic respiratory
diseases 9.6%
Cancers 7.8%
 11

Fig 2.2: Estimated percentage of deaths, by cause, Member countries of the South-East Asia
Region, 2008
NCDs account
for more than
100

half of all deaths

in most SEAR
countries
80

60
Percent

40

20

0
te ar pa
l sh an ia sia RK a nd s
-L
es nm Ne de ut Ind ne DP
nk ila ive
r a la Bh o La a ld
mo My ng Ind Sri Th Ma
Ti Ba

Noncommunicable Communicable diseases/ Injuries

diseases maternal conditions/
nutritional deficiencies

Source: Global Health Observatory. World Health Organization 2011.

Fig 2.3: Estimated percentage of premature deaths (under 60 years of age), by cause,
South-East Asia Region vs rest of the world, 2008

SEAR has a
higher
50 South-East Asia Region

proportion of
Rest of the world

premature NCD
deaths than the
40

rest of the world

30
Percent

20

10

0
All NCDs Cancer Diabetes Cardiovascular Chronic
diseases respiratory
diseases

Source: Global Health Observatory. World Health Organization 2011.

NCD deaths account for a massive 70% and Similar observations were noted for all
76%, respectively of all deaths (1). This high major NCDs and occur in almost all countries
NCD mortality among the economically of SEAR (Figure 2.3). The proportion of
productive age group is premature and largely premature deaths among those below 60 years
preventable. of age in SEAR was the highest in Bangladesh

2011
12

38% of deaths were due to NCDs (1). High nutritional conditions would decrease to nearly
premature mortality was noted particularly for one third from 37% to 14% by 2030 (Figure 2.5)
cancer deaths 48% of cancer deaths in the (5). According to the same projections, increase
Region occurred in those below 60 years of age in NCD deaths among males and females would
(Figure 2.3). be 22% and 25%, respectively, in just 11 years
from 2004 to 2015 (5).
NCD death rates vary greatly among SEAR
Member countries (Annex 2). In 2008, Bhutan National surveys from SEAR countries
had the highest age-standardized death rates per also observed a steep increase in the proportion
100 000 population for NCDs among both males of NCDs deaths. In Indonesia, the proportion of
and females (801 in males and 667 in females) NCD deaths increased from 42% in 1995 to 60%
(1). Age-standardized NCD death rates were in 2007 (6) (Figure 2.6). In Sri Lanka, during
higher among males than females for all major the past half-century, the proportion of deaths
NCDs, except for diabetes where males and due to circulatory diseases increased from 3%
females had similar death rates (Figure 2.4). to 24% while those due to communicable
diseases decreased from 24% to 12% (7).

Similar trends have been observed in NCD-

Trends in NCD Mortality and related morbidities. The trend in hospitalization
Morbidity of selected diseases in Sri Lanka showed a steady
increase in major NCD cases during 19702008,
Based on projections made in 2004, NCD
and a reduction in hospitalizations due to
deaths in the Region are likely to increase by
infectious diseases (Figure 2.7). A remarkable
nearly 60%, from 7.9 million to 12.5 million by
increase in hospitalizations for the major NCDs
2030 (5). At the same time, the percentage of
during the past two decades has also been
total deaths due to communicable diseases,
documented in Thailand (Figure 2.8).
maternal and perinatal conditions as well as

Fig 2.4: Age-standardized mortality rates per 100 000 population by sex, South-East Asia
Region, 2008

NCD mortality
800 Male

rates are
Female
Age-standardized death rates per 100 000

higher in males
700

600
than females
500

400

300

200

100

0
All NCDs Cardiovascular Cancer Chronic Diabetes
diseases respiratory
diseases

Source: Global Health Observatory. World Health Organization 2011.

2011
 13

Bhutan saw a 31% increase in alcohol- Disease-Specific Burden and

related diseases (from 1217 in 2005 to 1602
cases in 2009); a 20% increase in circulatory
system-related diseases (from 21 345 in 2005 to
26 937 cases in 2009); and an alarming 63%
increase in diabetes (from 944 in 2005 to 2605
in 2009) (8).
Trends
CVDs, cancers, diabetes and CRDs are the
four major NCDs that contribute to more than
80% of NCD deaths in this Region. Significant
differentials exist across Member countries in
the burden of these diseases.

Fig 2.5: Trends in estimated percentage of deaths by cause of death, South-East Asia
Region, 2004 and 2030
2004

NCD deaths are

80
2030
70
projected to
increase in the
coming years
60

50
Percent

40

30

20

10

0
Communicable NCDs Injuries
diseases/maternal
and perinatal conditions/
nutritional deficiencies

Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine 2006, 3(11):e442.

Fig 2.6: Trends in percentage of deaths by cause, Indonesia, 1995-2007

70 Increasing
trend in NCD
HHS 1995

deaths in
HHS 2001
60
Indonesia
BHR 2007

50

40
Percent

30

20

10

0
Maternal and Communicable Noncommunicable Injury
perinatal condition disease disease

HHS: household survey; BHR: basic health research

Source: Ministry of Health, Indonesia, Country Report, March 2011

2011
14

Fig 2.7: Trends in hospitalization rates per 100 000 population, by selected diseases,
Sri Lanka, 19712008

Consistent
increase in
Intestinal infectious diseases
1200

hospitalization
Malaria
Hypertensive diseases

due to NCDs
Ishaemic heart diseases

and reduction
1000 Diabetes mellitus

in infectious
diseases
800
Cases per 100 000

600

400

200

0
1997-79

198688

198991
197476

198082

198385

199294

199597

199800

200406

200708
197173

200103
Source: NCD Profile, Ministry of Health, Sri Lanka, 2010

Fig 2.8: Trends in hospitalization rates per 100 000 population, by selected diseases,
Thailand, 19852006

Significant
increase in
700 Diabetes

hospitalization
Heart diseases
Cancer
due to NCDs in
600

500
Thailand
Cases per 100 000

400

300

200

100

0
1989

1993

1995
1987

1991

1997

1999

2003

2005
1985

2001

Source: Thai Health Profile, 2005-2007

Cardiovascular diseases Of the 7.9 million deaths attributed to

NCDs in SEAR in 2008, 3.6 million (45%) were
CVDs are a group of large number of
due to CVDs (1). The proportion of deaths due to
conditions relating to the heart and blood
CVDs was the lowest in Maldives (34%) and
vessels. The major CVDs include hypertensive
highest in Bhutan (53%). In India, CVDs are the
heart disease, ischaemic heart disease,
leading cause of death in both males and
rheumatic heart disease and cerebrovascular
females and in urban as well as rural areas (2).
disease or stroke.

2011
 15

Types of CVDs vary among countries related death rate increased from 7% to 18%
(Figure 2.9). The commonest CVDs in the during the same period (11). In India, the
Region are ischaemic heart disease, stroke and number of new cases of CVDs is projected to
hypertensive heart disease. Ischaemic heart increase to 64 million in 2015 (from 29 million
disease is the commonest cause of CVD deaths in 2000) (12); and stroke cases to increase to an
in all countries except Thailand where deaths estimated 1.7 million in 2015 (from 1.1 million in
due to cerebrovascular disease (stroke) exceeds 2000) (12).
deaths due to ischaemic heart disease.
Cancers
CVDs affect younger age-goups in SEAR
than in their counterparts in western countries. Cancers are predicted to become an
For example, CVD mortality in India in the 30 increasingly important cause of morbidity and
59 years age-group is twice than that in the US mortality in the next few decades, all over the
(9). Nearly 52% of CVD deaths in India occur world (13).
below the age of 70 years compared with 23%
In SEAR, 1.1 million people died of cancers
in established market economies (10).
in 2008 (14). Of the 569 000 cancer deaths in
The trends for CVDs in the Region are of males, the commonest sites of cancers were the
concern. For example, in Bangladesh, CVDs lungs (17%, including trachea and bronchus),
were the main cause of death in 2008 27% of followed by mouth and oropharynx (15%), and
all deaths and are projected to rise to 37% by liver (7.5%) (14). Among women, cervical and
2030 (5). DPR Korea reported stroke-related breast cancers accounted for 35% of all cancer
death rate increase from 3.8% to 25% during a deaths (14). The estimated percentage of cancer
30-year period (19601991) and heart-disease- deaths varied from 6.4% in India to 13% in DPR
Korea and Indonesia (1).

Fig 2.9: Percentage of deaths due to CVDs*, by type of CVD, South-East Asia Region, 2008

35
Other cardiovascular diseases

30 Hypertensive heart disease

Cerebrovascular diseases

25 Ischaemic heart disease

20
Percent

15

10

Ischaemic heart
disease is the
5

commonest type
of CVD death in
0

most SEAR
Myanmar

Thailand

Bangladesh

Indonesia
Nepal
India

Maldives

DPRK
Bhutan
Timor-Leste

Sri Lanka

countries

* CVDs = cardiovascular diseases

Source: Global Health Observatory. World Health Organization 2011. http://apps.who.int/ghodata/?region=searo (accessed on 13 May 2011).

2011
16

Based on country reported data, of the
150 000 cancer-related deaths occurring
annually in Bangladesh, more than one half die
within five years of diagnosis (15). In India,
cancers caused a larger percentage of deaths
among females than males in both urban and
rural areas during 20012003 (2).
A large proportion of cancer deaths occur
in the economically productive age group. Fifty-
two per cent of cancer deaths among women and
45% of cancer deaths among men occur below
the age of 60 years (1). In a five-city study in
India, nearly 50% of cancer mortality was
reported among those below 55 years of age (16).
In addition to high mortality, SEAR has
high cancer-related morbidity. An estimated
1.7 million new cases of cancer occur each year
in the Region. Figure 2.10 shows that among
males, lung cancers are most common followed
by oral cancer, while among females, breast and
cervix uteri cancers have the highest incidence.
There are differences in the incidence of
various cancers among Member countries.
Among women, the incidence of cervical cancer
exceeded that of other cancers in Bangladesh,
Bhutan, India and Nepal, whereas in
DPR Korea, Indonesia, Myanmar, Sri Lanka
and Thailand, breast cancer ranked first. Among
men, the incidence of lung cancer was higher
than that of other cancers in all Member
countries except Thailand, where the incidence
of liver cancer was the highest (14).
Data for the period 19842004 from five
urban and one rural cancer registry in India

Fig 2.10: Incidence of selected cancers per 100 000 population, by sex, South-East Asia
Region, 2008

Incidence/100 000 population

30 20 10 0 10 20 30

Lung
Breast
Cervix uteri
Lip/oral cavity
Oesophagus
Stomach
Colorectum
Liver
Non-Hodgkin lymph
Larynx
Ovary
Bladder FEMALES MALES
Brain/Nervous
Leukaemia
Thyroid
Hodgkins lymphoma
Kidney
Lung and oral
cancer in males
Prostate

and breast and

Corpus uteri

cervical cancer in
Testis

females are most

Gallbladder

common
Pancreas

Source: GLOBOCAN 2008. International Agency for Research on Cancer and World Health Organization

2011

indicated that, cancers of the prostate, colon,
rectum and liver increased significantly among
males, while cancers of the breast, corpus uteri
and lung increased among females (17).
Trends in cancer incidence from seven
major hospitals in Nepal revealed that among
women breast cancers were common during
younger age, cervical cancers were common
during middle age and lung cancers during old
age. In males, leukaemias and lymphomas
occurred more often during youth, lung and
stomach cancers occurred during middle age,
and cancers of the lung, stomach and larynx
were common in old age (18).
The present trend suggests that cancer
incidence is increasing in most Member countries
of the Region. The majority of cases of all cancer
types present at a late stage of the disease and
with complications, which imposes a heavy
burden on the family and health-care system.
Diabetes mellitus
Diabetes is defined as having a fasting
plasma glucose value 7 mmol/l (126 mg/dl) or
being on medication for raised blood glucose.
Uncontrolled diabetes increases risk of CVD and
can lead to retinopathy, nephropathy and
gangrene, among other conditions (13).
Diabetes is growing significantly in SEAR
countries, placing enormous restrictions on
those who suffer this lifelong disease. An
estimated 305 000 deaths were attributed to
diabetes alone in 2008; the number of deaths
were slightly more among males than females
(1). Diabetes specific death rates vary
enormously across countries in SEAR from 56
per 100 000 population in Thailand to 5.8 per
100 000 in the Maldives (1). DPR Korea,
Indonesia and Thailand showed substantially
higher deaths attributed to diabetes among
females than males (Annex 1; 1).
17
Based on results of the STEPS surveys, the
highest prevalence of diabetes was in Bhutan
(12% in males and 13% in females) and the
lowest in Indonesia and Myanmar (6%7% in
both sexes) (Figure 2.11). There are an
estimated 81 million people living with diabetes
in the Region. According to the International
Diabetes Federation, estimates were slightly
lower ranging from 7.0% in the 2079 years age
group in 2010 to a projected rise to 8.4% in
2030 (19). Diabetes prevalence was consistently
higher among the urban population than those
residing in rural areas. In Bangladesh, diabetes
prevalence in urban areas was twice as much as
that in rural areas (8% vs. 4%); in Nepal
diabetes prevalence was 3% in rural areas and
15% in urban areas (10); in Sri Lanka, diabetes
prevalence in urban areas was 16.4% while that
in rural areas was 8.7% in 200506 (20).
Late diagnosis of diabetes is a major
problem in the Region. A Nepal study found
high diabetes prevalence among the elderly, the
majority of whom were previously undiagnosed
(21). In Sri Lanka, one third of those with
diabetes were undiagnosed (20). In a national
sample of 24 417 persons over 15 years of age in
urban Indonesia, undiagnosed diabetes mellitus
was present in 4.2% and impaired glucose
tolerance (IGT) was present in 10.2%. IGT
prevalence was 5.3% in the youngest age group
(1524 years) (22).
An increasing trend in diabetes prevalence
has been reported from several countries. In
Bangladesh, prevalence increased threefold,
from 2.3% in the 1999 to 6.8% in 2004 (23).
Age-standardized diabetes prevalence in a rural
area in Sri Lanka increased from 2.5% in 1990
to 8.5% in 2000 (24). In India, diabetes
prevalence in urban areas increased tenfold
from 1.2% to 12.1% during 19712000 (25,26)
while that in rural areas trebled from 2.2% to
6.4% in just 14 years during 19892003 (27).
2011
18

Fig 2.11: Percentage of adult population with raised blood glucose level*, South-East Asia
Region, 2008

Nearly one in
10 adults in the
Region has
14

raised blood
Male
Female

glucose
12

10

8
Percent

0
Indonesia
India

Myanmar

Thailand
Bhutan

Nepal

Sri Lanka
Bangladesh

Maldives

* Fasting glucose >7.0 mmol/L or on medication for diabetes

Source: World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011
Note: Data adjusted for 2008 for comparability

According to the national Thailand health Timor-Leste to 11% in India). Age-standardized

survey, mean fasting blood sugar among those death rates of CRDs were lowest in DPR Korea
aged 3559 years increased from 87 mg/dl in (60 per 100 000 population) and highest in
1991 to 92 mg/dl in 1996, to 100 mg/dl in 2004 India (154 per 100 000 population) (1).
(4,28).
According to national reports from
Chronic Respiratory Diseases Thailand, asthma prevalence was estimated at
4 million cases affecting 6.8% of the adult
Chronic respiratory diseases narrow air population (29). Nation-wide asthma
passages of the lungs and obstruct breathing, prevalence in Indonesia was reported to be 4%
thereby severely affecting quality of life. Major in 2007 (30). For 2011, the projected prevalence
chronic respiratory diseases include COPD, rate of chronic asthma in India in the age group
asthma and occupational lung disease. These 1559 years is 19 per 1000 population in urban
diseases can affect all age groups and are not areas and 26 per 1000 in rural areas; and the
predominant in old age unlike many other total number of chronic asthma cases is nearly
NCDs. Most CRDs are preventable and curable. 32 million (31).
Yet, an estimated 1.4 million people died of
CRDs in SEAR in 2008; of these, 86% deaths Statistics on CRDs in SEAR are generally
were due to COPD and 7.8% due to asthma (1). limited. Consequently, the true burden of CRDs
is not appreciated. Intensive efforts are required
In the Region, CRDs accounted for an to generate robust data on CRDs.
estimated 9.6% of all deaths in 2008 (3.6% in

2011
 19

Other NCDs disease and 0.15% of stage-V chronic kidney

Besides the major NCDs, many other
chronic conditions and diseases contribute
significantly to the burden of disease on
individuals and families. Particularly significant
in the Region are chronic kidney disease,
chronic liver disease and thalassaemia.
Chronic kidney disease is a slow
progressing disease and usually takes many
years to manifest clinically. This also is an
under-diagnosed disease resulting in lost
opportunities for prevention. A significant
number of people are affected by chronic kidney
disease in the Region. In a Bangladesh slum
(n=1000) 16% had chronic kidney disease (32).
In a large cross-sectional study (n=3398), of the
apparently healthy Indian central government
employees 18 years, nearly 15% were in early
stages of chronic kidney disease (33). Data
obtained from various nephrology centres in
Indonesia showed that incidence and
prevalence of end-stage renal disease in Java
and Bali are increasing over time (34). In
Thailand, a nationally representative sample (of
3117 people aged 15 years) showed 8.1%
prevalence of stage-III chronic kidney disease
in 2004, 0.2% of stage-IV chronic kidney
disease (35).
The most common liver diseases are
hepatitis, cirrhosis and carcinomas. Cirrhosis
can affect all age groups but is more commonly
seen among men aged 4569 years. The
problem is particularly severe in SEAR with
about 284 000 cirrhosis deaths constituting
nearly 30% of global deaths (1). Hepatitis B
virus and Hepatitis C virus are significant
contributors to liver disease in this Region.
Maldives has the highest prevalence of
thalassaemia in the world with a carrier rate of
18% (36). The average frequency of -
thalassaemia in India is 3%4% although it
greatly varies across the country (37). In
Indonesia, the carrier frequency of thalassemia
in some areas was 6%10% (38). Bangladesh
has a 7% thalassemia carrier rate which equals
more than 10 million people; and 7000 babies
are born each year with thalassemia (39). These
data suggest that screening and genetic
counseling for haemoglobinopathies should be
integrated into the health care system in
Member countries of SEAR so as to avert
exhorbitant treatment costs as well as human
suffering.

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5. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS
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16. Marimuthu P. Projection of cancer incidence in five cities and cancer mortality in India. Indian Journal of
Cancer 2008;45:47.
17. India National Council of Medical Research. IMCR Bulletin, Vol 40, No. 2, February 2010.
http://www.icmr.nic.in/bulletin/english/2010/ICMR%20Bulletin%20February%202010.pdf (accessed on 9 July
2011).
18. Pradhananga KK et al. Multi-institution hospital-based cancer incidence data for Nepal: an initial report.
Asian Pacific Journal of Cancer Prevention 2009;10:25962. http://www.ncbi.nlm.nih.gov/pubmed/19537894
(accessed on 21 September 2011).
19. International Diabetes Federation. http://www.idf.org/ (accessed on 21 September 2011).
20. Katulanda P et al. Prevalence and projection of diabetes and pre-diabetes in adults in Sri Lanka Sri Lanka
Diabetes, Cardiovascular Study (SLDCS). Diabetes Medicine 2008;25:10629.
http://www.ncbi.nlm.nih.gov/pubmed/19183311 (accessed on 21 September 2011).
21. Chhetri MR, Chopman RS. Prevalence and determinants of diabetes among the elderly population in the
Kathmandu valley of Nepal. Nepal Medical College Journal 2009;11:348.
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22. Mihardja L et al. Prevalence and determinants of diabetes mellitus and impaired glucose tolerance in
Indonesia (a part of basic health research/Riskesdas). Acta Medica Indonesia 2009;41:169-74.
http://www.inaactamedica.org/archives/2009/20124611.pdf (accessed on 21 September 2011).
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Research and Clinical Practice 2007;77:3005.
24. Illangasekera U et al. Temporal trends in the prevalence of diabetes mellitus in a rural community in Sri
Lanka. Journal of the Royal Society for the Promotion of Health 2004;24:92.
25. Ramachandran A. Epidemiology of diabetes in Indiathree decades of research [review]. Journal of the
Association of Physicians India 2005;53:348.
26. Pradeepa R, Mohan V. The changing scenario of the diabetes epidemic: implications for India [review]. Indian
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27. Ramachandran A et al. Temporal changes in prevalence of diabetes and impaired glucose tolerance
associated with lifestyle transition occurring in the rural population in India. Diabetologia 2004;47:8605.
Epub 2004 Apr 28.

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28. Porapakkham Y et al. Prevalence, awareness, treatment and control of hypertension and diabetes mellitus among
the elderly: The 2004 National Health Examination Survey III, Thailand. Singapore Medical Journal 2008;49:86873.
29. Liwsrisakun CC, Pothirat C. Actual implementation of the Thai Asthma Guideline. Journal of the Medical Association
of Thailand 2005;88:898-902.
30. Report on Result of National Basic Health Research (RISKESDAS) 2007. The National Institute of Health Research
and Development, Republic of Indonesia, 2008.
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7_English.zip / (accessed on 21 September 2011).
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Commission on Macroeconomics and Health. New Delhi: WHO India, 2005
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32. Rahman MM et al. Detection of chronic kidney disease (CKD) in adult disadvantageous population in Bangladesh.
Chronic Kidney Disease 2006, MP281, iv393. http://ndt.oxfordjournals.org/cgi/reprint/21/suppl_4/iv390.pdf
(accessed on 21 September 2011).
33. Varma PP et al. Prevalence of early stages of chronic kidney disease in apparently healthy central government
employees in India. Nephrology Dialysis Transplantation 2010;9: 3011-7; Epub 2010 Mar 15.
34. Prodjosudjadi W. Incidence, prevalence, treatment and cost of end-stage renal disease in Indonesia. Ethnicity &
Disease 2006;16 (Suppl 2):S2-14-16. http://www.ncbi.nlm.nih.gov/pubmed/16774003 (accessed on 22 September
2011).
35. Ong-ajyooth L et al. Prevalence of chronic kidney disease in Thai adults: a national health survey. BMC Nephrology
2009;10:35. http://www.biomedcentral.com/content/pdf/1471-2369-10-35.pdf (accessed on 22 September 2011).
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http://www.unodc.org/pdf/india/publications/south_Asia_Regional_Profile_Sept_2005/11_maldives.pdf (accessed
on 22 September 2011).
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regions of Maharashtra and Gujarat. British Journal of Haematology 2010;149:739-47.
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22 September 2011).

2011
Chapter 3
 23

Risk Factors

I Four behavioural risk factors (tobacco use, unhealthy diet, physical

inactivity and harmful use of alcohol) are largely responsible for
majority of the NCDs.
I Behavioural risk factors lead to four key metabolic changes:
overweight/obesity; raised blood pressure; raised blood glucose; and
raised blood cholesterol.
I Behavioural and metabolic risk factors are highly prevalent in the
Region and on the rise.
I Hypertension, raised blood glucose and tobacco use are the top three
risk factors responsible for 3.5 million deaths in the Region every
year.

The four major NCDs namely CVDs,
diabetes, cancers and CRDs share four
common behavioural risk factors that account
for the majority of NCD deaths (Figure 3.1) (1).
These modifiable behavioural risk factors are
tobacco use, unhealthy diets, physical inactivity
and harmful use of alcohol. These behaviours in
turn lead to four key metabolic changes:
overweight/obesity, raised blood pressure,
raised blood sugar and raised blood cholesterol
(hyper-lipidaemia). The highest number of
deaths in SEAR are attributed to raised blood
pressure accounting for 9.4% of all deaths,
followed by raised blood glucose (6.8%),
tobacco use (6.8%), physical inactivity (5.1%)
and raised cholesterol (4.9%) (1) (Figure 3.2).
High blood pressure, tobacco use and high
blood sugar together account for approximately
3.5 million deaths each year in the Region.
This chapter provides evidence that NCD
risk factors are widely prevalent in this Region.
Data on risk factors are generated from WHO-
STEPS surveys (2) and reported as age
standardized rates in WHOs Global status
report on noncommunicable diseases 2010 (3).

2011
24

Fig 3.1: Shared risk factors for major noncommunicable diseases

4 modifiable
Tobacco Unhealthy Physical Harmful use shared risk
use diet inactivity of alcohol
factors cause
Cardiovascular     4 major NCDs
diseases which account
Noncommunicable diseases

Diabates     for 80% of all

(Type II) NCD deaths
Cancers    
Chronic
respiratory 
diseases

Fig 3.2: Estimated number of attributable deaths by risk factor, South-East Asia
Region, 2004

Hypertension,
2000

high blood
glucose and
Number of attributable deaths (000s)

1500 tobacco use are

top three risk
factors for death
1000

500

0
High blood glucose

of alcohol

and obesity
Unsafe water,
sanitation, hygiene

Suboptimal
breastfeeding

Overweight
Childhood and
maternal underweight

High cholesterol
Physical activity
Tobacco use

Indoor smoke
from solid fuels

Low fruit and

vegetable intake
High blood pressure

Harmful use

Risk factors

Source: Global health risks: mortality and burden of diseases attributable to selected major risks.
Geneva: World Health Organization, 2009.

Behavioural Risk Factors wide range of diseases that impact nearly every
organ of the body. Second-hand smoke also has
Tobacco use serious and often fatal health consequences; it
has many different chemicals, 50 of which are
Tobacco use is the single-most preventable
known to be associated with cancer (5).
cause of death in the world today. Tobacco is the
only legal consumer product that kills up to half Tobacco use is a serious public health
of those who use it (4). Tobacco use causes a concern in the Region where about 1 million

2011

tobacco-related deaths occur every year (1). It is
estimated that by 2030 tobacco use will account
for more deaths than total deaths from malaria,
maternal conditions and injuries combined (6).
Tobacco-related illnesses, such as cancers as
well as cardiovascular and respiratory diseases
are already major problems in most Member
countries of the Region. Four countries of SEAR
Bangladesh, India, Indonesia and Thailand
are among the top 20 tobacco-producing
countries in the world (7). The Region also has
some of the highest tobacco consuming
countries in the world India and Indonesia
are among the top ten tobacco consuming
countries in the world (8).
Types of tobacco products consumed
in the Region
Both smoking and smokeless types of
tobacco products are used in the Region. The
poorer sections of the population in this Region
smoke low-cost indigenous products, such as
bidis (Bangladesh, India, Nepal and Sri Lanka),
cheroots (Myanmar) and roll-your-own
cigarettes (Thailand). Manufactured cigarettes
are the preferred choice of the upper class in the
Region. Clove cigarettes called kreteks are
popular in Indonesia. Other forms of smoking
products used in Region are dhumti, chuttas,
chillums, hookah, pipes and cigars (8).
Smokeless tobacco products are used in
various ways chewing, sucking and applying
tobacco preparations to the teeth and gums. The
commonly used smokeless form of tobacco in
the Region is tobacco with betel quid (known as
paan in India, Bangladesh and Nepal; kwanya
in Myanmar and sirih in Indonesia). Tobacco
and lime mixture (known as khaini or surti in
India and khoinee in Bangladesh) is another
common tobacco product that is either
manufactured or prepared by the users
themselves. Gutkha, a manufactured tobacco
mixed with betel nut and other additives, is
popular among youth in India and gutkha
25
consumption is now prevalent throughout the
Region. The misconception about tobacco being
good for oral health, has been used as an
advantage by the tobacco industry, which has
produced tobacco products, such as dentifrice,
most common in India and Bangladesh in
different forms such as gul, gudaku, bajjar,
tapkir, lal dantmanjan.
The use of smokeless tobacco products
among children, youth and women has
increased in recent times in the Region, mainly
because of lack of adequate knowledge about
the addictive and harmful effects of smokeless
tobacco. Additionally, aggressive marketing by
the tobacco industry, easy accessibility to and
lower prices of smokeless tobacco products have
contributed to their widespread use in the
Region (8).
Tobacco use among adults
The prevalence of tobacco use varies
significantly across the Member countries of the
Region. Smoking is higher among men while
women usually take to chewing tobacco. The
prevalence of current use of any smoked
tobacco ranges from 26% (India) to 61%
(Indonesia) in males and from less than 1% (Sri
Lanka) to 29% (Nepal) among females. The
prevalence of daily cigarette smoking among
males ranges from 7% (India) to 53% (DPR
Korea). The prevalence of smokeless tobacco
product use among males ranges from 1.3%
(Thailand) to 51.4% (Myanmar); in females
prevalence of smokeless tobacco product use
ranges from 4.6% (Nepal) to 27.9%
(Bangladesh) (Table 3.1). Overall, tobacco use
among males is higher than among their female
counterparts in all Member countries of the
Region.
Tobacco use among students aged 1315
years
The findings of the Global Youth Tobacco
Survey (GYTS) reveal a high prevalence of
2011
26

Table 3.1: Prevalence of tobacco use, among adults by sex, South-East Asia Region, 20062009

Age-standardized prevalence of smoking Prevalence of smokeless

tobacco*

DAILY CURRENT
Males Females Total Males Females Total Males Females Total Year
Bangladesh 42 2 22 46 2 24 26.4 27.9 27.2 2009
Bhutan - - - - - - 21.1** 17.3** 19.4** 2007
DPR Korea 53 - - 57 - - N.A. N.A.
India 20 3 12 26 4 15 32.9 18.4 25.9 2009
Indonesia 54 4 29 61 5 33 N.A. N.A.
Maldives 38 9 24 43 11 27 N.A. N.A.
Myanmar 31 6 18 40 8 24 51.4 16.1 29.6 2009
Nepal 30 25 28 36 29 32 31.2 4.6 18.6 2008
Sri Lanka 21 <1 11 27 0.4 14 24.9*** 6.9*** 15.8*** 2006
Thailand 39 2 20 45 3 24 1.3 6.3 3.9 2009
Timor-Leste N.A. N.A. N.A. N.A. N.A. N.A. N.A. N.A. N.A.
N.A. = Not available
* WHO Report on the Global Tobacco Epidemic, 2011: warning about the dangers of tobacco. http://whqlibdoc.who.int/publications/2011/9789240687813_eng.pdf
**NCD Risk factor Survey, MOH Bhutan, 2007
***NCD Risk factor Survey, MOH Sri Lanka, 2006

tobacco use among youth in the Region. The
current use of any form of tobacco ranges from
8.5% (Maldives) to 55% (Timor-Leste) among
boys and from 3.4% (Maldives) to 30% (Timor-
Leste) among girls (Figure 3.3). The exceedingly
high tobacco use prevalence among youth in
Timor-Leste underscores their vulnerability to
NCDs in the future. The smoking rate among
students aged 1315 years is higher among boys
than girls (8).
current cigarette smoking prevalence showed a
significant decline from 10.2% in 2001 to 4.9%
in 2007. This decline was observed in both boys
(19% in 2001; 8.5% in 2007) and girls (3.2% in
2001; 1.3% in 2007). However, prevalence of
current use of other tobacco products showed a
notable increase from 5.7% in 2001 to 14% in
2007. This increase was observed in both boys
(9% in 2001; 20% in 2007) and girls (3.1% in
2001; 7.9% in 2007) (Figure 3.5) (11).

Trends in tobacco use Tobacco consumption and educational

level
Increasing smoking prevalence is a
concern in Indonesia where smoking prevalence An inverse relationship has been observed
among male youths more than doubled from between tobacco use and education. Bangladesh
14% in 1995 to 33% in 2004. Smoking GATS 2009 revealed that the prevalence of
prevalence among young females in Indonesia, current use of any smoked tobacco product is
although low, increased from 0.3% to 1.9% highest among those who had no formal
during the same period (Figure 3.4) (9). education (31%) and lowest among those who
had secondary education and above (14%) (12).
In Sri Lanka, current cigarette smoking Similarly, the prevalence of current use of any
prevalence decreased from 4% in 1999 to 2.4% smokeless tobacco product was highest among
in 2003 to 1.2% in 2007 (10). In Myanmar, those who had no formal education (42%) and

2011
 27

Fig 3.3: Prevalence of current tobacco use among students aged 1315 years by sex, South-
East Asia Region, 20062009
60 Variable, but
high tobacco
Boys

use among
Girls
50

youth in the
40 Region
Percent

30

20

10

0
2009
Thailand

2007
Maldives
2007
Nepal
2009
Bhutan

2007
Myanmar

2006
India
2009
Indonesia

2007
Bangladesh
2207
Sri Lanka
2006
Timor-Leste

Country and year of survey

Source: Global Youth Tobacco Surveys in Member countries of South-East Asia Region

Fig 3.4: Prevalence of smoking among students aged 1519 years, by sex, Indonesia,
19952004

Smoking among
Indonesian boys
has more than
40 Boys

doubled over a
Girls

decade
35
Both sexes
30

25
Percent

20

15

10

0
1995 2001 2004

Sources: National Socio-Economic Survey 1995, 2001, 2004. Ministry of Health Indonesia

lowest among those who had secondary schooling (68% in males; 33% in females) and
education and above (10%). India GATS (2009) lowest prevalence among those who had
revealed the highest prevalence of current use secondary education and above (31% in males;
of any tobacco among those who had no formal 3.6% in females) (Figure 3.6) (13). Similarly,

2011
28

Fig 3.5: Prevalence of current tobacco use among students aged 13-15 years, by sex,
Myanmar, 2001 and 2007

25 2001
Current cigarette smoker Current user of other
tobacco products 2007

20

15
Percent

10

Reduction in
cigarette
5

smoking but
increase in use
of other tobacco
0
Boys Girls Boys Girls

products
Source: Global Youth Tobacco Survey 2001 and 2007, Myanmar

Fig 3.6: Percentage of adults, who are current users of tobacco products, by education,
India, 2009

80 Male The less

educated are
more likely to
Female
70

60 use tobacco
50
Percent

40

30

20

10

0
No formal Less than Primary but Secondary
schooling primary less than and above
secondary
Education

Source: India Global Adult Tobacco Survey 2009

Thailand GATS (2009) revealed a higher than in those who had university level education
prevalence of current use of any smoked (14%) (14). In Sri Lanka, least-educated males
tobacco product among those who had less than were twice as likely to smoke as most-educated
primary (24%) and primary (29%) education males (15). In Indonesia, smoking prevalence
among men who had not completed elementary

2011

school was 72% compared with 50% among
men who had completed a bachelors degree
(16).
Tobacco consumption and place of
residence
Bangladesh GATS (2009) revealed that a
much higher percentage of people in rural areas
(14%) smoke bidis than those in urban areas
(4.7%) while the prevalence of cigarette
smoking was higher in urban areas (18%) than
in rural areas (13%) (12). Another study from
Bangladesh revealed that 60% men living in
slums smoked compared with 46% men living
in non-slum areas (17). In India, the prevalence
of current tobacco use (smoking and smokeless)
is greater in rural areas (38%) than in urban
areas (25%). Similarly, the prevalence of current
smokeless tobacco use is much higher in rural
areas (23%) than urban areas (14%) (13). As per
Thailand GATS (2009), the prevalence of any
smoked tobacco product among the rural
population was slightly higher than that for the
urban population (25% and 22%) (14). The type
Fig 3.7: Percentage of adults, who are current users of tobacco products, by wealth index,
Bangladesh, 2009
40
35
30
25
Percent
20
15
10
0
Lowest Low
Wealth index
Source: Bangladesh Global Adult Tobacco Survey 2009
29
of smoked tobacco products used also differed
between urban and rural smokers; the results
showed a higher prevalence of manufactured
cigarettes use in urban areas than in rural areas
(18% and 14%, respectively) and a higher
prevalence of hand-rolled cigarettes use in rural
areas as against urban areas (18% and 6%
respectively) (14).
Tobacco consumption and poverty
As per Bangladesh GATS (2009), the
prevalence of current use of any smoked
tobacco product and any smokeless tobacco
product decreased with increasing wealth index,
with the highest prevalence in the lowest wealth
index (29% and 36%, respectively) and lowest
prevalence in the highest wealth index (14% and
17%, respectively) (Figure 3.7) (12). Studies
from other sources also revealed consistent
results. Tobacco consumption is now
universally more common among lower
socioeconomic groups (18). In a survey of 471
143 persons of age >10 years in India in the year
19951996, people below the poverty line had
Tobacco use is
Any smoked tobacco product
Any smokeless tobacco product
highest
among the
poorest
Middle High Highest
2011
30
higher relative odds of chewing tobacco
compared to those above the poverty line, and
regular tobacco use significantly increased with
each diminishing income quintile (19). In
Indias National Family Health Survey (NFHS
II), prevalence among those in the richest
quintile was 16% compared to 40% among the
poorest quintile (20). Prevalence of tobacco
chewing among women labourers in Dharan,
Nepal (22%), was twice as much as the
prevalence among service class women (10%)
(21). The National Socio-Economic Survey 1995,
2001, 2004 for Indonesia revealed an increased
proportion of household expenditure spending
on tobacco products across all wealth quintiles
(6.4% in 1995; 9.6% in 2001; 12% in 2004).
However, a greater percentage of people in the
poorest quintile (6.1% in 1995; 9.1% in 2001;
11% in 2004) spent their household expenditure
on tobacco products than people in the
wealthiest quintile (4.9% in 1995; 7.5% in 2001;
9.7% in 2004).
Unhealthy diet
Due to globalization and urbanization,
there is a shift from a healthy traditional high-
fibre, low-fat, low-calorie diet containing whole
grains as well as fruits and vegetables, towards
calorie-dense foods that are high in saturated
fats, transfats, free sugars or salt. Foods that
are high in fats and sugars promote obesity, a
major risk factor for CVDs, diabetes and cancers
(22). Consumption of adequate servings of food
and vegetables on the other hand reduce the risk
of heart disease and some cancers. With regards
to unhealthy diet, three areas of particular
concern in the Region are low intake of fruits
and vegetables, high consumption of salt and
widespread use of transfat by the food industry.
Half a million deaths in the Region are
attributed to low intake of fruits and vegetables
(1). In SEAR Member countries, the prevalence
2011
of eating inadequate (less than five servings)
fruits and vegetables ranges from 60% to 97%
in males and 64% to 94% in females. In five of
eight Member countries for which data are
available, the prevalence of inadequate fruits
and vegetable consumption was higher among
females than males (Table 3.2). Considering the
low socioeconomic conditions and poor level of
awareness in a large segment of the population
in this Region, the findings that the vast
majority of the population eats less than five
servings of fruits and vegetables a day is not
surprising (Table 3.2). A major hindrance in
shifting to a healthy diet in this Region could be
the high cost of fruits and vegetables relative to
the income level of the population.
There is evidence of high consumption of
salt in many countries. High salt consumption is
associated with hypertension and adverse
cardiovascular events (23). According to the
National Heart Foundation Hospital and
Research Institute, Bangladesh, an average
Bangladeshi consumes around 16 g of salt per
day almost triple the recommended limit
(24). In Thailand, the average consumption of
salt per day among adults is 10.8 g (25). The
Chennai Urban Rural Epidemiology Study
(CURES) conducted on 1902 subjects showed
that the mean dietary salt intake (8.5 g/d) in the
population (26) was higher than that
recommended by WHO for adults (5 g or less).
Subjects in the highest quintile (mean salt
intake=13.8 g/d) of salt intake had a
significantly higher prevalence of hypertension
than those in the lowest quintile (mean salt
intake = 4.9 g/d) of salt intake (48% vs 17%,
p<0.0001). Subjects in the highest quintile of
salt intake also had significantly higher body
mass index (BMI) and waist circumference
(WC). The total calories and percentage of
calories from fat also increased significantly
across increasing quintiles of salt intake.
 31

Table 3.2 Percentage of male and female adults eating less than five
servings of fruits and vegetables, South-East Asia Region, 20042010

Member countries Male (%) Female (%) Both sexes (%) Year of survey

Bangladesh 94 93 93 2010

Bhutan 65 69 67 2007

India NR NR 86 2007-08

Indonesia 94 94 94 2007

Maldives 97 93 97 2004

Myanmar 90 91 90 2009

Nepal 61 64 62 2007

Sri Lanka 81 83 82 2007

Thailand 83 82 82 2005

Total (Range) 6597 6493 6297

Source: National NCD risk-factor surveys in Member countries

Another area of concern is that partially Physical inactivity

hydrogenated vegetable oils, which are
associated with coronary heart disease (27) are
commonly used in the preparation of
commercially fried, processed, bakery, ready-
to-eat and street foods in the Region. In India,
vanaspati brands, widely available in the
market used in the food industry (28), have
512 times higher trans fatty acid (TFA) levels
than the 2% limit set by some developed
countries (29). In Thailand, samples collected
from supermarkets and popular bakery stores
showed that shortenings (2.4 g), butter cookies
(2.1 g) and margarine (1.7 g) contained highest
quantities of TFA per 100 g of food (30).
Available regional data confirm current
evidence that higher intake of TFA may be
associated with increased risk of coronary heart
disease. A case-control study (n=3575) carried
out in India (1996) showed that ghee (clarified
butter) plus TFA in both rural and urban areas
were significantly associated with coronary
artery disease (31).
Lack of physical activity contributes
significantly to overweight and obesity, which is
a risk factor for many NCDs. Participation in
150 minutes of moderate to vigourous physical
activity per week is estimated to reduce the risk
of ischaemic heart disease by 30%, the risk of
diabetes by 27%, and the risk of breast and
colon cancer by 21%25% (32).
In SEAR, 5.1% of deaths are the
attributable to physical inactivity (Annex 4) (1).
This translates to nearly 800 000 deaths in the
Region per year (1). In SEAR countries, the
prevalence of insufficient physical activity
varied from 3% to 41% among males and from
6.6% to 64% among females. The highest
prevalence in both males and females was in
Bhutan (41% and 64%, respectively), followed
by Maldives (37% and 42%, respectively). In
eight of nine SEAR countries for which data are
available, prevalence of insufficient physical
activity was higher among females than males.

2011
32

Indonesia was the only exception. No data were followed by Nepal (17%). In eight countries for
available for DPR Korea and Timor-Leste which data were available, prevalence of alcohol
(Figure 3.8) consumption was higher among males than
females. No data were available for Maldives,
Harmful use of alcohol Thailand and Timor-Leste (Figure 3.9).

Alcohol is a psychoactive and potentially Evidence suggests that low socioeconomic

dependence-producing substance with severe groups often experience a higher burden of
health and social consequences when taken in alcohol-attributable diseases despite lower
excess. Harmful use of alcohol caused overall consumption levels (34).
2.5 million deaths each year globally in 2004
and an estimated 350 000 people died in SEAR A recent study from Sri Lanka found that
of alcohol-related causes in 2004 (1). two lowest income categories spent 40% of their
income on alcohol and smoking (35). Many
Across countries and cultures men are poor people in this Region indulged in binge
consistently more likely to consume alcohol drinking, so much so that almost nothing was
frequently and in larger amounts than women left from household expenditure to meet the
(33). The results of the STEPS survey confirm necessities of life such as food and shelter.
this sex differential. In SEAR Member countries, Health, particularly the preventive and
the prevalence of alcohol consumption varied promotive aspects, always receives low priority
from 2% to 44% among males and from 0.1% to in this segment of the population.
26% among females. The highest prevalence
among males was in DPR Korea (44%), followed In Bhutan, little stigma is attached to
by Nepal (40%) and Bhutan (35%). The highest alcohol use (36) and thus the usual barriers and
prevalence among females was in Bhutan (26%), deterrents to alcohol use inherent in some

Fig 3.8: Percentage of adults with insufficient physical activity*, South-East Asia Region,
2008

Many people
70
are not
sufficiently
Males
Females
60 physically
active
50

40
Percent

30

20

10

0
Bangladesh Bhutan India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand

Source: World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011.
Data adjusted for 2008 based for comparability

* Less than 30 minutes of moderate-to-vigorous activity at least five days a week.

2011

Fig 3.9: Percentage of adults consuming alcohol*, by sex, South-East Asia Region,
20072010
50
40
30
Percent
20
10
0
Bangladesh Bhutan DPR Korea
2010 2007 2008
Source: National NCD risk-factor surveys in Member countries
* People who have consumed alcohol in the past 30 days.
societies are not as apparent here. Until recently
it was not taboo for Bhutanese children to drink
at an early age and many women drink beer and
wine. Studies in the country have shown that
50% of the grain harvests of households are
used to brew alcohol; homemade alcohol
production exceeds industrial production.
Alcohol production and sale has become a
livelihood for a large number of people in
Bhutan. In certain areas, homemade alcohol is
the only source of cash income to farmers.
Alcohol is one of the five leading causes of death
in Bhutan (36).
Relatively few people in Bangladesh and
Indonesia drink alcohol. This may be a due to
the cultural setup in these countries.
Metabolic Risk Factors
Overweight and obesity
Overweight and obesity is defined based
on body mass index (BMI). BMI is calculated as
(weight in kg)/(height in metres)2. A person
33
Alcohol
Males
consumption is
Females
higher in males
than females
India Indonesia Myanmar Nepal Sri Lanka
2007 2007 2009 2007 2007
with BMI between 25.0 and 29.9 is considered
overweight and 30.0 is considered obese.
Truncal obesity is defined in terms of waisthip
(or waistheight) ratio. Raised BMI is among
the leading risk factors for NCDs. It accentuates
early development of type 2 diabetes and CVDs
by triggering metabolic dysfunctions and raising
blood pressure, blood glucose and cholesterol
levels. Overweight and obesity are the fifth
leading risk for global deaths. Globally, at least
2.8 million adults die each year as a result of
being overweight or obese (1). Annually,
350 000 deaths are attributed to overweight
and obesity in SEAR (1).
In SEAR Member countries, overweight
prevalence varied from 8% to 30% among males
and 8% to 52% among females. The highest
prevalence in both males and females was in
Maldives (30% and 52%, respectively) followed
by Thailand (26% and 36%, respectively). In
eight of nine SEAR countries for which data
were available, prevalence of overweight and
obesity was higher among females. Nepal was
the only exception. No data were available for
DPR Korea and Timor-Leste (Table 3.3).
2011
34

Table 3.3 Percentage of adult population that is overweight and obese,

South-East Asia Region, 2008
Overweight (BMI>25 kg/m2) Overweight (BMI>30 kg/m2)

Member countries Male Female Both sexes Male Female Both sexes

Bangladesh 7.6 7.8 7.7 1.0 1.3 1.1

Bhutan 25 24 24 4.7 6.6 5.5
India 10 13 11 1.3 2.5 1.9
Indonesia 16 25 21 2.5 6.9 4.7
Maldives 29 53 41 6.5 26 16
Myanmar 14 24 19 2.0 6.1 4.1
Nepal 9.8 8.9 9 1.4 1.6 1.5
Sri Lanka 17 27 22 2.6 7.3 5.0
Thailand 26 36 31 4.9 12 8.5

Source: World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011.
Data adjusted for 2008 for comparability

Childhood obesity is an emerging issue. In Among Thai adults, the prevalence of

a Mysore (India) study on 43 152 school
children, obesity and overweight prevalence was
3.4% and 8.5%, respectively (37). In a school
survey of 2156 children aged 1015 years in
Khon Kaen (Thailand) 28% were overweight
(38).
obesity increased from 23% in 2004 to 29% in
2009 among males and from 35% in 2004 to
41% in 2009 among females. Waist
circumference also showed an increase among
both males and females during the same period
(40) (Figure 3.10).

Data from eight Demographic and Health
Surveys conducted between 1996 and 2006
(19 211 women in Bangladesh, 19 354 women in
Nepal, and 161 755 women in India) showed
that between the first to the latest survey, the
prevalence of overweight increased from 2.7%
to 8.9% in Bangladesh, 1.6% to 10% in Nepal
and from 11% to 15% in India. The trend showed
significant ruralurban differences with the
increase being greater in rural compared with
urban areas in all three countries (41). On
comparing the first to the latest survey, the
prevalence of obesity also increased from 0.5%
to 1.4% in Bangladesh, from 0.1% to 1.1% in
Nepal, and from 2.2% to 3.4% in India. In all
countries, the prevalence of overweight was
positively associated with age, increasing
relative wealth and urban residence (39).
In general, obesity is more common in the
higher socioeconomic strata of society.
Indonesian adolescents from families with high
income were three times as likely to be obese
(41). In Thailand though obesity was strongly
associated with high socioeconomic status in
males but inversely in females, particularly for
those below 40 years (42). In Jaipur (India),
age-adjusted prevalence of obesity among
adults of age 2059 years was 9.5% in persons
with low education and 17% in persons with
high education (43). However, a recent review
of relationship between socioeconomic status
and obesity in 14 lower- to middle-income
countries including India showed that the
burden of obesity is shifting towards individuals
of lower socioeconomic status as a countrys
gross national product increases (44). A recent

2011
 35

Fig 3.10: Percentage of overweight adult population, by sex, Thailand, 20042009

50 Overweight Waist circumference 2004

2
BMI 25 kg/m 90.8 cm
2009

40

30
Percent

20

10

Increasing
obesity in
0
Male Female Male Female Thailand

Source: National Health Examination Surveys, 2004 and 2009

study that examined data from 26 developing conducted in 2005 in Health and Demographic
countries including South-East Asia found a Surveillance System (HDSS) sites from
higher prevalence of overweight than of Bangladesh (Matlab, Mirsarai, Abhoynagar, and
underweight among young women living in WATCH), India (Vadu), Indonesia (Purworejo),
rural and urban areas (45). Thailand (Kanchanaburi) and Viet Nam
(Filabavi and Chililab) revealed that a
Raised blood pressure considerable proportion of the study
Raised blood pressure (BP) is a major risk populations, especially those in the HDSS sites
factor for coronary heart disease as well as from India, Indonesia and Thailand had high
haemorrhagic stroke. Hypertension* is BP. The overall prevalence (men and women
responsible for nearly 1.5 million deaths in combined) ranged from around 15% to 28% of
SEAR (Annex 4). In a majority of countries of the adult population with one exception where
SEAR, more than one third of the adult prevalence was 9% (one of the HDSS in
population is hypertensive. Males have a slightly Bangladesh) (46).
higher prevalence of raised BP than females in In a recent study on 167 331 persons from
almost all SEAR countries (Figure 3.11). In the a rural area of Trivandrum (India), BP 140/90
10 countries for which data were available, the (either) mmHg was found in 43% men and 45%
prevalence of high BP ranged from 19% in women of age 3589 years (47). A seven-year
DPR Korea to 42% in Myanmar (Figure 3.11). average follow-up study showed an accelerated
No data were available from Timor-Leste. rise of all-cause mortality and ischaemic heart
Literature review also suggests that high disease mortality in the population with systolic
BP is indeed widespread in this Region. A study BP110 mmHg and diastolic BP80 mmHg.

* Systolic BP>40 mmHg and stroke or diastolic BP>90 mmHg or using medication
to lower BP

2011
36

Fig 3.11: Percenatge of adult population with high blood pressure*, South-East Asia Region,
2008

High blood
pressure is
50 Males Females

common in
40 both sexes

30
Percent

20

10

Sri Lanka**
Nepal*
DPR Korea*

India**

Myanmar**
Indonesia**

Maldives*
Bhutan**
Bangladesh*

Thailand**
Source: World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011.
Data adjusted for 2008 for comparability

* Systolic BP>40 mmHg and stroke or diastolic BP>90 mmHg or using medication to lower BP

Stroke mortality started to increase after sites in Bangladesh, India, Indonesia, Thailand
diastolic BP75 mmHg. Rise in mortality was and Viet Nam, age appeared to be a significant
relatively steeper for incremental systolic BP determinant of high BP among both men and
(2 mmHg) than for incremental diastolic BP (1 women and overweight was positively
mmHg). In a survey of 4616 persons aged 20 or associated with high BP in all sites (46).
more in Yangon (Myanmar) in 2003,
prevalence of hypertension was 34% (48). Raised cholesterol
National data from some countries Raised cholesterol (hypercholesterolemia)
indicate an increasing trend in the prevalence is widespread in SEAR and accounts for nearly
of raised BP. In Indonesia, percentage of adult 800 000 deaths annually (Annex 4). Raised
population with raised BP increased from 8% in cholesterol increases the risk of CVDs (52). This
1995 to 32% in 2008 (49). In Myanmar, the was also noted in studies conducted in the
Ministry of Health reported an increase in Region. For example, high levels of serum total
hypertension prevalence, from 18% to 31% in cholesterol and low density lipoprotein (LDL)
males and from 16% to 29% in females (50). cholesterol presented a significantly higher risk
during 20042009. Rapid urbanization and of ischaemic stroke in Bangladesh (53) and
transition from agrarian life to wage-earning, Indonesia (54).
modern city life are reported as major
Estimates available from six SEAR
contributors to increases in elevated BP in
Member countries showed remarkable
urban areas (51). In a study conducted in HDSS

2011
 37

variations in raised cholesterol levels, with the actions when two or more are simultaneously
highest prevalence (above 50% in both sexes) in present in the same person. Because of
Maldives and Thailand. Females had a higher clustering, the term metabolic syndrome is
prevalence of raised cholesterol than males in often used to describe the risk factor cluster of
five of six SEAR Member countries (Figure large waistline, high BP, raised blood sugar
3.12). level, low high density lipoprotein (HDL) level
and high triglyceride level. When occurring
In a rural population in Bangladesh,
together, they form a risky combination for the
hypercholesterolaemia (total cholesterol 240
development of NCDs. Metabolic syndrome
mg/dL) was found in 16% and high LDL
prevalence is high in the Region, e.g. in rural
cholesterol in 20% (55) in the age group 2079
Bangladesh, it was found in 21% women and
years. Different ethnic groups in Indonesia were
18% men (58). Among Indians, metabolic
found to have varying lipid profiles (56). In a
syndrome was prevalent in 19% males with
community in eastern Nepal, 13% had
higher educational status and 25% in those with
hypercholesterolemia in the age group 3586
lower educational status (59). Females had
years (57).
higher prevalence of metabolic syndrome and
similar trends with respect to education as
Cluster of risk factors
among men (59). In Sri Lanka, 62% of current
NCD risk factors are known to result in smokers were also alcohol consumers (60).
accentuated outcomes through synergistic Findings from a study conducted among 18 494

Fig 3.12: Percentage of adult population with raised total cholesterol, South-East Asia
Region, 2008

One third to one

half of adults
60 Males Females

have raised
50 cholesterol

40
Percent

30

20

10

0
Indonesia**

Myanmar**
Maldives*

Thailand**
Bhutan**

India**

Source: World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011.
Data adjusted for 2008 for comparability

2011
38

study participants in HDSS sites in Bangladesh,
India, Indonesia, Thailand and Viet Nam,
revealed a substantial proportion (>70%) of the
largely rural populations having three or more
risk factors for chronic NCDs. Chronic NCD risk
factor clustering was associated with increasing
age, being male and higher educational
achievements (46).
Other risk factors
While the risk factors discussed above are
major contributors to NCDs, other factors also
play a role. Prominent among them are
infections, environmental factors such as
pollution and arsenic, and exposures such as to
asbestos. Stress may also act as a trigger for
some NCDs.
About one fifth of the cancer burden is
attributable to a few specific chronic infections
(61). The principal infectious agents (each
responsible for approximately 5% of cancers)
are human papillomavirus (cancers of the
cervix, anogenital tract and oro-pharynx),
hepatitis B virus and hepatitis C virus (primary
liver cancers), and Helicobacter pylori (cancers
of the stomach).
Apart from infectious agents, a wide range
of environmental causes, encompassing
environmental contaminants or pollutants,
occupationally-related exposures and radiation,
together make a significant contribution to
cancer burden and are often modifiable at low
cost (3).

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59. Reddy KS et al. Educational status and cardiovascular risk profile in Indians. Proceedings of the National Academy of
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Cancer 2006;118:3030-3044.

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Chapter 4
 43

Drivers of NCDs

I NCDs have their origin in the social, cultural, economic and

environmental conditions of societies.
I Globalization, unplanned urbanization, poverty, poor health systems
and social inequities are major determinants of NCDs.
I Socioeconomic determinants can influence peoples exposure and
vulnerability to NCDs and can also influence health outcomes.

Socioeconomic conditions have an patterns from infectious diseases to NCDs, and

enormous impact on population health. Socio-
economic determinants can influence peoples
exposure and vulnerability to NCDs and can
also influence health outcomes. This chapter
reviews the major determinants of NCDs
including poverty, illiteracy, poor health
infrastructure and social inequities on one side
and demographic transition in terms of
increasing life expectancy, and urbanization
and globalization on the other. These
determinants trigger risk factors that
increasingly lead to NCDs (Figure 4.1).
Population Ageing
NCDs have emerged as a public health
problem in SEAR mainly due to epidemiological
transition, characterized by a change in disease
from a demographic transition due to increased
longevity and a rise in the ageing population.
People in this Region are now living longer
(Annex 5) and closing the gap with the worlds
average life expectancy. This is primarily a
result of marked reduction in infant and child
mortality and control of communicable diseases
in most SEAR Member countries. As a result,
typical population pyramids are changing from
a pyramid shape to a bell shape to a barrel
shape (Figure 4.2). It is projected that from
2000 to 2025, the proportion of population
above 65 years will increase from 3.6% to 6.6%
in Bangladesh, from 4.4% to 7.7 % in India and
from 6.3% to 12.3% in Sri Lanka. Ageing due to
this transition will increase the number of NCD
cases because prevalence of NCDs increases
with age (1).

2011
44

Fig 4.1. Schematic representation of an iceberg for NCDs

Cardiovascular diseases
Cancers
Chronic respiratory diseases
NCDs Diabetes

Raised blood pressure

Metabolic Raised blood glucose
risk factors Abnormal blood lipids
Overweight/obesity

Tobacco use
Behavioural Unhealthy diet
risk factors Physical inactivity
Harmful use of alcohol

Social Illiteracy
Poverty
determinants
Globalization
Urbanization

Urbanization Major urban differentials exist in the

prevalence and levels of risk factors and diseases.
Urbanization in SEAR is occurring at a
Studies have shown the correlation of
rapid rate. It increased from 26% in 1990 to
urbanization with an increase in behavioural and
33% in 2009 (2). The projected percentage of
metabolic risk factors, i.e. smoking, overweight,
population residing in urban areas will more
raised blood pressure, low physical activity, as
than double by 2050 in most of the Member
well as prevalence of some major NCDs (3).
countries (Figure 4.3).
The ICMR (Indian Council of Medical
Urban lifestyles increase the risk of NCDs
Research) and WHO multi-centric study
by reduced opportunities for physical activity,
conducted in six states of India among men and
increased exposure to environmental pollutants
women aged 1564 years shows that
and stress, and increased availability of
behavioural, anthropometric and biochemical
processed and unhealthy foods. Increasing
risk factors of NCDs are more prevalent in
urbanization is also causing traditional healthy
urban than in rural areas (Figure 4.4) (4).
habits to change to unhealthy habits.

2011
 45

Fig 4.2: Population projections for Bangladesh and India, 2011, 2025 and 2050

Bangladesh, 2011 Bangladesh, 2025 Bangladesh, 2050

Male 100+ Female Male 100+ Female Male 100+ Female
9094 9094 9094
8589 8589 8589
8084 8084 8084
7579 7579 7579
7074 7074 7074
6569 6569 6569
6064 6064 6064
5559 5559 5559
4549 4549 4549
4044 4044 4044
3539 3539 3539
3034 3034 3034
2529 2529 2529
2529 2529 2529
2529 2529 2529
2024 2024 2024
1519 1519 1519
1014 1014 1014
59 59 59
04 04 04

10 8 6 4 2 0 0 2 4 6 8 10 10 8 6 4 2 0 0 2 4 6 8 10 10 8 6 4 2 0 0 2 4 6 8 10
Population (in millions) Population (in millions) Population (in millions)

India, 2011 India, 2025 India, 2050

Male 100+ Female Male 100+ Female Male 100+ Female
9094 9094 9094
8589 8589 8589
8084 8084 8084
7579 7579 7579
7074 7074 7074
6569 6569 6569
6064 6064 6064
5559 5559 5559
4549 4549 4549
4044 4044 4044
3539 3539 3539
3034 3034 3034
2529 2529 2529
2529 2529 2529
2529 2529 2529
2024 2024 2024
1519 1519 1519
1014 1014 1014
59 59 59
04 04 04

10 8 6 4 2 0 0 2 4 6 8 10 10 8 6 4 2 0 0 2 4 6 8 10 10 8 6 4 2 0 0 2 4 6 8 10
Population (in millions) Population (in millions) Population (in millions)

Source: US Census Bureau, International Data Base

A study conducted in Sri Lanka showed compared to medium- and high-urban

that prevalence of diabetes mellitus, overweight categories (5).
and insufficient physical activity was highest
A study from Tamil Nadu (India) found
among urban men and women compared to
that being urban (measured by population size,
those among the middle- and lower-urban
access to markets, communication, etc.) is
categories. The smoking prevalence among men
associated with smoking, increased body-mass
was highest among the low-urban category,
index (BMI), blood pressure and physical

2011
46

Fig 4.3: Projected mid-year population, residing in urban areas, South-East Asia Region,
2010-2050

100
Dramatic
increase in
2010

urbanization
2050

expected
80

60
Percent

40

20

0
Bhutan

DPR Korea

Maldives
Bangladesh

Nepal

Sri Lanka
Myanmar

Timor-Leste
India

Indonesia

Thailand
Source: World Urbanization Prospects. The 2007 Revision. Highlights. Department of Economic and Social Affairs Population Division.
United Nations New York, 2008.

Fig 4.4: Prevalence of NCD risk factors in urban and rural areas, by sex, India, 2003-2006

80 NCD risk
factors are
Urban

more prevalent
70 Rural

60 in urban areas

50
Percent

40

30

20

10

0
Female
Male

Female

Female

Female

Female
Male

Male

Male

Male

BMI30 Increased WC Physical Blood glucose Total

inactivity at 126 mg/dl cholesterol
work 200 mg/dl

WC = waist circumference; BMI = body mass index; increased WC (Men 90 cm; Women 80 cm)
Source: Shah B, Mathur P. Surveillance of cardiovascular disease risk factors in India: the need & scope. Indian Journal of Medical Research
2010;132:634-42.

2011
 47

inactivity in men and high BMI and physical with NCDs are doubly disadvantaged; on the
inactivity in women (3). However, this study one hand, low levels of income affect health
found that being urban is positively associated behaviours and lifestyle choices; health-
with increased consumption of fruits and damaging behaviours are found to be common
vegetables in both sexes. among the poor, and low income may affect
health directly, for example, due to low
Globalization purchasing power for a healthy diet. On the
other hand, access to health care is low among
The rapidly growing burden of NCDs in
the poor and NCDs are expensive to treat and
low- and middle-income countries is also driven
may push a family into poverty through out-of-
by globalization of trade and market economy.
pocket expenditures, thereby limiting their food
All economies work on the principle of demand
and health-seeking choices. Poverty in turn is
and supply, i.e. they influence demand and
associated with other social determinants of
accordingly modify supply systems
chronic diseases, such as inadequate education,
manufacturing and service sectors. Moreover,
weak social network, social exclusion and long-
globalization is decreasing trade barriers and
lasting psychological stress.
populations are now subjected to international
marketing and advertising. Cardiovascular diseases (CVDs) and their
risk factors were originally more common in
Globalization has brought processed foods
upper socioeconomic groups in the developed
and diets high in total energy, fats, salt and
world but have gradually become more
sugar into billions of homes, and people in
common in lower socioeconomic groups (6). In
developing countries are now consuming more
SEAR, many risk factors and NCDs are already
processed foods than ever before. Rise in
equally and more prevalent in the lower
income is increasing the purchasing capacity
socioeconomic strata of society. For example,
and may be facilitating consumption of
in Indonesia, hypertension was as common
processed food, beverages and tobacco.
(33%) in the top income quintile as (31%) in the
A significant proportion of global bottom quintile (7).
marketing is now targeted at children in
Tobacco and poverty form a vicious circle.
developing economies and is a key contributor
Tobacco is a special case of a preventable risk
to unhealthy behaviour. This has resulted in a
that disproportionately affects the poor. The
situation where unhealthy options (be it
poorest quintiles are more likely to smoke daily
tobacco, alcohol or food) are more often easily
and more likely to smoke larger quantities (see
available, cheaper and more attractive. As a
Chapter 3). Expenditure on tobacco
result, the level of exposure of individuals and
consumption displaces income available for the
populations to risk factors for NCDs may be
familys food, education and health care. A
higher in the Region than in high-income
study conducted in Sri Lanka revealed that the
countries, where people tend to be protected by
two lowest income categories (monthly income
comprehensive interventions.
<US$ 76) spent more than 40% of their income
on concurrent alcohol and tobacco use while the
Poverty
next income category (US$ 76143) spent 35%
A large segment of the population in SEAR of their income on alcohol and tobacco. The
still lives below the poverty line. The NCD poor spent less than those with higher income
pandemic originates from poverty and on alcohol and tobacco but given the mean
disproportionately affects the poor. Poor people

2011
48
expenditure of over 40% of income on these
substances, the daily survival of the poor is
severely constrained (8).
Understanding the links between poverty
and NCDs would help in developing appropriate
policies to address this. One possibility is
material deprivation due to poverty that
restricts choices and pushes people into high-
risk behaviours. This causes not only an early
onset of NCDs, but also complications that
cannot be averted as access to health care is also
limited resulting in early death. The other
possibility is that recent developments have
generated high incomes for some erstwhile
deprived groups in developing countries that
has eased choices to indulge in a risky lifestyle
thus exacerbating NCDs (9).
The outcome of all diseases, particularly of
NCDs (since they require prolonged care), is
worse in poor countries, particularly where
access to health care is dependent on the ability
to pay (6). Total expenditure on health in SEAR
Member countries is low (Annex 6), with a
maximum of 14% GDP in Timor-Leste in 2008
and just 2.3% in Indonesia and Myanmar. In
India, total health expenditure as percentage of
GDP (4.2%) is about one third that of USA (10).
The irony in this impoverished Region is that
more than one half (59% in 2008) of health
expenditure is met with private resources,
mostly out of pocket. This places a
disproportionate burden on the poor. Social
security is practically non-existent for large
segments of the population. In 2008, per capita
total expenditure on health was $PPP 116 on
average in the Region and government
expenditure was just about 33% in populous
countries, such as Bangladesh and India, and a
dismal 7.5% in Myanmar (Annex 6).
Illiteracy
Education is a crucial factor for
sustainable development and the most
2011
important underlying determinant of health at
both individual and community levels.
Educated people benefit through increased
knowledge of protecting health, a better
understanding of health-promoting lifestyles
and seeking proper health care. Literacy levels
in SEAR have considerably improved from an
average of 52% during 199099 to 71% in 2007.
However, 30% of the Regions population
remains illiterate (11). Low levels of literacy
affect health behaviours and lifestyle choices, so
that people fall easy and early prey to NCDs. An
inverse relationship between tobacco use and
education has been observed in the Region.
Studies have revealed that both smoking and
smokeless tobacco use are more prevalent
among the less educated in Bangladesh, India,
Indonesia, Sri Lanka and Thailand (see Chapter
2). Illiteracy and a poor level of awareness can
also result in high consumption of salt, as well
as use of saturated fats and trans fats and thus
aggravate development of NCD risk factors.
Underdeveloped health system
Underdeveloped health systems and mal-
distribution of health care is also an important
determinant of health. Under-developed and
under-resourced health-care systems worsen
the impact of the NCD epidemic. Current health
systems in SEAR have many limitations to
tackle NCDs. First, there is unequal distribution
of health workers, who particularly concentrate
in urban areas. Moreover, there is a
disproportionately higher number of health
personnel working at the institutional level of
medical care vis--vis community level workers
including health volunteers delivering public
health services. Also, there is insufficient
attention to involve the workforce from other
sectors or disciplines beyond health. Second,
health workers lack training in providing NCD
services at the primary care level, particularly,
little attention is paid to health promotion and
primary prevention. Finally, essential drugs for
 49

NCDs are often not available at the primary care
centres.
Annex 7 shows key indicators of the health
workforce in SEAR countries. With the
exception of a few SEAR countries, health care
personnel in every category are understaffed.
The health workforce density in SEAR countries
is low with a regional average of five physicians
and 13 nurses/midwives per 10 000 population,
against 14 and 30, respectively in the global
average. The health infrastructure situation is
also unfavourable with some countries, where
while the number of hospital beds considerably
increased over time, the number of health
centres remain low. This is a major constraint
in sustainable development of the health sector
and in improving access to health care. Health
expenditure ratios in SEAR countries (Annex 6)
indicate a large variation among SEAR
countries. A slight improvement in out-of-
pocket expenditure and general government
expenditures on health could be observed
between 2000 and 2008; however some other
crucial indicators show that this Region is well
below the global average (Annex 6).
In summary, public health infrastructure
in most SEAR countries is not adequate and the
value of public health is not adequately
appreciated. Development of only the
institutional health system may not be enough
for tackling NCDs; public health interventions
(including health promotion and disease
prevention as a primary prevention) are also
needed. At the same time, curative service
cannot be ignored. Public health interventions
should reach the poor, un-reached and
underprivileged.

REFERENCES
1. US Census Bureau, International Data Base
http://www.census.gov/population/international/data/idb/region.php?N=%20Region%20Results%20&T=2&A=both&RT
=0&Y=2000,2011,2025&R=123&C=BG,IN,CE (accessed 28 December 2011).
2. World Health statistics 2011. Geneva, World Health Organization 2011.
http://www.who.int/whosis/whostat/EN_WHS2011_Full.pdf (accessed 28 December 2011).
3. Allender S et al. Level of urbanization and noncommunicable disease risk factors in Tamil Nadu, India. Bulletin of
the World Health Organization 2010; 88:297-304.
4. Shah B, Mathur P. Surveillance of cardiovascular disease risk factors in India: the need & scope. Indian Journal of
Medical Research 2010;132:634-42. http://icmr.nic.in/ijmr/2010/november/1122.pdf (accessed 28 December 2011).
5. Allender S et al. Quantifying Urbanization as a Risk Factor for Noncommunicable Disease. Journal of Urban Health
2011;88:906-18.
6. Equity, social determinants and public health programmes. Geneva, World Health Organization 2010.
7. National Institute of Health Research and Development, Ministry of Health. Report on Result of National Basic Health
Research, 2008.
8. de Silva V, Samarasinghe D, Hanwella R. Association between concurrent alcohol and tobacco use and poverty. Drug
and Alcohol Review 2011;30:69-73.
9. Yach D, Hawkes C, Gould CL, et al. The global burden of chronic diseases: overcoming impediments to prevention
and control. Journal of the American Medical Association 2004;291:2616-22.
10. Ilangho RP. Review series: lung disease around the world: lung health in India. Chronic Respiratory Disease
2007;4:107-10.
11. World health statistics 2010. Geneva, World Health Organization 2011.

2011
Chapter 5
 51

Economic Burden of NCDs

I The economic consequences of NCDs are enormous, both at the

micro- and macro-economic levels.
I The earnings spent on unhealthy risk behaviours, such as tobacco use
and harmful use of alcohol, leave decreased financial resources for
essential items, such as food, education and daily consumables.
I Expenditure on NCD treatment results in catastrophic health
expenditures and impoverishment of affected families.

The economic burden of NCDs and risk
factors may be examined in the context of
microeconomy (household financing of care,
changes in consumption patterns, and foregone
earning of individuals and households due to
the ill health in the population), and
macroeconomy (the expenditure on
infrastructure and GDP losses due to ill health
in the population). This chapter examines the
impact of NCDs and their risk factors on
economic development in countries of SEAR, at
the national and household level.
Economic burden of NCDs at the
National Level
The macroeconomic impact of NCDs is
profound as they cause loss of productivity and
decrease in GDP. A recent study by Harvard
School of Public Health and World Economic
Forum (WEF) estimates that over the next 20
years, at the global level, NCDs will cost more
than US$ 30 trillion, representing 48% of
global GDP in 2010, and will push millions of
people below the poverty line (1). According to
a macroeconomic analysis, it is estimated that
each 10% increase in NCDs is associated with
a 0.5% lower rate of annual economic growth
(2).
At the national level, negative impacts of
NCDs also include large-scale loss of
productivity as a result of absenteeism and
inability to work and loss of lives due to
premature deaths (<60 years), and ultimately a
decrease in national income. The cumulative
projected cost of CVDs in terms of GDP loss by
2015 in five SEAR countries is estimated to
amount to more than 20 billion dollars (Table
5.1) (3).

2011
52

Table 5.1: Projected cost of cardiovascular disease in terms of lost

GDP in selected countries of South-East Asia Region, 2006 and 2015

Foregone GDP* Cumulative GDP loss

(US$ billions) (US$ billions) by 2015

Member countries 2006 2015 2015 as proportion

of 2006 estimates

Bangladesh 0.08 0.14 175% 1.1

India 1.35 1.96 145% 17
Indonesia 0.33 0.53 158% 4.2
Myanmar 0.03 0.06 200% 0.43
Thailand 0.12 0.18 150% 1.5

Source: Abegunde DO, et al. The burden and cost of chronic diseases in low-income and middle-income countries.
Lancet 2007;370:1929-38.
*GDP: Gross Domestic product

As NCDs are chronic in nature and require
long term treatment and care, countries are
spending large sums of money for management
of people inflicted with NCDs. A major part of
these costs is associated with expensive
infrastructure, largely at the tertiary level, for
investigation technologies and for drugs.
Some examples of high expenditure on
health care financing in the Region are:
Average cost of illness per diabetic patient
I
I Economic loss in 2008 in Indonesia due to
tobacco-attributed premature mortality,
morbidity and disability was estimated to
be 339 trillion Rupiahs (US$ 34 billion).
This was much higher than 45 trillion
Rupiahs (US$ 4.5 billion) revenue collected
by the Government from tobacco in the
same year (5).
I Economic implications of COPD in India
reveals that the cost of COPD treatment is
increasing in both urban and rural areas

in Thailand was US$ 881 in 2008; this

represented 21% of per capita GDP of
Thailand (4).
I Total annual health expenditure spent by
Indonesian people in 2008 for diseases
attributed to tobacco amounted to
15 trillion Rupiahs (~US$ 1.5 billion) for in-
patient services and 3.1 trillion Rupiahs
(~US$ 0.31 billion) for out-patient services.
By applying GDP per capita (in 2008) of
US$ 1420, at the macro level, the tobacco-
attributed loss of disability adjusted life
years (DALYs) caused an economic loss of
US$ 19 billion in Indonesia (5).
(Figure 5.1). It is estimated that more than
Rs 48 000 crore will be spent by patients
and their families on COPD treatment alone
in 2016 (6).
Economic burden of NCDs at
household level
NCDs have a detrimental impact on
individuals and families. Loss of household
income among the poor occurs due to high costs
incurred because of unhealthy behaviours
(tobacco use, harmful use of alcohol), out-of-
pocket health-care expenditure (for treatment
of NCD and their complications), and loss of

2011

Fig 5.1: Projected cost of treatment for chronic obstructive pulmonary disease (COPD) by
residence, India 1996-2016
6000 Total
Rural
Urban
5000
4000
Rupees in million
3000
2000
1000
0
1996
Source: Economic burden of chronic obstructive pulmonary disease, NCMH Background Paper Burden of Disease in India.
wages (due to disease, disability and premature
death), thus exacerbating poverty. Risky
behaviours, such as smoking and alcohol use,
cost a significant proportion of the household
income for the poor. Because of prolonged
illnesses in NCDs and since NCDs affect the
most productive periods of life, the consequent
loss of productive capacity affects earnings; and
this combined with high health-care costs
associated with NCDs, drives poor families
further into poverty.
Household expenditure incurred on risky
behaviours
Tobacco and alcohol use are addictive and
come at a cost that could have a detrimental
impact on household budget. In Bangladesh, the
poorest spend about 10 times as much on
tobacco as on education (Figure 5.2) (7). The
average amount spent on tobacco each day
would generally be enough to make the
difference between at least one family member
having just enough to eat to keep from being
malnourished (8).
53
COPD
treatment cost
is expected to
increase in
urban and
rural areas
alike
2001 2006 2011 2016
In Myanmar, although the actual
household expenditure on tobacco was lower in
the low-income groups, the percentage of
monthly expenditure for tobacco products was
highest among the lowest income groups and
fell steadily for higher income groups. Indian
households with tobacco users had lower
consumption of certain commodities (such as
milk, education, clean fuels and entertainment),
which may have a more direct bearing on
women and children in the household than on
men, suggesting that tobacco spending also had
negative effects on per capita nutrition intake
(10).
Families in Delhi (India) with at least one
member consuming three or more drinks per
week spent almost 14 times more on alcohol
each month compared with families where no
member consumed more than one drink (11).
Excessive drinking also resulted in fewer
financial resources for food, education and daily
consumables and more debts.
2011
54

Fig 5.2: Ratio of expenditure on tobacco to education, by household expenditure

group, Bangladesh, 1995-96

The poorest
spend about 10
12

times as much
on tobacco as on
Tobacco to education expenditure ratio
10

education in
8
Bangladesh

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
(poorest) (richest)
Household expenditure group

Source: Efroymson D et al. Hungry for tobacco: an analysis of the economic impact of tobacco consumption on the poor in Bangladesh.
Tobacco Control 2001;10:212-7.

In Indonesia, the average budget spent in resourced and there is little social security
2008 by an individual smoker to purchase coverage, treatment of NCDs results in
tobacco in one month was 216 000 Rupiahs catastrophic health expenditures and
(US$ 22), and the total amount spent by impoverishment. For example, in Sri Lanka,
Indonesian smokers on tobacco in one year was treatment of diseases such as diabetes is posing
153 trillion Rupiahs (US$ 15.3 billion) (5). In a severe burden on households, pushing even
2007, 11% of monthly household expenditure was non-poor households into poverty (14). A study
on tobacco the second highest expenditure revealed that the median daily cost of hospital
category after food expense and nearly four times stay due to NCDs in a teaching hospital in
than that for education (Figure 5.3). Sri Lanka was Rs 340 (15). These turn into
enormous costs for the family.
In Nepal the poorest spend 10% of their
income on cigarettes against 5% by the Further, in India, the share of out-of-
wealthiest (12). pocket expenditure due to NCDs among the
economically better off households increased
Health care expenses incurred at
from 32% in 1995 to 47% in 2004, indicating the
household level
growing financial impact of NCDs at the
More than one half of health expenditure household level (16). In India, diabetes
in SEAR is met by private resources, that too treatment can cost a low-income household, a
mostly out of pocket (13). As public health-care third of their monthly income (16). Out-of-
facilities and services are inadequately pocket expenditure associated with acute and

2011
 55

Fig 5.3: Distribution of monthly household expenditure, by expense category,

Indonesia, 2007

Tobacco
expenditure
accounts for a
tenth of the total
household
Health 12%

expenditure in
Indonesia
Other expenses 2%
Education 3%

Tobacco 11%
Food 72%

Source: Ministry of Health, National Institute for Health, Research and Development, Indonesia

long-term effects of NCDs can result in Loss of wages

catastrophic health expenditure. In India, 25%
Most people with NCDs cannot continue
of families with a member with CVD experience
working and forego personal and household
catastrophic expenditure and 10% are driven to
income. Duration of NCDs is longer compared
poverty (17). The situation is much worse with
with other health conditions. In India, duration
cancer treatment expenses, where almost 50%
of illness, defined as days when people could not
of households with a member with cancer
work, was 5070 days or more for some NCDs
experience catastrophic spending and 25% are
(17). The annual income loss from missed work,
driven to poverty by health-care expenses. The
time given for care taking, and premature
odds of incurring catastrophic hospitalization
deaths are also significant. The total income loss
expenditure were nearly 160% higher with
due to chronic diseases in India was between
cancers than when hospitalization was due to a
Indian Rupee (INR) 10941113 billion. Of this,
communicable disease (17).
income loss due to hypertension was the highest
In some SEAR countries, up to 40% of (INR 199 billion), followed by diabetes
household expenditures for treating NCDs are (INR 163 billion) and CVDs (INR 144158 billion)
financed through borrowing and sale of assets (Figure 5.4) (17).
driving people further into debt and poverty
(17).

2011
56

Fig 5.4: Annual income loss from missed work, time for care giving, and premature death
among households with a member suffering from an NCD, India, 2004

NCDs lead to
huge loss in
household
140 Missed work Caregiving Premature death

120 wages
Income loss (billion rupees)

100

80

60

40

20

0
Cardiovascular Hypertension Diabetes Asthma Respiratory Injuries
disease illness

Source: Mahal A et al. The economic implications of non-communicable diseases for India. Health, Nutrition and Population (HNP) Discussion Paper.
2010.

REFERENCES
1. The global economic burden of non-communicable diseases. A report by the World Economic Forum and the Harvard
School of Public Health. September 2011
http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf
(accessed 28 December 2011).
2. Stuckler D. Population causes and consequences of leading chronic diseases: a comparative analysis of prevailing
explanations. Milbank Quarterly 2008;86:273326. http://onlinelibrary.wiley.com/doi/10.1111/j.1468-
0009.2008.00522.x/pdf (accessed 28 December 2011).
3. Abegunde DO et al. The burden and cost of chronic diseases in low-income and middle-income countries. Lancet
2007;370:1929-38.
4. Chatterjee S et al. Cost of diabetes and its complications in Thailand: a complete picture of economic burden.
Health and Social Care in the Community 2011;19:289-98.
5. National Institute for Health, Research and Development, Indonesia. Soewarta Kosen. Ministry of Health, Republic of
Indonesia, 2009.
6. Murty KJR, Sastry JG. Economic burden of chronic obstructive pulmonary disease. NCMH Background Paper-Burden
of disease in India. Mahavir Hospital and Research Centre
http://whoindia.org/LinkFiles/Commision_on_Macroeconomic_and_Health_Bg_P2_Economic_burden_of_chronic_obs
tructive_pulmonary_disease.pdf (accessed 28 December 2011).
7. Efroymson D et al. Hungry for tobacco: an analysis of the economic impact of tobacco consumption on the poor in
Bangladesh. Tobacco Control 2001;10:212-7.

2011
 57

8. Ali Z et al. Appetite for nicotine. An economic analysis of tobacco control in Bangladesh. Health, Nutrition and
Population (HNP) Discussion Paper. Economics of Tobacco Control Paper No. 16. Nov 2003
http://www.searo.who.int/LinkFiles/NMH_ApetiteforNicotine.pdf (accessed 28 December 2011).
9. Kyaing NN. Tobacco economics in Myanmar. Health, Nutrition and Population (HNP) Discussion Paper. Economics of
Tobacco Control Paper No. 14. October 2003. http://www.searo.who.int/LinkFiles/NMH_EconomicsMyanmar.pdf
(accessed 28 December 2011).
10. John RM. Crowding out effect of tobacco expenditure and its implications on household resource allocation in India.
Social Science Medicine 2008;66:1356-67. Epub 2008 Jan 9.
11. Saxena S et al. Alcohol and drug abuse. New Age Publishers and National Book Trust, New Delhi, 2003.
12. Karki Y et al. A study on the economics of tobacco in Nepal. Washington, DC:The World Bank; 2003.
13. World Health Organization. World Health statistics 2011. Geneva, 2011.
http://www.who.int/whosis/whostat/EN_WHS2011_Full.pdf (accessed 28 December 2011).
14. Perera M et al. Equity in health carethe case of diabetes in Sri Lanka. Marga Institute
http://www.margasrilanka.org/reading_equity.htm (accessed 28 December 2011).
15. Kasturiratne A et al. Morbidity pattern and household cost of hospitalisation for non-communicable diseases (NCDs):
a cross-sectional study at tertiary care level. Ceylon Medical Journal 2005;50:109-13.
16. Ramachandran A et al. Increasing expenditure on health care incurred by diabetic subjects in a developing country:
a study from India. Diabetes Care 2007;30:2526.
17. Mahal A et al. The economic implications of non-communicable diseases for India. Health, Nutrition and Population
(HNP) Discussion Paper. 2010.
http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627-
1095698140167/EconomicImplicationsofNCDforIndia.pdf (accessed 28 December 2011).

2011
Chapter 6
 59

National Response to NCDs

I NCDs are now recognized as an important health problem in all

Member countries.
I Health ministries of Member countries currently lead NCD national
policies and programmes.
I Risk factor surveillance has been established in most Member
countries but morbidity and mortality surveillance is generally
ineffective.
I Existing primary health-care systems need to be strengthened to
address NCDs at the grass root level.

Member countries in the Region have Institutional Capacity for NCD

initiated measures to combat NCDs. WHO Prevention and Control at the
Regional Office for South-East Asia (SEARO) Central Level
conducted a survey in 11 Member countries,
using a semi-structured self-administered The health ministries in all 11 Member
questionnaire during 2010*, to assess their countries have formed a separate unit/
current capacity to respond to NCDs. This department for NCD prevention and control. An
chapter presents the results of this survey and NCD focal point for NCD prevention and
also highlights innovative practices in select control, such as the NCD programme manager,
countries. is available at the health ministry level in all

* SEAR NCD website: http://www.searo.who.int/en/Section1174/Section1459.htm

2011
60
countries. The main functions of the NCD
unit/department are to plan, coordinate,
implement, monitor and evaluate NCD
prevention and control activities in the country.
The NCD units scope of work includes the
entire spectrum of NCD prevention and control,
ranging from health promotion and primary
prevention to early diagnosis, treatment and
care.
The staff at the central level varies widely
from 24 persons in Bangladesh, DPR Korea,
Nepal, Sri Lanka and Timor-Leste; to 813
persons in Bhutan, India, Maldives and
Myanmar; and 5075 in Indonesia and
Thailand. However, many countries have
identified inadequacies in knowledge and skills
among their existing public health workforce to
carry out assigned functions of NCD prevention
and control at national and subnational levels.
Central NCD units support national
institutions, such as specialty hospitals and
centres, national public health institutions as
well as professional associations.
National Policies, Strategies, Plans
and Programmes for NCD
Prevention and Control
National NCD policies should be
multisectoral in nature and integrated within
the national health and development
programmes. Further, NCD programmes need
to be integrated (and not disease specific)
because of common/shared risk factors that are
responsible for these NCDs.
Policies/plans/programmes
There is a high level of national
commitment for tackling NCDs as reflected by
the large number of policies, strategies, plans,
2011
programmes, legislations/regulations and
networks that are reported as being
implemented or operational in Member
countries. Countries are moving from disease-
specific or risk factor-specific approaches
towards a more integrated approach. Nine
Member countries reported have integrated
NCD policies that are largely comprehensive in
terms of covering multiple risk factors and
diseases. Cancers and diabetes are the most
targeted diseases for control and chronic
respiratory diseases the least targeted. By 2010,
all 11 Member countries had at least one
policy/strategy/plan/programme to address
NCDs, and these were operational in seven
countries (Table 6.1).
A dedicated budget for policy/plan/
programme implementation is available in six
countries, while seven countries also have a
monitoring and evaluation component. All
countries have measurable outcome targets as
part of the strategy/programme/action plan.
While CRD is the least targeted disease, tobacco
(its primary cause) is the most targeted risk
factor for control, followed by harmful use of
alcohol. On the contrary, while diabetes is the
most targeted disease, diet and physical activity
are the least targeted risk factors.
National NCD guidelines
The availability and implementation of
guidelines is one major way to promote
evidence-based care. Disease-specific guidelines
that are under development or have been
partially implemented in a few countries are
given in Table 6.2.
Legislative measures on NCD
prevention and control
Legislative measures and effective law
enforcement are key to implementing
comprehensive NCD prevention and control
 61

programmes. Legislation serves to countries except Indonesia have ratified the

institutionalize NCD control programmes and WHO FCTC and are implementing the various
creates, legitimizes and finances an authority to elements of MPOWER a package of six
implement and direct a policy programme for effective tobacco control policies (Table 6.3).
NCD control in a country. In Member countries,
In Thailand, the Thai Health Promotion
tobacco has been addressed almost universally
Foundation (ThaiHealth) has played a crucial
by legislation. Tobacco legislation is available in
role in NCD prevention and control, particularly
10 countries, five countries have alcohol
in increasing tobacco taxation. The consistent
legislation, two countries address legislation on
increase in taxes over the past several years has
diet and nutrition and only one country has
led to a steady decrease in smoking prevalence
physical activity legislation. Legislative support
among adults. Similar taxation is needed to
for other risk factors is yet to be fully developed
reduce the demand for other unhealthy
in Member countries. The WHO Framework
products such as sugary drinks; conversely,
Convention on Tobacco Control (FCTC) is the
subsidies should be provided on fruits and
first legally binding international treaty to
vegetables.
reduce harm due to tobacco. In SEAR, all

Table 6.1: Number of South-East Asia Region Member countries with

policies, strategies, action plans and programmes for NCD prevention and
control, 2010 (n=11)
Integrated or disease- Policy Strategy Plan Programme Any of
specific tools these
Integrated 9 9 9 8 11
Heart diseases 4 6 6 7 7
Cancer 4 6 6 8 8
Diabetes 3 5 6 7 8
Chronic respiratory disease 2 4 5 5 6
Source: World Heath Organization. Assessment of capacity for prevention and control of chronic noncommunicable diseases.
New Delhi, 2011.

Table 6.2: Number of countries with national-level NCD guidelines,

South-East Asia Region, 2010 (n=11)
Availability of national Implementation
Health conditions/ level guidelines
services Available Under Full Partial
development

Diabetes 8 1 5 4
Hypertension 8 1 5 4
Overweight/obesity 2 2 2 1
Dyslipidemia 3 1 1 2
Alcohol dependence 5 1 3 2
Tobacco dependence 4 2 2 3
Dietary counselling 6 1 4 3
Physical inactivity 4 1 3 1
Source: World Heath Organization. Assessment of capacity for prevention and control of chronic noncommunicable
diseases. New Delhi, 2011.

2011
62

Table 6.3: Status of implementation of Framework Convention on Tobacco Control in South-East Asia
Region, 2011

FCTC Implementation Bangladesh Bhutan DPRK India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste

Ratification of WHO FCTC X

Monitor tobacco use and prevention policies
Global Adult Tobacco
Survey (GATS) X X X X X X X
Global Youth Tobacco
Survey (GYTS) X
Protect people from tobacco smoke
Smoke-free health care facilities
Smoke-free government facilities X X X X
Smoke-free public transport X X X X
Smoke-free educational institutes X
National law requiring fine
for smoking X X X
Fines levied on the establishment X X X X X X
Offer help to quit tobacco use
Tobacco quit lines available X X X X X X X X X
Warn about dangers of tobacco use
Graphic health warnings X X X X X X X X X
Textual health warning NA X X X X X
Enforce Bans on tobacco advertising, promotion and sponsorship
Ban on national TV and radio X X X
Ban at point of sale X X X
Ban on billboards and
outdoor advertising X X X
Raise taxes on tobacco
Taxation rate on cigarettes 68% NA NA 46% 54% 32% 50% 29% 73% 69% NIL

Source: Narain, et al. Noncommunicable diseases in the South-East Asia Region: strategies and opportunities. NMJI 2011 (in press)
Implemented X not implemented NA information not available

Bangladesh is the first country in the formulating evidence-based policies, planning

Region to establish a National Tobacco Control appropriate interventions and services, and
Cell (NTCC) under the Bloomberg Initiative. monitoring progress towards desired goals.
Bangladesh is exemplary in the developing There are three essential elements of a
world as it conducts mobile courts drives across comprehensive NCD surveillance system,
the country to enforce tobacco control law and namely: (1) surveillance for exposure to
take cognizance of violations of the law (Box behavioural and metabolic risk factors;
6.1). (2) surveillance for disease outcomes (morbidity
and mortality); and (3) surveillance/monitoring
of health system response.
Surveillance and Monitoring
Risk factor surveillance
Accurate information through a
At least one NCD risk-factor survey
sustainable surveillance system is essential for
(national or subnational) has been completed in

2011
 63

Box 6.1: Innovative law enforcement using mobile courts, Bangladesh

The mobile court drives is a unique feature of the judicial system in Bangladesh
for hastening the dispensation of justice in non-criminal cases. It is being used for
enforcing anti-tobacco laws. Violation of tobacco products advertisement bans is
one of the offences try-able by a mobile court. An empowered magistrate tries
the case on the spot, ensures immediate removal of the advertisement and
Mobile courts, Bangladesh

punishes the perpetrator as per the law. Members of law enforcing agencies
including the police, provide the magistrate with necessary support.

Onthespot actions have been taken by removing billboards containing

advertisement of tobacco products and also by removing other promotional
materials from places such as fast-food corners, snooker-playing places and
restaurants. The youth of the country have shown active involvement during the
drives of mobile courts by voluntarily participating in removing billboards,
signboards and other promotional objects. The mobile court drives have also
played an exceptionally important and exemplary role in the enforcement of
smoke-free laws in the country.

The mobile court drives have received tremendous support from the civil society.
The initiative has received huge media coverage and contributed in creating
awareness about the law among the public. As a result of the enthusiastic effort
of the Government, local administration and development partners, and
particularly due to the unique efforts by mobile courts, tobacco advertisements
on billboards or signboards have become almost non-existent in Bangladesh.

all 11 Member countries. In six countries,
surveys were done at the national level. In India,
the process of national-level surveys is under
way. In most countries, risk factor surveys are
carried out as special or vertical surveys.
Indonesia and Thailand are the only two
countries that integrated risk-factor questions
into the general health survey or behavioural
risk-factor surveys. Tobacco use surveys have
been done more frequently compared to other
risk factors. Four countries conducted at least
one round of GATS. Ten countries completed at
least one round of GYTS and all 10 countries
conducted more than one round of GYTS (Table
6.4). Risk-factor surveys, based on WHO STEPS
approach that aims to collect information on
risk behaviours (tobacco and alcohol use,
physical inactivity and unhealthy diet),
physiological variables (weight and height and
blood pressure), and biochemical variables
(blood sugar and blood lipids), have now been
conducted in all countries (Table 6.4). While
behavioural variables were collected in all 10
countries, physiological risk factors (BMI and
hypertension) have been measured in national-
level surveys in four countries, and blood sugar
has been measured in three countries. No
country has yet reported a national-level lipid

2011
64

Table 6.4: Type of risk surveys conducted and the latest year, countries of
WHO/SEA Region
Country STEPS* GATS** GYTS*** GSHS****
Latest No. of Latest No. of Latest No. of Latest No. of
rounds rounds rounds rounds
Bangladesh 2010 2 2009 1 2007 2 NA NA
Bhutan 2007 1 NA NA 2009 2 NA NA
DPRK 2009 3 NA NA NA NA NA NA
India 2006 2 2009-2010 1 2009 3 1 2009
Indonesia 2006 3 on-going 1 2009 7 1 2006
Maldives 2004 1 NA NA 2007 3 1 2010
Myanmar 2007 3 NA NA 2007 3 2 2007
Nepal 2007 3 NA NA 2007 3 1 2003
Sri Lanka 2007 2 NA NA 2007 3 1 2008
Thailand NA NA 2009 1 2009 3 2 2009
Timor Leste NA NA NA NA 2009 2 1 2009
Sources:
* STEPS Country reports http://www.who.int/chp/steps/reports/en/index.html
** http://www.searo.who.int/en/Section2666/Section2670_15825.htm#GATS
*** http://www.searo.who.int/LinkFiles/TFI_FCTC-2009.pdf;
http://www.searo.who.int/en/Section2666/Section2670_15825.htm#GYTS
**** World Heath Organization. Assessment of capacity for prevention and control of chronic noncommunicable diseases. New
Delhi, 2011.
NA = Not available
GYTS: Global Youth Tobacco Survey
GSHS :Global School-based Student Health Survey
GATS : Global Adult Tobacco Survey
STEPS: Stepwise approach to NCD risk factor surveillance

measurement survey. Most countries have
completed only one round of STEPS survey;
therefore, sufficient information for trends
estimation for diseases and risk factors on a
nationally representative sample is not available
in the Region.
In most Member countries, the health
ministry is the lead agency for planning and
implementing risk factor surveys. However, a
major limitation of risk factor surveys is that
they are not institutionalized and are done on
an ad hoc basis depending on the availability of
funds rather than on a regular periodic basis at
fixed intervals.
Morbidity and mortality surveillance
Disease-specific morbidity data are
generally collected through a routine health
information system in all 11 countries; mortality
data are included in nine countries. However,
most mortality and morbidity data are hospital-
based. Many countries are using a standardized
protocol for data collection and quality control
procedures are reportedly in place. Morbidity
and mortality data obtained from routine health
information systems are being used for target
setting in NCD prevention and control in many
Member countries.
Disease-specific registries are an
important source of morbidity and mortality
data. The disease registries for NCDs have been
most commonly established for cancer, followed
by diabetes and stroke. About half of these are
national-level disease registries and most are
hospital-based (Table 6.5). Maldives has no
disease registry except for thalassemia.

2011
 65

Table 6.5: Number of disease registries reported by Member countries,

South-East Asia Region
Indicator Cancer Diabetes Myocardial Stroke Chronic
infarction respiratory
diseases

Disease registry present 9* 5 3 4 3

Scope
National 5 2 1 2 2
Sub-national 4 3 2 2 1
Source of data
Population-based 3 1 1 1 1
Hospital-based 8 4 2 3 2
* Number of countries answering in the affirmative.
Source: World Heath Organization. Assessment of capacity for prevention and control of chronic noncommunicable
diseases. New Delhi, 2011.

Bangladesh has subnational hospital-based
registries for all listed diseases and DPR Korea
reported having population-based national-
level registries for several NCDs. Sri Lanka has
registries on cancers and also has a chronic
kidney disease registry. Myanmar and Timor-
Leste have not yet reported on registries.
system for monitoring response to the NCD
epidemic. At the global level, indicators and
targets are currently being developed to monitor
the global and national response to the NCD
epidemic. Developing monitoring systems for
the future is a major priority for countries.

A major limitation of mortality and

morbidity surveillance systems in the Region is Health System Capacity for NCD
that they are largely hospital-based, which Prevention, Early Detection,
compromises the representativeness of the Treatment and Care
information generated. While hospital-based
Traditionally, health systems in SEAR are
disease-specific registries are a useful source for
geared towards providing maternal and child
obtaining clinical data, such as disease patterns
health care, immunization and deal with
and survival rates, population-based disease
communicable diseases; NCDs have been
registries are needed for estimation of incidence
generally neglected. With the emergence of
rates that are currently lacking from the Region.
NCDs, it is imperative to reorient health
Moreover, establishment and management of
systems and retrain health personnel to provide
disease registries need technical expertise and
long-term prevention, care and treatment
are resource intensive.
services to address NCDs.

Surveillance and monitoring system

NCD prevention and control at
for health system response
primary health-care level
According to available information, no
The availability of services at the primary
country in the Region has a comprehensive
health-care level has become more

2011
66

comprehensive over the years. All Member Availability of diagnostic facilities

countries provide at least one NCD-related for NCDs at primary health care
service at the primary health-care level in public level
health facilities. This includes mainly risk factor
A selected set of diagnostic devices to
and disease management (10 countries),
detect risk factors is essential at the primary
primary prevention and health promotion (11
health-care level. All Member countries have
countries) and early diagnosis of NCD risk-
blood pressure measurement facility available
factors (9 countries). However, not much
at the primary health-care level. Blood glucose
progress has been achieved in promoting home-
and weight measurement facilities are available
based care. In SEAR countries, pilot projects for
in nine countries. Cancer detection services are
integrating NCDs within the primary health-
the least available, possibly due to their high
care system are under way in Bhutan and Sri
technical requirements (Table 6.6). The major
Lanka (Box 6.2), and are planned in Maldives
reason reported for lack of these services has
and Indonesia.
been the non-availability of equipment. In some

Box 6.2: Integrating NCD prevention and control into primary health care services, Sri Lanka

The WHO Package of Essential Noncommunicable Diseases Interventions (WHO

PEN) for primary care is an innovative response to the NCD challenge. PEN is a
prioritized set of cost-effective interventions, tools and aids that help deliver
Integrated primary heath care services

acceptable quality of care even in resource-poor settings. It includes the entire

spectrum of services from health promotion to prevention of risk factors and
NCDs to management, care, treatment and referral. The essential components of
PEN include: assessment of health system capacity; use of standard protocols for
diagnosis and treatment of major NCDs at primary level; use of WHO/ISH risk
charts for assessing an individuals risk; essential medicines and essential
equipments; and essential recording and reporting tools.

A pilot PEN project was initiated in Badulla district in Sri Lanka in 2009. A
Sri Lanka

baseline assessment of all health facilities was done using a structured

questionnaire. Most of the essential equipment recommended in the PEN were
already available in the primary care centres; additional equipment, namely
blood glucometers, urine protein test strips and peak flow meters were procured
and supplied to all institutions. The essential list of medicines proposed for PEN
was reviewed by expert groups in the country and steps were taken to include
these into the essential list of medicines at the primary health care level. A
striking feature of this project is the use of non health workers at the community
level, for mobilizing the community members especially for systematic screening
at primary care level. All persons over 40 years of age were requested to visit
their nearest health facility to undergo a medical check-up including an
assessment of cardiovascular risk by checking BMI, blood pressure and blood
sugar. To maintain proper records, several data collection formats were
developed including screening cards, patient health records, OPD registers and
clinic registers.

2011

Table 6.6: Availability of NCD tests and procedures (in more than 50% of
facilities) at primary health care level, SEAR, 2010
Health condition Procedure
Overweight Weight measurement
and obesity Height measurement
Waist circumference
Cancer Cervical cytology
Acetic visualization
Faecal occult blood test
Digital examination for
bowel cancer
Breast cancer by palpation
Mammogram
Colonoscopy
Diabetes Blood glucose
Oral glucose tolerance test
Glycosylated haemoglobin
(HbA1c)
Fundal examination
Foot vibration perception
by tuning fork
Foot vascular status by
doppler
Cardiovascular Electrocardiogram
diseases Blood pressure
Lipids including LDL, HDL
and triglycerides
Chronic
respiratory
diseases Spirometry
Source: World Heath Organization. Assessment of capacity for prevention and control of chronic noncommunicable diseases.
New Delhi, 2011.
countries like Bangladesh, these services are not
included in the primary health-care package
and thus there has been no planning to either
provide these equipments at the primary health-
care level or to train human resources for it.
NCD-related drugs
An uninterrupted and sustained supply of
quality-assured essential drugs for NCDs is
fundamental to NCD control. For this purpose,
an effective drug procurement supply and
67
No. of countries Reasons for non-availability
where available Lack of Lack of
equipment trained staff
9 2 0
8 2 0
4 2 5
2 6 3
1 4 3
4 3 3
3 2 3
8 1 1
0 9 1
1 7 2
9 2 0
3 2 2
2 8 0
1 2 6
2 3 3
0 8 1
5 5 0
11 0 0
3 6 0
1 6 2
management system is essential. All Member
countries have an essential drugs list and many
of the NCD-related drugs are in the national
essential drugs lists. Most of these drugs are
generally available at public sector health
facilities. The least available are nicotine
replacement therapy and oral morphine. High-
end technology for the management of NCDs
like renal dialysis, radiotherapy and
chemotherapy are available in public health
systems of seven of 11 Member countries.
2011
68

Health Financing budget. General government revenue is the

The commitment of Member countries to
NCD prevention and control is reflected in NCD
programmes being funded largely by regular
government budgets. All 11 Member countries
have allocated for NCD prevention and control
in their respective regular health ministry
main source of funding for NCD prevention and
control activities in all Member countries except
Maldives and Sri Lanka. For these two
countries, international donors are a significant
source of funding. In Thailand, sin tax from
tobacco and alcohol is used to finance health
promotion activities (Box 6.3). Out-of-pocket

Box 6.3: Innovative financing for NCD prevention and control, Thailand

The Thai Health Promotion Foundation (ThaiHealth), established in 2001, is

the first organization of its kind in Asia and has been created under the Health
Promotion Foundation Act B.E. 2544 (2001). ThaiHealth gets funded from sin
taxes. These 'sin taxes' are a revenue source for innovative projects and
Innovative financing,

activities to promote public health. ThaiHealth receives 2% of total national

tax revenue on alcohol and tobacco products equivalent to about US$ 35
million per year. There are 12 programmes funded by ThaiHealth which
include tobacco consumption control, alcohol consumption control, physical
Thailand

activity and sports for health, as well as health risk factors control such as
nutrition, traffic injuries and disaster prevention.

In 2008, ThaiHealth financed tobacco control campaigns (105 million baht or

US$ 3 million), smoke-free projects (38 million baht or US$ 1.08 million) and
other tobacco control projects, as well as research (40 million baht or US$
1.14 million). Sin tax has helped generate additional funds for health
promotion and led to a significant reduction in smoking prevalence. During the
Funds ten years of existence, the percentage of regular smokers was reduced
by 10%, with an 30% increase in excise tax.

Trends in smoking prevalence and excise tax, Thailand, 1990-2010

Excise tax (%) Consistent

reduction in
Regular smokers (%) 100
smoking
30

prevalence
with increase
25
80
Regular smokers (%)

in
tobacco tax
20
60
Excise tax (%)

15
40
10

20
5

0 0
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Source: National Statistics Office 2010; Excise Department, Ministry of Finance, Thailand.

2011

expenditure is the main funding source in India.
In all countries, funding covered all
activities/functions related to treatment and
control (except in Timor-Leste), prevention and
health promotion (except in Sri Lanka), and
surveillance, monitoring and evaluation (except
in Bhutan and Sri Lanka).
Health insurance is not a major source of
funding in this Region. NCD-related services
and treatment are covered by health insurance
in five countries. Of these, two countries
(Sri Lanka and Thailand) have full population-
level coverage by insurance. In India, less than
20% of the population is covered by insurance,
while in Indonesia and Maldives, insurance
coverage is estimated to be 20%50%.
Community/home care for people with end-
stage diseases like cancers are available in three
countries DPR Korea, Myanmar, Thailand.
Partnerships and Collaboration
The involvement of sectors other than
health has a major impact on shaping physical
and social environments that determine health
behaviours. Intersectoral coordination and
69
collaboration are important for creating an
enabling environment where people can make
appropriate choices that promote their health.
Interventions for NCD prevention and control
have to be multisectoral and multidisciplinary
and should act at multiple levels. In addition,
the private sector has a major role to play in
determining the consumption of tobacco,
alcohol and dietary items. Its involvement needs
to be regulated through appropriate
mechanisms. Governments of Member
countries are moving towards establishing
mechanisms for intersectoral coordination.
All countries reported having
partnerships/collaborations between various
departments/sectors in place for implementing
key activities related to NCDs. The key
mechanisms used for such collaborations are
cross-departmental or ministerial committees
in 10 countries; interdisciplinary committees in
nine countries and a joint task force in six
countries. The key stakeholders involved are
government ministries (in all countries); UN
agencies (all countries except Indonesia); other
international agencies (nine countries);
academic institutions and nongovernmental
organizations (10 countries); and private sector
(eight countries).
2011
Chapter 7

Major Challenges in Prevention and
Control of NCDs
The South-East Asia Region has a huge
population base with 1.7 billion people and is a
diverse Region with the population size of
Member countries varying from 1.2 billion in
India to less than a million in Maldives and
Bhutan. Additionally, there are enormous
intercountry and intracountry differences in
topography, culture, ethnicity, etc. Addressing
health issues in such large and diverse
populations poses many challenges.
Furthermore, high out-of-pocket expenditure
on health care, poor coverage of health and
social insurance schemes and unregulated role
of the private sector undermines equitable
health care in most countries of this Region. The
specific challenges in NCD prevention and
control are as follows:
Lack of strong national partnerships
for multisectoral actions
The underlying determinants for NCDs
mainly exist in non-health sectors, such as
agriculture, urban development, education and
trade. Intersectoral collaboration is therefore
essential to create an enabling environment,
which promotes healthy lifestyles. Intersectoral
partnerships are however not easy to forge as it
means coming together of many sectors with
competing interests and priorities. Lack of
effective partnerships among different
development sectors at the national level is one
of the major weaknesses in the Member
countries. Because the health sector bears the
71
brunt of NCDs, ministries of health must carry
out high-level advocacy and take the lead in
bringing together the different stakeholders to
address NCDs. Without effective and strong
partnerships among different sectors, NCD
prevention will remain an elusive goal.
Weak surveillance systems
Lack of availability of robust surveillance
and research data on NCDs is an important
barrier to effective planning and
implementation of NCD prevention and control
programmes in the Region. There are many
issues with the current surveillance systems.
First, NCD surveillance systems are often not
institutionalized and rarely integrated into the
national health information systems. Although
almost all countries have conducted one or
more NCD risk factor surveys, these are not yet
routine; and are usually dependent on funds
and other factors. Second, there is lack of a
comprehensive framework for surveillance and
monitoring at the national and subnational
levels. Specific indicators and clear targets at the
national and subnational levels and systems for
monitoring are non-existent. Without such a
system, uniform tools for data collection,
systematic data analyses or standard reports to
guide the programme do not exist. Third, most
countries do not report reliable mortality
statistics due to weak civil registration systems.
Fourth, population-based cause-specific
morbidity and mortality data collection systems
continue to be poor. While coverage for
2011
72
morbidity data in national information systems
has shown an increase, it is still hospital-based.
Finally, surveillance and research for NCDs are
poorly funded.
Limited access to prevention, care
and treatment services for NCDs
Lack of access to basic prevention and
treatment in the primary health care setting
including access to affordable medicines and
health-care services are major causes of
premature deaths due to NCDs. Limited
emphasis on public health and primary care
results in inefficient and unsustainable NCD
programmes and poor health outcomes. In most
countries, the major investment on NCD
prevention and control is for tertiary care
services, which are available to a limited
number of people living in urban areas. A
general lower resource allocation to health does
not allow for the development of an adequate
primary health care infrastructure. As a result,
opportunities for early diagnosis are lost and
NCDs are diagnosed in late stages as heart
attacks, strokes and diabetes complications
which require tertiary care. Moreover,
community- and home-based palliative care are
nonexistent. The health system in the Member
countries of SEAR should provide a continuum
of NCD care for NCDs and their risk factors
from prevention and early diagnoses through to
treatment and care.
Limited human resources for NCDs
Health systems in the Region are
characterized by inadequate human resources
capacity to address NCDs both in terms of
number of health workers and their training.
Existing health professionals are concentrated
in urban areas at the tertiary care level, resulting
2011
in an inadequate workforce capacity at the
primary care level. Moreover, health workers
particularly at the primary care level are trained
traditionally in communicable diseases and
maternal and child health issues, and have
limited training in addressing NCDs and their
risk factors. There is a need to develop effective
tools for training health workers in NCD
prevention, early diagnosis, treatment and care.
Insufficient allocation of funds
Funds allocated for NCD programmes are
disproportionately lower than the disease
burden. A low allocation of government budget
on health and for NCDs in particular, persists
in many Member countries of the Region.
Moreover, available health funds are stretched
thin to meet the acute demands of addressing
communicable diseases as well as maternal and
child health issues, leaving minimal funds for
NCDs. Some countries are generating funds
through innovative financing schemes such as
sin tax on tobacco and alcohol. There is a need
to increase both domestic and international
resources to address NCDs.
Difficulties in engaging the industry
and private sector
Profit making industries, such as the food
and beverage industry, are a major contributor
to NCDs. Dialogue is needed with the industry
to influence them to voluntarily reformulate
products with lower sodium, lower sugar and
eliminate trans fats. While the need to engage
the industry is acknowledged, the mechanisms
are not easy, given their profit-making interests.
Strong government regulations, both fiscal and
legislative, need to be enforced to ensure
compliance of the industry with health policy
norms.
 73

Lack of social mobilization society and government agencies for NCDs. One
of the lessons to be learned and applied from
The ministries of health of Member
HIV control programmes in the Region is to
countries run NCD programmes and policies.
organize social mobilization to increase the
There is inadequate community mobilization
demand for investments for NCD control
and weak coordination among the few existing
programmes.
civil society agencies, as well as between the civil

2011
Chapter 8
 75

WHO Initiatives in NCD Prevention and

Control

Over the past decade, WHO has played a
leadership role in addressing the NCD
pandemic at global, regional and country levels.
WHO has raised the priority accorded to NCDs
through high-level advocacy, set norms and
standards, generated the evidence base for
effective policies, strategies and interventions
as well as for surveillance, monitoring and
evaluation. In SEAR, there has been a growing
recognition and commitment to address NCDs.
SEARO is coordinating activities for prevention
and control of NCDs for its 11 Member
countries; providing technical and financial
support to countries in NCD surveillance,
monitoring, evaluation, research, policy and
strategy development; assisting countries in
integrating NCD control in their primary
health-care based health systems, and;
promoting and forging partnerships for NCD
prevention and control in the Region.

Global initiatives
May 2000 The World Health Assembly endorsed the Global strategy on the
prevention and control of NCDs, providing a global vision for
addressing them. The global NCD strategy has three objectives: (i)
mapping the NCD epidemic and its causes; (ii) reducing main risk
factors through health promotion and primary prevention
approaches; and (iii) strengthening health care for people already
afflicted with NCDs.

May 2003 The World Health Assembly endorsed the WHO Framework
Convention on Tobacco Control.

May 2004 The World Health Assembly endorsed the Global strategy on diet,
physical activity and health.

December 2006 The UN General Assembly adopted resolution A/RES/61/225,

encouraged Member States to develop national policies for the
prevention and control of diabetes.

May 2008 The World Health Assembly endorsed the Action Plan for the
Global Strategy for the Prevention and Control of NCDs
(20082013).

2011
76

May 2010 The World Health Assembly endorsed the Global Strategy to
Reduce the Harmful Use of Alcohol.

May 2010 The A/RES/64/265 was adopted unanimously by the UN General

Assembly calling for a High-level Meeting on NCDs.

April 2011 The first global ministerial conference on healthy lifestyles and NCD
control was held in Moscow culminating in the Moscow Declaration.

May 2011 The Sixty-fourth World Health Assembly endorsed resolution WHA
64.11 on Preparation for the UN High-level Meeting (UNHLM) on
noncommunicable diseases.

September 2011 The UNHLM was conducted in New York with participation of heads
of states, ministers and other high-level delegates from Member
countries. The outcome of the UNHLM meeting was the adoption of
a political declaration on NCDs. The political declaration is expected
to galvanize support from governments and international donors
for increased financial resources for NCD interventions; act as a
milestone in advocating for Healthy Public Policies/Health in All
Policies approach to the prevention and control of NCDs; help
produce measurable targets and commitments from governments
and the international community to act against NCDs and provide
an impetus to implement the global strategy for the prevention and
control of NCDs (2000) as well as the action plan (20082013)
endorsed by the World Health Assembly in 2008.

Regional Initiatives
Some of the recent regional events and initiatives for prevention and control of NCDs are listed
below:

November 2005 South-East Asian Network of NCD (SEANET-NCD) was created at

a regional meeting in Bondos, Maldives, to strengthen and formalize
regional partnerships on NCD prevention and control. SEANET-
NCD meets biennially and greatly facilitates WHO advocacy for
multisectoral approaches in integrated NCD prevention and control.

October 2006 A regional meeting on implementing the global strategy on diet,

physical activity and health in the SEAR was organized in Yangon,
Myanmar to facilitate regional and country-level implementation of
the global strategy.

September 2007 The Regional Framework for Prevention and Control of NCDs was
endorsed at the Sixtieth session of the WHO Regional Committee
for South-East Asia, vide its resolution on Scaling up Prevention
and Control of NCDs in the South-East Asia Region
(SEA/RC60/R4). The key elements of the regional framework
included: epidemiological assessment of NCDs and their

2011
 77

determinants; awareness generation and high-level advocacy;

formulation and adoption of policy and strategic plan for integrated
prevention and control of major NCDs; capacity building; resource
mobilization; as well as multisectoral and multilevel actions to
modify determinants.

October 2007 The second meeting of SEANET-NCD was held in Phuket, Thailand.
The inputs for development of a regional and global plan of action for
integrated prevention and control of NCDs were discussed.

June 2009 The third Meeting of SEANET-NCD was held in Chandigarh, India.
The meeting reviewed the progress in scaling up of NCD prevention
and control, particularly the role of SEANET. The meeting also
discussed and contributed to global recommendations on marketing
of food and non-alcoholic beverages to children.

September 2009 The 31st session of South East Asia-Advisory Committee on Health
Research (SEA-ACHR) was held in Kathmandu. The session
discussed research priorities in NCDs and called for intersectoral
collaboration in carrying out research on NCDs.

September 2010 The Sixty-third session of the WHO Regional Committee for South-
East Asia discussed progress in prevention and control of NCDs in
the Region.

January 2011 A Regional Civil Society Meeting, with support from SEARO was
organized by the Nepal Public Health Foundation (NPHF) in
Kathmandu, during 1923 January, 2011. This meeting resulted in
the Kathmandu Call for Action on NCDs.

March 2011 A regional meeting on health and development challenges of NCDs

was held during 14 March in Jakarta, Indonesia with participation
of all the 11 Member States of the Region. The meeting culminated
in the Jakarta Call for Action on prevention and control of NCDs
and preparation of a report on key messages for UNHLM.

July-September 2011 Country-level multistakeholder meetings were held in 10 of the 11

Member States, along the lines of the regional consultation in
Jakarta, with WHO support. As part of preparations for these
meetings, some countries undertook an assessment of the NCD
situation as well as national capacity and health system response to
address NCDs. The national meetings aimed to discuss inputs to the
UNHLM, build consensus on a multisectoral response to the NCD
epidemic and trigger the development of national multisectoral
medium-term plans for prevention and control of NCDs.

September 2011 The Sixty-third Health Ministers meeting discussed and adopted
ten key messages for the UNHLM from SEAR.

2011
Chapter 9

The Way Forward
The UNHLM on NCDs held in New York
during 1920 November was a turning point in
the global struggle against NCDs. This was the
second time in the history of the United Nations
that the General Assembly met with the
participation of heads of state and government
on a health issue with a major socioeconomic
impact. The HLM was attended by 113 Member
States, including 34 presidents and prime
ministers, three vice presidents and deputy
prime ministers, 51 ministers of foreign affairs
and health, 11 heads of UN agencies, and
hundreds of representatives from civil society.
From SEAR, heads of states from Bangladesh
(Prime Minister) and Maldives (Deputy), health
ministers from India, Indonesia, Maldives,
Thailand and Sri Lanka, and high-level
delegates from other countries participated in
the UNHLM.
The outcome of the meeting was a Political
Declaration of commitment, which was adopted
by the General Assembly on 19 September 2011
as resolution A/RES/66/2. It acknowledges the
rapidly growing magnitude of NCDs in
developing countries and its increasingly
devastating health and socioeconomic impacts
and calls for concrete and comprehensive action
by Member States and the international
community.
79
Guiding Principles for NCD
Prevention and Control
The following guiding public health
concepts should be used for NCD prevention
and control measures in the Region:
Integrated approach: As the four major
I
NCDs causing 80% of NCD deaths result
from shared risk factors, there is a need for
an integrated approach to address NCDs
together as a cluster of diseases instead of
addressing each NCD separately as an
individual disease.
I Multisectoral actions: Major
determinants of NCDs lie outside the scope
of the health sector. Therefore control of
NCDs requires effective multisectoral
actions and adoption of Health in All
policies. This means that sectors outside
health must consider health issues while
formulating policies, strategies and
standards. With the exception of the
tobacco industry, the private sector can
immensely contribute to addressing NCD
prevention and control.
I Life course approach: Individuals are
influenced by factors acting at all stages of
their life span and risk of developing NCDs
increases with age. Using the life course
2011
80
approach, NCDs and their risk factors are
best addressed throughout the course of
peoples lives, through promotion of healthy
behaviours and early diagnosis and
treatment that begins before pregnancy and
continues through childhood, adolescence,
adult life to old age.
I Equity and social justice: NCD
prevention and control measures should be
affordable, appropriate and accessible to
diverse groups programmes should be
gender sensitive and gender specific.
Priority should be given to the poorest and
the socially disadvantaged sections of
society.
Evidence-based and culturally
I
appropriate interventions: NCD
intervention strategies need to be based on
sound scientific evidence. A coordinated
agenda for NCD surveillance and research
is essential to strengthen the evidence base
for cost-effective and culturally appropriate
NCD prevention and control measures.
Specific strategies and
Interventions for NCD Prevention
and Control
The vision and framework for reversing
the NCD epidemic is articulated in WHOs
global strategy for prevention and control of
NCDs, 20082013 Action plan for the global
strategy for the prevention and control of
noncommunicable diseases and the Regional
framework for the prevention and control of
noncommunicable diseases. The key strategies
recommended by WHO and endorsed by
Member countries are as follows:
2011
Health promotion and primary
prevention to reduce risk factors for
NCDs using multisectoral approach
The majority of NCDs can be averted
through interventions and policies that reduce
major risk factors. Population-wide primary
prevention approaches are cost-effective and
interventions that combine a range of evidence-
based approaches have better results. Priority
should be given to implementation of practical
and affordable Best Buys interventions. A best
buy is an intervention that is not only highly
cost-effective but also feasible and culturally
acceptable to implement. The recommended
Best buys are given in Box 9.1.
Health system strengthening for
early detection and management of
NCDs
In conjunction with primary prevention
interventions, improved access to early
detection and providing essential standards of
care for those with major NCDs at the primary
health-care level, will have the greatest potential
for reversing the progression of disease,
preventing complications, reducing
hospitalizations and health care as well as out-
of-pocket expenditures. The WHO package of
essential NCD interventions (PEN), which
includes standardized tools for health facility
assessment, essential diagnostic equipment,
essential drugs, counseling of patients,
recording and reporting, and community
mobilization is an innovative package for
increasing access to high-quality, low-cost care
for people at high risk for NCDs. In SEAR
Member countries, pilot projects for integrating
NCDs within the primary health-care system are
under way in Bhutan and Sri Lanka (The PEN
 81

Box 9.1: Cost-effective interventions (best buys) for preventing NCDs

Risk factor/disease Interventions
Tobacco use Protect people from tobacco smoke
Warn about the dangers of tobacco
Enforce bans on tobacco advertising
Raise taxes on tobacco
Harmful use of alcohol Enforce bans on alcohol advertising
Restrict access to retailed alcohol
Raise taxes on alcohol
Unhealthy diet Reduce salt intake in food
Replace trans fat with polyunsaturated fat
Cardiovascular diseases and diabetes Provide counselling and multi-drug therapy (including glycaemic
control for diabetes mellitus) for people with 10-year
cardiovascular risk >30%
Treat acute myocardial infarction (with aspirin)
Cancers Hepatitis B vaccination to prevent liver cancer
Detection and treatment of precancerous lesions of the cervix and
early stage cervical cancer
Source: World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011.

project), and are planned in DPR Korea, for risk factors (or measurement of exposure),
Indonesia, Maldives, Myanmar and Nepal in the disease morbidity or mortality (or measurement
near future. of outcomes), and assessment of health system
capacity and response. Measurable core
The delivery of effective NCD
indicators for each have to be adopted and used
interventions is determined by the capacity of
to monitor trends and progress. Emphasis
health-care system. The existing organizational
should be placed on surveillance of both
and financial arrangements surrounding health
behavioural and metabolic risk factors. To
care need to be reoriented to address the long-
ensure an effective surveillance system,
term needs of people suffering from and
countries should make efforts to integrate and
vulnerable to NCDs. Broad-based initiatives to
institutionalize NCD surveillance into the
achieve equity in health-care financing are vital
national health information system, for long-
protections against the risk of catastrophic
term sustainability.
NCD-related health-care costs. Additionally,
initiatives aimed at health systems reform Countries also need to have a prioritized
should include specific NCD related endpoints research agenda and carry out formative and
in universal coverage goals. operational research with major focus on
primary prevention and early diagnosis of
Surveillance and research NCDs, addressing social and economic
determinants as well as developing and testing
Surveillance and monitoring of NCDs is
multisectoral approaches to NCD prevention
essential to policy and programme
and control. Allocation of budget for research
development. A comprehensive national NCD
and building up of research work force should
surveillance system should include surveillance
also be a priority.

2011
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Role of Different Agencies in NCD prevention and control of NCDs as many

Prevention and Control determinants of NCDs lie outside the health

sector. Significant roles can be played by
A multisectoral approach and involvement governments, development partners, civil
of different agencies is key to addressing society, academia, media and the private sector
(see Box 9.2).

Box 9.2: Role of partners in prevention and control of NCDs

Responsibility of I Make noncommunicable diseases (NCDs) a national development agenda and include
governments health in all policies.
I Set and effectively enforce health promoting norms, standards and strategies.
I Set up surveillance and monitoring to track the NCD epidemic and its control.
I Mobilize and coordinate multisectoral responses and strengthen the engagement of
all sectors in NCD prevention and control.
I Provide equitable access to affordable, effective health care for the prevention and
management of NCDs.

Responsibility of I Mobilize political and social awareness and support for prevention and control of NCDs.
civil society I Act as a counterbalance to commercial and private sector interests against healthy
policies.
I Provide prevention and health care services to fill gaps in public and private sector
services.
I Hold governments accountable for delivering on NCD commitments.

Responsibility of I Build capacity of human resources in NCD prevention and control.

academia I Independently monitor and evaluate progress in achieving outcomes by both the
government and private sector.
I Generate evidence and ensure an evidencepolicy interface.

Responsibility of I Raise public awareness among the general population about prevention of risk factors
media for NCDs.
I Create an enabling environment for behaviour change.
I Sensitize political leadership about the importance of multisectoral actions for NCD
prevention and control.
I Act as a watchdog to offset commercial interests against healthy policies.

Responsibility of I Work closely with the government to promote healthy lifestyles, for example by
private sector reformulation to reduce salt, trans fats and sugar in their products.
(except the I Improve health of their employees through workplace wellness programmes.
tobacco industry) I Ensure responsible marketing by helping to make essential medicines more
affordable and accessible.

Reponsibility of I Prioritize NCD prevention and control in aid programmes.

development I Strengthen support for full and effective implementation of global strategies to address
partners NCDs.
I Coordinate and pool technical expertise to strengthen normative guidance to achieve
the best results at the country level.

2011

The NCD epidemic places an enormous
toll in terms of disease morbidity and mortality
and inflicts serious damage to human
development in both social and economic
spheres. Actions based on best available
83
scientific evidence need to be designed,
implemented and monitored. A multisectoral
approach that mobilizes all stakeholders is
essential for long-term progress. Efforts and
involvement of all partners will contribute to
sustained improvement in public health.
2011
Annexes
 Annex 1: Estimated number of deaths (in thousands) by major noncommunicable diseases
(NCDs), 2008

Country All NCDs Cancers Diabetes mellitus Cardiovascular diseases Chronic respiratory diseases
Females Males Total Females Males Total Females Males Total Females Males Total Females Males Total
Bangladesh 285.5 313.3 598.8 54.6 48.9 103.5 9.4 10.2 19.6 148.9 166.9 315.8 31.4 37.4 68.8
Bhutan 1.4 1.7 3.1 0.3 0.3 0.5 0.0 0.1 0.1 0.7 0.9 1.6 0.1 0.2 0.3
DPR Korea 71.4 61.5 132.9 15.1 11.9 26.9 3.6 2.3 5.9 36.9 29.9 66.8 7.2 7.0 14.1
India 2273.8 2967.6 5241.4 312.5 321.9 634.4 80.4 96.3 176.7 1002.5 1330.6 2333.1 472.1 618.7 1090.8
Indonesia 481.7 582.3 1063.9 104.8 110.7 215.5 25.7 22.6 48.3 235.6 277.5 513.1 45.5 73.8 119.4
Maldives 0.4 0.5 0.9 0.2 0.2 0.4 0.0 0.0 0.0 0.1 0.2 0.3 0.0 0.1 0.1
Myanmar 116.6 125.8 242.5 24.1 21.8 45.8 4.5 4.2 8.7 61.1 64.2 125.3 12.3 14.7 27.0
Nepal 42.8 48.8 91.7 11.1 8.9 20.0 1.6 1.6 3.2 20.6 24.5 45.1 4.1 5.6 9.7
Sri Lanka 51.1 66.8 117.9 8.5 8.5 17.0 3.8 3.3 7.1 22.8 30.6 53.5 6.5 8.8 15.3
Thailand 191.3 227.1 418.4 35.1 35.6 70.7 22.5 13.3 35.8 75.8 84.4 160.2 10.3 30.0 40.3
Timor-Leste 1.0 1.4 2.4 0.2 0.3 0.5 0.0 0.0 0.1 0.5 0.7 1.2 0.1 0.2 0.3
SEAR total 3517.2 4396.7 7913.9 566.5 568.9 1135.4 151.6 153.8 305.4 1605.6 2010.3 3615.9 589.7 796.4 1386.1

Source: Global Health Observatory, World Health Organization, 2011

2011
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Annex 2: Age-standardized death rates due to noncommunicable diseases (NCDs) per 100 000
population in Member countries of SEAR, 2008

Country All NCDs Cancers Diabetes mellitus Cardiovascular diseases Chronic respiratory diseases
Females Males Total Females Males Total Females Males Total Females Males Total Females Males Total
Bangladesh 654.7 751.2 701.7 106.2 104.5 105.0 22.1 25.6 23.8 371.0 424.2 397.2 73.7 91.7 82.5
Bhutan 667.2 801.0 735.2 119.0 131.8 124.8 18.7 26.1 22.3 372.1 444.7 409.8 73.0 93.3 83.5
DPR Korea 477.4 644.4 547.6 98.9 122.0 106.4 23.1 22.6 23.1 245.1 318.3 278.6 48.8 77.2 59.9
India 582.3 793.0 684.6 72.0 78.9 75.0 21.0 26.9 23.8 268.7 366.1 316.5 128.5 181.2 153.6
Indonesia 547.8 762.7 647.0 109.4 136.5 120.9 29.0 29.9 29.5 278.2 373.9 323.6 53.6 103.1 75.8
Maldives 564.5 621.9 593.7 228.8 290.9 261.5 8.2 3.7 5.8 214.1 215.2 214.1 66.5 60.2 63.1
Myanmar 591.5 755.6 667.1 116.3 124.5 119.8 23.4 25.6 24.4 317.8 398.0 355.0 63.0 91.6 76.0
Nepal 543.5 711.0 620.2 118.8 114.0 116.4 21.0 24.5 22.6 285.7 379.6 329.0 55.8 87.1 70.1
Sri Lanka 490.5 781.4 623.1 79.0 91.6 84.3 36.7 39.8 38.2 220.0 364.5 285.7 62.3 107.1 82.3
Thailand 563.2 811.3 675.0 97.6 115.6 105.9 64.4 46.4 56.3 229.7 304.2 265.3 30.7 119.2 68.6
Timor-Leste 476.8 649.6 559.7 95.0 121.5 107.5 19.3 21.8 20.5 258.3 336.6 296.1 50.0 77.8 63.2
Source: Global Health Observatory, World Health Organization 2011
 Annex 3: Age-standardized incidence per 100 000 persons of common
cancers in Member countries of SEAR, 2008

Cancer site
Country Breast Cervix uteri Liver Colorectum Lung Prostate
(females) (females) Females Males Females Males Females Males (males)
Bangladesh 27.2 29.8 3.5 4.1 4.0 4.5 8.7 30.4 1.9
Bhutan 8.0 20.4 4.0 8.1 4.4 7.9 10.8 8.7 1.7
DPR Korea 30.5 6.6 7.2 15.8 16.0 15.0 25.8 34.0 2.3
India 22.9 27.0 1.2 3.2 3.5 4.3 2.5 10.9 3.7
Indonesia 36.2 12.6 3.5 10.3 15.6 19.1 10.9 29.8 10.6
Maldives 46.0 13.3 0.0 0.0 2.0 7.8 0.0 20.3 3.0
Myanmar 32.5 26.4 6.3 16.5 12.0 12.3 13.9 22.9 5.8
Nepal 23.5 32.4 1.1 1.7 4.8 5.3 18.2 20.7 2.2
Sri Lanka 29.1 11.8 1.0 2.3 5.8 7.5 2.7 12.0 5.8
Thailand 30.7 24.5 19.9 40.6 13.4 13.2 12.1 26.8 6.5
Timor-Leste 29.6 11.4 2.5 7.6 11.2 17.6 7.2 28.6 7.9
Source: GLOBOCAN 2008. International Agency for Research on Cancer and World Health Organization

2011
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2011
Annex 4: Estimated attributable deaths by major risk factor, SEAR, 2004

Risk factor Attributable deaths Attributable fraction

(number in thousands) (%)
Childhood and maternal under-nutrition
Underweight 828 964 5.4
Iron deficiency 121 815 0.8
Vitamin A deficiency 252 301 1.7
Zinc deficiency 110 583 0.7
Sub-optimal breastfeeding 365 751 2.4
Other nutrition-related risk factors and physical activity
High blood pressure 1 438 405 9.4
High cholesterol 756 213 4.9
High blood glucose 1 044 497 6.8
Overweight and obesity 343 366 2.2
Behavioural risk factors
Low fruit and vegetable intake 449 583 2.9
Physical inactivity 781 670 5.1
Addictive substances
Tobacco use 1 037 188 6.8
Alcohol use 354 481 2.3
Illicit drug use 72 879 0.5
Sexual and reproductive health
Unsafe sex 331 809 2.2
Unmet contraceptive need 72 526 0.5
Environmental risks
Unsafe water, sanitation, hygiene 598 668 3.9
Urban outdoor air pollution 207 114 1.4
Indoor smoke from solid fuels 630 336 4.1
Lead exposure 70 137 0.5
Global climate change 57 982 0.4
Occupational risks 270 000 1.8
Other selected risks
Unsafe health care injections 121 294 0.8
Child sexual abuse 37 998 0.2
Source: Global health risks, World Health Organization 2009
 Annex 5: Regional and global demographic indicators

Population
Country Total Aged Aged Annual growth rate (%) Living in urban areas (%) Median
(millions) under 15 (%) over 60 (%) age (years)
2009 2009 2009 19891999 19992009 1990 2000 2009 2009
Bangladesh 162 31 6 2.0 1.6 20 24 28 24
Bhutan 0.7 31 7 0.0 2.5 16 25 36 24
DPR Korea 24 22 14 1.3 0.5 58 60 63 34
India 1200 31 7 1.9 1.6 26 28 30 25
Indonesia 230 27 9 1.5 1.3 31 42 53 28
Maldives 0.3 28 6 2.5 1.4 26 28 39 24
Myanmar 50 27 8 1.4 0.8 25 28 33 28
Nepal 29 37 6 2.5 2.1 9 13 18 21
Sri Lanka 20 24 12 0.9 0.8 17 16 15 30
Thailand 68 22 11 1.0 0.9 29 31 34 33
Timor-Leste 1.1 45 5 1.2 3.3 21 24 28 17
SEAR 1 784 30 8 1.8 1.5 26 29 33 26
Global 6 817 27 11 1.5 1.2 43 47 50 29
Source: World Health statistics 2011. World Health Organization 2011.

2011
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2011
Annex 6: Health expenditure in Member countries of SEAR, 2000 and 2008 comparison

Total expenditure on health General government Out-of-pocket Per capita total Per capita government
as percent of gross expenditure on health as expenditure as percent expenditure on health expenditure on health
domestic product percent of total of private (PPP int. $) (PPP int. $)
government expenditure expenditure on health

Country 2000 2008 2000 2008 2000 2008 2000 2008 2000 2008
Bangladesh 2.8 3.3 7.6 7.4 95.1 96.5 22 44 9 14
Bhutan 6.7 5.5 12.6 13 free services free services 165 263 131 217
DPR Korea ---- ---- ---- ----
India 4.6 4.2 3.9 4.4 92.2 74.4 69 122 19 40
Indonesia 2 2.3 4.5 6.2 72.9 70.3 47 91 17 49
Maldives 8.7 13.7 11.1 13.8 73.8 72 242 769 113 470
Myanmar 2.1 2.3 1.2 0.7 99.2 95.7 12 27 2 2
Nepal 5.1 6 7.7 11.3 91.2 72.4 43 66 11 25
Sri Lanka 3.7 4.1 6.9 7.9 83.3 86.7 101 187 49 82
Thailand 3.4 4.1 9.9 14.2 76.9 68.1 165 328 92 244
Timor-Leste 8.8 13.9 12.7 11.9 43.4 37.2 67 112 48 93
SEAR 3.9 3.8 4.7 5.6 89.4 75.1 64 116 21 46
Source: World Health Statistics 2011, World Health Organization 2011
 Annex 7: Health workforce in Member countries of SEAR

Physicians 20002010 Nursing and midwifery Public health workers Community health workers
personnel 20002010 20002010 20002010
Country Number Density* Number Density* Number Density* Number Density*
Bangladesh 43 315 3.0 39 992 2.7 6 091 0.4 48 692 3.3
Bhutan 52 0.2 545 3.2 80 0.4 195 0.9
DPR Korea 74 597 32.9 93 414 41.2 2 685 1.2
India 660 801 6.0 1 430 555 13.0 50 715 0.5
Indonesia 65 722 2.9 465 662 20.4 6 493 0.3
Maldives 552 16.0 1 539 44.5 478 13.8
Myanmar 23 709 4.6 41 424 8.0 2 013 0.4 3 247 0.6
Nepal 5 384 2.1 11 825 4.6 172 0.1 16 206 6.3
Sri Lanka 10 279 4.9 40 678 19.3 2 411 1.1
Thailand 18 918 3.0 96 704 15.2 2 151 0.4
Timor-Leste 79 1.0 1 795 21.9 22 0.3 10 0.1
SEAR 903 408 5.4 2 224 133 13.3 119 543 0.9
Global 9 171 877 14.0 19 379 771 29.7 1 369 772 4.0
Source: World Health Statistics 2011, World Health Organization 2011
* per 10 000 population

2011
91

2011
Note on data sources and limitations
1. Mortality data presented in Chapter 2 were obtained primarily
from estimates presented in the Global Health Observatory (GHO)
Data Repository 2011, provided in the following website link
http://www.who.int/gho/mortality_burden_disease/global_bur
den_disease_DTH6_2008.xls.
The data presented on the website are for the year 2008 and are
updates on estimates of deaths by cause, age and sex using the
same general methods as previous revisions carried out by WHO
for 2002 and 2004. Mortality estimates are based on analysis of
latest available national information on levels of mortality and
cause distributions as at the end of 2010 together with latest
available information from WHO programmes, International
Agency for Research on Cancer (IARC) and Joint United Nations
Programme on HIV/AIDS (UNAIDS) for specific causes of public
health importance and using the 2008 revision of the population
estimates for WHO Member States prepared by the UN
Population Division. Further details of the methods, sources of
data and the reference year are provided in Annex xx at the end of
this document and on the website http://apps.who.int/ghodata/
?vid=2490.
In addition, mortality and morbidity data reported in country
reports were used wherever available. However, these country
92
reports contained limited or disparate information and were not
readily accessible. Moreover, country-specific definitions and
methodologies limited comparability of data across countries.
Most country reports used hospital-based data, sometimes only
from one location in the country, thus limiting the
representativeness of the data. Some countries used registration
data that were grossly incomplete and underreported. Extensive
efforts were made to locate regional literature and web documents,
and the same have been used extensively in this report.
2. Methods for risk factor data are presented in the Global status
report on noncommunicable diseases 2010. Briefly, these data are
based on country reported results from national surveys as well as
published and unpublished literature. These data have come from
surveys/studies that fulfilled certain criteria such as: a random
sample of the general population, with clearly indicated survey
methods (including sample size) and risk factor definitions.
Adjustments were made for the following factors so that the same
indicator could be reported for a standard year (in this case 2008)
in all countries: standard risk factor definition, standard set of age
groups for reporting, and representativeness of the population.
Using regression modeling techniques, crude adjusted rates for
each indicator were produced. To further enable comparison
 continued...
among countries, age-standardized comparable estimates were
produced by adjusting crude estimates to an artificial population
structure that closely reflected the age and sex structure of most
low- and middle-income countries.
3. Data presented in Chapter 5 were obtained from a capacity
assessment survey using a structured tool. An important
limitation is that data were reported by the national NCD focal
persons and may be prone to reporting bias. While the countries
had been asked to provide supportive documents for verification,
these documents were not always provided, or they were not
always in English. Thus, little verification was possible on the
reported information. Another limitation is that while the survey
2011
focused largely on quantitative indicators, the qualitative aspects
were not adequately covered. For example, while the survey
focuses on the availability of guidelines, equipments and services
in the countries with a yes or no response, it does not elicit crucial
aspects related to coverage or quality of services. Third, since this
was a self-administered questionnaire, it was not possible to
explain or clarify the questions or use probes. Thus, it is possible
that the respondents may not have understood clearly some
questions or differentiated distinctly between policies, strategies,
programmes or plans. Therefore responses related to some of the
questions may not have been accurate. Finally, data on the role of
the private sector, which manages a major share of NCDs, could
not be obtained in the survey.
93
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2011
 Noncommunicable

Noncommunicable Diseases in the South-East Asia Region 2011

Diseases in the
South-East Asia Region

|
This report describes the current burden of noncommunicable
diseases in the South-East Asia Region, their underlying risk

2011

Situation and Response

factors and socioeconomic determinants. The report also
summarizes the progress countries are making for tackling
the NCD epidemic, provides the base for regional and country
responses, highlights some good country practices and
recommends the way forward in addressing NCDs and risk
factors in a comprehensive and integrated way. The report is
intended for policy-makers in health and development,
health professionals, researchers and academia, and other
Situation and Response
key stakeholders involved in prevention and control of NCDs.

WHO
SEARO