To reduce the avoidable burden of morbidity, mortality and disability due to noncommunicable diseases (NCDs), which remain as one of the greatest, under-funded public health challenges of this century.
The current 5 × 5 approach to NCDs, favored by WHO, focuses on five diseases (cardiovascular diseases, cancers, diabetes, chronic respiratory diseases, and mental ill-health) and five risk factors (tobacco use, unhealthy diet, physical inactivity, harmful use of alcohol, and air pollution). The NCD’s has become the leading cause of death in most countries, resulting in 200 million premature deaths among women and men aged between 30 and 70, the majority living in low- and middle-income countries. During the next 10 years, another 150 million people will die from NCDs between the ages of 30 and 70. Most of these deaths can be avoided or delayed.
The rising burden of non-communicable diseases (NCD) and mental health conditions constitute a major public health challenge in Pakistan, that has a serious negative impact on social and economic development, and it is a serious threat to progress related to sustainable development goals (SDGs) and universal health coverage (UHC).
The non-communicable diseases (NCD) including mental health are becoming a major socio development challenge for Pakistan. Burden of the non-communicable disease group which was 29.9% (18,869 DALYs lost per 100,000 population) of the total burden in the year 2000 has increased its share to 43.7% (18,385 DALYs lost per 100,000 population) in 2019.
Mortality data demonstrate a similar pattern and the total NCD related deaths were estimated to be 55.3% of all 1.49 million deaths in the country in 2019.
The same comparison at provincial and area level in Pakistan indicate serious equitable challenges and delayed epidemiological transition especially in Sindh, Khyber Pakhtunkhwa, Gilgit Baltistan and Baluchistan. Sindh has 42.8% to NCD share of total deaths.
NCD’s are classified into twelve disease groups in Pakistan. Primarily driven by five main disease groups:
- 1. Cardio- vascular diseases
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The Global Burden of Disease (GBD) data for Pakistan reports that ischemic heart disease (IHD) related death and disability increased by 29% between 2009 and 2019. Stroke related death and disability increased by 20%, while diabetes related death and disability increased by 87% in the same time period. In Pakistan, 55% of NCD mortality is due to CVDs, which is expected to rapidly rise in coming years
Hypertension is one of the world’s silent killers, with more than 1.1 billion people living with hypertension. According to the WHO Hypertension fact sheet for Pakistan, 37.3% of the adult population and around 20.2% of the total population have hypertension
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The Global Burden of Disease (GBD) data for Pakistan reports that ischemic heart disease (IHD) related death and disability increased by 29% between 2009 and 2019. Stroke related death and disability increased by 20%, while diabetes related death and disability increased by 87% in the same time period. In Pakistan, 55% of NCD mortality is due to CVDs, which is expected to rapidly rise in coming years
- 2. Cancers
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Cancers (Neoplasms) are the second leading group of morbidity and mortality among NCD in Pakistan. GBD 2019 estimated that there were more than 4.1 million cancer cases in Pakistan, whereas new cases were more than 2.77 million. Around 179,773 cancer related patients’ deaths were estimated in the same year.
Cancers like breast, lung, liver, colorectal, prostate, head and neck carcinoma are most commonly diagnosed in Pakistan. Hepatocellular cancer is a common tumor in Pakistan, linked to the high background prevalence of hepatitis C and B. In 2019, more than 3.37 million out of total of 4.1 million cancer cases were estimated as benign in Pakistan.
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Cancers (Neoplasms) are the second leading group of morbidity and mortality among NCD in Pakistan. GBD 2019 estimated that there were more than 4.1 million cancer cases in Pakistan, whereas new cases were more than 2.77 million. Around 179,773 cancer related patients’ deaths were estimated in the same year.
- 3. Diabetes and Chronic kidney diseases
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Another ‘Silent Killer’ in the NCD group is Diabetes - a major public health issue in Pakistan. Further, complications of diabetes include stroke, cardiovascular diseases, chronic kidney disease (CKD)/ renal failure, cataract and others. GBD 2019 estimated that there were more than 19 million diabetes and chronic kidney disease cases in Pakistan, whereas new cases were more than 795,706.
According to a systematic review on Type 2 diabetes in Pakistan, in males the prevalence is 11.20% and in females 9.19%. The mean prevalence in Sindh province is 16.2% in males and 11.70 % in females. The prevalence of type 2 diabetes mellitus in urban areas is 14.81% and 10.34% in rural areas of Pakistan.
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Another ‘Silent Killer’ in the NCD group is Diabetes - a major public health issue in Pakistan. Further, complications of diabetes include stroke, cardiovascular diseases, chronic kidney disease (CKD)/ renal failure, cataract and others. GBD 2019 estimated that there were more than 19 million diabetes and chronic kidney disease cases in Pakistan, whereas new cases were more than 795,706.
- 4. Mental disorders
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Historically, mental health has been a neglected area in Pakistan. Between 1999 and 2009 the country recorded only a 1% increase in the loss of mental health disorder related DALYs while between 2009 and 2019 the increase was 8%.
Mental disorders include a wide range of conditions, with three major conditions including depressive disorders, anxiety disorders and schizophrenia.
Mental disorders are usually not considered a direct cause of death and most of the deaths are categorized under injuries including self-harm etc. More than 85,000 deaths were estimated as a result of injuries in 2019.
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Historically, mental health has been a neglected area in Pakistan. Between 1999 and 2009 the country recorded only a 1% increase in the loss of mental health disorder related DALYs while between 2009 and 2019 the increase was 8%.
- 5. Chronic respiratory diseases
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- Major diseases include chronic obstructive pulmonary disease (COPD), pneumoconiosis, asthma, interstitial lung disease and pulmonary sarcoidosis and other chronic respiratory diseases. COPD and asthma form the major burden in this group with annual DALYs loss of 1.7 million and 0.56 million respectively in 2019. Chronic respiratory diseases contribute to more than 82,000 annual deaths and the number is rising with increasing environmental pollution/ smoke.
A risk factor is a characteristic, condition, or behavior that increases the possibility of getting a disease or injury. Risk factors for diseases are classified into three major categories:
1. Environmental / occupational risks e.g., household air pollution, unsafe water source, unsafe sanitation.
2. Behavioral risks e.g., low birth weight, smoking, non-exclusive breastfeeding, etc.
3. Metabolic risks: high systolic blood pressure, high fasting plasma glucose, high body mass index, etc.
At the global level, five major risks are:
1. High systolic blood pressure
2. Smoking
3. High fasting plasma glucose
4. Low birth weight and
5. High body mass index.
In the context of NCD diseases in Pakistan, key risks factors include:
- 1. Unhealthy diets
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- Unhealthy diet is “dietary intake: <7 servings of fruits and/or vegetable in the last 7 days”. People in the country consume less fruits than vegetables; on an average fruit is consumed only up to 2.3 days in a week and vegetable over 4.4 days.
- 2. Tobacco use
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The Stepwise approach to surveillance (STEPS) survey of 2013-2014 shows that prevalence of current tobacco smokers in Pakistan are 13.9% in both genders combined. Smoking is more prevalent among males (27.8%) while 4.2% of the females are smokers in both genders, average age to start smoking is 22.1 (21.4-22.9). Exposure to second-hand smoke was observed in 86% of restaurants while it was 76% on public transportation.
According to GYTS 2013, among the youth (13-15 years of age students), 10.7% of school students (13.3% boys and 6.6% girls) currently use tobacco.
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The Stepwise approach to surveillance (STEPS) survey of 2013-2014 shows that prevalence of current tobacco smokers in Pakistan are 13.9% in both genders combined. Smoking is more prevalent among males (27.8%) while 4.2% of the females are smokers in both genders, average age to start smoking is 22.1 (21.4-22.9). Exposure to second-hand smoke was observed in 86% of restaurants while it was 76% on public transportation.
- 3. Air Pollution
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In the South Asia, Pakistan ranks as the worst in air pollution measured as particulate matter (PM) (measures PM10). Concentrations of noxious particulate matter (PM) in Pakistan are significantly higher than those found across South Asia.
Pakistan's urban air pollution is amongst the most severe in the world. Karachi, the biggest metropolitan city in the country, is reported to be the fifth most polluted city in the world.
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In the South Asia, Pakistan ranks as the worst in air pollution measured as particulate matter (PM) (measures PM10). Concentrations of noxious particulate matter (PM) in Pakistan are significantly higher than those found across South Asia.
- 4. Physical Inactivity
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Physical inactivity is described as the absence of body movement, when energy consumption approximates that at resting levels. Poor nutrition and physical inactivity are the main factors of death.
Obesity is considered to be the primary cause for many non-communication diseases (NCD), including diabetes, hypertension, osteoporosis, and stroke. The main causes of overweight and obesity in Pakistan are unawareness, high density diet consumption, and physical inactivity. Overall, 53% women do not follow-on physical activity. In comparison 25% of the men are reportedly physically inactive.
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Physical inactivity is described as the absence of body movement, when energy consumption approximates that at resting levels. Poor nutrition and physical inactivity are the main factors of death.
PPHI is currently engaged in collaborative efforts with other organizations to execute interventions targeting Non-Communicable Diseases (NCDs) at the primary healthcare level. A recent development involves the signing of Memoranda of Understanding (MOUs) with National Institute of vascular Cardio Disease (NIVCD) and Baqai Institute of Diabetology and Endocrinology (BIDE).
PPHI has undertaken a collaborative commitment with NICVD, with the objective of implementing the standardized protocol developed by the NICVD team within primary healthcare facilities. The support from NICVD encompasses the provision of cardiovascular disease prevention protocols, assistance in CPR training, and support in ACLS/BCLS training.
PPHI has additionally entered into a Memorandum of Understanding (MOU) with the Baqai Institute of Diabetology and Endocrinology (BIDE) to standardize diabetic care in all primary healthcare facilities managed by PPHI Sindh.
PPHI health facilities offer services for non-communicable diseases across different terms. The data for various conditions served is presented below.
| COPD | Asthma | Ischemic Heart Disease | Hypertension | Diabetes Mellitus | Depression | Drug Dependence |
|---|---|---|---|---|---|---|
| 15,429 | 134,521 | 2,462 | 115,400 | 70,750 | 41,058 | 1,057 |