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# Noncommunicable Diseases: Health Burden, Economic Impact and Strategic PrioritiesCHAPTER 1

Jai Prakash Narain,
Tanzin Dikid,
Rajesh Kumar

INTRODUCTION
Noncommunicable diseases or NCDs are now the leading cause of mortality in the world, contributing to an estimated 38 million deaths annually which is nearly two-third of all deaths.13 As noninfectious conditions, NCDs are often characterized by long duration and slow progression. The most common of these include cardiovascular diseases, cancer, diabetes and chronic lung disease. Others include mental health problems and injuries.
The epidemiological evidence has been building for years that non-communicable diseases are a serious and growing problem in developing countries, having a disproportionate impact in poor resource settings. With 80% of the global NCD-related deaths occurring in low and middle income countries, these diseases pose a grave threat to national health and development.
The major NCDs share a few and shared behavioral risk factors namely tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. These modifiable risk factors are high among poor people and in poor nations. The good news is that rising trend of NCDs and associated risk factors can be arrested by scaling up simple interventions, most of which cost very little.
Despite the evidence of an increasing burden and availability of cost-effective interventions, little has been done by national and global policy-makers to address NCDs in a systematic and pragmatic way. The existing national programs for NCDs in most countries rely on biomedical models that exclude prevention interventions and focus largely on providing hospital-centered medical services to those who have already developed NCDs and are often at an advanced stage of disease. In an era of skyrocketing health care expenses, tragically NCDs are exacerbating poverty and widening inequities, particularly in South Asia where most healthcare costs are met by out-of-pocket expenditure. Such models of NCD programs that emphasize exclusively curative services fail to reach the masses and are unaffordable for both governments and families.
The World Health assembly in 2012 set a target of reducing NCD mortality rates by 25% by 2025 (referred to as 25 by 25 target). These targets cannot be achieved without implementing innovative approaches to deliver health care 2and prevention and promotive services, built on the foundation of partnerships that facilitate behavior change and adoption of healthy choices. There is a critical need to apply a comprehensive and integrated approach along a continuum of health promotion, disease prevention and treatment services from institution to community and family level, and based on the principles of primary health care, equity and social justice.

BURDEN: MORTALITY AND RISK FACTORS

Global Situation
Review of available data show that NCDs are a real and present danger.1 In 2012, an estimated 38 million of the 56 million deaths worldwide were due to noncommunicable diseases including injuries. This constitutes 65% of all deaths, nearly twice compared to communicable, maternal, perinatal, and nutritional cause which together contribute 34% of the deaths (Fig. 1).
The NCDs comprise mainly cardiovascular diseases which contribute 38% of noncommunicable diseases deaths, followed by cancers (27%), chronic respiratory diseases (8%) and diabetes (4%). In terms of numbers, the cardiovascular diseases (CVDs) consisting of ischemic heart diseases, stroke, hypertensive heart disease and congestive heart failure, cause 17.5 million deaths annually (7.4 million due to heart attack or ischemic heart disease and 6.7 million due to strokes). Over past decade, CVDs have become the single largest cause of death.
Several of these deaths (9 million) were premature deaths occurring among those below 70 years of age; 80% of which can be prevented.
According to WHO, the number of NCD deaths has increased worldwide and in every region since 2000, when there were 31 million NCD deaths.
Fig. 1: Proportion of global deaths under the age 70 years, by cause of death, comparable estimates, 2012Source: WHO Global NCD Report, 2014
3
Fig. 2: Estimated number of deaths due to noncommunicable diseases, by six WHO regions, 2012.Source: WHO NCD Report, 2014
Abbreviations: AFR, African Region; AMR, Region of the Americas; SEAR, South-East Asia Region; EUR, European Region; EMR, Eastern Mediterranean Region; WPR, Western Pacific Region
NCD deaths have increased the most in the WHO South-East Asia (SEA) Region, from 6.7 million in 2000 to 8.5 million in 2012, and in the Western Pacific Region, from 8.6 million to 10.9 million (Fig. 2).
Death and disease from NCDs now outnumber those from communicable diseases in every region, except Africa. This indicates that contrary to the general belief that NCDs occur mainly in affluent countries, the burden of NCDs is very high in low and middle income countries. A higher proportion (48%) of these deaths in these countries were premature compared to high-income countries (26%).1,2
Unless addressed urgently, the global NCD epidemic is expected to continue to grow due to factors such as an aging population, globalization, unplanned urbanization and lifestyle changes. By 2030, the annual number of deaths from noncommunicable diseases will increase to 52 million (contributing to 75% of global deaths).3
In addition to the big four, mental illness, also called mental disorders, is also an important public health problem in the world, responsible for conditions such as depression which affects nearly 150 million people to suicide which take a toll of nearly 900,000 lives each year.

Regional Situation
The burden of NCDs is high and rising in most countries of Asia including those in the SEA Region where NCDs are the number 1 killer.2 What is of most concern is that the probability of dying from one of the four main NCDs between ages 30 and 70 although varied by region, is the highest in the SEA Region (25%) compared to 15% in the Region of the Americas (Fig. 3).
Each year, 8.5 million people in the SEA region die of NCD, which is 62% of all deaths in the region. Moreover, in many countries, NCDs strikes at a younger age than in high income countries. For example, in India, the CVD mortality in 4the 30–59 years’ age group is twice that in the USA,4,5 and the number of CVD cases is likely to increase from 29 million in 2000 to 64 million in 2015.6
Fig. 3: Probability of dying from NCDs among those in 30–70 year age group, by WHO regionsSource: WHO NCD Report, 2014
Abbreviations: AFR, African Region; AMR, Region of Americas; SEAR, South-East Asia Region; EMR, Eastern Mediterranean Region; WPR, Western Pacific Region
CVDs are clearly the most common among the NCDs; their contribution to all deaths in the country range from 15% in Afghanistan to 44% in Maldives.
An estimated 1.2 million deaths occurred due to cancers in SEA Region and deaths are projected to continue to rise. The most common site affected is the lung (17%), followed by the mouth and oropharynx (15%), and liver (7.5%). Among women, cervical and breast cancers account for 35% of all cancer deaths; the incidence of cervical cancer exceeded that of other cancers in Bangladesh, Bhutan, India and Nepal, whereas in Thailand, Sri Lanka, Myanmar and DPR Korea, breast cancer was the most common cancer among women.7
Nearly 11% of the population in the Region suffers from diabetes,8 with prevalence of raised blood sugar varying among the countries.1 India has 62 million people with diabetes, next only to China with 92 million cases, the highest number in the world. Approximately half of those with diabetes remain undiagnosed. The prevalence of diabetes is consistently higher in urban than in rural areas. However, in rural Bangladesh, prevalence increased 3-fold, from 2.3% in 1999 to 6.8% in 2004.9 The age-standardized prevalence of diabetes in a rural area in Sri Lanka increased from 2.5% in 1990 to 8.5% in 2000.10 In India, the prevalence of diabetes in urban areas rose from 1.2% to 12.1% during 1971–2000;11,12 in rural India, the prevalence trebled from 2.2% to 6.4% in just 14 years (1989 to 2003).13
Of 1.4 million deaths due to respiratory diseases, 86% were due to chronic obstructive pulmonary disease (COPD) and 7.8% due to asthma.14 Age-standardized death rates for COPD were more than double in India compared 5with other countries of the region.14 For 2011, the projected prevalence rate of chronic asthma in India in the 15–59 years age group is 19 per 1000 population in urban and 26 per 1000 in rural areas, and the total number of chronic cases of asthma is nearly 32 million.15

Risk Factors
Noncommunicable diseases (NCDs) are attributed to four common and shared behavioral risk factors— tobacco use, unhealthy diet, lack of physical activity and harmful use of alcohol. According to WHO, prevalence of these risk factors vary widely among countries of Asia (Table 1).
Tobacco is one of the most harmful substances contributing globally to 6 million deaths annually; 30% of all cancers result from tobacco use alone (smoking or chewing) which can be prevented by avoiding or modifying risk factors. Use of tobacco, which is linked with a number of health problems namely cancer, chronic respiratory disease, tuberculosis, etc. While China alone has more than 320 million smokers, the SEA Region is home to nearly 250 million smokers and an equal number of smokeless tobacco users.
According to World Bank, tobacco consumption is common among the poor within both rich and poor nations and is rising rapidly in low-income countries.47
 Table 1   Prevalence of NCD risk factors (%) in selected countries in Asia, 2012
Country
Smoking
Insufficient physical activity
Alcohol use disorder
Overweight (BMI >25)
Raised blood sugar
Raised blood pressure
22.8
25.1
0.8
14.8
7.7
25.6
Bhutan
-
7.5
1.7
21.5
9.8
27.3
Cambodia
21.3
9.7
4.3
14.0
6.8
24.4
China
26.8
23.8
4.8
30.5
10.1
18.8
India
12.7
12.1
2.5
18.9
8.5
25.4
Indonesia
36.5
22.8
0.8
20.8
8.0
23.3
Japan
-
38.7
3.3
25.3
11.2
16.9
Laos
-
9.0
4.3
14.4
6.4
24.1
Malaysia
23.6
51.6
2.3
38.4
9.9
22.1
Maldives
21.6
30.3
1.9
24.2
8.2
21.6
Myanmar
22.6
9.0
1.5
14.5
6.3
23.7
Nepal
-
3.3
1.4
15.0
8.2
26.6
Pakistan
21.0
24.0
0.3
19.0
8.6
27.9
Singapore
15.6
33.7
0.9
31.7
9.8
14.1
Sri Lanka
14.3
23.7
3.0
22.4
10.3
21.1
Thailand
-
14.6
4.9
27.7
10.9
21.3
Vietnam
24.3
23.6
4.6
16.8
6.0
22.2
In India, smoking among skilled and unskilled workers in Delhi was 68.8-fold higher than professionals, supervisors or officers; and among illiterates in Mumbai was 7.2 times vs those with college education. In China, people with no education were 6.9 times more likely to smoke than people with university degree. The prevalence of smoking is higher among men than women, and is increasing among the young population. In Indonesia, prevalence of smoking among teenage boys increased from 14% to 37% and in teenage girls from 0.3% to 1.6% during 1995 to 2007.16 In Sri Lanka, prevalence of smoking among young boys doubled from 6% to 12% in 1999–2007.17 During 2012, smoking prevalence in Asian countries varied from 12.7% in India to 36.5% in Indonesia.1
Excessive use of alcohol is also linked with many types of cancers and cardiovascular diseases. Use of alcohol, particularly among men, is relatively higher than among women. Alcohol use is often considered as a masculine activity and is disapproved among women. Heavy drinking by men is usually tolerated in society. Alcohol use disorder defined simply as drinking alcohol in excess, endangering both themselves and others varies in Asia from 0.3% in Pakistan to 4.9% in Thailand. Such behavior by poor and their alcohol dependence often leads to diversion of scarce financial resources from essential necessities such as food, child education and health care.
Globalization and unplanned urbanization are also contributing to a major shift in life styles and food consumption patterns in many developing countries. Consumption of processed food rich in sugar, salt, and unhealthy fats instead of natural food are resulting in rapid increase in the number of overweight people at risk of NCDs. On the other hand, nearly 80% of the population do not eat enough fruits and vegetables and a quarter of the population does not have sufficient physical activity.18 Studies in Tamil Nadu show that prevalence of NCD risk factors such as smoking, low physical activities and hypertension are higher among people living in urban areas.19 Furthermore, modernization and industrialization lead to a sedentary life with limited physical activity at the work place and also at home.
Apart from the behavioral risk factors, there are metabolic risk factors such as over weight, elevated blood glucose levels, high blood pressure and high cholesterol which act as predisposing or intermediate factors for development of NCDs. These factors are highly prevalent and rising. For example, among adults in Thailand, rates of overweight increased from 20% to 38% and rates of obesity doubled from 5% to 10% during 1991–2004.20 Obesity among children is an emerging issue. Rates of overweight/obesity were higher among Indian children from a higher socioeconomic status.21 Globally, in 2012, an estimated 44 million (6.7%) of children under 5 years of age were overweight or obese world-wide, up from 31 million in 1990. Based on this latest figure, the global prevalence of overweight and obese children has grown from around 5% in 1990 to 7% in 2012.1
Many NCDs are caused also by exposure to infectious agents. Infectious agents cause 13–20% of the cancers globally;22 for example, human papillomavirus (HPV), which is the most common cause of cancer among women, causes cancer of the cervix; hepatitis B virus (HBV) and hepatitis C virus (HCV) cause hepato-cellular carcinoma; and Helicobacter pylori causes cancer of the stomach. Other examples of NCDs linked to infectious agents include rheumatic heart disease, type I diabetes, acute glomerulonephritis and preventable blindness (due to trachoma).23,24 Conversely, NCDs and their risk factors also increase the risk 7of certain infectious diseases. For example, diabetes is associated with a 3-fold increased incidence of tuberculosis as seen in sub-Saharan Africa.25

LINK WITH POVERTY AND ECONOMIC DEVELOPMENT
Three types of costs are attributed to NCDs: Direct costs such as the cost of treatment; indirect costs such as loss of workforce productivity and earnings; and costs resulting from the psychosocial suffering of the family due to illness among loved one, as a consequence, the economic impact at the national and household levels is dire, as explained below:

Impact on National Economies
NCDs constitute a growing public health emergency, especially in the developing world. They have a profound health and national development in two main ways—by increasing demand for health care system and lost productivity due to prolonged illness. Although available data on economic impact are scant, most health economists believe that NCDs will have long-term economic impact globally, with consequences most severe in the poorer countries. For example, with two-thirds of world's poor in Asia, NCDs constitute a present and real danger in this region, likely to threaten the prospects of economic security and prosperity of it's people.
For every 10% increase in mortality from NCDs, a country's yearly economic growth is expected to decrease by an estimated 0.5%.26 The average cost of illness per diabetic patient in Thailand was US$881 in 2008, which was 21% of the per capita GDP.27 Annual income loss from NCDs, arising from days spent ill, foregone wages and cost of treatment run into billions of dollars annually. In India, the percent GDP loss due to NCDs is likely to increase from 0.35% in 2005 to 1.5% by 2015.28 The World Health Organization predicts India and China will respectively lose US$237 billion and US$558 billion of national income to diabetes and cardiovascular disease between 2005 and 2015. According to the World Economic Forum, the developing countries by 2015 stand to collectively lose$ 7.3 trillion due to heart disease, cancer, diabetes and lung diseases (an annual loss of 4%).

Impact at Individual and Household Level
The poor are disproportionately affected by NCDs; they are not only at greater risk for NCDs due to higher prevalence of risk factors but when sick with NCDs cannot manage access to appropriate health care. The unhealthy behavior (such as tobacco and alcohol use) leads to loss of household income, while sickness results in loss of productivity (due to disease, disability and premature death) and high out-of-pocket health care expenditure (on treatment). All these exacerbate poverty as a vicious circle. This is especially true in the SEA Region as the proportion of NCD deaths below the age of 60 years is higher in this region (34%) compared with the rest of the world (23%) (Fig. 4).
Moreover, the earnings spent on tobacco and alcohol lead to decreased financial resources for essential items such as food, education and daily consumables, thereby affecting women and children in particular. In Nepal, the 8poor spend 10% of their income on cigarettes.29
Fig. 4: Percentage of deaths due to noncommunicable diseases (NCDs) in persons < 60 years, by type of NCD, South-East Asia region Vs Rest of the world, 2008.Source: Narain et al. Natl J Med India. 2011;24:280-7
Furthermore, nearly two-thirds of the expenditure on health is met by private resources, almost entirely out-of-pocket.30
A major barrier which act as risk factor include the lack of access to health services. While the poor are at an increased risk for exposure to risk factors such as smoking and an unhealthy diet, they in addition, also have poorer accessibility to health care services. Poverty and illiteracy are closely linked to the risk factors for NCDs such as hypertension.31 The association between smoking and poverty indicates that those who are the poorest are also more likely to smoke daily and more often per day.32
The social, cultural and economic determinants of health play an important role besides the existing policy framework and structural environment. These factors not only expose populations to greater risk of NCDs and they are unable to make the healthy choices. The disparities and inequalities especially in access to health care by the poorest of the poor and the resultant out of pocket expenditure drive the poor further into poverty from which they cannot escape.
In India, the share of out-of-pocket expenditure due to NCDs increased from 31.6% in 1995 to 47.3% in 2004, indicating the growing financial impact of NCDs at the household level.33 In 2004, 40% of household expenditure for treating NCDs in India was financed by household borrowing and sale of assets.34 As public health care facilities and services are inadequately resourced and there is little social security coverage, treatment of NCDs results in catastrophic health expenditures and impoverishment. The treatment of diabetes can cost a low- income household one-third of their income.35 The poor have to often travel greater distances to obtain access to modern medical care than the non-poor. As most poor lack coverage with health insurance which reduces their ability to afford care, they tend to delay diagnosis or seeking care or self medicate, which have their own consequences.9
The poor and the disadvantaged in the society therefore carry heavy burden of NCDs, face greater barriers to care and support, and thereby poorer health outcomes than those who are better advantaged. In the developing countries, while rich manage to live with NCDs, the poor are more likely to die from them because they lack the resources to manage living with the disease.

TACKLING NONCOMMUNICABLE DISEASES: OPPORTUNITIES AND CHALLENGES
The high and increasing burden of NCDs and it's economic consequences point to the need for greater priority to be accorded to NCDs with specific attention to reducing high-risk behaviors by the poor. While the major risk factors which are relatively few and are shared by most NCDs, these can be reduced relatively cheaply through health promotion and other community based prevention interventions.
In the High-level Meeting (HLM) of the UN General Assembly held in New York, September 2011, the Heads of State and Government of 192 member countries, made a commitment to accelerate national and international response to NCDs. The UN HLM is a turning point in advocacy for high-level commitment and mobilizing a broad ‘whole of the society’ approach to the prevention and control of NCDs. This was only the second time that the UN General Assembly discussed a global public health issue, the first being HIV/AIDS in 2001. There is high expectation that the 2011 HLM will do for NCDs what the UN General Assembly Special Session in 2001 did for HIV/AIDS in mobilizing national and international commitments for action, forging broad partnerships, and setting measurable targets and mechanisms to monitor progress towards prevention and control of NCDs.
However, many challenges are in the way of effectively implementing NCD prevention and control initiatives in low and middle income countries. For example, health services in many countries are week and already over-stretched to the limit. They suffer from serious workforce shortages, both in quantity as well as in basic skills and expertise in NCD prevention and control.
Another major constraint is the lack of essential standards of health care for people with chronic diseases. Financing of NCD programs is also an overriding constraint in most countries. Moreover, NCD surveillance in most countries is ad hoc, fragmented, and rarely institutionalized.

KEY STRATEGIES AND INTERVENTIONS
The vision and framework for reversing the NCD epidemic is articulated in WHOs Global strategy for prevention and control of noncommunicable diseases 2008–2013,36 Action plan for the global strategy37 and the Regional framework for NCD prevention and control.38
The key strategies include the following:
Surveillance and research: Surveillance is critical for generating data to quantify and track NCDs and their determinants and to provide valuable evidence that can be used for policy development, shaping strategies, evaluating the impact of interventions and for advocacy.10
NCD surveillance has three key components: Monitoring exposure (risk factors and determinants), outcome (morbidity and disease-specific mortality), and health system response and capacity. While monitoring risk factors and mortality requires special surveys, outcome measures in terms of morbidity can be included in the routine reporting system. Monitoring NCDs, however, requires a set of standardized core indicators so that these could be measured on an ongoing basis as a part of the program. Assessing the capacity and response of the health system including policy changes is also a key aspect of program monitoring.
The Political Declaration of the recent UN High Level Meeting on NCDs urges Member States to integrate NCD surveillance with existing surveys and surveillance systems as follows: “Strengthen, as appropriate, country-level surveillance and monitoring systems, including surveys that are integrated into existing national health information systems and include monitoring exposure to risk factors, outcomes, social and economic determinants of health, and health system responses, recognizing that such systems are critical in appropriately addressing NCDs.”
Reducing the risk factors and creating health promoting environments: There is enough evidence to suggest that specific interventions are available that are effective in tackling NCDs and their risk factors. These include (1) population level interventions and (2) individual based interventions.
The population based interventions include health promotion and information campaigns encouraging reduction in consumption of tobacco, alcohol, and salt; promoting healthy eating (such as of fruits and vegetables) and physical activity; fiscal measures that increase the price of unhealthy food content or reduce the cost of healthy foods rich in fiber; and regulatory measures that improve nutritional information or restrict the marketing of unhealthy foods to children can be cost-effective.39 The cost of implementing population-based primary prevention interventions is relatively small.40,41
The individual-based interventions on the other hand include the prevention and management of heart disease and stroke, as well as early detection (through screening) and treatment of cancer.
WHO has recently identified a set of ‘best buys’ which are not only high-impact and cost-effective interventions, but are also feasible to implement and culturally acceptable in the developing country settings (Box 1). Creating health awareness about unhealthy diets and physical inactivity through the mass media and interpersonal approaches is an important and cost-effective strategy for population-level prevention of NCDs. Involvement of the community and creation of an enabling environment are crucial for bringing about a sustained behavior change, especially among the youth.
These measures pertain to primary prevention of NCDs by reducing the behavioral risk factors and to secondary prevention through early detection of biochemical or intermediate risk factors. In the area of cancer, population-based screening programs can reduce cancer mortality in a cost-effective manner.
In addition to health promotion, legislation can play a vital role in primary prevention. The WHO Framework Convention on Tobacco Control (FCTC) is the first legally binding international treaty to reduce harm due to tobacco.42 In Asia, all countries except Indonesia have ratified the FCTC and are implementing the 11MPOWER package (Box 2).43
Key cost effective interventions include tobacco tax increases thereby increasing price, dissemination of information on health risks of smoking through health warnings on tobacco packs, restrictions on smoking in public places and work places, and comprehensive ban on advertising, promotion and sponsorship—each of which constitute best buy.
Evidence also shows that physical activity of at least 30 minutes per day significantly reduces NCDs including the risk of breast and colon cancer. These include walking, cycling, sports and other recreational activities. Such policies can be part of a school-based or work place-based policy. Such interventions can be promoted through mass media or interpersonal approaches at the community level.
Unhealthy diet is also associated with high-risk of NCDs such as CVD, cancer and diabetes. Therefore healthy diet-related campaigns can provide messages regarding the need for limiting intake of total fats, switching from saturated fats to unsaturated fats and eliminating intake of trans fats; reducing intake of sugar and salt; and increasing consumption of fruits and vegetables (at least 5 helpings per day). Discouraging marketing of foods high in salt, fat and sugar especially to children can be effective in reducing NCDs.
Development and compliance with policies to promote healthy lifestyles and reduce risk factors requires commitment and action from multiple sectors, including the food industry, departments of agriculture, youth affairs, urban planning, etc. Other risk factors for NCDs should also be addressed in primary prevention, e.g. increasing the coverage of HBV vaccines.
Early detection and management: In conjunction with primary and secondary prevention interventions, early detection and management of NCDs through strengthened health systems can considerably reduce the disease burden. Improved access to highly cost-effective interventions, which include proactive early detection and providing essential standards of care for those with the major 12NCDs at the primary health care level, will have the greatest potential for reversing progression of disease, preventing complications, reducing hospitalizations, and health care and out-of pocket expenditures.44
Increasing access to high-quality, low-cost medicines for people at high-risk for heart disease or stroke, and for those who already have diabetes, cancer and chronic respiratory diseases, as well as provision of pain relief for end-of-life care are important considerations. Antihypertensive drugs, lipid-lowering drugs, antithrombotic drugs, diuretics, palliative care medicines and anti-diabetic drugs are part of the WHO Essential List of Medicines.45
These prevention measures can be cost-effective compared to when the patient is diagnosed with NCD which then requires surgical or long-term interventions which are also very expensive with relatively poor health outcome. Moreover, such facilities are available only in urban settings, beyond the reach of the poor rural population and use of such services can drain meager financial resources of the family leading to catastrophic expenditure and to poverty.
Mobilizing national and international support: Clearly, NCDs are preventable and their advance can be reversed, provided that appropriate action is taken with urgency. NCD prevention should therefore be assigned a high priority in national context and as a part of national development initiatives and related investment decisions.
The countries must demonstrate political commitment by developing national policies and strategies through broad consensus building exercise and by allocating appropriate levels of resources. National NCD committee headed by the high level of Government can facilitate demonstration of the political will and bringing together and fully engage various partners and stakeholders in implementation of national plan on NCD prevention and control.
To actively engage nonhealth sectors for implementing effective NCD preventive interventions, the principle of ‘health in all policies’ should be adopted as most of the social determinants of NCDs lie outside the scope of the health sector.
Multi- and bi-lateral partners must also consider NCDs as a priority as a part of their development assistance and fulfill the commitment of partnerships agreed to an international for a such as United Nations High level meeting and at World Health assembly resolutions.
In summary, political will and leadership is required at all levels. The message is loud and clear that without a sustained political commitment by national 13governments as well as at the local level, NCD strategies cannot be implemented effectively and rising trends cannot be reversed.

PRIORITIES FOR NATIONAL PROGRAMS
To achieve the vision and goal of reducing the avoidable burden of NCDs, the national programs must be guided by a set of principles including the equity based approach to address the social determinants of health; multi-stakeholder engagement and multi-sectoral action; empowerment of people and communities in order that they take responsibility and action for their own health; strategies that are based on scientific evidence and best practice; and finally ensuring that all people have equitable access without discrimination to the preventive, promotive and clinical services including essential medicines.
The following priorities and approaches must be considered with urgency:
1. Focusing on primary prevention and best buys: As highlighted above, national programs should adopt and scale up a package of essential NCD prevention and control measures which have the clear evidence of high cost-effectiveness and feasibility of implementation. Population-based interventions aimed at reaching populations with messages, using a combination of communication technologies could be applied, complemented by individual-based health interventions such as early detection through screening mechanisms. In this regard, priority and focus should be on implementing and scaling up best buys for best impact.
Thailand is an example of a successful tobacco control program, where consistent increase in taxes over the past several years has led to a steady decrease in prevalence of smoking among adults; increasing taxation on tobacco and alcohol has also helped to generate revenue that can be used for health promotion.46 Similar taxation is needed to reduce the demand for other unhealthy products such as sugary drinks; conversely, subsidies should be provided on fruits and vegetables.
2. Strengthening health system capacity for efficient service delivery: Strengthening of health care systems to address NCDs must be undertaken through re-arranging the allocation of human and financial resources so that adequate resources become available to tackle NCDs at national and local levels, improving governance and implementing innovative financing mechanisms.
In the mean while, opportunity should be taken to address the following set of activities within existing framework:
• Training of health care workers:
Training of primary health workers in prevention and control of NCDs should be integrated with the activities of the primary health care system and should have a nationwide coverage.
• Ensuring availability of essential and affordable medicines and technologies: 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 management system is essential. A selected set of diagnostic devices to detect risk factors should be available at the primary health care level.
• Establishing a Framework for Monitoring activities and evaluating results: The existing health information system can be geared to monitor progress 14in implementation of NCD policies and strategies; track the availability and distribution of human resources, equipment and supplies; and monitor the cost and impact of implementing NCD interventions within primary health care.
The program should regularly measure progress being made towards achieving indicators and targets as agreed to at the international level (Box 3). India, in addition to these nine indicators, has added household air pollution as the 10th indicator to be measured.
3. Inter-sectoral engagement and action: Effective prevention and control of NCDs demands a multi-sectoral response to address the underlying social determinants that increase the risk of developing NCDs, and support formulation of appropriate national, as well as legislative and institutional changes. Effective community-based NCD interventions also require community participation and engagement, supportive policy environment partnerships among national authorities, nongovernmental organizations, academia and the private sector.
• Reversing the epidemic of NCDs in particular requires engagement from civil society and the private sector. Civil society institutions are uniquely placed to mobilize political awareness and support for NCD prevention and control. They play a key role in advocating for NCDs to be a part of the global development agenda. NGOs and Civil society organizations contribute to capacity-building, contribute to prevention and treatment services for cardiovascular disease, cancer, diabetes and respiratory diseases, often filling gaps between services provided by the private and government sectors. The role and capacity of civil society should be supported and strengthened at the national and international levels.
• With the exception of the tobacco industry, the private sector can make a decisively important contribution to addressing NCD prevention 15challenges. Companies should work closely with governments to promote healthy lifestyles and implement action to promote healthy diet by reformulation to reduce salt, trans-fat and sugar in their products; ensuring responsible marketing; and helping to make NCD essential medicines more affordable and accessible. Such actions need to be monitored by the national program. Companies should also adopt and strengthen programs to improve the health and well-being of their employees through workplace health promotion and specific NCD prevention schemes. The industries can help by reducing pollution and creating health promoting environment.
4. Delivering services using primary health care approach: NCD prevention and control programs must ideally be implemented through the health system based on primary health care. In 2010, World Health Organization (WHO) initiated the Package of Essential Noncommunicable Disease Interventions or WHO PEN(4) which envisages delivering a prioritized set of cost-effective interventions of acceptable quality. It reinforces health system strengthening by contributing to building blocks of the health system. It is the minimum standard for NCD and promoted as an important first step for integration of NCD into PHC.
This model has been tried out in Sri Lanka and Bhutan on a pilot basis. The review of these projects carried out recently showed that community-level health promotion, disease prevention, early diagnosis, and treatment and referral services for NCDs can be delivered through the PHC system.
5. Establishing Linkages and mainstreaming NCDs in ongoing programs: Many communicable diseases, such as tuberculosis and HIV have a chronic course similar to NCDs. Several approaches to leveraging synergies to improve efficiency and health outcomes of communicable and noncommunicable diseases can be identified. For example, primary care provides a common platform where both type of diseases can be effectively addressed through preventive and curative interventions.
There are data to indicate that diabetes is often complicated by the presence of tuberculosis and therefore mechanisms are required for collaboration between the respective programs. The link between TB and diabetes requires interventions that address both the diseases. For example, screening for tuberculosis in people with diabetes and screening for diabetes in those with tuberculosis offers opportunities to enhance case detection and facilitate prevention of diabetes or TB-related complications.
Similarly, gestational diabetes during pregnancy can result in birth defects and an increase in miscarriages. Integrating diabetes and gestational diabetes screening and treatment into other maternal health interventions and services at primary health care level can ensure early detection, better care for women and reduced maternal mortality. A comprehensive response for prevention and control of noncommunicable diseases should also take cognizance of a number of other conditions to be addressed through integrated approaches.

CONCLUSION
The cardiovascular diseases, cancers, diabetes and chronic respiratory diseases constitute the biggest threats to health globally, with capacity to undermines social and economic development at the household and national levels. NCDs and 16their risk factors are increasing relentlessly and unchecked due to many factors including globalization, urbanization and aging populations. Unless actions are taken early, the growing burden of these chronic diseases will overstretch the fragile health infrastructure and reverse development gains already achieved. A paradigm shift is needed: from addressing each NCD separately to collectively addressing a cluster of diseases in an integrated manner; from using a biomedical approach to a public health approach to NCDs (based on the principles of primary health care and universal access); and from a clinical approach to a more comprehensive approach with emphasis on primary prevention based on health promotion, early detection and treatment, and surveillance. The rising burden of NCDs can indeed be reversed through scaling up implementation of population-wide and individual oriented interventions which are highly cost-effective. High levels of commitment, good planning and coordination, community mobilization and multi-sectoral actions are needed to achieve the goal of a world free of the avoidable burden of noncommunicable diseases.
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