NCDs are the biggest cause of death 10%

Total number of deaths in the world

60 million

5.8 M
50 million 40 million 30 million 20 million 10 million 0 million

26.0 M
( above the age of 60 )

(60% of all deaths)

CVDs, Cancer Chr Resp Dis DM

( below the age of 60 )

9.0 M

18.0 M
Low-income countries

Group III - Injuries Group II Other deaths from noncommunicable diseases Group II Premature deaths from noncommunicable diseases (below the age of 60yrs) which are preventable Group I Communicable diseases, maternal, perinatal and nutritional conditions

Indonesia 2010

237.6 M population
- 33 Provinces, - 505 districts & towns

+ 52%

Causes of Death pattern in Indonesia

Causes of Death % Causes of Death Pneumonia Diarrhea Gastric ulcer Typhoid Malaria Meningitis/Encephalitis Congenital malform Dengue Tetanus Septicemia Malnutrition % 3,8 3,5 1,7 1,6 1,3 0,8 0,6 0,5 0,5 0,3 0,2

Stroke 15,4 Tuberculosis 7,5 Hypertension 6,8 Injury 6,5 Perinatal/maternal 6,0 Diabetes Mellitus 5,7 Neoplasm/cancer 5,7 Liver disease 5,1 Ischemic Heart Dis. 5,1 Lower resp. tract 5,1 4,6 dis. Heart disease
Source: BHR, 2007

NCD : 59,5% CVD & risk factors : 28,1%

Causes of Death, All Ages in Indonesia

1995, 2001, 2007
59.5

60
49.9

50 40

+ 19% / yrs + 1% /10 yrs

Africa + 27% E. Mediterranean + 25%

44.2 41.7

30 20
10.1

31.2 28.1

10 0

5.9 6 6

7.3 6.5 HHS 1995 HHS 2001 BHR 2007

Maternal and Perinatal conditions

Communicable Disease

oncommunicable Disease

Injury

HHS=Household Health Survey BHR =Basic Health Research

Prevalence of NCDs Cases NCDs ases

NCDs cases
Hypertension Stroke Heart disease Arthritis Land traffic injuries Asthma DM DM (urban population) Tumor/cancer

%
1.7 8. 7.2 0. 25,9 .5 1.1 5.7 .
5

Source: BHR, 2007 *>10 year old; #>15 year old; ** 15 year old (BHR, 2010)

HYPERTENSION : PREVALENCE & COVERAGE

Coverage : Proportion patients diagnosed or under medical treatment

NO NO TX

HYPERTENSION

DIAGNOSED OR UNDER TREATMENT

BHR 2007
6 7

Risk Factors
Risk factors
Everyday servings salty foods Everyday servings fatty foods < 5 servings of fruits & vegetables Lack of physical activity Smokers (> 15 yrs of age) Overweight & obese Emotional-mental disorder Alcohol use

%
2 .5* 12.8* 9 . * 8.2* .7** 19.1# 11. # . *

Source: BHR, 2007 *>10 year old; #>15 year old; ** 15 year old (BHR, 2010)

80% of smokers live in the developing countries

Tobacco caused 5.4 million deaths in the world (1 death every 6.5 seconds)

Indonesia :
300,000 deaths each year due to tobacco
INDONESIAN SMOKERS Smoking Prevalence (>15 Th) Male Smokers (>15 Th) Women (>15 Th) Population exposed to cigarette smoke BHR 2007 33,4% 65,3% 5,06% 84,5 % BHR 2010 34,7% 65,9% 4,2% 76,1%
8

Teenage Trend smoking prevalence

The prevalence of teenage smokers according to age group 15-19 years, by sex - in Indonesia,
40 35

37.3 32.8 24.2 Laki Male 13.7 12.7

17.3

30 25 20
15 10

18.8

Female Pe re mpuan
Total

5 0

7.1 0.3 1995

0.2
2001

1.9

1.6

2004

2007

Source: Susenas (1995, 2001, 2004) dan BHR 2007

Global Youth Tobacco Survey in Indonesia (2007)

20, % junior high school student smokes

TOBACCO

DIET

PHYSICAL ACTIVITY

ALCOHOL
10

The changing rates of coronary heart disease in adults in Norway.

00

50

00 Men 0- 9 250 Men 50-59 yrs. 200 Women 0- 9 Women 50-59

150

Note: during the Second World War there was an acute fall in total and saturated fat intake followedy a rise at b the end of the war. Thefall in death rates was preceededby a progressivereductionin total and saturated fat intake and with an increase in polyunsatuated fat consumption. Blood cholesterol concentrations fell.

Death rate of CHD (per 100,000

100

50

0 1920

19 0

19 0 Year

1980

2000

11

What are our prevention priorities?

CVD, CANCER, COPD, DM & RISK FACTORS

Non-modifiable Risk Factors - Age - Sex - Genes Intermediate Risk Factors

End Points
- Coronary HD - Stroke - Peripheral Vascular Dis - Several cancers - COPD/ emphysema - Health, wellbeing
12

Hypertension Blood lipids Obesity / Overweight Diabetes Glucose Intolerance

Behavioural Risk F : - Tobacco

- Diet - Physical Activity - Alcohol Socio-Econ, Cultural & Environmental Conditions, and Modernisation, Mechanisation, Urbanisation, Globalisation

National capacity for NCD prevention and control

Few clear policies and strategies Limited resources Fragmented and uncoordinated care Low commitment to prevention Lack of surveillance systems Inadequate treatment guidelines PHC capacity to deal with NCDs is poor Severe lack of investment in research
13

Epidemiologic Transition

Low Risk

POPULATIONS
Public Health Interventions
Epidemiologic Transition

High Risk

Low Risk

INDIVIDUALS
Clinical Interventions

High Risk

14

GO RED FOR WOMEN

Indonesian actions ..

15

Promote Regular Physical Activities

16

N
o

S
m o k I n g

C
a m p a I g n

17

Educational talks, seminars, radio and TV talk-shows, exhibitions, free health checks and a variety of competitions (writing, poster drawing, etc)
18

Indonesia Heart Foundation Publications

IHF quarterly newsletter Posters, brochures, leaflets

www.inaheart.or.id 19

Package of Essential NCD (PEN) interventions for primary care

- Assess Capacity & Coverage - Identify Needs

Protocols for primary Care

Essential Equipmens

Thermometer Measurement Tape Stethoscope BPMD Weighing Machine Nebulizer Peak Flow Meter Glucometer Urine dipsticks ECG Machine

PEN
WHO/ISH Risk Charts Provide Essential Medicines

Essential Recording Tools/MIS

Aspirin, ISDN, CPG, HCT, Nifedepine, Amlodipin, Captopril, Enalapril, Bisoprolol, Frusemide,Spironolacton,Glibenclamide Metformin,Simvstatn Insulin, Atorvastatin Atenolol, Bronchodilator inhaler
20

Top referal & Quartenery care

Tertiary CV. Care

Secondary CV Care

INDONESIAN NCVC INTEGRATED CV SERVICE IN PROVINCE HOSPITAL CV(TYPE A & IN SERVICE B) DISTRICT HOSPITAL (TYPE C & D) PRIVATE PRACTICE PUBLIC HEALTH CARE

Primary CV Care Basic Health Care

Public Health & Self Health Care (Community Based)

NGO IHF etc. 21

POPULATION DISTRIBUTION AND TERTIARY CARDIOVASCULAR SERVICES

4
12

3 6 4 2 9 11
11 Samarinda

Padang 5 Bengkulu 2 2

3.5 30 36

2 2

- RSJPD HK - RSCM - RSHS - Bdg

40

Existing CV center

3 RS Dr.S RS SA - Malang

8.870 PHC, 23.163 sub-centers, 1.556 hospitals, 500 Cardiologist

22

AGE STANDARDIZED MORTALITY CAUSE BY ISCHEMIC HEART DISEASE/100.000 INHIBITORS

10 more cardiology & vascular medicine dept. was appointed as an education center in 2010 IHA target : 1000 cardiologist in 2020
UN data 2008

23

IHA OBJECTIVES OF CVD PREVENTION :

1. Maintain low risk of CVD population lifelong To help those at increase total CVD risk to reduce it. 2. To achieve the characteristics of healthy condition : - no smoking - no alcohol - healthy food choices - low salt consumption - physical activity; 30 min of moderate activity/day - BMI < 25 kg/m2 and avoidance of central obesity - BP < 140/90 mmHg - Total cholesterol < 190 mg/dl (< 5 mmol/l) - LDL cholesterol < 115 mg/dl (< 3 mmol/l) - Blood glucose < 110 mg/dl (< 6 mmol/l)
24

IHA OBJECTIVES OF CVD PREVENTION :

3. To achieve more rigorous risk factor control in high risk subjects; especially those with established CVD or DM : - BP < 130/80 mmHg if feasible - Total cholesterol < 175 mg/dl (< 4.5 mmol/l) - LDL cholesterol < 100 mg/dl (< 2.5 mmol/l) - Fasting BS < 110 mg/dl (< 6 mmol/l) & HbA1c <6.5% 4. To consider cardioprotective drug tx in these high risk subjects especially those with established atherosclerotic CVD
25

Conclusion :
 CVDs (Hypertension, stroke, HD) the leading cause of death in Indonesia exacerbates poverty  The prevalence of hypertension is high, not well treated  Parliament : Increase budget for health !  MOH : - Increase NCDs/CVDs prev. & control budget - Integrated National plans of action
(for: tobacco control, diet improvement, physical activity, no alcohol)

- Coordination & collaborative action of all sectors:

government, medical societies, civil society, private sectors and media

- Scale up packages of effective intervention - Strengthen Primary HC & improve referrals - Universal coverage  Surveillance on the impact of interventions  Promote & support research on CVDs prev & control

26

THANK YOU FOR YOUR ATTENTION

27

20