A review of non-communicable disease in low- and middle-income countries

1.1. The NCD burden: the leading causes of death and disease 

The global burden of non-communicable disease (NCD) continues to grow. NCDs (principally cardiovascular diseases, diabetes, cancers and chronic respiratory diseases) caused an estimated 35 million deaths in 2005 (60% of all deaths globally), and mortality is projected to increase by 17% by 2015.1 Eighty percent of all NCD deaths occur in low- and middle-income countries (LAMICs)2 and these conditions were responsible for 50% of the disease burden in 2005.3 Death rates from NCDs are considerably higher in LAMICs than in high-income countries: estimated to be 56% higher in men and 86% higher in women in 2005.3 While currently 5 out of the 10 leading causes of death are related to NCDs, 8 out of the 10 will be linked to these conditions by 2030.4

NCDs are responsible for significant premature mortality and morbidity throughout the world, but particularly in LAMICs. In LAMICs the disease develops at an earlier age than in high-income countries, often resulting in a prolonged period of disability before death. The rapidly increasing burden of these diseases is affecting poor and disadvantaged populations disproportionately, contributing to widening health gaps between and within countries. As NCDs are largely preventable, the number of premature deaths can be greatly reduced.5, 6

The four most prominent NCDs [cancer, cardiovascular disease, chronic obstructive pulmonary disease (COPD) and diabetes] share modifiable and preventable risk factors related to lifestyles. These factors are predominantly tobacco use, unhealthy diet, physical inactivity and the harmful use of alcohol.

1.2. Serious implications for socio-economic development 

NCDs have serious implications for macroeconomic development and can impede the international efforts at poverty reduction. If left unaddressed, an estimated US$84 billion of economic production will be lost as a result of heart disease, stroke and diabetes alone in 23 LAMICs.3 For example, total diabetes-related costs have been estimated at between 2 and 4% of gross domestic product in most LAMICs. The global cost of the harmful use of alcohol in 2002 has been estimated to be between US$210–665 billion.7

The economic burden attributable to these health problems can also be measured in terms of household impact. In the poorest households of some developing countries, 5–15% of total disposable income is spent on tobacco, and 15–25% of household income on the treatment of diabetes.8 Many people living with disabilities are trapped in a life of poverty because of the barriers disabled people face in taking part in education, employment and social activities. Millions of people are impoverished each year around the world as a result of catastrophic health expenditures.9

Although not included in the Millennium Development Goals (MDG), NCDs impose a heavy burden on socio-economic development and are closely associated with poverty. The Plan of Implementation of the World Summit on Sustainable Development (Johannesburg, 2002) includes a call to action to “Develop or strengthen … programmes to address noncommunicable diseases and conditions, such as cardiovascular diseases, cancer, diabetes, chronic respiratory diseases, injuries, violence and mental health disorders and associated risk factors, including alcohol, tobacco, unhealthy diets and lack of physical activity.”10 A resolution on tobacco control by the United Nations Economic and Social Council recognizes the link between tobacco use and poverty.11 Bilateral policies for development assistance have started to recognize that LAMICs increasingly face a problem with NCD.12, 13, 14

In its recent report entitled ‘The U.S. Commitment to Global Health: Recommendations to the New Administration’, the Institutes of Medicine in the USA strongly advocates action on the prevention and control of NCDs as a global health priority, particularly in LAMICs.15

The world's largest philanthropic organizations have started to call for LAMICs to implement interventions to reduce tobacco use and save lives.16

2.1. Cardiovascular disease 

There is a widespread mistaken belief that the global burden of cardiovascular diseases is diminishing. Despite declining mortality in some developed countries, such as the USA, Canada and Finland, heart disease remains the dominant public health problem in these societies. Most Eastern European countries are experiencing high and increasing mortality rates due to cardiovascular diseases. A major cause of concern is the projected rise of these diseases in LAMICs over the coming decades, particularly due to population ageing.17

In 2004 it was estimated that cardiovascular diseases caused approximately 17 million deaths worldwide (29% of all deaths), and of these about 80% (14 million) occurred in LAMICs.18 In 2004 there were over five times as many deaths from stroke in LAMICs (5 million) than in high-income countries (0.75 million)18 and the number of deaths due to heart attacks was almost 6 million in LAMICs compared with 1.3 million in high-income countries.18

While coronary heart disease is, in general, less common in pre-menopausal women than in similarly aged men, in many areas of the world it is the most common cause of death in women. Given the longer life expectancy of women, they contribute increasingly to cardiovascular deaths and disability after the sixth decade of life. The result is that, over their entire lifespan, women are more affected by heart attacks and strokes than men–a fact not fully appreciated by many health professionals, and by women themselves. Furthermore, pregnancy-associated hypertension is an important health problem in LAMICs, where it is the major cause of premature birth and perinatal death, and causes approximately 16% of maternal mortality, rising to 26% in Latin America and the Caribbean.19

2.2. Cancer 

WHO reports that there were an estimated 14.5 million new cancer cases in 2004, with approximately 66% occurring in LAMICs.20 This represents a steady increase since the first estimates issued over 30 years ago. Sixty-four percent of lung cancer (12.7% of the total), 82% of stomach cancer (8.2% of the total), 56% of breast cancer (7.6% of the total), 52% of colon and rectal cancer (9.5% of the total), 47% of prostate cancer (5.3% of the total) and over 90% of cervical cancer (3.6% of the total) occurred in LAMICs in 2004.20

Over three-quarters of lung cancer cases are related to smoking. Trends are predicted by past cigarette consumption patterns in the population and are expected to continue to increase globally, particularly in LAMICs, due to the heavy marketing and uptake of tobacco products in these countries. Stomach cancer is highest in Eastern Europe and Eastern Asia. Declining incidence in high-income countries has been well documented and in all likelihood relates to dietary change, particularly a decline in salt consumption. Breast cancer closely parallels levels of socio-economic development. Incidence is rising in most countries, although there have been declines in mortality in some jurisdictions (North America and northern Europe). Colorectal cancers have a similar geographical distribution and incidence rates have also been increasing.

In 2002, it was estimated that chronic hepatitis B infection (HBV) was killing 340 000 people per year from liver cancer and cirrhosis with 82% in LAMICs.20 It is largely preventable, as about 80% of cases are related to infection with hepatitis viruses, principally HBV, with geographical patterns mirroring infection. In 2002 a quarter of a million women died from cervical cancer, with 98% attributable to human papillomavirus. Falling incidence rates in high-income countries are generally attributed to screening. Vaccines now exist to prevent most of these deaths. Prostate cancer displays a significant geographical variation, which is largely unexplained.

Finally, occupational carcinogens were estimated to kill at least 152 000 people per year. Indoor and outdoor air pollution was estimated to lead to 71 000 cancer deaths annually.21 Globally demographic changes alone will increase new cancer cases significantly by 2030 with the bulk of the increase in LAMICs.22

2.3. Chronic obstructive pulmonary disease 

COPD is caused primarily by tobacco smoking, with some due to environmental air pollution and occupational hazards, and incidence trends rise with age.23 In 2004 COPD was estimated to have caused 3 million deaths worldwide (5.1% of the total) with over 90% of these deaths occurring in LAMICs.24 Mortality rates of COPD are expected to continue to rise in these countries due to the rise in cigarette smoking. Prevalence is tied strongly to cigarette smoking at the population level, and over 15% of middle-aged smokers have abnormal lung function. There is a general underreporting of this condition.

COPD has a significant economic and social cost to society, in the form of health-care costs and loss of productivity caused by the illness.23 Hospital costs are high, particularly those associated with treating chronic respiratory failure. COPD is one of the leading causes of lost days of work.

2.4. Diabetes 

WHO estimates that in 2005 there were 1.1 million deaths from diabetes globally (3.3% of the total), with 80% occurring in LAMICs.24 The number of deaths is projected to rise to 2.2 million in 2030.25 Routine sources of mortality statistics underestimate the impact of diabetes on mortality. Using more refined methods, about 3 million deaths globally can be attributed to diabetes every year.26

In 2004 the number of adults with diabetes worldwide was estimated to be 170 million, and the number is projected to increase to 366 million in 2030.27 More recent estimates from the International Diabetes Federation project the number of people with diabetes to reach 380 million in 2025.28 The projected increase is thought to be relatively highest in the Middle East, sub-Saharan Africa and India. Eighty percent of people with diabetes live in developing countries, and of the top 10 countries with highest prevalence, practically all are LAMICs.29

There is evidence to suggest that the prevalence of diabetes in LAMICs is increasing faster than in high-income countries. In the urban population of Chennai, the prevalence is reported to have increased by 72% in only 14 years.30 Similarly, population-based surveys in China have shown that although the prevalence of diabetes is considerably lower than in India, it has also risen substantially within a relatively short period of time.31 If current trends prevail, diabetes prevalence is expected to rise even in countries where the young adult population is currently decimated by the AIDS epidemic.32

Diabetes could pose a challenge to achieving the MDGs. About 15% of new tuberculosis cases in India can be attributed to diabetes.33 Shifting diabetes onset towards younger age groups means that increasingly more pregnancies are associated with diabetes, thus affecting the immediate maternal and child outcome of pregnancy as well as the long-term risk of diabetes and cardiovascular diseases in the offspring.34 A resolution on diabetes was passed by the UN General Assembly during its 65th session (agenda item 113) calling for increased awareness of diabetes and related complications and encouraging countries to develop prevention and control programs.

4.1. Prevention 

The concept of early intervention for prevention of NCD has been advocated for some time.39, 40 Experience over the past 30 years or more has demonstrated that primary prevention and promotion policies and programs need to be based in the community with an intersectoral structure such that they involve many sectors of society with an interest in and influence on health and development.

There is good evidence that community-based interventions to reduce NCD and related risk factors are both effective and cost effective in high-income countries and LAMICs.41, 42 In particular, there is evidence for comprehensive public-health intervention strategies directed at tobacco control measures and salt reduction in LAMICs.41 It has been estimated that if implemented in the 23 countries which represent 80% of the global NCD burden the impact of these strategies would be to avert 13.8 million deaths over a 10-year period (2006–2015) at low and affordable cost for LAMICs.5

The WHO Framework Convention on Tobacco Control (WHO FCTC) is the first global health treaty negotiated under the auspices of WHO.43 This convention is an evidence-based treaty that reaffirms the right of all people to the highest standard of health. Based on the WHO FCTC, WHO recommends a technical assistance package of six proven tobacco control policies designed to help countries implement and build on some of the core elements of the WHO Framework Convention. They include measures proven to reduce the prevalence of tobacco use.

Although there has been progress in recent years, no government is yet fully implementing all of these key interventions, not more than 5% of the world's population is covered by comprehensive tobacco control policies.44

Interventions on diet and physical activity are also effective and suitable for resource-constrained settings. These include laws and regulations, tax and price interventions, improving the built environment, advocacy, mass media, community-based interventions, school- and workplace-based interventions, screening and clinical prevention. Current evidence points to the fact that multi-component interventions which are adapted to the local context are the most successful.45, 46

There is good evidence that use in primary care of an individual-level multidrug regimen targeting elevated blood pressure and blood cholesterol combined with aspirin would reduce mortality from cardiovascular disease significantly, and with scaling up in the 23 countries mentioned above would avert a further 17.9 million deaths at low cost in LAMICs over 10 years (2006–2015).6

There is good evidence to support programs for the prevention of type 2 diabetes particularly targeted to dietary habits, physical activity and overweight and obesity. There have been a number of studies in both LAMICs and high-income countries that have demonstrated the feasibility and cost-effectiveness of measures for diabetes prevention.47, 48, 49, 50

The examples above demonstrate the feasibility of the delivery of low-cost, effective interventions targeting populations as a whole and individuals at high risk with substantial benefit in a relatively short period of time. Specifically the tobacco, salt and multidrug measures alone represent a potential saving of over 32 million lives in 10 years.

4.2. WHO response to the global challenge 

Much of NCD can be prevented or treated by low-cost, high-impact and evidence-based interventions. Investing in such interventions, particularly those related to primary prevention, provide the highest return in health and economic terms.

The importance to global health of addressing these health problems has been receiving increasing recognition and attention. The United Nations General Assembly, the World Health Assembly, and WHO Regional Committees have adopted resolutions and calls for action, highlighting the need to raise awareness and institute effective prevention and control measures. While more calls for action are needed, there is also an urgent need for greater support and collaboration with public and private partners to avoid duplication and fragmentation. The NCD work of WHO is primarily guided by these resolutions and the lessons learned over the past decade to help improve the ability of partners to work more effectively together.

4.3. Lessons learned from international experience and the work of WHO in countries 

Much is known about the prevention and control of NCD. Countries can reverse the advance of these health problems if appropriate action is taken. The work of WHO is being guided by the lessons learned from existing knowledge and experience, some of which are summarized below.

Restricting strategies to reducing exposure to established risk factors is insufficient. A comprehensive strategy must also include prevention of the emergence of risk factors in the first place and address their social determinants.

In any population, most people have a moderate level of risk factors, and the minority have a high level. Those at moderate risk contribute more to the societal burden of disease than those at high risk. Consequently, strategies need to combine an approach to reduce risk factor levels in the whole population while simultaneously targeting high-risk individuals.

In order to achieve substantial reductions in morbidity and improved disease outcomes, delivery of interventions should be of an appropriate scale, coverage and intensity and sustained over an extended period of time.

Success of interventions require community participation, supportive policy decisions, intersectoral action, legislation and collaboration with non-governmental organizations and the private sector. Joint work with non-health sectors is essential. Decisions made outside the health sector have a major influence on risk factors and determinants. More health gains, particularly at a population level, are achieved by influencing policies in other domains than by changes in health policy alone.

The long-term needs of people with NCDs and disabilities are rarely met successfully by the present organizational and financial arrangements of health-care systems. Priority should be given to integrating basic prevention and control measures into primary health care and re-orienting health systems for more effective care for chronic conditions.

International public health advocacy in this area needs to be driven by the key idea that NCD is closely linked to socio-economic development. These conditions are closely related to poverty and contribute to it. They need, therefore, to be included in the global discussions on development. Clearly, if the high mortality and heavy burden of disease experienced by LAMICs are to be tackled comprehensively and ultimately successfully, global development initiatives need to take into account the prevention and control of NCD.

The concept of integration is central to a strategic approach to tackling NCD. A number of risk factors are common to NCD and joint action on these factors is an efficient and effective way of reducing the burden of these diseases by assuming these actions within the framework of primary health care.51 A comprehensive integrated approach is one that recognizes that a broad range of social and biological determinants are at the root of NCD and that intervention strategies need to address profound issues of equity related to health and health outcomes. Consequently, health systems need to accommodate multiple program approaches involving multiple sectors of society operating at multiple levels to effectively deal with NCD and its risk factors in all relevant groups of society.

From the perspective of NCD management there is a compelling case for integrated chronic care. Many individuals with NCD have more than one. People with cancer may, and often do, have heart disease with perhaps diabetes and\or arthritis. This has produced an increasing prevalence of polypharmacy with significant problems from drug interactions and side effects, to say nothing of real harm to patients. From a clinical perspective chronic disease management is an increasingly complex and technical environment in which integration of care is becoming far more crucial to success, both in term of overall patient outcomes but also from an effectiveness and cost-effectiveness perspective such that an integrated, systems approach to management is optimal.

4.4. Assessing national capacity for NCD prevention and control 

In 2001, WHO conducted a global survey to assess the capacity of member states in the area of NCD prevention and control. A similar exercise was repeated in 2005.52, 53 The survey and other sources of data revealed major gaps in the capacity of countries to tackle NCD. For example, a substantial proportion of countries have no adequate NCD control policies, only about half have concrete plans for cancer control or tobacco control and most countries have no data on NCD risk factors in their annual health reports or regular health reporting systems. There were major gaps in the availability and skills of health professionals, and a considerable proportion of countries reported similar gaps in the availability and affordability of essential medicines, particularly in primary health care.

It is clear from such surveys that NCD prevention is increasingly recognized by health policymakers as a major health priority, but in most cases this is not translated into serious policies or plans. Where there are policies and/or programs in place, the approach to policy development and program implementation is often fragmented and uncoordinated.

To address these gaps, there is a pressing need for technical assistance to countries in dealing with NCD and in developing national policy frameworks that would serve as a vehicle for advocacy, awareness, capacity building and implementation of interventions.

4.5. Strategic directions 

For WHO going forward the broad strategic directions and lines of action are primarily based on the 2000 Global Strategy for the Prevention and Control of Noncommunicable Diseases (WHA53.17) and the corresponding 2008 Action Plan to implement the Global Strategy (A61/18, WHA61.14) within the context of the general directions and priorities of WHO's Medium-term Strategic Plan for 2008–2013.

Strategically there is a focus on five broad interrelated areas: (1) advocacy, targeting stakeholders with the best available evidence for prevention and treatment; (2) normative work, providing norms and standards to support evidence-based prevention and management guidelines; (3) technical support, supporting implementation, building national capacity and monitoring progress; (4) strategic support, for research and development; and (5) global partnerships, taking the lead in strengthening international partnerships for surveillance, prevention, health promotion and management.

4.6. 2008 NCD Action Plan 

In leading and catalysing an intersectoral, multilevel response to the growing burden of NCD with a particular focus on LAMICs and vulnerable populations, WHO has developed an action plan with the overall purpose of: mapping the emerging epidemics of noncommunicable diseases and analysing their social, economic, behavioral and political determinants; reducing the level of exposure of individuals and populations to the common modifiable risk factors for noncommunicable diseases and their determinants; and strengthening health care for people with noncommunicable diseases by developing evidence-based norms, standards and guidelines for cost-effective interventions.

The plan is based on current scientific knowledge, available evidence and a review of international experience. It comprises a set of actions which, when performed collectively by member states and other stakeholders, will tackle the growing public-health burden imposed by NCD. In order for the plan to be implemented successfully, high-level political commitment and the concerted involvement of governments, communities and health-care providers are required; in addition, public-health policies will need to be reoriented and allocation of resources improved.

The action plan sets out six key objectives and provides details of the respective actions and performance indicators for stakeholders at all levels, namely local, national and international. The six objectives include raising the priority accorded to noncommunicable diseases in development work; establishing and strengthening national policies and plans; promoting interventions to reduce the main shared modifiable risk factors; promoting research and partnerships for the prevention and control of noncommunicable diseases; and monitoring noncommunicable diseases and their determinants and the evaluation of progress at the national, regional and global levels. Each of the six objectives of the action plan includes sets of priority actions for member states, WHO and the international community.