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Chronic Diseases and Health Promotion – www.who.int/chp/en
Gojka RoglicWorld Health Organization, Geneva,
Switzerland
What can WHO do to control the epidemic of diabetes?
Chronic Diseases and Health Promotion – www.who.int/chp/en
The World Health Organization
• United Nations specialized agency for health
• Governed by 192 Member States
• Headquarters in Geneva• Six regional offices• Numerous country offices
Support to member states to enhance the health of their populations
Chronic Diseases and Health Promotion – www.who.int/chp/en
The World Health Organization• First World Health Assembly 1948
• Priorities for the organization:• Malaria
• Tuberculosis
• Venereal diseases
• Maternal and child health
• Sanitary engineering
• NutritionSupport to member states to enhance the health of their populations
Chronic Diseases and Health Promotion – www.who.int/chp/en
Examples of WHO activities
• Successful: Smallpox eradication 1977
Campaigns against yaws, endemic syphilis, leprosy, trachoma, malaria in Europe
Control of cholera pandemic
Chronic Diseases and Health Promotion – www.who.int/chp/en
Examples of WHO activities
• Moderately successful, ongoing:
Polio eradication (since 1988)
Expanded programme on Immunization (since 1974)
"3 by 5" initiative (antiretroviral therapy for 3 million people in low and middle-income countries by end of 2005)
Chronic Diseases and Health Promotion – www.who.int/chp/en
Examples of WHO activities
• Unsuccessful: Safe Motherhood Initiative (aim in 1987: reduce maternal morbidity & mortality by 50% by the year 2000)
Chronic Diseases and Health Promotion – www.who.int/chp/en
The comparative advantages of WHO are:
- Neutral status- Nearly universal membership- Impartiality- Strong convening power- Normative and technical roles
Chronic Diseases and Health Promotion – www.who.int/chp/en
Three sources of funding
WHOProgramme
budget
Assessed Contributions and Miscellaneous Income
(Regular budget )
Assessed Contributions and Miscellaneous Income
(Regular budget )
Negotiated core voluntary
contributions
Negotiated core voluntary
contributions
Project-type voluntary contributions
Project-type voluntary contributions
Chronic Diseases and Health Promotion – www.who.int/chp/en
81 Member States
103 Member States at less than
0.01%10 major contributors
77 %
22 %
<1 %
Assessed contributions to Regular Budget - 10 member states pay 77 %
Assessed contributions to Regular Budget - 10 member states pay 77 %
Chronic Diseases and Health Promotion – www.who.int/chp/en
Top 10 Country contributions to WHO's Regular Budget 2008-09 in %
1- USA 22 % 2- Japan 16.6% 3- Germany 8.57%4- UK + Northern
Ireland 6.64%5- France 6.30%
6- Italy 5.07%7- Canada 2,97%8- Spain 2,96%9- China 2.66%10- Mexico 2.25%
Following countries: Republic of Korea 2.17% Netherlands 1.87% Australia 1.78% / Brazil 0.87%
Switzerland 1.21%
Chronic Diseases and Health Promotion – www.who.int/chp/en
81 Member States
103 Member States at less than
0.01%10 major contributors
77 %
22 %
<1 %
Source of voluntary contributions 2006-2007Source of voluntary contributions 2006-2007
Chronic Diseases and Health Promotion – www.who.int/chp/en
0
1,000
2,000
3,000
4,000
5,000
6,000
1994-1995
1996-1997
1998-1999
2000-2001
2002-2003
2004-2005
2006-2007
2008-2009
2010-2011
2012-2013
2014-2015
US
$ (
mil
lio
ns
)
Voluntary Contributions
Regular Budget
72%
83%
28% 17%
Without action the imbalance between voluntary contributions and regular budget will continue to increase
Chronic Diseases and Health Promotion – www.who.int/chp/en
What about chronic, noncommunicable diseases (NCDs)?
Chronic Diseases and Health Promotion – www.who.int/chp/en
Adult mortality
Chronic Diseases and Health Promotion – www.who.int/chp/en
2005 2006-2015 (cumulative)
Geographical regions (WHO classification)
Total deaths
(millions)
NCD deaths (millions)
NCD deaths
(millions)
Trend: Death from infectious
disease
Trend: Death from NCD
Africa 10.8 2.5 28 +6% +27%
Americas 6.2 4.8 53 -8% +17%
Eastern Mediterranean 4.3 2.2 25 -10% +25%
Europe 9.8 8.5 88 +7% +4%
South-East Asia 14.7 8.0 89 -16% +21%
Western Pacific 12.4 9.7 105 +1 +20%
Total 58.2 35.7 388 -3% +17%
Noncommunicable diseases
WHO projects that over the next 10 years, the largest increase in deaths from cardiovascular disease, cancer, respiratory disease and diabetes will occur in Sub-Saharan Africa (+27%)
Chronic Diseases and Health Promotion – www.who.int/chp/en
• 57 Million Total Deaths
• 35 Million due to Chronic Disease
• 16 Million Deaths less than 70 yrs
Importance of Chronic DiseasesImportance of Chronic Diseases
Chronic Diseases and Health Promotion – www.who.int/chp/en
Expenditure within WHO HQ
ONLY US$ 0.50 SPENT ON LEADING CHRONIC
DISEASES PER DEATH COMPARED WITH $7.50
FOR LEADING COMMUNICABLE DISEASES
World Health OrganizationDepartment of Chronic Diseases and Health PromotionDepartment of Chronic Diseases and Health Promotion
Funding for Noncommunicable Chronic Diseases at WHO
Other NCDs
Injuries
CVD
DM
CD
Global NCD disease burden Total WHO expenditure on NCDs
In 2002, 3.5% of total budget of US$ 43.6 million on NCDs
Source: WHO long-term strategy for prevention and control of leading chronic diseases© World Health Organization [2004]
World Health OrganizationDepartment of Chronic Diseases and Health PromotionDepartment of Chronic Diseases and Health Promotion
Official Overseas Development Aid to the health sector in 2002
Donor aid for the health sector
Increased health support by donors mostly directed towards HIV/AIDS, not NCDs
allocated toNCDs
(including mental health)
Source: WHO long-term strategy for prevention and control of leading chronic diseases© World Health Organization [2004]
World Health OrganizationDepartment of Chronic Diseases and Health PromotionDepartment of Chronic Diseases and Health Promotion
World Bank and Regional Development Banks
of their $4.2 billion total to health, population and nutritionbetween 1997 and 2002
World Bank loans for chronic diseases
Source: WHO long-term strategy for prevention and control of leading chronic diseases© World Health Organization [2004]
Chronic Diseases and Health Promotion – www.who.int/chp/en
33 %mental health
30 %tobacco
37 %unspecified chronic disease components
WHO is the largest source of funding for chronic diseases
WHO provides tenfold more funds than all bilateral agencies combined
Nevertheless…..
Overall US$ 16 million
WHO expenditure for chronic disease 1998 2002
Tobacco
Mental disorders
Other chronic disease activities
US$ 383,000
US$ 7.1 million
US$ 9.4 million
US$ 13.2 million
US$ 13.3 million
US$ 14.3 million
US$ 43.6 million
Chronic Diseases and Health Promotion – www.who.int/chp/en
What about chronic, noncommunicable diseases?
1998 – Tobacco Free Initiative to coordinate a global response to the Tobacco epidemic
Chronic Diseases and Health Promotion – www.who.int/chp/en
What about chronic, noncommunicable diseases?
2000 World Health Assembly adopts the Global Strategy for the Prevention and Control of Noncommunicable diseases
Chronic Diseases and Health Promotion – www.who.int/chp/en
What about chronic, noncommunicable diseases?
2003 – World Health Assembly adopts the Framework Convention on Tobacco Control – first treaty negotiated under the auspices of WHO (in force since 2005)
Chronic Diseases and Health Promotion – www.who.int/chp/en
What about chronic, noncommunicable diseases?
2004 – World Health Assembly adopts the Global Strategy on Diet, Physical activity and Health
Chronic Diseases and Health Promotion – www.who.int/chp/en
What about chronic, noncommunicable diseases?
2005 – First WHO report on chronic,noncommunicable diseases
Chronic Diseases and Health Promotion – www.who.int/chp/en
• February – Informal consultations with Member States, International Partners and the business community
• April – Final draft of Action Plan available online
• May – adoption by the World Health Assembly
2008: Action Plan for the Global Strategy
Chronic Diseases and Health Promotion – www.who.int/chp/en
Scope of the Action Plan
• The major noncommunicable diseases: • Cardiovascular disease• Cancer• Respiratory disease• Diabetes
• The main causes are 4 shared preventable risk factors: • Tobacco use• Unhealthy diet• Physical inactivity • Harmful use of alcohol
Chronic Diseases and Health Promotion – www.who.int/chp/en
What about diabetes?
Chronic Diseases and Health Promotion – www.who.int/chp/en
Noncommunicable Diseases and Mental Health Cluster
Cardiovascular diseases: 1 person
Cancer: 2 persons
Asthma and COPD: 2 persons
Diabetes: 1 person
Chronic Diseases and Health Promotion – www.who.int/chp/en
The beginnings of the WHO Diabetes Programme in the 1980s…….
Dr Hilary King
Chronic Diseases and Health Promotion – www.who.int/chp/en
The WHO Diabetes Programmeat its strongest (early 2000s) …..
Chronic Diseases and Health Promotion – www.who.int/chp/en
The core functions of WHO
• Providing leadership and engaging in partnerships where joint action is needed
• Shaping the research agenda, stimulating the generation and translation of knowledge
• Setting norms and standards• Articulating ethical and evidence-based policy
options• Providing technical support• Monitoring the health situation and assessing health
trends• High-level advocacy and awareness raising on
matters critical to health
Chronic Diseases and Health Promotion – www.who.int/chp/en
WHO core function: Partnership where joint action is needed
International Diabetes Federation (IDF)
•A natural ally and partner to WHO
•In official relations since 1957
Chronic Diseases and Health Promotion – www.who.int/chp/en
Partnership where joint action is needed
WHO
• Works with governments
• Strong public health voice
• WHO offices in almost every country
• Global reference centre for health statistics
• Has prestige among governments/health ministries
IDF
• Works through member associations
• Strong lay and professional advocacy voice
• Network of member associations
• Well-developed secretariat to respond to calls for information
• Has prestige among NGOs and private sector
Chronic Diseases and Health Promotion – www.who.int/chp/en
WHO-IDF Collaboration• Norms and standards
• Capacity building (Cambridge Seminar)
• Global estimates
• Management of diabetes in crises and humanitarian settings
• Awareness raising
• Access to essential medicines/equipment
Chronic Diseases and Health Promotion – www.who.int/chp/en
WHO core function : Awareness- raising and advocacy
• Rationale for investing in chronic diseases that share the same risk factors
• Evidence for dispelling myths on chronic diseases
Chronic Diseases and Health Promotion – www.who.int/chp/en
Joint WHO-IDF project, supported by the World Diabetes Foundation
Chronic Diseases and Health Promotion – www.who.int/chp/en
• To achieve a major increase in the awareness of the impact of diabetes in low and middle income countries
Main aim of Diabetes Action Now…..
Chronic Diseases and Health Promotion – www.who.int/chp/en
Chronic noncommunicable diseases effectively excluded from Millennium Development Goals
Chronic diseases excluded from UNICEF Action Plan for "A World Fit for Children" and from WHO/UNICEF high
level consultation
Chronic diseases excluded from UNFPA initiatives, and from WHO/UNFPA high-level consultations
Chronic Diseases and Health Promotion – www.who.int/chp/en
Diabetes is an obstacle to achieving the Millennium Development Goals……
• Diabetes is likely to be responsible for 15% of all new tuberculosis cases in India
(AIDS accounts for 3-4%)
Chronic Diseases and Health Promotion – www.who.int/chp/en
Diabetes Action Now – Diabetes Awareness in Chennai (Murugesan et al, 2007)
Policy makers (n=20)
General public (n=3681)
Do not know what diabetes is 35% 60%
Think diabetes is preventable by meditation
61% 6.3%
Correctly identify healthy body size
15% 25%
Correctly identify healthy body shape
0% 25%
Analysis of articles on diabetes in India (2005)
Online newspapers:
The Hindu – 39 articles The Hindustan Times – 21 articles The Indian Express – 2 articles The Times of India – 17 articles
WHO/IDF key messages in newspaper articles (India, 2005)
Diabetes is a life threatening illness: 10%
Diabetes is a common condition and its frequency is increasing dramatically: 40%
A full and healthy life is possible with diabetes: 30%, but only a clear statement in a few articles
In many cases, diabetes can be prevented: 40%
Chronic Diseases and Health Promotion – www.who.int/chp/en
Raising awareness….
Chronic Diseases and Health Promotion – www.who.int/chp/en
Chronic Diseases and Health Promotion – www.who.int/chp/en
UN Resolution on Diabetes…..
Chronic Diseases and Health Promotion – www.who.int/chp/en
WHO Region 2000 2006
AFR 17 25
AMR 46 63
EMR 46 69
EUR 53 67
SEAR 50 67
WPR NA NA
TOTAL 41 56
Percentage of countries with specific action plan for diabetes control (WHO, 2007)
Chronic Diseases and Health Promotion – www.who.int/chp/en
WHO core function: Setting norms and standards
• What is diabetes?Definition, Diagnosis and Classification of
Diabetes Mellitus
WHO report 1965WHO report 1980WHO report 1985WHO report 1999
Chronic Diseases and Health Promotion – www.who.int/chp/en
• Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycaemia
WHO/IDF consultation report 2006
Norms and standards
Chronic Diseases and Health Promotion – www.who.int/chp/en
Definition,Diagnosis and Classification of Diabetes Mellitus, 2009
• HbA1c for diagnosis• "Pre-diabetes"• Refinement of etiological classification
Norms and standards
Chronic Diseases and Health Promotion – www.who.int/chp/en
The metabolic syndrome: useful concept or clinical tool?
2009
Norms and standards
Chronic Diseases and Health Promotion – www.who.int/chp/en
WHO core function: Monitoring the health situation
Surveillance of chronic, noncommunicable diseases
• STEPS – stepwise methodology for monitoring risk factor prevalence in countries
• Global InfoBase – data warehouse that collects, stores and displays information on chronic diseases and risk factors by country (country profiles, comparison of countries)
http://www.who.int/ncd_surveillance/infobase
Chronic Diseases and Health Promotion – www.who.int/chp/en
Monitoring the health situation• Is diabetes a public health problem?
King et al, 2000 Wild et al, 2004
Global estimates and projections of diabetes prevalence
Chronic Diseases and Health Promotion – www.who.int/chp/en
Monitoring the health situation
• Number of deaths attributable to diabetes in the world in 2000
= 2.9 million
(routine health statistics estimate ~1 million deaths)
Roglic et al, 2005
• Is diabetes a public health problem?
Chronic Diseases and Health Promotion – www.who.int/chp/en
Update: Global Burden of Diseases, Injuries, and Risk Factors Study 2005
Harvard Initiative for Global Health
Institute for Health Metrics and Evaluation, University of Washington
Johns Hopkins University
University of Queensland
WHO
• Prevalence• Incidence• Mortality• Complications
Chronic Diseases and Health Promotion – www.who.int/chp/en
WHO core function: Articulating evidence-based policy options
Global Strategy on Diet, Physical Activity and Health
2004
What can countries do to prevent diabetes?
WHO Global Strategy on Diet, Physical Activity and Health (DPAS) - a public health tool to support countries fight the increasing burden of NCDs by
reducing major risk factors through public health actions
Increasing awareness of importance of healthy diet and physical activity
Developing, strengthening and implementing policies and plans on healthy diet and physical activity and engaging all sectors
Monitoring science and promoting research
DPAS
Implementation should be coordinated by governments
Based on multisectoral action involving the private sector and civil society
Makes specific recommendations for governments, civil society groups, international agencies and the private sector
WHO has initiated dialogue with the food and non-alcoholic beverages industry on issues of food labelling, salt content and marketing
DPAS implementation at country levels
Several countries have developed national diet & PA strategy / plans /materials / platform, modelled after DPAS, e.g.
Spain
Chile
Diet, PA & tobacco guide
CAN WE PUT SWISS BALANCE HERE ?
Healthy Eating - Healthy Action Oranga Kai - Oranga Pumau
Stategic Framework andImplementation Plan
New Zealand
Chronic Diseases and Health Promotion – www.who.int/chp/en
WHO Region 2006
AFR 8
AMR 26
EMR 0
EUR 45
SEAR 50
WPR NA
TOTAL 26
Percentage of countries implementing the Global Strategy on Diet and Physical Activity
(WHO, 2007)
Chronic Diseases and Health Promotion – www.who.int/chp/en
Articulating evidence-based policy options
Prevention of diabetes mellitus (1994)
Update 2009
What is the evidence for prevention of diabetes and prevention of its complications?
Chronic Diseases and Health Promotion – www.who.int/chp/en
Articulating evidence-based policy options
Screening for Type 2 Diabetes
2003
To screen or not to screen?
Chronic Diseases and Health Promotion – www.who.int/chp/en
WHO core function: Stimulating and supporting research
• 1975 Multinational Study of Vascular Disease in Diabetes
• Follow-up
Chronic Diseases and Health Promotion – www.who.int/chp/en
Stimulating and supporting research
• 1991 DiaMond study of global incidence of type 1 diabetes (coordinated by Helsinki and Pittsburgh)
Chronic Diseases and Health Promotion – www.who.int/chp/en
Stimulating and supporting research
• Health beliefs and awareness of diabetes in Chennai (Murugesan et al, 2007)
• Health beliefs and awareness of diabetes in Cameroon (ongoing)
• Cost of diabetes in Shanghai (China) and Tanzania
Chronic Diseases and Health Promotion – www.who.int/chp/en
In China, the DM/nonDM ratio of
• Direct Health Expenditure is 2.4
• Indirect Health Expenditure is 5.7
• Total Health Expenditure is 2.7
Stimulating and supporting research
Chronic Diseases and Health Promotion – www.who.int/chp/en
Stimulating and supporting research
• Impact of the diabetes epidemic on TB trends in India (Stevenson et al, 2007)
Chronic Diseases and Health Promotion – www.who.int/chp/en
Stimulating and supporting research
Long-term follow-up of the Da Qing diabetes prevention trial cohort (Lancet, May 2008)
Chronic Diseases and Health Promotion – www.who.int/chp/en
Cumulative incidence of DM in Da Qing Follow-up Study (Li et al, 2008)
0102030405060708090
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Follow-up (years)
% w
ith
dia
be
tes
Control groupIntervention group
Chronic Diseases and Health Promotion – www.who.int/chp/en
Diabetes WHO Collaborating centres
Chronic Diseases and Health Promotion – www.who.int/chp/en
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