Noncommunicable Diseases in the Western Pacific Region. A Profile

Noncommunicable Diseases in the Western Pacific Region A Profile

Noncommunicable Diseases in the Western Pacific Region A Profile

WHO Library Cataloguing in Publication Data Noncommunicable diseases in the Western Pacific Region: a profile 1. Chronic diseases prevention and control. 2. Data collection. 3. Registries. I. World Health Organization Regional Office for the Western Pacific. ISBN 978 92 9061 563 7 (NLM Classification: WT 500) World Health Organization 2012 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to the Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, (fax: +632 521 1036, e-mail: publications@wpro.who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

Noncommunicable Diseases in the Western Pacific Region: A Profile Table of Contents Preface 5 Summary 7 1. Introduction 9 2. Burden of noncommunicable diseases 10 3. Risk factors for noncommunicable diseases 17 4. NCD country capacity 23 5. NCD country profiles 29 6. Key findings and recommendations 57 Annexes 59 Annex 1 - Regional Commitments on NCD 59 Annex 2 - Exploratory Notes on Country Estimates 63 Annex 3-2008 Comparable Estimates of NCD Mortality 68 Annex 4 - WHO STEPwise Surveillance for NCD Risk Factors 69

4 Noncommunicable Diseases in the Western Pacific Region: A Profile Acknowledgements This profile was prepared with input from Dr Annette David, Dr Cherian Varghese, Dr Hai-Rim Shin, Ms Marie Clem Carlos, Dr Han Tieru, Ms Leanne Riley, Ms Regina Guthold, Ms Melanie Cowen, Dr Ashley Bloomfield, Ms Anjana Bhushan, Dr Manju Rani, and Professor Donald Matheson. It was reviewed by Professor Ruth Bonita and Dr Kyungwon Oh.

Noncommunicable Diseases in the Western Pacific Region: A Profile 5 Preface Prevention and control of noncommunicable diseases (NCDs) are national, regional and global priorities. Despite progress, more needs to be done to address the burden and socioeconomic consequences of NCDs. Regional and global declarations in 2011 have reiterated the commitment of Member States to NCD prevention and control. While efforts are ongoing to address the challenges of NCD prevention and control, a forceful response is required at the national and regional levels. Reliable and timely data are mandatory for the planning and evaluation of NCD programmes. However, setting up and maintaining surveillance systems can be difficult for low- and middle-income countries. Regardless, the NCD burden, in terms of mortality and risk factors, have to be kept under regular surveillance. Information on health system indicators and capacity are also critical for introducing and evaluating interventions. Policies in related domains such as trade, agriculture and marketing also need monitoring as they impact NCDs. The political declaration of the United Nations High-level Meeting on Noncommunicable Diseases in September 2011 is a clear indication of the high level of commitment for NCD prevention and control worldwide. At the sixty-second session of the WHO Regional Committee for the Western Pacific, Member States discussed options for expanding and intensifying NCD prevention and control in the Region. Given the huge burden and unacceptable rates of preventable premature morbidity and mortality from NCDs, we have to move towards time-bound targets with indicators and an accountability framework. This regional profile, based on the WHO Global status report on noncommunicable diseases, will serve as a baseline for measuring the impact of our efforts in NCD prevention and control in the Western Pacific Region. Let us continue to work together to prevent NCDs and promote health and development for all people of the Region. Shin Young-soo, MD, Ph.D. Regional Director

Noncommunicable Diseases in the Western Pacific Region: A Profile 7 Summary This profile of noncommunicable diseases (NCDs) in the Western Pacific Region is based largely on the WHO Global status report on noncommunicable diseases published in 2011. Country-specific data are classified by income category to reflect the variations among countries in the Region and to serve as a baseline for further monitoring. Mortality from NCDs is higher in low- and middle-income countries (LMIC) than in high-income countries (HIC). The gap between the two income groups is even more pronounced for NCD deaths below the age of 70 years. Efforts are also needed to strengthen mortality registration and certification systems in LMIC. Disease registries are not widely available in the Region, making it difficult to assess morbidity. National-level data on cancer burden are available from GLOBOCAN 2008, and are presented in terms of incidence and mortality. Variations in the rate of breast and uterine cervical cancer in women are also highlighted. Diabetes prevalence is more than 10% in almost all the Pacific island countries. Prevalence of risk factors is a pointer to the burden of NCDs. The wide variation in tobacco prevalence in the Region indicates that there is potential to reduce tobacco use in many countries. Obesity and lack of physical activity are serious issues in most countries and indicate a need for the promotion of healthy diets and physical activity through multisectoral actions. Alcohol consumption also shows wide variation. Raised blood pressure and blood cholesterol levels are uniformly high in the region. Population trends help to estimate the future burden of NCDs. National capacity for assessment of NCD prevention and control were undertaken by WHO in 2004 and 2010. NCD country profiles, which include mortality, risk factors, and capacity to prevent and control NCDs, are presented for all Member States in the Region. Periodic evaluation can help countries to scale up NCD prevention and control. This regional profile presents a situational analysis and can serve as a baseline for Member States to move towards time-bound targets.

Noncommunicable Diseases in the Western Pacific Region: A Profile 9 1. Introduction Noncommunicable diseases (NCDs), principally cardiovascular diseases, cancer, diabetes and chronic respiratory diseases, impose a major and growing burden on health and development in the Western Pacific Region. NCDs are the leading causes of death and disability in the Region, responsible for 80% of all deaths in a region that is home to more than one quarter of the world s population. Of particular concern is the high level of premature mortality from NCDs (deaths before 70 years of age) in several low- and middle-income countries (LMIC). There are indications that NCD-related morbidity and mortality will continue to rise if urgent measures are not taken. The High-level Meeting of the General Assembly on the prevention and control of NCDs in September 2011 firmly placed NCD prevention and control as a global priority. Efforts are also ongoing at the regional and national levels to scale up NCD prevention and control. Regional commitments, particularly the Seoul Declaration and the Honiara Communiqué on the Pacific NCD Crisis (Annex 1), reflect the collective will to expand and intensify efforts for NCD prevention and control in the Region. One of the key ingredients for advancing the NCD agenda is to have an overview of the current NCD situation mortality, morbidity, risk factors and country capacity. The data and findings presented in the profile are mainly from the WHO Global status report on noncommunicable diseases released in 2011. 1 The profile has four major sections: burden, risk factors, country capacity for NCD prevention and control, and NCD country profiles. All estimates were prepared by WHO, using multiple data sources and analytical methods (Annex 2). The data are presented by country groupings high-income countries (HIC) and low- and middleincome countries (LMIC) as per the World Bank income categories as of July 2011. 2 The NCD country profiles in Section 5, however, use the 2008 World Bank income categories. There are many challenges in data collection and analysis in LMIC. Mortality registration is often weak, disease registries are suboptimal, and risk factor surveys are sporadic. National governments are responsible for leading and facilitating the collection of data and processing of information for action. Other groups such as academia and civil society are well positioned to support these efforts and use the data in innovative ways. The WHO STEPwise approach to surveillance of NCD risk factors (STEPS) has been adopted in some LMIC of the Region to measure trends, either as a stand alone format or incorporated into national health surveys. WHO has been undertaking a major exercise in passive epidemiological surveillance, gathering published and unpublished data and information about key aspects of NCD globally. The findings in this profile are limited to the global comparisons. There is also a need to have better indicators to demonstrate the full information on the actual implementation of interventions. This brief profile provides a baseline for measuring our efforts and encourages scaling up national surveillance frameworks for NCD prevention and control, especially in LMIC. 1 Global status report on noncommunicable diseases. Geneva, WHO, 2011. Available online at http://www.who.int/chp/ncd_global_status_report/en/ 2 World Bank List of Economies. Washington, DC, The World Bank, 2011. Available online at http://siteresources.worldbank.org/datastatistics/ Resources/CLASS.XLS

10 Noncommunicable Diseases in the Western Pacific Region: A Profile 2. Burden of noncommunicable diseases Mortality In 2008, more than a quarter of the 36 million deaths from NCDs worldwide were from the Western Pacific Region. Globally, NCD deaths are projected to increase by 15% between 2010 and 2020 (to 44 million deaths), with the highest numbers predicted in the Western Pacific (12.3 million deaths) and South-East Asia (10.4 million deaths) Regions. Comparable estimates of NCD mortality for 2008 total NCD deaths, percentage of NCD deaths occurring under the age of 70, and age-standardized death rates per 100 000 are presented for each Member State of the Region in Annex 3. Overall mortality from noncommunicable diseases Figure 1 presents the age-standardized death rate from NCDs in the Region. The data are presented in ascending order of mortality rates in HIC and LMIC. There is a two- to three-fold difference in male NCD mortality rates between HIC and LMIC. Figure 1. Age-standardized death rate (per 100 000) from NCD, Western Pacific Region, 2008 1400 1200 Men Women Age-standardized death rate per 100,000 1000 800 600 400 200 0 Japan Australia Singapore New Zealand Republic of Korea, the Brunei Darussalam Cook Islands Malaysia Tonga China Viet Nam Solomon Islands* Philippines Micronesia, the Federated States of* Vanuatu* Samoa* Palau* Niue Kiribati Papua New Guinea* Lao People s Democratic Republic, the* Mongolia* Fiji Cambodia* Tuvalu Marshall Islands, the* Nauru High Income Low- and middle-income *Countries have a high degree of uncertainty because they are not based on national NCD mortality data. The estimates for these countries are based on a combination of country life tables, cause of death models, regional cause of death patterns, and WHO and UNAIDS programme estimates for some major causes of death (not including NCDs). Source: Global status report on noncommunicable diseases. Geneva, WHO, 2011.

Noncommunicable Diseases in the Western Pacific Region: A Profile 11 Premature mortality from noncommunicable diseases Premature deaths from NCDs result in loss of productivity and have an impact on the economy. Figure 2 presents the proportion of all NCD deaths occurring under the age 70 in the Western Pacific Region, highlighting the greater burden borne by LMIC. Figure 2. Percentage of all NCD deaths under age 70, Western Pacific Region, 2008 100 Men Women 75 % of all NCD deaths 50 25 0 Australia Japan New Zealand Republic of Korea, the Singapore Brunei Darussalam Viet Nam China Tonga Samoa* Micronesia, the Federated States of* Malaysia Vanuatu* Lao People s Democratic Republic, the* Cook Islands Solomon Islands* Tuvalu Niue Palau* Philippines Mongolia* Fiji Papua New Guinea* Nauru Cambodia* Kiribati Marshall Islands, the* High Income Low- and middle-income *Countries have a high degree of uncertainty because they are not based on national NCD mortality data. The estimates for these countries are based on a combination of country life tables, cause of death models, regional cause of death patterns, and WHO and UNAIDS programme estimates for some major causes of death (not including NCDs). Source: Global status report on noncommunicable diseases. Geneva, WHO, 2011.

12 Noncommunicable Diseases in the Western Pacific Region: A Profile Cardiovascular disease and diabetes mellitus Age-standardized death rates from cardiovascular disease and diabetes mellitus are provided in Figure 3. Substantial differences in mortality rates are seen between HIC and LMIC. Figure 3. Age-standardized death rate (per 100 000) from cardiovascular disease and diabetes, Western Pacific Region, 2008 1000 Men Women Age-standardized death rate per 100,000 750 500 250 0 Japan Australia Republic of Korea, the New Zealand Singapore Brunei Darussalam China Malaysia Cook Islands Viet Nam Philippines Tonga Solomon Islands* Kiribati Mongolia* Micronesia, the Federated States of* Papua New Guinea* Vanuatu* Lao People s Democratic Republic, the* Palau* Samoa* Cambodia* Niue Fiji Tuvalu Marshall Islands, the* Nauru High Income Low- and middle-income * Country data not available. Estimate based on a combination of country life tables, cause of death models, regional cause of death patterns, and WHO and UNAIDS programme estimates for some major causes (not including chronic diseases). Source: Global status report on noncommunicable diseases. Geneva, WHO, 2011.

Noncommunicable Diseases in the Western Pacific Region: A Profile 13 Cancer Within the Region, cancer deaths make up one quarter of all NCD deaths. Variation in death rates across countries is presented in Figure 4. Figure 4. Age-standardized death rate (per 100 000) from cancer, Western Pacific Region, 2008 300 Men Women Age-standardized death rate per 100,000 200 100 0 Brunei Darussalam Australia Singapore New Zealand Japan Republic of Korea, the Kiribati Cook Islands Tonga Samoa* Micronesia, the Federated States of* Niue Solomon Islands* Palau* Vanuatu* Philippines Marshall Islands, the* Fiji Tuvalu Nauru Malaysia Viet Nam Cambodia* Lao People s Democratic Republic, the* Papua New Guinea* China Mongolia* High Income Low- and middle-income * Country data not available. Estimate based on a combination of country life tables, cause of death models, regional cause of death patterns, and WHO and UNAIDS programme estimates for some major causes (not including chronic diseases). Source: Global status report on noncommunicable diseases. Geneva, WHO, 2011.

14 Noncommunicable Diseases in the Western Pacific Region: A Profile Morbidity Morbidity data on the four principal NCDs are not uniformly available. Only cancer and diabetes mellitus are addressed in this profile. Population-based disease registries are essential to generate incidence data on NCDs. Cancer Morbidity data on cancer come from GLOBOCAN 2008, 3 which provides comparable estimates on incidence and mortality of cancers worldwide in 2008. Figure 5 presents age-standardized cancer incidence in men and women and demonstrates the wide variation across countries. Figure 5. Age-standardized incidence rate of cancer (all sites except non-melanoma skin cancer), Western Pacific Region, 2008 400 Men Women Age-standardized rate per 100,000 300 200 100 0 Brunei Darussalam Singapore Japan Republic of Korea, the New Zealand Australia Solomon Islands Samoa Vanuatu Fiji Philippines Malaysia Cambodia Micronesia, the Federated States of Lao People s Democratic Republic, the Viet Nam Papua New Guinea China Mongolia High Income Low- and middle-income Source: IARC Globocan 2008 3 GLOBOCAN 2008. Lyons, International Agency for Research on Cancer, 2008 (http://globocan.iarc.fr/)

Noncommunicable Diseases in the Western Pacific Region: A Profile 15 In women, breast and cervical cancer are among the leading causes of cancer deaths. The variation in incidence among countries is in large part a reflection of heterogeneous screening and early detection programmes throughout the Region in addition to the underlying differences in occurence (Figure 6). Figure 6. Age-standardized incidence rate of breast and cervix uteri cancer, Western Pacific Region, 2008 100 Breast Cervix Age-standardized rate per 100,000 75 50 25 0 Brunei Darussalam Republic of Korea, the Japan Singapore Australia New Zealand Mongolia Viet Nam Lao People s Democratic Republic, the Papua New Guinea Solomon Islands Cambodia China Samoa Vanuatu Fiji Philippines Malaysia High Income Low- and middle-income Source: IARC Globocan 2008

16 Noncommunicable Diseases in the Western Pacific Region: A Profile Diabetes mellitus Diabetes mellitus 4 is an important marker of the burden of NCD in a population. It is the leading cause of renal failure in many populations. Figure 7 shows a marked variation in prevalence rates of diabetes in the Region, and very little difference in prevalence among men and women in most countries. Figure 7. Age-standardized prevalence of diabetes mellitus in adults aged 25+ years, comparable estimates, Western Pacific Region, 2008 40 Men Women 30 Prevalence % 20 10 0 Republic of Korea, the Japan Singapore Australia Cambodia Philippines Viet Nam Vanuatu China Mongolia Malaysia Nauru Fiji Micronesia, the Federated States of Papua New Guinea Tonga Solomon Islands Cook Islands Samoa Kiribati Marshall Islands, the High Income Low- and middle-income Source: Global status report on noncommunicable diseases. Geneva, WHO, 2011. 4 Diabetes is defined as having a fasting plasma glucose value 7.0 mmol/l (126 mg/dl) or being on medication for raised blood glucose.

Noncommunicable Diseases in the Western Pacific Region: A Profile 17 3. Risk factors for noncommunicable diseases The levels of NCD risk factors in the population are important indicators of future disease burden. Four modifiable risk factors are responsible for two thirds of NCDs in the Region: tobacco use, unhealthy diets, physical inactivity and harmful use of alcohol. Significant gains can be made in the Region by addressing all of these risk factors as well as the metabolic and physiologic changes: obesity, raised blood pressure, raised blood glucose, and unhealthy lipid profiles. Behavioural risk factors Tobacco use Tobacco use is the leading cause of preventable deaths globally and within the Region. The percentage of men and women who smoke daily varies considerable by country, with rates ranging from less than 15% to 74% in men, and from under 2% to 62% in women (Figure 8). The variation in rates of tobacco use prevalence is a reflection of tobacco control efforts and indicates the huge potential for reducing rates further in countries. Figure 8. Age-standardized prevalence of daily tobacco smoking in adults aged 15+ years, comparable country estimates, Western Pacific Region, 2008 75 Men Women 50 Prevalence % 25 0 Australia New Zealand Singapore Japan Republic of Korea, the Fiji Vanuatu Micronesia, the Federated States of Marshall Islands, the Palau Philippines Cook Islands Tonga Malaysia Solomon Islands Viet Nam Mongolia Nauru Lao People s Democratic Republic, the Cambodia China Tuvalu Papua New Guinea Samoa Kiribati High Income Low- and middle-income Source: Global status report on noncommunicable diseases. Geneva, WHO, 2011.

18 Noncommunicable Diseases in the Western Pacific Region: A Profile Unhealthy diet Unhealthy diet is composed of multiple elements. Comparable data on the prevalence of this parameter across countries were not available. Metabolic and physiologic risk factors such as obesity, diabetes and high blood cholesterol are indirect indicators of the prevalence of unhealthy diets in the population. Physical inactivity Physical inactivity 5 is variable across the Region, with prevalence rates ranging from 10% to 70% in men and women. Women tend to report more physical inactivity than men, especially in PIC (Figure 9). Figure 9. Age-standardized prevalence of insufficient physical activity in adults aged 15+ years, comparable country estimates, Western Pacific Region, 2008 75 Men Women 50 Prevalence % 25 0 Australia New Zealand Japan Mongolia Cambodia Viet Nam Lao People s Democratic Republic, the Papua New Guinea Philippines China Tonga Samoa Solomon Islands Kiribati Nauru Marshall Islands, the Malaysia Micronesia, the Federated States of Cook Islands High Income Low- and middle-income Source: Global status report on noncommunicable diseases. Geneva, WHO, 2011. 5 Insufficient physical activity is defined as less than 30 minutes of moderate activity five times per week, or less than 20 minutes of vigorous activity three times per week, or equivalent.

Noncommunicable Diseases in the Western Pacific Region: A Profile 19 Harmful use of alcohol There is a high level of variation in alcohol consumption. Total adult per capita consumption of pure alcohol (litres) for both sexes is presented in Figure 10. Figure 10. Total adult (15+ years of age) per capita consumption of pure alcohol (litres) for both sexes, Western Pacific Region, 2008 20 Adult capita consumption of pure alcohol (litres) 15 10 5 0 Singapore Brunei Darussalam Japan New Zealand Australia Republic of Korea, the Malaysia Vanuatu Solomon Islands Tuvalu Kiribati Fiji Cook Islands Mongolia Papua New Guinea Viet Nam Tonga Samoa Cambodia Nauru Micronesia, the Federated States of China Philippines Lao People s Democratic Republic, the Niue Palau High Income Low- and middle-income Source: Global status report on noncommunicable diseases. Geneva, WHO, 2011.

20 Noncommunicable Diseases in the Western Pacific Region: A Profile Metabolic/physiologic risk factors Behavioural risk factors lead to metabolic/physiologic risk factors such as overweight and obesity, raised blood pressure, raised blood glucose, and unhealthy lipid profiles. These risk factors operate on a risk continuum and population-based approaches are needed to reduce the mean levels in the population. Mean levels of systolic blood pressure, body mass index (BMI), blood glucose, and total cholesterol are incorporated in the NCD country profiles in Section 5. This section presents the prevalence of risk factors using the cut-off levels used in the WHO Global status report on noncommunicable diseases 2010. Overweight and obesity Overweight and obesity 6 lead to adverse effects on blood pressure, cholesterol, triglycerides and insulin resistance. The risks of coronary heart disease, ischaemic stroke and type 2 diabetes mellitus increase steadily with increasing BMI. Raised BMI also increases the risk of cancer of the breast, colon/rectum, endometrium, kidney, oesophagus (adenocarcinoma) and pancreas. 7, 8 The prevalence of obesity among adults in the Region varies from under 5% to 75%. Women are more likely to be obese than men, especially in many PIC (Figure 11). Figure 11. Age-standardized prevalence of obesity in adults aged 20+ years, comparable country estimates, Western Pacific Region, 2008 75 Men Women 50 Prevalence % 25 0 Japan Singapore Republic of Korea, the Australia New Zealand Viet Nam Cambodia Lao People s Democratic Republic, the Philippines China Malaysia Papua New Guinea Mongolia Fiji Vanuatu Solomon Islands Micronesia, the Federated States of Kiribati Marshall Islands, the Samoa Tonga Cook Islands Nauru High Income Low- and middle-income Source: Global status report on noncommunicable diseases. Geneva, WHO, 2011. 6 Overweight is defined as body mass index (BMI) 25 kg/m 2, while obesity as BMI 30 kg/m 2. 7 The World health report 2002: Reducing risks, promoting healthy life. Geneva, World Health Organization, 2002. 8 Policy and action for cancer prevention. Food, nutrition, and physical activity: a global perspective. Washington, DC, World Cancer Research Fund/ American Institute for Cancer Research, 2009.

Noncommunicable Diseases in the Western Pacific Region: A Profile 21 Raised blood pressure Raised blood pressure 9 has been shown to be positively linked to stroke and coronary heart disease and to multiple end-organ complications. All countries in the Region have prevalence rates of raised blood pressure over 20%, with country-specific rates ranging from 25% to 50%. Rates among women are almost as high as men in all the countries. Prevalence of raised blood pressure does not show a marked difference between HIC and LMIC (Figure 12). Figure 12. Age-standardized prevalence of raised blood pressure in adults aged 25+ years, comparable country estimates, Western Pacific Region, 2008 75 Men Women 50 Prevalence % 25 0 Republic of Korea, the Australia New Zealand Singapore Japan Papua New Guinea Cambodia Solomon Islands Lao People s Democratic Republic, the Philippines Viet Nam Malaysia Marshall Islands, the China Kiribati Fiji Tonga Micronesia, the Federated States of Samoa Cook Islands Nauru Vanuatu Mongolia High Income Low- and middle-income Source: Global status report on noncommunicable diseases. Geneva, WHO, 2011. 9 Raised blood pressure is defined as systolic blood pressure of 140 mmhg and/or diastolic blood pressure of 90 mmhg, or using medication to lower blood pressure.

22 Noncommunicable Diseases in the Western Pacific Region: A Profile Raised cholesterol Raised cholesterol 10 increases the risk of heart disease and stroke. The prevalence of raised cholesterol is higher in HIC than LMIC. Uniformly high rates are observed in both men and women (Figure 13). Figure 13. Age-standardized prevalence of raised total cholesterol 11 in adults aged 25 years, comparable country estimates, Western Pacific Region, 2008 75 Men Women 50 Prevalence % 25 0 Republic of Korea, the Australia Singapore New Zealand Japan Cambodia Solomon Islands Samoa China Kiribati Papua New Guinea Mongolia Philippines Nauru Marshall Islands, the Micronesia, the Federated States of Tonga Fiji Cook Islands High Income Low- and middle-income Source: Global status report on noncommunicable diseases. Geneva, WHO, 2011. 10 Ezzati M et al. Selected major risk factors and global and regional burden of disease. The Lancet, 2002, 360:1347 1360. 11 Raised cholesterol was defined, in these estimates, as 5.0 mmol/l or 190 mg/dl or higher.

4. NCD country capacity Noncommunicable Diseases in the Western Pacific Region: A Profile 23 NCD country capacity surveys (CCS) were undertaken by WHO in 2004 and 2010 to update information on individual country capacity to address NCD prevention and control. Collated information from countries is available in the Global Health Observatory Data Repository (http://apps.who.int/ ghodata/). Country capacity surveys: 2004 and 2010 In the Region, twenty-seven countries and areas responded to the survey in 2004 and 35 responded in 2010. Table 1 shows the status of selected parameters in both years. Table 1. Comparison of country capacity indicators, Western Pacific Region, 2004 and 2010 NCD POLICY AND PROGRAMME INFRASTRUCTURE 2004 (n=27) Indicator Number of countries with national NCD entity (focal point, unit or department) 14 32 Number of countries with an allocated budget for NCD prevention and control 24 30 Number of countries with an integrated NCD policy, strategy and/or action plan 15 28 2010 (n=35) Number of countries with legislation (acts, laws, regulations, ministerial decrees, policies, plans, procedures, etc.) on: Tobacco Control 22 29 Nutrition 17 23 Physical Activity 9 21 Alcohol Consumption 12 19 Diabetes 15 25 Number of countries completing at least one round of WHO STEPS survey 10 22 Number of countries with surveillance system that covers the following risk factors: Tobacco Control 17 31 Alcohol Consumption 13 29 Unhealthy Diet 12 30 Physical Inactivity 12 27 Diabetes/Raised Blood Glucose 18 28 Hypertension/Raised Blood Pressure 17 29 Overweight and Obesity 15 30 Dyslipidaemia 10 25 Number of countries with clinical protocols, guidelines, standards for the treatment/management of the following: Hypertension 16 32 Diabetes Mellitus 18 33 Source: NCD country capacity survey data, WHO Western Pacific Regional Office, 2004 and 2010.

24 Noncommunicable Diseases in the Western Pacific Region: A Profile Country capacity 2010 NCD unit and policies Thirty-two of the 35 countries and areas that responded to the 2010 survey have a unit, branch or department in the Ministry of Health (or its equivalent) designated for NCD prevention and control. Twenty-eight have an integrated NCD policy, strategy and/or action plan and specific policies that address risk factors, most notably tobacco use. Though structures and mechanisms vary, most countries and areas have a designated NCD unit and policies for NCD risk factor reduction (Table 2). Table 2. Dedicated NCD unit, integrated NCD policy, and policies on risk factors, Western Pacific Region, 2010 Country Dedicated NCD office in Ministry of Health Integrated NCD Policy Alcohol Policy addressing specific risk factors Unhealthy diet Physical inactivity Tobacco American Samoa Yes No No No No Yes Australia Yes Yes Yes Yes Yes Yes Brunei Darussalam No No Yes Yes Yes Yes Cambodia Yes Yes Yes No* No* Yes China Yes No No Yes No No Cook Islands Yes Yes No* No* No* Yes Fiji Yes Yes Yes Yes Yes Yes French Polynesia Yes Yes Yes Yes Yes Yes Guam Yes No Hong Kong (China) Yes Yes Yes Yes Yes Yes Japan Yes Yes Yes Yes Yes Yes Kiribati Yes Yes Yes Yes Yes Yes Lao People s Democratic Republic, the Yes Yes No* No* No* Yes Macao (China) Yes No No Yes Yes Yes Malaysia Yes Yes No Yes Yes Yes Marshall Islands, the Yes Yes Yes No* No* Yes Micronesia, the Federated States of Yes Yes Yes Yes Yes Yes Mongolia Yes Yes Yes Yes Yes No* Nauru Yes Yes No* Yes Yes No* New Caledonia Yes Yes Yes Yes Yes Yes New Zealand No No Yes Yes Yes Yes Niue Yes Yes Yes Yes Yes Yes Northern Mariana Islands, the Commonwealth of the Yes No Yes Yes Yes Yes Palau Yes Yes No* Yes No* Yes Papua New Guinea Yes Yes No* No* No* Philippines Yes Yes No* No* No* Yes Republic of Korea, the Yes Yes Yes Yes Yes Yes Samoa Yes Yes No* Yes Yes Yes Singapore Yes Yes Yes Yes Yes Yes Solomon Islands Yes Yes No* No* No* Yes Tokelau No Yes Yes Yes Yes Yes Tonga Yes Yes No* Yes No* No* Tuvalu Yes Yes No* No* No* Yes Vanuatu Yes Yes Yes Yes Yes Yes Viet Nam Yes Yes No No No Yes Note: *Not a standalone policy but was reported as part of the integrated national policy

Noncommunicable Diseases in the Western Pacific Region: A Profile 25 Health reporting, information systems, monitoring and surveillance Twelve of the 35 countries and areas have incorporated population-based, cause-specific mortality data into their national health reporting systems. While many countries and areas in the Region have a cancer registry, only 10 countries maintain a population-based cancer registry. Twenty-six countries and areas reported having risk factor surveys, and of which, 23 are based on populations (Table 3). The WHO STEPwise approach to surveillance of NCD risk factors (STEPS) has been used in 22 countries and areas of the Region either in a stand alone format or incorporated into national health surveys (Annex 4). Repeated surveys at regular intervals are essential to measure trends. Table 3. Surveillance data in national health reporting systems, Western Pacific Region, 2010 Country Mortality Cancer Registry Risk Factors American Samoa No Yes Yes* Australia Yes* Yes* Yes* Brunei Darussalam Yes* Yes Yes* Cambodia Yes Yes No China Yes* Yes* Yes Cook Islands Yes Yes* Yes Fiji Yes Yes* Yes French Polynesia Yes Yes No Guam Yes Yes* Yes Hong Kong (China) Yes* Yes* Yes* Japan Yes* Yes* Yes Kiribati Yes Yes* Yes Lao People s Democratic Republic, the No Yes* Yes Macao (China) Yes Yes Yes Malaysia Yes Yes* Yes* Marshall Islands, the Yes Yes Yes Micronesia, the Federated States of Yes Yes* Yes Mongolia Yes Yes* Yes Nauru Yes Yes* Yes New Caledonia Yes* Yes* Yes New Zealand Yes* Yes* Yes* Niue Yes Yes* Yes Northern Mariana Islands, the Commonwealth of the Yes Yes Yes Palau Yes* Yes No Papua New Guinea Yes* Yes* Yes Philippines Yes Yes* Yes* Republic of Korea, the Yes* Yes* Yes* Samoa Yes No No Singapore Yes* Yes* Yes* Solomon Islands No Yes No Tokelau Yes* Yes* Yes Tonga Yes Yes* Yes Tuvalu Yes No No Vanuatu Yes Yes* Yes* Viet Nam Yes Yes No *Population-based data

26 Noncommunicable Diseases in the Western Pacific Region: A Profile Health system capacity for NCD prevention, early detection, treatment and care within the primary health care system A majority of the respondent countries and areas have evidence-based national guidelines, protocols and/or standards for diabetes (94%) and hypertension (91%) (Table 4). Nearly half of the 35 countries and areas have insurance coverage for NCDs (46%), while 29 countries and areas have a list of essential NCD-related medicines. Accessibility to community or home care for people with advanced or end-stage NCDs was reported by 14 countries and areas. Health promotion, partnerships and collaboration Thirty-two of the 35 countries and areas reported engaging in partnerships to implement NCD activities (Table 5). Key stakeholders are nongovernmental organizations, the private sector, and non-health government ministries or departments. A majority of countries and areas reported implementing fiscal interventions for NCD prevention and control (86%). About one third reported having established earmarking of taxes on substances such as tobacco and alcohol. Fifteen have regulations on the marketing of food to children, while nine have enforcement mechanisms.

Noncommunicable Diseases in the Western Pacific Region: A Profile 27 Table 4. Health system capacity for NCD prevention, early detection, treatment and care within the primary health care system, Western Pacific Region, 2010 Country / Area Diabetes Hypertension Guidelines/protocols/standards for the mgmt of conditions for NCDs Overweight and obesity Blood lipids Alcohol dependence Tobacco dependence Dietary counseling Physical activity counseling Health care system factors affecting NCD management Essential list of medicine Health insurance coverage American Samoa Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Australia Yes Yes Yes Yes Yes Yes Yes Yes No Yes Brunei Darussalam Yes Yes No Yes No Yes Yes No Yes No Cambodia Yes Yes No No No No Yes Yes Yes No China Yes Yes Yes Yes Yes Yes Yes Yes Yes No Cook Islands Yes Yes Yes No No No Yes Yes Yes No Fiji Yes Yes Yes Yes No No Yes Yes Yes No French Polynesia Yes Yes Yes Yes No No No Yes Guam Hong Kong (China) Yes Yes No Yes Yes Yes Yes Yes Yes Yes Japan Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Kiribati Yes Yes Yes Yes Yes No Yes Yes Yes No Lao People s Democratic Republic, the Yes Yes No No No No Yes Yes Macao (China) Yes Yes Yes Yes No Yes No No Yes No Malaysia Yes Yes Yes Yes No Yes Yes Yes Yes Yes Marshall Islands, the Yes Yes Yes Yes No No Yes Yes Yes No Micronesia, the Federated States of Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Mongolia Yes Yes No No Yes Yes Yes Yes Yes Yes Nauru Yes Yes No Yes No No No No Yes No New Caledonia Yes Yes Yes Yes Yes Yes Yes No Yes New Zealand Yes Yes Yes Yes No Yes Yes Yes Yes Yes Niue Yes Yes Yes Yes No Yes Yes No Yes No Northern Mariana Islands, the Commonwealth of the Yes Yes No Yes Yes Yes No Yes Yes Palau Yes Yes Yes Yes Yes Yes No No Yes No Papua New Guinea Yes Yes Yes Yes Yes Yes Yes Philippines Yes Yes Yes Yes No Yes Yes Yes Yes Yes Republic of Korea, the Yes Yes Yes Yes Yes Yes Yes Yes Samoa Yes Yes Yes No No No No Yes No Singapore Yes Yes Yes Yes Yes No Yes Yes Yes Yes Solomon Islands Yes No No No No Yes Yes Yes Yes No Tokelau Yes Yes No No No No No No Yes No Tonga Yes Yes No Yes No No Yes Yes Yes Yes Tuvalu Yes Yes Yes Yes No Yes Yes Yes Yes No Vanuatu Yes Yes Yes No No Yes Yes Yes Yes No Viet Nam No No No No No No No No Yes Yes

28 Noncommunicable Diseases in the Western Pacific Region: A Profile Table 5. Health promotion, partnerships, and collaboration, Western Pacific Region, 2010 Country / Area With partnerships / collaborations Other Government Ministries (Non-health) Key stakeholders Health promotion initiatives Other international institutions Academia and research centres NGOs / communitybased organizations / civil society Private Sector Fiscal interventions Earmarking of taxes Initiatives to regulate food marketing to children American Samoa Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Australia Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Brunei Darussalam Yes Yes Yes Yes Yes Yes No No No Cambodia Yes No Yes Yes Yes Yes Yes Yes No No No China No Yes No No No Cook Islands Yes Yes Yes No No Yes Yes Yes No No No Fiji Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes French Polynesia Yes Yes No Yes No Yes No Yes Yes No No Guam Yes Yes No No Yes Yes Yes Yes Yes Yes No Hong Kong (China) Yes Yes No No Yes Yes Yes Yes No No No Japan Yes Yes Yes Yes Yes Yes Yes No Yes Yes Kiribati Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Lao People s Democratic Republic, the No Yes Yes* Macao (China) Yes Yes No No Yes Yes Yes Yes No No No Malaysia Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes* Marshall Islands, the Yes Yes No No No Yes Yes Yes No No No Micronesia, the Federated Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes States of Mongolia Yes Yes Yes Yes Yes Yes No Yes Yes No No Nauru Yes Yes No Yes No Yes Yes Yes No No No New Caledonia Yes Yes No Yes No Yes Yes Yes Yes Yes Yes* New Zealand Yes No No No Yes Yes Yes Yes No No No Niue Yes Yes No No No Yes Yes Yes No No No Northern Mariana Islands, the Commonwealth of the Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Palau Yes Yes No Yes Yes Yes Yes Yes No No No Papua New Guinea Yes Yes No Yes No Yes Yes Yes Yes Yes Philippines Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Republic of Korea, the No Yes Yes Yes Yes Samoa Yes Yes Yes Yes Yes Yes Yes No Yes Yes Singapore Yes Yes Yes Yes Yes No No Yes No Yes Yes* Solomon Islands Yes Yes Yes Yes No Yes No No No No Tokelau Yes No Yes Yes No No No No No No Tonga Yes Yes Yes Yes Yes Yes Yes Yes No No No Tuvalu Yes Yes Yes Yes No Yes No Yes No Yes Yes Vanuatu Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes* Viet Nam Yes Yes Yes Yes Yes Yes No Yes No No No Enforcement of food marketing regulations Notes: *Yes=Food marketing regulation to children is self-regulated

5. NCD country profiles Noncommunicable Diseases in the Western Pacific Region: A Profile 29 The NCD country profiles in this section present data of each country related to their NCD mortality, risk factors and capacity to prevent and control NCDs. 12 The data presented in each of the country profiles were derived from several sources, as detailed in Annex 2. 12 Noncommunicable diseases country profiles. Geneva, WHO, 2011. Available online at http://www.who.int/nmh/countries/en/index.html.

30 Noncommunicable Diseases in the Western Pacific Region: A Profile Australia 2010 total population: 22 268 384 Income group: High NCD mortality 2008 estimates males females Total NCD deaths (000s) 63.4 63.2 NCD deaths under age 60 (percent of all NCD deaths) Age-standardized death rate per 100 000 13.4 9.2 All NCDs 364.8 246.3 Cancers 140.8 92.9 Chronic respiratory diseases 25.6 15.5 Cardiovascular diseases and diabetes 136.3 88.6 Behavioural risk factors Current daily tobacco smoking 18.3 15.4 16.8 Physical inactivity 38.0 42.5 40.3 Proportional mortality (% of total deaths, all ages) Other NCDs 17% Diabetes 3% Communicable, maternal, perinatal and nutritional conditions 4% Injuries 6% CVD 35% Respiratory Metabolic risk factors diseases 6% Raised blood pressure 41.1 32.0 36.4 Raised blood glucose 10.8 8.0 9.4 Overweight 68.2 59.3 63.7 Cancers Obesity 26.4 27.1 26.8 29% Raised cholesterol 55.9 58.9 57.4 NCDs are estimated to account for 90% of all deaths. Metabolic risk factor trends mmhg 136 133 130 127 124 121 118 Mean systolic blood pressure kg/m 2 Mean body mass index 30 28 26 24 22 20 Mean fasting blood glucose 5.8 5.6 5.4 5.2 5.0 4.8 Country capacity to address and respond to NCDs Males Females Mean total cholesterol 6.0 5.8 5.6 5.4 5.2 5.0 Has a Unit / Branch / Dept in MOH with responsibility for NCDs Yes Has an integrated or topic-specific policy / programme / action plan which is currently operational for: There is funding available for: Cardiovascular diseases No NCD treatment and control Yes Cancer Yes NCD prevention and health promotion Yes Chronic respiratory diseases No NCD surveillance, monitoring and evaluation Yes Diabetes No Alcohol Yes National health reporting system includes: Unhealthy diet / Overweight / Obesity Yes NCD cause-specific mortality Yes Physical inactivity Yes NCD morbidity Yes Tobacco Yes NCD risk factors Yes Number of tobacco (m)power measures Has a national, population-based cancer registry Yes implemented at the highest level of achievement 3/5

Noncommunicable Diseases in the Western Pacific Region: A Profile 31 Brunei Darussalam 2010 total population: 398 920 Income group: High NCD mortality 2008 estimates males females Total NCD deaths (000s) 0.5 0.5 NCD deaths under age 60 (percent of all NCD deaths) Age-standardized death rate per 100 000 41.4 30.0 All NCDs 534.3 488.7 Cancers 97.0 98.1 Chronic respiratory diseases 69.0 44.0 Cardiovascular diseases and diabetes 292.7 275.4 Behavioural risk factors Current daily tobacco smoking Physical inactivity......... Proportional mortality (% of total deaths, all ages) Other NCDs 14% Communicable, maternal, perinatal and nutritional conditions 10% Injuries 8% CVD 33% Metabolic risk factors Diabetes Raised blood pressure......... 11% Raised blood glucose Cancers......... Respiratory 16% Overweight......... diseases Obesity......... 8% Raised cholesterol NCDs are estimated to account for 82% of all deaths. Metabolic risk factor trends mmhg 136 132 128 124 120 116 Mean systolic blood pressure kg/m 2 Mean body mass index 28 26 24 22 20 18 Mean fasting blood glucose 5.6 5.4 5.2 5.0 4.8 4.6 Country capacity to address and respond to NCDs Males Females Mean total cholesterol 5.6 5.4 5.2 5.0 4.8 4.6 Has a Unit / Branch / Dept in MOH with responsibility for NCDs No Has an integrated or topic-specific policy / programme / action plan which is currently operational for: There is funding available for: Cardiovascular diseases No NCD treatment and control Yes Cancer No NCD prevention and health promotion Yes Chronic respiratory diseases No NCD surveillance, monitoring and evaluation Yes Diabetes Yes Alcohol Yes National health reporting system includes: Unhealthy diet / Overweight / Obesity Yes NCD cause-specific mortality Yes Physical inactivity No NCD morbidity Yes Tobacco Yes NCD risk factors No Number of tobacco (m)power measures Has a national, population-based cancer registry Yes implemented at the highest level of achievement 1/5 = no data available

32 Noncommunicable Diseases in the Western Pacific Region: A Profile Cambodia 2010 total population: 14 138 255 Income group: Low NCD mortality* 2008 estimates males females Total NCD deaths (000s) 31.1 25.5 NCD deaths under age 60 (percent of all NCD deaths) Age-standardized death rate per 100 000 56.2 34.8 All NCDs 957.9 592.2 Cancers 144.9 90.0 Chronic respiratory diseases 129.0 60.4 Cardiovascular diseases and diabetes 480.4 338.7 Proportional mortality (% of total deaths, all ages)* Injuries 7% CVD 21% Behavioural risk factors Current daily tobacco smoking 45.6 3.7 23.7 Physical inactivity 10.8 10.9 10.9 Metabolic risk factors Diabetes 3% Raised blood pressure 30.5 25.1 27.6 Other NCDs Raised blood glucose 3.9 4.5 4.2 11% Overweight 10.8 13.2 12.1 Obesity 1.5 2.7 2.1 Raised cholesterol 26.4 31.1 29.0 NCDs are estimated to account for 46% of all deaths. Metabolic risk factor trends Communicable, maternal, perinatal and nutritional conditions 46% Cancers 7% Respiratory diseases 5% mmhg 124 122 120 118 116 114 112 110 Mean systolic blood pressure kg/m 2 Mean body mass index 26 24 22 20 18 16 Mean fasting blood glucose 5.4 5.2 5.0 4.8 4.6 4.4 Country capacity to address and respond to NCDs Males Females Mean total cholesterol 4.8 4.6 4.4 4.2 4.0 3.8 Has a Unit / Branch / Dept in MOH with responsibility for NCDs Yes Has an integrated or topic-specific policy / programme / action plan which is currently operational for: There is funding available for: Cardiovascular diseases Yes** NCD treatment and control Yes Cancer Yes** NCD prevention and health promotion Yes Chronic respiratory diseases No NCD surveillance, monitoring and evaluation Yes Diabetes Yes** Alcohol Yes** National health reporting system includes: Unhealthy diet / Overweight / Obesity Yes** NCD cause-specific mortality Yes Physical inactivity Yes** NCD morbidity Yes Tobacco Yes** NCD risk factors No Number of tobacco (m)power measures Has a national, population-based cancer registry No implemented at the highest level of achievement 0/5 * The mortality estimates for this country have a high degree of uncertainty because they are not based ** = covered by integrated policy/programme/action plan on any national NCD mortality data. The estimates are based on a combination of country life tables, cause of death models, regional cause of death patterns, and WHO and UNAIDS program estimates for some major causes of death (not including NCDs).

Noncommunicable Diseases in the Western Pacific Region: A Profile 33 China 2010 total population: 1 341 335 152 Income group: Lower middle NCD mortality 2008 estimates males females Total NCD deaths (000s) 4323.3 3675.5 NCD deaths under age 60 (percent of all NCD deaths) Age-standardized death rate per 100 000 22.8 17.4 All NCDs 665.2 495.2 Cancers 182.3 105.0 Chronic respiratory diseases 118.4 88.7 Cardiovascular diseases and diabetes 311.5 259.6 Behavioural risk factors Current daily tobacco smoking 49.3 2.1 26.3 Physical inactivity 29.3 32.0 30.6 Proportional mortality (% of total deaths, all ages) Metabolic risk factors Respiratory diseases 15% Raised blood pressure 40.1 36.2 38.2 Raised blood glucose 9.5 9.3 9.4 Cancers Overweight 25.5 25.4 25.4 21% Obesity 4.7 6.7 5.7 Raised cholesterol 31.8 35.3 33.5 NCDs are estimated to account for 83% of all deaths. Metabolic risk factor trends Other NCDs 7% Diabetes 2% Communicable, maternal, perinatal and nutritional conditions 7% Injuries 10% CVD 38% mmhg Mean systolic blood pressure 129 127 125 123 121 119 kg/m 2 Mean body mass index 28 26 24 22 20 18 Mean fasting blood glucose 5.8 5.6 5.4 5.2 5.0 4.8 Country capacity to address and respond to NCDs Males Females Mean total cholesterol 5.0 4.8 4.6 4.4 4.2 4.0 Has a Unit / Branch / Dept in MOH with responsibility for NCDs Yes Has an integrated or topic-specific policy / programme / action plan which is currently operational for: There is funding available for: Cardiovascular diseases No NCD treatment and control Yes Cancer Yes NCD prevention and health promotion Yes Chronic respiratory diseases No NCD surveillance, monitoring and evaluation Yes Diabetes No Alcohol No National health reporting system includes: Unhealthy diet / Overweight / Obesity Yes NCD cause-specific mortality Yes Physical inactivity No NCD morbidity Yes Tobacco No NCD risk factors Yes Number of tobacco (m)power measures Has a national, population-based cancer registry Yes implemented at the highest level of achievement 0/5

34 Noncommunicable Diseases in the Western Pacific Region: A Profile Cook Islands 2010 total population: 20 288 Income group: Upper middle NCD mortality 2008 estimates males females Total NCD deaths (000s) 0.0 0.0 NCD deaths under age 60 (percent of all NCD deaths) Age-standardized death rate per 100 000 39.4 30.6 All NCDs 592.0 326.3 Cancers 58.6 57.4 Chronic respiratory diseases 61.3 26.3 Cardiovascular diseases and diabetes 350.7 180.0 Proportional mortality (% of total deaths, all ages) Communicable, maternal, perinatal and nutritional conditions 19% Injuries 7% CVD 37% Behavioural risk factors Current daily tobacco smoking 38.9 29.7 34.4 Physical inactivity 71.6 73.0 72.3 Metabolic risk factors Other NCDs 15% Raised blood pressure 46.0 36.8 41.5 Cancers Raised blood glucose 19.5 20.5 20.0 Diabetes Respiratory 10% Overweight 91.0 89.9 90.5 5% diseases Obesity 59.7 67.9 63.7 7% Raised cholesterol 58.8 57.3 58.1 NCDs are estimated to account for 74% of all deaths. Metabolic risk factor trends Mean systolic blood pressure Mean body mass index No Data Available No Data Available Mean fasting blood glucose Mean total cholesterol No Data Available No Data Available Country capacity to address and respond to NCDs Males Females Has a Unit / Branch / Dept in MOH with responsibility for NCDs Yes Has an integrated or topic-specific policy / programme / action plan which is currently operational for: There is funding available for: Cardiovascular diseases Yes** NCD treatment and control Yes Cancer Yes** NCD prevention and health promotion Yes Chronic respiratory diseases No NCD surveillance, monitoring and evaluation Yes Diabetes Yes** Alcohol Yes** National health reporting system includes: Unhealthy diet / Overweight / Obesity Yes** NCD cause-specific mortality Yes Physical inactivity Yes** NCD morbidity Yes Tobacco Yes** NCD risk factors Yes Number of tobacco (m)power measures Has a national, population-based cancer registry No implemented at the highest level of achievement 1/5 ** = covered by integrated policy/programme/action plan