Mortality rates relating to non-communicable diseases (NCDs) are rising worldwide. So are morbidity rates – that is, the incidence of disease. Most of this relates to four disease groups: cardiovascular and chronic respiratory diseases, cancer and diabetes. These diseases cause disability, suffering and loss of opportunity for many millions worldwide.
Once seen as diseases of the rich world, a result of diet, sedentary lives and aging societies, today NCDs are on the rise in developing and middle-income countries – significantly so in Asia. When the region was widely impoverished, people were too busy eking out a living to become obese; cigarettes and alcohol were expensive and lifespans short. Rising living standards, along with the broader availability of medication and vaccines, mean that communicable diseases are being reduced. Yet, while far fewer Asians are dying of infectious diseases, growing numbers are living long enough to develop chronic NCDs.
By 2008, NCDs had become the world’s most common cause of death, says Irina A. Nikolic, senior health specialist in the World Bank Group Global Health Practice. Lead author of
, Nikolic says they accounted for 36 million deaths, or 63% of the global total, with 78% occurring in developing and middle-income countries. Some 16 million of these deaths were premature, with the vast majority again occurring in developing and middle-income countries. Since then, the trends have continued. While some high-income countries have reduced death rates related to cardiovascular disease, NCDs are becoming an ever larger portion of the Why NCDs Matter (2011) global burden of disease. “By 2030, they could account for three-quarters of the disease burden in middle-income countries, up from two-thirds in 2011 and approaching the level of high-income countries.”
In developing countries, NCDs will increase more rapidly, approaching the levels of middle-income countries today. Meanwhile, some countries will still be contending with significant rates of the communicable diseases that ravage the poor, such as malaria, typhoid and diarrhea.
“These countries will be facing a double burden of disease,” comments Nikolic. “Tuberculosis and water-borne infections are still prominent in South-East Asia, for example, even as the level of NCDs is growing rapidly.”
ECONOMIC BURDEN OF DISEASE
Further, compared to higher-income counterparts, many developing countries face high NCD levels at earlier stages of economic development. People are contracting them at a younger age, likely to suffer ill effects for longer and to die more prematurely from them. This has consequences both for individuals and entire societies.
World Economic Forum estimates that over the next 20 years, NCDs will cost more than $46 trillion, representing 48% of global GDP in 2010. The costs include far more than the direct medical ones. They hit economies through reduced labor productivity and absenteeism, which affects company competitiveness and national growth. They strain health systems and, if the breadwinner is stricken, this can result in lost earnings or even jobs, pushing families into poverty. Family members may be forced to give up employment or forgo education to take care of the ill person.
For example, there are more than nine million Indonesian adults suffering from diabetes. According to a
report by McKinsey, this costs the Indonesian health system $1.6 billion a year – 40% of government spending on NCDs overall. If no effective action is taken by 2020, there could be a total of 1.2 million new cases and an overall $66 billion GDP loss attributable to diabetes alone. NO MEDIA SPOTLIGHT
Such figures make NCDs one of our greatest global heath challenges, but they rarely generate big headlines. Pandemic outbreaks, new infections like the Zika virus or the growing resistance to antimicrobial drugs, grab the media spotlight. While heart disease may not rouse the same reporting passion, says Nikolic, what is lost by lack of coverage is the magnitude of the challenge. “We argued, and it is the case still, that decision-makers need to put more priority on addressing NCDs, particularly in developing countries where their rapid increase will pose dramatic challenges to economies, health systems, families and individuals.”
Many health systems in developing countries are woefully ill prepared for the challenge, as they are designed for acute rather than chronic problems. As noted, diabetes is rapidly increasing in Indonesia, yet only half of sufferers are diagnosed as equipment is lacking in many public health centers. Jim Yong Kim, president of the World Bank, has noted that analysis of universal health coverage systems in 24 countries shows coverage and implementation are weakest for NCDs.
Nikolic argues that mounting evidence indicates how millions of deaths can be averted and economic losses reduced by billions of dollars. “There are concrete measures that can reduce the costs and suffering linked to NCDs,” she says, “and as NCDs have often received less focus, solutions can be effective and inexpensive.”
World Health Organization report estimated the cost for population-based measures to reduce tobacco and harmful alcohol use, as well as unhealthy diet and physical inactivity, at $2 billion per year for all developing and middle-income countries – less than $0.40 per person. Yet while the solutions may be effective and inexpensive, the difficulty is that implementation runs into a complex overlap between food-industry practices, political priorities and established mind-sets and behaviors, says Nikolic. “Even rich countries are finding this hard to change.”
Obesity, a key modifiable risk factor in NCDs, is becoming a weighty burden worldwide. Almost a third of the world’s population is overweight or obese. This has an impact on global GDP of $2.1 trillion, rivalling smoking and armed violence, war and terrorism,
according to McKinsey.
Public Health England has estimated that if obesity were reduced to 1993 levels, the National Health Service would save £1.2 billion a year ($1.6 trillion) by 2034, not including the large cost of treating associated diseases. Yet despite all the interventions and analysis, waistlines will continue to expand, with 36% of men and 33% of women predicted to be obese in 2030 (up from one in five today). A COMPREHENSIVE APPROACH
If a wealthy nation like the United Kingdom, with a well-funded health care system, has difficulties tackling NCDs, what chance do cash-strapped developing nations have? “The mistake is to see it predominantly as a health challenge,” responds Nikolic. “What is required is a comprehensive approach that makes NCDs everyone’s business.”
The greatest impact, she explains, can be achieved with healthy public policies that promote prevention and control throughout the life cycle, while strategically adapting health systems and societies. In developing countries, existing communicable disease management channels and community worker schemes should be used to complement expensive hospital-based care. Linked to this should be a comprehensive approach that includes education and agriculture, as well as other sectors that target NCD risk factors and promote a healthy lifestyle.
This will not be easy, concludes Nikolic. But if it is not attempted, NCDs could spiral out of control, significantly increase out-of-pocket costs for patients and undermine the sustainability of public health systems. “However, if we get it right, reducing diseases and deaths from non-communicable diseases will be one of best-value investments we can make to increase the health and well-being of people.”