Chronic Emergency: Why NCDs Matter

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H N P D i s c u s s i o N P a P

Chronic Emergency: Why NCDs Matter

Irina A. Nikolic, Anderson E. Stanciole, Mikhail Zaydman


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Irina A. Nikolic, Anderson E. Stanciole, Mikhail Zaydm

July 2011


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Health, Nutrition and Population (HNP) Discussion Pape

This series is produced by the Health, Nutrition, and Population Family (HNWorld Banks Human Development Network (HDN). The papers in this serprovide a vehicle for publishing preliminary and unpolished results on HNP encourage discussion and debate. The findings, interpretations, and coexpressed in this paper are entirely those of the author(s) and should not be attany manner to the World Bank, to its affiliated organizations or to members ofof Executive Directors or the countries they represent. Citation and the use opresented in this series should take into account this provisional character.

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Health, Nutrition and Population (HNP) Discussion Pa


Irina A. Nikolic PhDa

Dr. Anderson E. Stanciole PhDa

Mikhail Zaydma

a Health, Nutrition, and Population, Human Development Network, The World B

Paper prepared in support of the World Banks work in Health, Nutrition, and PoThe work program is financed by the World Bank.

Abstract: Chronic Emergency: Why NCDs Matter examines the magnituchallenge posed by noncommunicable diseases (NCDs) in middle- and locountries, and makes the case for elevating the challenge as a priority item to athe agenda of decision-makers.

NCDs are on the rise in all middle- and low-income country regions. By 2030,

expected to account for three quarters of the disease burden in middle-income up from two-thirds today and approaching the level of high-income countriesincome countries, the NCD share of the disease burden will increase even morand will approach the levels currently found in middle-income countries. Attime, many low-income countries will continue to contend with scommunicable disease burdens, thus facing a double burden of disease.compared to their higher-income counterparts, many developing countries elevated NCD levels at earlier stages of economic development and with

compressed timeline to address the challenge.

The overall economic and social cost of NCDs vastly exceeds their direct medNCDs affect economies, health systems, and households and individuals througof drivers such as reduced labor productivity, higher medical treatment costssavings. These drivers aggregate into significant socioeconomic impacts, includareas of: country productivity and competitiveness; fiscal pressures; health and poverty, inequity and opportunity loss.

Despite the magnitude of the NCD challenge, there is considerable space fWhile most countries will not be able to treat their way out of the NCD because of the immense costs such a strategy requires, they can target NCD riand promote healthier lifestyles through focused prevention efforts while also fstrategic adaptation measures to mitigate the impact of NCDs on economi


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Disclaimer: The findings, interpretations and conclusions expressed in the entirely those of the authors, and do not represent the views of the World

Executive Directors, or the countries they represent.

Correspondence Details: Dr. Irina A. Nikolic, World Bank, 1818 H StWashington, DC, 20433. Email: [email protected]


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Table of Contents

Acknowledgements ..............................................................................................

Preface ...................................................................................................................

IThe Mounting Challenge of NCDs ................................................................

Rising NCD challenge in middle-income and low-income countries .............

Healthy years of life lost .................................................................................

Increased NCD burdens at lower levels of economic development ...............

IIBeyond Health Alone: the Socioeconomic Impact of NCDs ....................

Economies .......................................................................................................

Health systems ................................................................................................

Households and individuals............................................................................

Key impact areas ............................................................................................

III

Addressing The NCD Challenge: the Scope for Action ..........................The need for a multisectoral response ............................................................

Abatement through targeted prevention .........................................................

Strategic adaptation to mitigate the impact of NCDs .....................................

Country-tailored responses and the role of the international community......

References .............................................................................................................


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Acknowledgements

This paper was authored by Irina A. Nikolic, with Anderson E. Stanciole andZaydman. The team is grateful to our peer reviewers and colleagues for their incontributions. The peer reviewers included Enis Baris, Daniel Cotlear, and PMarquez. In addition, the team received a variety of valuable inputs from cacross the World Bank, including through a workshop organized as a backgrounthis paper. This work also drew on insights from recent reports and regional anstudies, which can be found in the References section, as well as data and

provided by country partners, counterparts in WHO and other UN agencies, colleagues and experts during the recent regional and global consultanoncommunicable diseases. The team is grateful to the World Bank for publireport as an HNP Discussion Paper.


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Preface

Noncommunicable diseases (NCDs), including cardiovascular diseases, cancerespiratory diseases, and diabetes, cause tens of millions of deaths each yearwhich are preventable and premature. They cause vast numbers of people impose high long-term costs on health systems, and deplete household incnational economies. In middle- and low-income countries, they present a fchallenge.

The current global focus on NCDs, including the first Global Ministerial ConfHealthy Lifestyles and NCDs and the United Nations General Assemblys HMeeting on NCDs, mark a new level of attention to these challenges. Althincreased attention is encouraging, there are reasons to be concerned that thecould fall short of what is required. First, decision-makers at all levels may notaking into account the extent of the NCD challenge in developing countries. ANCDs might not be sufficiently elevated on national and global agendas. Secocould continue to be seen as predominantly a health challenge, with insufficientpaid to their escalating costs on households, health systems, and economieresponses to the challenge could be too narrow and left to the health sector, whrequired is a comprehensive approach that makes NCDs everyones business.

The overarching goal of this paper is to inform stakeholders understandin

increasing burden and wide-ranging costs of NCDs in middle- and low-incometo help raise the NCD challenge to the level of priority it warrants. T

contributes to the World Banks work in strengthening health, nutrition, and poutcomes, and complements its commitment to the Millennium Developme(MDG) agenda. The paper draws on a range of current data, as well as recenand country studies, to illustrate the magnitude of the chronic emergency preNCDs, particularly in middle- and low-income countries. It shows that challenge in middle-income countries is approaching that of high-income counis rising rapidly in low-income countries. What makes the NCD challenge daunting for many developing countries is that, compared to their high

counterparts, they will be facing such elevated NCD levels, including amoworking-age populations, at earlier stages of economic development and witcompressed timeline to address the challenge.

The paper also emphasizes the breadth and complexity of the challenge by ehow NCDs affect national economies, health systems, and households and in


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I The Mounting Challenge of NCDs

The great majority of NCD-related mortality and morbidity is caused by fougroups: cardiovascular diseases, cancer (malignant neoplasms), chronic rdiseases, and diabetes. Together with other NCDs, such as digestive diseasehealth disorders, and musculoskeletal conditions, these diseases cause pmortality, disability, suffering, and loss of opportunity for many millions of peothe globe. NCDs are already the worlds largest cause of death, accounting for deaths in 2008, or 63 percent of the global total, with 78 percent of these deaths

in middle- and low-income countries. They are also a leading cause of morbpoor health (WHO 2011a).

As discussed below, the NCD challenge in middle-income countries is approafound in high-income countries, and is also rising rapidly in low-income countresult of people being affected by NCDs at a relatively younger age, suffering of NCDs for longer periods in their lives, and dying prematurely from NCDs, Npose a formidable health and development challenge for these countries. Furmany of these countries will lose out on benefits offered by their demographic and will instead experience the challenge presented by rapidly and unhealthpopulations. The magnitude of the challenge is also shown by the high nhealthy years of life lost as a result of NCDs. Unless they can stem the tide many developing countries will face substantial NCD burdens but at a loweeconomic prosperity and with less time to adapt.

The underlying causes of increased NCD levels in developing countries hexplored elsewhere. The key point to be made here is that while some of the iNCDs is a result of the success many countries have had in extending lives, inccurbing communicable diseases, a significant portion of the increase is a conseother addressable risk factors, many of which are linked to urbanization, modeand lifestyle changes. Particularly significant risk factors include physical unhealthy diets (including excessive salt, fat, and sugar intake), obesity, tobexcessive alcohol consumption, and exposure to environmental pollution. F

populations, exposure to multiple risk factors combined with inadequate phealthcare and education can constitute a clustering of risk factors that fueling the rise in NCD levels amongst those least able to afford the consequenc

Rising NCD challenge in middle-income and low-income countries


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chronic emergency of NCDs, and many others will face an NCD challenge

magnitude in the near future.

In absoluteterms,deaths from NCDs in middle- and low-income countries areto rise by over 50 percent, from an estimated 28 million in 2008 to 43 millionThe change will be particularly substantial in Sub-Saharan Africa, where Naccount for 46 percent of all deaths by 2030, up from 28 percent in 2008, andAsia, which will see the share of NCD deaths increase from 51 percent to 72 perthe same time frame (Exhibit 1). Morbidity data, while less systematically

paint a similar picture. By 2030, cancer incidence is projected to increase by 7in middle-income countries, 82 percent in low-income countries, and 40 percenincome countries (WHO 2011a).

NCDs will also increasingly impact younger and working-age populations in dcountries. While the share of NCD-related deaths amongst those 15 to 59 year

+17%

+5%

+3%

+11%

+1%

-5%

41%

28%

62%

53%

65%

62%

59%

57%

69%

62%

66%

+44%

65%

70%

73%

Deaths from NCDs as a share of total deaths, 2008-20301

All ages, percent

High-income countries

Europe andCentral Asia

East Asiaand Pacific

Latin Americaand theCaribbean

Middle East

and NorthAfrica

SouthAsia

Sub-SaharanAfrica

Middle-

and

low-income

countriesby region

Ages 15-59, percent

51%

78%

46%

28%

72%

69%

81%

72%

85%

76%

89%85%

89%

87%

+13%

+12%

+39%

+64%

+1%

+4%

+12%

Between 20082030, NCD-dea share of totaare projected by 1% in highmiddle-, and 4low-income co

For the 15-59age populatioprojections incdecrease of -5high-income, increases of 1middle-, and 3low-income co

Exhibit 1. NCDs present a major and rising challenge in all middle- and low-income cou

regions, including amongst younger and working-age populations

Notes: 1 Analysis by region uses WHO updated estimates for 2008 and baseline projections for 2030; analysis by income group uses WHO 2008-2030 basel

Sources: World Bank analysis by the authors, based on the WHO Global Burden of Disease estimates and projections and the World Bank regional/income co


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The effects of increased NCD prevalence in relatively younger populations can For example, life expectancy in the Russian Federation lags behind that of the 1

member countries of the European Union (the EU-15) by 14 years on averNCDs accounting for 66 percent of the years of life lost (Marquez 2008, WHOA World Bank study of neighboring Ukraine found that one in four people beages of 18 and 65 has an NCD and that a growing number of young adults affected. That and other similar findings prompted the conclusion that the coulose the next generation to chronic disease (World Bank 2010a).

In South Asia, the situation is similarly serious, even though its population is o

younger than in most other regions. Cardiovascular diseases are already a majodeath and disability and a main driver of the regions NCD epidemic. Inaverage age of first-time heart attack sufferers is 53, lower by six years than in the world (Engelgau et al. 2011). In the Middle East and North Africa, NCD pis increasing amongst women and adolescents, driven by factors unrelated to agincreasing rates of obesity and smoking (World Bank 2010b). A recently cstudy of six eastern Caribbean countries similarly found that the prevalence of steadily increasing, particularly amongst women, and that more children are

overweight (World Bank 2011b). In Dominica, for example, obesity prevalencwomen is expected to rise to 65 percent by 2015 (World Bank 2011b), uppercent in 2008 (WHO 2011a).

From an economic development perspective, the rise of NCDs amongstpopulations is cause for particular concern because it will diminish the abilitycountries to capitalize on the opportunities that would otherwise be provideddemographic dividendthat is, the economic benefits generated during twhen a relatively larger portion of the population is of working age. During thone would expect higher economic output per capita, which allows greatgeneration and more resources to be channeled into savings and productive invThe significance of missing out on the demographic dividend will becom

apparent when many countries are confronted with the rapid aging of their poThe proportion of people over 65 years of age is expected to double over a peryears in Brazil, 25 years in India, and 26 years in China. In many high-income

the same demographic transition took more than a century (Cotlear 2011). Wlevels also rising, many developing countries will face a compound challengeand unhealthy aging that threatens to place significant pressure on their econsocial structures while compressing the timeline available for effective adaptatio

China provides a vivid illustration of the impact of these factors. The country h


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morbidity and disability in relatively younger populations are of great concernhalf of Chinas NCD disease burden occurs in people under 65 years of age. In

Chinas mortality rate for certain major NCDs, such as stroke, chronic opulmonary diseases, and cancers, is several times higher than in some higcountries (World Bank 2011c).

Healthy years of life lost

A particularly meaningful measure of the impact of NCDs is the number of hea

of life lost as a result of the diseases. That measure can be calculated indisability-adjusted life years (DALYs), which is the sum of productive life yepremature mortality and disability. NCDs are expected to account for three qtotal DALYs in middle-income countries by 2030, up from two-thirds in 2008the level of high-income countries. In low-income countries, the share oattributable to NCDs will increase rapidly during the same time period, and wilthe share due to communicable diseases and injuries by 2030 (Exhibit 2).

Exhibit 2. NCDs will be the largest share of disease burden and the leading cause

of healthy years lost across all country income groups by 2030

52%30% 20%

2030

4%

88%

15%

2030

55%

15%

2008

37%

11%100% 9%

2008

6%

86%

9%

2030

10%

76%

14%

2008

65%

394

288

+37%

20302008

398358

2008

+11%

2030

107104

2008

+3%

2030

Low-income

countries

Middle-income

countries

High-income

countries

Projected NCD-related DALYs1 (millions)

Percentage distribution of projected DALYs by cause (%)

Noncommunicablediseases and conditions Injuries

Communicable diseases, maternal,perinatal and nutritional conditions


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multiple of five at present), the large number of total DALYs illustrates the trhuman and economic cost of NCDs in these countries.

Increased NCD burdens at lower levels of economic development

NCDs present a particularly daunting challenge for middle- and low-income because of the scale of the burden relative to their level of economic developmillustration below compares age-standardized NCD-related DALYs per 10population relative to national GDPs, using 2004 data (the most recent com

available for country DALY estimates), to highlight the magnitude of the (Exhibit 3). As discussed above, NCD burdens are expected to rise substantiallmiddle- and low-income countries, which will make the challenge evenparticularly as the increase will, in comparison with high-income countries, ocompressed timeline and often without corresponding rapid increases in econsocietal prosperity.

Level of NCD burden

Age-standardizedNCD-related DALYs

per 100,000of population1, 2004

Level of economic development

GDP per capita in current US$, 2004 (log scale)

5,000

10,000

15,000

20,000

10 100 1,000 10,000 100,000

Population size, 2

High-income coun

Middle-income co

Low-income coun

Exhibit 3. Middle- and low-income countries are facing higher NCD burdens

at lower levels of economic development

Notes: 1 WHO estimates of age -standardized DALYs for 2004 (last available year) computed using standard categories and methods to ensure cross-country


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Many low-income countries will, in addition, continue to face major commdisease burdens, resulting in a double burden of disease. In Sub-Saharan A

South Asia in particular, communicable diseases such as tuberculosis, rinfections, water- and vector-borne diseases, and HIV/AIDS are expected tprominent even as NCD levels grow rapidly. Other health burdens, some of also linked to increased risk for NCDs, such as fetal and early childhood mawill additionally remain a challenge (Engelgau et al. 2011).

Moreover, the challenge of confronting NCDs at a lower level of economic devcan converge with related policy challenges. For example, rising food prices m

reflecting structural changes in the global economy, and could exacerbate challenge. Higher food prices will heighten risk factors related to poor malnutrition, and poor families affected by NCDs will find it harder to meet tneeds. Some middle-income countries will be confronted with increasing NCDin the face of already existing dependency ratio and social welfare system cwhich will make effective response even more challenging.


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II Beyond Health Alone: the Socioeconomic Impact of

The impact of the mounting NCD challenge cannot be appreciated without cothe full range of direct and indirect effects that NCDs have on economies asystems, as well as on the affected individual and his or her household. Indeemeasure, the cost of NCDs to economies and societies is high and can vastly edirect medical costs of NCDs.

A number of key drivers account for the high and broad-reaching cost of NCD

4). These drivers constitute specific effects on economies, health systhouseholds and individuals, which combine to have substantial impacts oneconomic and human development outcomes. Key areas of such impactdecreased country productivity and competitiveness; greater fiscal pressures; dhealth outcomes; and increased poverty, inequity and opportunity loss.

Exhibit 4. NCDs have a significant impact on economies, health systems and household

Economies

Reduced labor supply

Reduced labor outputs (e.g.,cost of absenteeism)

Lower tax revenues

Lower returns on humancapital investments

Increased public health andsocial welfare expenditures

Cost to employers (e.g.,productivity, health)

Health systems

Increased consumption ofNCD-related healthcare

High medical treatment costs(per episode)

Demand for more effectivetreatments (e.g., cost of

technology and innovation)Health system adaptation

needs and costs (e.g.,organization, servicedelivery, financing)

Households and indiv

Reduced well-being

Increased disabilities apremature deaths

Household income deloss, or impoverishme

Higher health expendiincluding catastrophicspending

Savings and assets los

Reduced opportunities

Key drivers

Country productivityand

competitiveness

Fiscalpressures

Healthoutcomes

Poverty, ineqand

opportunity

Key impact areas

Source: World Bank analysis bythe authors


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Examples of economic impa

China: reducing cardiovascu

mortality by 1% per year betw2010 and 2040 could genera

economic value equivalent toChinas real GDP in 2010 or US$10.7 trillion (World Bank

Egypt: NCDs could be leadin

overall production loss of 12Egypts GDP (Rocco et al. 20

Brazil: costs of NCDs betwe

government expenditures, lower returns on human capital investments, and higto employers (for example, from reduced productivity and higher employer h

costs).

Several studies have examined the general link between NCDs and economic pAlthough these studies differ in their assessment of the precise magnitude othere is a broad consensus that it is substantial. A review undertaken for a 2found the cost of chronic diseases and their risk factors to be significant andranging from less than 1 percent up to nearly 7 percent of a national GDP (Suhr2006). A study of 23 middle- and low-income countries with high NCD burd

that if no significant reduction to the risk of chronic diseases occurred, an US$84 billion of GDP would be lost between 2005 and 2015 due to just threecardiovascular disease, diabetes, and stroke (Abegunde et al. 2006, 2007). Anofound that for every 10 percent increase in NCD-related mortality, annual growth would be reduced by 0.5 percent, an estimate that led the World Economto rank NCDs as one of the top global threats to economic development (Beagle2011).

Research at the country level further illustrates the economic effects of NCDUnited States, where one in three people reports suffering from at least one NCDestimated the impact of seven NCDs (cancer, heart disease, hypertensiodisorders, diabetes, pulmonary conditions, and stroke) at over US$1 trillioeconomic outputs in 2003 (mostly in productivity losses) compared to an impathan US$300 billion in health expenditures. The study concluded that the impact on GDP linked to reduced labor supply and lower rates of investment is(DeVol et al. 2007).

Similar effects are found in developing countries. Estimates from a 2011 Wreport on NCDs in China indicate that reducing cardiovascular mortality by 1 pyear over a 30-year period (20102040) couldgenerate an economic benefit equivalent to 68percent of the countrys real GDP in 2010morethan US$10.7 trillion at purchasing power parity.The society-wide economic costs of NCDs areeven higher if measured by the value attributed tohuman life and health. By this measure, reducingmortality from cardiovascular disease by 1 percentper year would equal an annual benefit of about15 percent of Chinas 2010 GDP or US$2.3


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dependents could increase the odds of a future economic slowdown, while alsosignificant social challenge (World Bank 2011c).

Dying Too Young, a World Bank study of the impact of premature mortalihealth due to NCDs and injuries in the Russian Federation found that the annuabsenteeism due to ill-health, driven in large part by NCDs, equated to approximpercent of GDP due to total production losses and benefits paid to absent emplosame study estimated that on average 10 days are lost per employee per yeillness in Russia, compared to an average of 7.9 days in the EU-15 countrieBank 2005b). A study of Brazil found that the financial and economic costs

between 2005 and 2009 would amount to approximately 10 percent of the countGDP (World Bank 2005a).

A study of Egypt found the aggregate labor supply to be approximately 19 percits potential, driven by lost employment and reduced numbers of hours workedreporting chronic conditions. The findings implied an overall production loss o12 percent of Egypts national GDP (Rocco et al. 2011). In Ukraine, NCDs, heavily concentrated among working age males, have had a devastating effe

countrys labor force. One third of people die before the age of 65, with NCDsto account for over 80 percent of those deaths (World Bank 2010a). And, a refound that if NCDs were eliminated in India, the countrys 2004 GDP would hincreased by 4 to 10 percent due to losses averted for the health system, indivithe economy (Mahal et al. 2010, Engelgau et al. 2011).

Health systems

NCDs will place substantial and increasing demands on health systems. prevalence of NCDs rises, there will be greater demand for NCD-related hservices, including diagnosis and treatment. In addition to increasing demandsystems scarce human resources, rising NCD levels will exacerbate health challenges. NCDs are generally more expensive to treat than communicableThe chronic nature of NCDs requires patients to have multiple interactions wsystems, frequently in more expensive inpatient settings and over long time

Treating NCDs, particularly in advanced stages, tends to require the applicatiocostly and advanced medical technologies and pharmaceuticals. People suffeNCDs often require disability management and long-term care. Moreovfrequently involve comorbiditiesone person may suffer from two or more NC

H l h di b h bli d i lik l i i


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Several studies have illustrated the substantial effects NCDs could have on tsystems of middle- and low-income countries resulting from changing di

demographic profiles. A case study of Indonesia found that the countrys healneeds to prepare for a future of rising healthcare demand as the psimultaneously grows, ages, and becomes wealthier, with as much as four-fihealthcare demand driven by NCDs by 2020 (Adeyi et al. 2007). A study of thFederation found that circulatory system diseases, respiratory diseases, and system diseases alone accounted for more than 40 percent of the countrys toexpenditures (World Bank 2005b). In Brazil, there has been a significant indemand for the more expensive treatments required by older patients, alo

reduction in demand for the cheaper treatments typically used for younger pcurrent trends continue, the number of people over 60 years of age who need care will triple by 2040 (World Bank 2011a).

While more research into the likely effects of NCDs on health systems is nemagnitude of the challenge can also be illustrated through a simple compariprevalence of obesity in the United States and Mexico is similar, at 31.8 percenpercent respectively (WHO 2011a). Estimates of the direct medical costs of

the United Stateswhich represent just one third of overall costs from obescountryrange from US$147 billion to US$160 billion or approximately UUS$520 per capita annually (Finkelstein et al. 2008, Algazy et al. 2010). That 7 percent of the total United States health expenditures per capita, and 15 pgovernment healthcare expenditures per capita. In Mexico, total annuexpenditures per capita have been estimated at US$588, of which USgovernment expenditures (WHO 2011b). While the cost of providing manservices is certainly much lower in Mexico than in the United States, this co

highlights the challenge developing countries face with respect to NCD expenditures: they would have to spend high proportions of their entire health baddress just some of the NCDs if they were to treat NCDs at the level of the higcountries.

Health systems in many countries will also need to undergo significant adaptatiare to address NCDs effectively. In addition to the increasing demand for services, NCDs will require health systems to improve across a number including service delivery, human capital (particularly in terms of medical skillcontrol and licensing, organizational structure, information management, infrmanagement, and health financing. Health systems in some low-income counface a particular challenge, as they will need to find a means of coping with thburden of NCDs and communicable diseases. However, there may be oppor


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Examples of potential healthadaptation actions to addres

Improve financial health prot

Create new fiscal space (e.gtobacco taxation)

Improve financial allocations taking NCDs into account

Strengthen prevention and thprimary care in addressing N

Adapt healthcare organizatioservice delivery models (e.g.

integrate NCD services alongcontinuum of care)

Build on synergies with the e

health programs (e.g., materchild health, communicable d

Develop a comprehensive lif

approach to NCD prevention

Strengthen human resourceshealth (e.g., skills, incentives

(Adapted from World Ba

Health financing models will likewise need toevolve to ensure long-term sustainability. Health

coverage and benefits packages will need to adjustto the changing nature of demand, while thefinancing models will need to reflect the differentcost pattern of NCDs. Different approaches, suchas changes to provider payment mechanisms andpayor models to incentivize desired behaviors,implementation of suitable social health protectionmodels, and effective use of tools such as health

technology assessments, innovative risk factorreporting, and disease surveillance systems, willall be important to consider and apply in atargeted manner. Such reforms can be done in aless costly and more effective manner if strategicsteps are taken in advance. Even if that is thecase, however, health system adaptation and itscosts represent another substantial effect of NCDs.

Indeed, a recent study of macro-fiscal implicationsof healthcare reforms found that the issue of healthcare reform will be a policy challenge in coming years (IMF 2010).

Households and individuals

NCDs can have serious social and economic effects on the well-being and dev

potential of affected individuals and their households. The most immediate imof course, in the suffering and decreased well-being caused by the disease. Nalso have severe economic consequences for the individual and his or heincluding a decrease or loss of household income, impoverishment, high and pcatastrophic health expenditures, savings and assets loss, and reduced opportufamily members.

People affected by NCDs are often at increased risk of losing their jobs and inc

their ability to capture educational and economic opportunities may also suffer. people suffering from chronic disease in Egypt, the probability of being emplopercentage points lower than the average, and their working time is reduced byper week on average (Rocco et al. 2011). In some cases, family members musup jobs or forgo formal education in order to take care of an ill person.


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Examples of impact on hous

Egypt: amongst people suffe

NCDs, probability of being eis about 25 percentage point

than the average (Rocco et a

China: a change in adult hecan result in 16% gain in houworked and 20% gain in indiv

income (World Bank 2011c)

India: 40% of household NCtreatment expenditures are f

by household borrowing andassets (Mahal et al. 2010)

South Asia: chances of cata

hospitalization expenditures higher for cancer patients anhigher for cardiovascular dis

patients than those withcommunicable diseases requ

hospitalization (Engelgau et

countries, women and girls may be particularly affected by NCDs, not only dirwhen, as a result of certain circumstances, which could include impact of antheir family, they forgo education or employment opportunities and thus becomrisk to financial insecurity later in life (McKinsey 2010).

NCD-related healthcare costs can significantly affect households financial sevidenced by recent World Bank studies of NCD impacts in South Asia. In share of out-of-pocket household healthexpenditures on NCDs was found to haveincreased from 32 percent to 47 percent between

1995-1996 and 2004, with a large portion of thoseexpenditures (about 45 percent) spent onmedicines (Mahal et al 2010). These studies alsoshow that the costs of hospitalization due to anNCD can be very large relative to individualincome levels. The cost of a single hospital stayfor cancer or heart disease was found to equate tobetween 40 and 50 percent of per capita annual

income in a public healthcare setting and between80 and 90 percent in a private healthcare setting(Mahal et al. 2010). As approximately 40 percentof household NCD treatment expenditures inIndia are financed by household borrowing andsales of assets, the data indicates significant levelsof financial vulnerability to NCDs (Mahal et al.2010, Engelgau et al. 2011).

NCDs also increase the risk of incurring catastrophic health costs. In Southchance of incurring catastrophic hospitalization expenditures was 160 percent hcancer patients and 30 percent higher for those with a cardiovascular disease thfor those with a communicable disease requiring hospitalization. In India, 25 families with a male family member suffering cardiovascular disease experiecatastrophic expenditures, and 10 percent are driven into poverty as a result. Fcases, the effects were even worse: 44 percent of households experienced caspending and 24 percent were impoverished due to the related healthcare (Mahal et al 2010, Engelgau et al. 2011).

One of the above-mentioned studies of NCDs in South Asia concluded thatassociated with chronic NCDs are likely to weigh more heavily on those lea


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Key impact areas

As indicated in Exhibit 4, the various drivers described above combine to havorder impacts on top-line economic and human development outcomes. Wimpacts result, in part, from the drivers discussed in each area, they are alindirectly by drivers in other areas. For example, while an NCD-related loss and assets may in the first instance affect the well-being of the affected individuor her family, it also undermines the overall economic performance by diminfamilys purchasing power. Key areas of impact include:

1. Country productivity and competitiveness: The studies discussed abovstrong evidence that increased NCD burdens have the potential to decrease productivity and negatively impact countries competitiveness. Indeed, prresults from a forthcoming World Economic Forum-funded study and othresearch could be pointing to the costs of NCDs in these countries bsignificant and even potentially overwhelming if current trends continue While the linkage is, on a certain level, intuitive, research that clarifies the form of the impact, generally and in individual countries, is crucial for ga

support for action.

2. Fiscal pressures: NCDs also place greater pressures on governmenpositions, particularly through lost tax revenue and increased health aprotection expenditures. Reduced fiscal space not only limits governments

invest in economic development and general social welfare, it also impedeson NCD prevention and mitigation, further highlighting the need for early,and cost-effective action. As with the impact on economies, mor

understanding of the fiscal impact of NCDs, particularly at the individualevel, will be crucial for marshaling support, as well as for clarifying the timspace for action.

3. Health outcomes: Increased NCD levels will obviously have a direct imcountrys health outcomes. However, in addition to the direct health effectson affected individuals, NCDs can contribute to diminished health outoverwhelming health systems and diverting resources from other health

They can also impoverish families so that other family members are exgreater health risks (e.g., from poor nutrition or reduced access to phealthcare). Further, the rise of NCDs will, in one form or another, require of country health systems. If governments wait for NCDs to force the chcost will be unnecessarily high and systems are likely to be overwhelmed sod li b ti l lt i ll H if t t k i


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development and health outcomes, and further fuel negative effects on ecNCDs affect the lives of individuals and their families, and stand to einequities in many societies that already face significant human devchallenges. As discussed further below, governments may be able to taketo reduce such effects and mitigate the overall impact of NCDs onhouseholds.

Deepening the understanding of these impact areas and identifying effectivemitigate the effects of NCDs in these and other priority areas should be a pdeveloping countries and their partners.


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III Addressing the NCD Challenge: the Scope for Act

Confronted with evidence of the impending chronic emergency of NCDs, makers may understandably be concerned that calls for action represent anothefor scarce public resources to be shifted to one more item on an ever growiurgent priorities. In the case of NCDs, there is no question that effectively respthe NCD challenge will require a significant contribution of resources. Howrising attention being given to NCDs is in large part motivated by the goal of taknow to avoid much larger costs down the road, while also enabling millions of

live longer, healthier, more fulfilled and productive lives. As daunting as challenge may appear, there is considerable scope for action, including fmeaningful steps now to help prevent NCDs and mitigate their impacts.

The need for a multisectoral response

Effective prevention and mitigation measures cannot be implemented by health

alone; instead they require action from a variety of government ministries global, regional, national, and local stakeholders across the public and private secivil society. Highlighting the breadth of the NCD challenge is thus important broader range of stakeholders aware of the challenge and the need for action bhealth sector. The accompanying World Bank paper, Effective RespNoncommunicable Diseases: Embracing Action Beyond the Health Sector, exscope for response in greater depth, and considers the role that actors fromsectorsincluding health, education, urban planning, agriculture, transp

industrycan play in preventing NCDs (Meiro-Lorenzo et al. 2011).

Abatement through targeted prevention

Most countries lack the resources to treat their way out ofthe NCD challengea strategy would, in any event, constitute an inefficient use of resources. Actitherefore be taken to curb NCD risk factors and promote healthier lifestyles

NCD incidence rates and push back the age of NCD onset. A growing body ofshows that targeted prevention measures can cost-effectively reduce the burden both through individual-based and population-based interventions. For exampleon diabetes incidence conducted as a background for this paper indicates that,for each dollar invested in a limited prevention package (focused on exercise


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and physical activity, and reduction in harmful use of alcohol. The fiftintervention focuses on cardiovascular disease risk reduction through access todrugs and technologies (Beaglehole et al. 2011).

As noted, effective implementation of these types of prevention measures macontributions from actors outside the health sector. That is certainly the case wto promote healthier lifestyles, which can involve, for example, economic poliadjusting tax-based incentives to change behaviors, private employers partichealth education and management programs, and city managers and urbantaking steps to reduce pollution and expand options for increased physical ac

the last example illustrates, strategies outside the national-level can provide support to prevention efforts. Sub-national governments, including cities, caplayers given their role, in, amongst other things, providing health, education, welfare services, setting consumption taxes and other regulations relevant to Nfostering behavioral change to address NCD risk factors. Regional responses ceffective. A recent study recommended a set of regional strategies for NCD pin South Asia, including harmonization of tobacco policies and regulatadvertising bans, tobacco taxation) and standardization of food labeling

(Engelgau et al. 2011).

Any comprehensive strategy to address NCDs should begin by considering thescost-effective prevention interventions and drawing on best practices for dimplementing, and monitoring them.

Strategic adaptation to mitigate the impact of NCDs

While prevention measures should be at the center of any response to the NCD cit is not realistic to expect to fully stem rising NCD levels. Indeed, some of thin NCDs is an almost inevitable result of economic growth and increased ccommunicable diseases. Like the response to the climate change challeimperative to determine what strategic adaptation measures can be pursued simpacts of NCDsat the level of economies, health systems, househoindividualscan be mitigated. Stakeholders need to take strategic steps now

for the chronic emergency of NCDs rather than wait until the crisis forces cha

For economies, strategic adaptation involves exploring ways to mitigate the NCDs on productivity and competitiveness. For example, it may be apprsupport targeted educational and worker training programs if NCDs are impac

l d d i i i i i d i Eff i i i i


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Strengthening health systems through strategic adaptation, as mentioned above,for improving prevention efforts, and will also be necessary for ensuring thsystems are not overwhelmed by increased demands for NCD treatment servexample, health systems can explore ways of complementing expensive hospcare (e.g., in some settings, by leveraging existing communicable diseases machannels and community health worker schemes) and developing strategies for eproviding key pharmaceuticals. Defining best-buys, not only in terms of pbut also in terms of effective and impactful treatment options, and equitablythem to populations will be very important.

The importance of taking steps in advance to mitigate the impact of NCDs onindividuals and households should not be overlooked. The onset of an NCDtremendous impacts on households beyond the immediate health effects of thAt a high level, investments in poverty reduction and education should be pintegrated approach to NCDs. In some countries, improved and expanded socprotection, disability, unemployment, and life insurance schemes can play creating a social safety net that reduces the magnitude of NCDs impact.

interventions that enable people to continue to be productive and active can mi

impact on individuals and households as well on the economy. Systems for freentry to the workforce (and to educational programs) for family members dcaring for the ill person may also be of value in protecting households from the NCDs.

Country-tailored responses and the role of the international community

It makes tremendous sense for countries to learn from the experiences of othergrappling with NCDs, particularly given the relatively long period of time somehave explored innovative methods of responding. However, as with any devchallenge, such lessons need to be tailored to fit the specific circumstancecountry. While the impact of NCDs will be broadly felt across the developing nature ofNCDs effectsand the implications for policycould vary substanti

For example, an initial distinction can be drawn between middle-income cou

low-income countries. Many middle-income already face high NCD prevalenand must grapple with major NCD-related health expenditures along with theconomic impact associated with larger numbers of working-age people suffechronic conditions. In many low-income countries, on the other hand, NCD prerising from a lower base and must be addressed alongside often very serious b

i bl di i h f f P li d f di


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Finally, it is worth reflecting on the role of the international community, andWorld Bank and other global and regional development partners and actorsaddress the mounting NCD challenge. The current global process demonstrateawareness and level of commitment to support regions, countries, and commaddressing NCDs. This commitment needs to be followed by continued support

International development and health organizations can provide support in a ways. For example, the World Bank can assist countries with their efforts toeffective NCD prevention, treatment, and monitoring programs into their existsystems, drawing on cross-country and cross-sector experiences in effectively

and implementing such programs. It can help countries address the link betwand poverty, including by developing strategies to support the most vpopulations. Further, it can also support countries in designing and utilizing imechanisms to foster behavior change (e.g., results-based financing). Those few of many examples. As discussed throughout this paper, NCDs presentreaching challenge demanding a multifaceted response, and a wide range omechanisms should be available to countries facing such a challenge.

Global and regional level actors can further support country actions by pknowledge sharing, facilitating networks, evaluating interventions, and developand regional standards. They can also build on existing channels and mechanias international agreements that support national actions (such as the WHO FrConvention on Tobacco Control) or tobacco advertising and tax harmonizatiowhich provide lessons and models for collaboration that could be applied to othareas, such as reducing salt intake and promoting healthier nutrition. Global anactors can also support country-led NCD action plans through financing

prevention, treatment, and adaptation measures, and through efforts at intpolicy coordination.

In summary, decisive country leadership that engages stakeholders across the pprivate sector, and from civil society, can enable developing countries toconsiderable gains in addressing NCDs over the critical period ahead. ThNations General Assembly High-level Meeting on NCDs should be the stongoing collaborative process of identifying best practices and supporting mi

low-countries in preventing NCDs and mitigating their impacts so that peoplehealthier, wealthier, and happier lives.


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Chronic Emergency: Why NCDs Matter

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