Coalition on Circulatory Health White Paper

WHITE PAPER FOR CIRCULATORY HEALTH

DRIVING SUSTAINABLE ACTION FOR CIRCULATORY HEALTH 1 WHITE PAPER FOR CIRCULATORY HEALTH DRIVING SUSTAINABLE ACTION FOR CIRCULATORY HEALTH

2 CONTENTS EXECUTIVE SUMMARY 4 PART 4: SUCCESS STORIES 26 Introduction 26 SUCCESS STORY 1: The excise tax

PART 1: BACKGROUND 6 reform in the Philippines 27 Why circulatory diseases matter 8 Challenge The Global Coalition for Response Circulatory Health 10 Outcomes Purpose of this White Paper 12 SUCCESS STORY 2: Primary care prevention of heart disease and PART 2: THE GLOBAL BURDEN stroke in the Seychelles 28 OF CIRCULATORY DISEASE 13 Challenge The circulatory system 13 Response Associated conditions and risk factors 14 Outcomes Associated conditions and SUCCESS STORY 3: Nurses stepping metabolic risk factors 14 up to curb NCDs in Tonga 29 Behavioural risk factors 15 Challenge Other modifiable factors 16 Response Non-modifiable risk factors 16 Outcomes The burden of circulatory disease 17 SUCCESS STORY 4: SMART Health Costs of circulatory disease 20 for better cardiovascular health in India 31 Challenge PART 3: LIVING WITH Response CIRCULATORY DISEASES 21 Outcomes Introduction 22 SUCCESS STORY 5: Reduced mortality through systematic screening Community Voices 22 and treatment 32 Challenge Response Outcomes

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION WHITE PAPER FOR CIRCULATORY HEALTH CONTENTS

SUCCESS STORY 6: Taxing ACKNOWLEDGEMENTS 3 sugar-sweetened beverages in Mexico 33 The Global Coalition for Circulatory Health “Global Coalition” would like to acknowledge and thank all those who contributed to the writing, research, development, editing and design of this White Paper. We are Challenge especially indebted to the people living with circulatory diseases and to their families for sharing their stories Response with us. Particular thanks are due to the people and organizations below who made this document possible. Writer: Tania Séverin, Polyscope Communication. Outcomes Expert Contributors: Mischa Terzyk (Framework Convention Alliance), David Stewart (International Council of Nurses), Sabine Dupont and Lorenzo Piemonte (International Diabetes Federation), Anne Hradsky, PART 5: TAKING ACTION 35 Valerie Luyckx and Luisa Strani (International Society of Nephrology), Michael Moore (World Federation of Public Health Associations), David Wood (World Heart Federation), Dan Lackland and Norm Campbell Why are heart disease and stroke (World Hypertension League), Domingo Orozco Beltran, Manuel Sanchez Molla, Viviana Martinez-Bianchi and a public health issue? 35 Garth Manning (World Organization of Family Doctors), Maria Fredin Grupper, Werner Hacke, Bo Norrving and Taking action 36 Patrik Michel (World Stroke Organization). Reviewers: Florence Berteletti, Jean-Luc Eiselé, Mihela Kralj, Pilar Millan, Sharon Mitchell, Pablo Perel, Andrea Vassalotti, Alastair White (World Heart Federation). PILLAR 1: Prioritizing multisectoral and cost-effective interventions 37 Project coordinator: Oana Scarlatescu (World Heart Federation). PILLAR 2: Fostering access to Design: MINT® designbymint.com © prevention and care 38 Global Coalition for Circulatory Health 2018 PILLAR 3: Mobilizing resources 39 Suggested citation: Driving Sustainable action for Circulatory Health. White Paper on Circulatory Health. PILLAR 4: Measuring and Geneva, Switzerland. Global Coalition for Circulatory Health. 2018. tracking progress 40 You may copy, redistribute and adapt the work for non-commercial purposes, provided the work is Global Coalition’s commitments 41 appropriately cited, as indicated above. In any use of this work, there should be no suggestion that the Global Coalition for Circulatory Health as a whole or any of its member organizations endorse any specific organization, product or service. The use of the logos of the Global Coalition organizations is not permitted. GLOBAL COALITION MEMBERS 42 If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the Global Coalition for Circulatory Health. The Global Coalition References 43 is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”.

The Global Coalition for Circulatory Health and its member organizations have taken all reasonable precautions to verify the information 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 Global Coalition for Circulatory Health or its members shall be liable for damages arising from its use. WHITE PAPER FOR CIRCULATORY HEALTH EXECUTIVE SUMMARY

CIRCULATORY DISEASES ARE THE WORLDS’ NUMBER 1 CAUSE OF DISABILITY AND DEATH

irculatory diseases governments to scale up their action the Third UN HLM on NCDs, but also are the world’s number against circulatory diseases and look beyond the High-Level Meeting 1 cause of disability to enact priorities as identified by to drive action on circulatory health 4 the WHO Independent High-Level for the years to come. and death. Together, Commission on Non-Communicable heart disease, stroke, Diseases (NCDs) and approved They rely on four core Cdiabetes and kidney disease during the Third High-level Meeting pillars which: of the UN General Assembly on NCDs lead to more than 20 million • Ar e grounded in evidence; deaths each year and to more (UN HLM on NCDs) organized in New York on 27 September 2018. than 374 million years of life • Ar e globally relevant, taking into account regional or national lost. Beyond these massive, The Global Coalition for Circulatory differences; and sometimes abstract Health, which was formed in 2017 to figures, they affect millions drive the urgent action for circulatory • Can be acted upon by members health, is the only network of of the Global Coalition for of individuals, young and Circulatory Health and their old, rich and poor, in urban international, regional and national organizations advocating for global, regional and national and rural settings, on all increased prevention, control and networks. continents. treatment of all circulatory diseases. All the members of the Coalition Because circulatory diseases share commit to work together to support a range of, mostly modifiable, global, regional and national health common risk factors, coordinated administrations and organisations in action can result in major gains their action. in the quality of life for individuals and cost savings for society. Health In order to guide and support systems worldwide would therefore governments and intergovernmental greatly benefit from mobilising agencies in their actions, the Global sufficient resources to preventing Coalition for Circulatory Health and fighting circulatory diseases. has identified a range of priority This is why the Global Coalition actions. These are meant to reinforce for Circulatory Health urges recommendations that stem from

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION WHITE PAPER FOR CIRCULATORY HEALTH EXECUTIVE SUMMARY TAKING ACTION PILLAR 1: PRIORITIZING MULTISECTORAL AND COST-EFFECTIVE INTERVENTIONS

irculatory diseases can • The full implementation of the WHO • The implementation of the largely be prevented Framework Convention on Tobacco HEARTS package; Control (FCTC); and managed through • The treatment of all patients with effective and efficient • The fight against obesity; hypertension and high-risk patients with statins and aspirin; prevention and early • The introduction of fiscal measures; Cdetection mechanisms. This • The integrated management of • Food reformulation efforts. is why governments are urged circulatory diseases, especially to develop and implement Further, focusing on secondary with existing communicable diseases policies that are conducive prevention, the Global Coalition programmes (e.g., HIV, Tuberculosis.) to a healthy life for their for Circulatory Health strongly supports: populations. In this respect, the The Recommendations refer to the following clauses • The implementation of the WHO Global Coalition for Circulatory in the Political Declaration of the 3rd United Nations best-buy dedicated to Counselling Health strongly supports: High-Level Meeting on Non-Communicable Diseases: OP1; and multi-drug therapy; OP2; OP3; OP4; OP5; OP6; OP7; OP15; OP16; OP18; OP20; OP23; OP26; OP28.a 5 PILLAR 2: FOSTERING ACCESS TO THE PREVENTION AND CARE OF CIRCULATORY DISEASES

o live full and healthy society organizations and the essential medicines by adequately lives, people at- risk of private sector; trained staff by optimizing the health workforce and enabling health or living with circulatory • An improved access to proven drugs, workers to work to their full scope including low-cost combination diseases need strong of practice, i.e., in the areas where pills, as part of a package of essential health systems, that are they are educated, authorized and treatment and services to control designed to deliver universal competent to perform. T b heart disease and stroke; health coverage (UHC) and to ensure access to prevention, • An improved access to relevant screening, and care for all. The technology, notably by increasing the availability of basic and evidence Global Coalition for Circulatory supported diagnostic tools; The Recommendations refer to the following clauses in the Health strongly supports: Political Declaration of the Third United Nations High-Level • The implementation of innovative Meeting on Non-Communicable Diseases: OP1; OP2; OP14; • The development of intersectoral information systems, such as mobile- OP19; OP20; OP22; OP24; OP25. collaborations between all relevant health technologies and telehealth departments, as well as with civil programmes; The prescribing of

aThe recommendations and clauses refer to the draft Political Declaration released in August 2018. bSpecifically, aspirin, clopidogrel, ACE inhibitors, angiotensin receptor antagonists, beta-blockers, calcium channel antagonists, diuretics, statins and a basic range of short and long-acting insulins and oral anti-diabetics must be generally available at no or low costs. DRIVING SUSTAINABLE ACTION FOR CIRCULATORY HEALTH

PILLAR 3: MOBILISING RESOURCES FOR CIRCULATORY HEALTH

nvesting in the fight • The taxation of unhealthy resources at national level, against circulatory products such as alcohol, tobacco, in particular by enforcing adequate diseases is cost-effective. unhealthy foods and non-alcoholic taxation policies and through beverages (such as sugar- carefully selected public-private For example, investing sweetened beverages); collaborations. US$ 1.27 per person per Iyear in low- and middle- • The use of these revenues to advance the prevention and control income countries (LMICs) until of circulatory diseases; 2030 can save an estimated 8.2 million lives and yield • The development of innovative financing mechanisms to ensure Recommendations refer to the following clauses in the a return on investment of that sufficient funds are available Political Declaration of the Third United Nations High- at least US$ 7. The Global to achieve health objectives. In Level Meeting on Non-Communicable Diseases: OP3; Coalition for Circulatory the longer term, each country is OP5; OP8; OP30. Health strongly supports: called upon to mobilise sufficient 6 PILLAR 4: MEASURING AND TRACKING PROGRESS

he Global Coalition • The development of reliable health for Circulatory Health information systems to monitor strongly supports health behaviours, risk factors, and morbidity and mortality; the introduction of instruments which help • The implementation of the World Ttrack progress on circulatory Health Organization’s Global Monitoring Framework; diseases in a clear, timely and transparent fashion. The • A global agreement on Global Coalition fully supports: international standards for data collection, to enable • The implementation of reliable, comparisons across countries, simple, and fit-for-purpose sur- sectors, and systems. veillance systems for monitoring The Recommendations refer to the following clauses the burden of circulatory diseases, in the Political Declaration of the Third United Nations prevalence of risk factors, and High-Level Meeting on Non-Communicable Diseases: treatment of circulatory diseases OP10; OP11; OP29; OP32. at national and global levels;

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION EXECUTIVE SUMMARY

By 2030 the total Circulatory Together, heart Why it global cost of CVD diseases are the disease, stroke, is set to rise from diabetes and kidney matters world’s number 1 approximately disease lead to more cause of disability US$ 957 billion in than 20 million and death. 2015 to a deaths each year. US$ 1,044 billion. 55 percent are 100 million people direct healthcare The global Circulatory a year fall into costs, and 45 burden of CVD, extreme poverty diseases percent are due diabetes and because of strongly affect to indirect costs, kidney disease, unaffordable mainly losses of quality of life. expressed health costs. productivity. in disability- adjusted life Global ageing trends will further add to Circulatory diseases years (DALYs) the problem, as the risk of heart disease, place a heavy amounted to stroke and other comorbidities increases financial burden on almost half a with age. The risk of stroke doubles every individuals and on billion years in decade after the age of 55. health systems. 2016. 7

Why Fighting Investing US$ 1.27 per person per year in low- and action is circulatory middle-income countries until 2030 can save an worthwhile diseases will estimated 8.2 million lives, decrease premature lead to positive mortality from NCDs by 15 percent, and yield a outcomes. return on investment of at least US$ 7.

US$1 invested in reducing tobacco Approximately use can yield a return of 75 percent of CVD In the Philippines, US$ 7.43. Managing CVD and is attributable to increased tobacco taxation diabetes can yield a return of US$ modifiable risk decreased smoking 2.8 and reducing unhealthy diet can factors such as high bring a return of US$ 12.82! prevalence among adults blood pressure, from 29.7 percent in 2009 diabetes, high to 23.8 percent in 2015. cholesterol and obesity, tobacco In low-income neighbourhoods This represents a 19.9 use, alcohol in Berkeley, USA, sugary drink percent relative decline consumption, consumption declined by 21 percent of the tobacco physical inactivity after a tax on sugar-sweetened use prevalence. and unhealthy diet. beverages was introduced. Conversely, sales of untaxed beverages rose. PART 1_Background WHY CIRCULATORY 1. DISEASES MATTER… The heart and brain are our best companions: • Controlling hypertension, the number one risk factors for mortality and disability 1. LET’S TREASURE worldwide, is believed to significantly reduce the risk of stroke, coronary heart THEM! disease and heart failure 1,2,3. • The average heart beats about 100’000 a day, and the brain’s 80 billion neurons communicate thousands of times every second to make humans human. It takes just a few minutes after cardiac arrest before a person + experiences brain death and therefore complete death. 100’000 80 billion neurons cardiac arrest beats a day communicate thousands just a few minutes before of times every second brain death/complete death 8

Cardiovascular disease (CVD) and associated conditions are leading causes CVD killed 2. of death and disability: 17.64 million people LET’S CHANGE THAT! in 2016 • CVD, including heart disease and stroke, are the leading cause More than of mortality worldwide4. CVD killed 17.64 million people in 20165. The global burden of CVD, diabetes and kidney disease, expressed in disability-adjusted life years (DALYs) equalled 75% 6 CVD related almost half a billion years in 2016 . • More than 75 percent of CVD-related deaths occur in low- and deaths middle-income countries7. in low and middle income countries • Adults with diabetes have a 2–4 fold increased risk of dying from heart diseases compared to those without diabetes8. Life expectancy is reduced by 12 years in diabetes patients Adults with CVD with previous CVD9. diabetes • An estimated 7.1 million people died as a result of uncontrolled hypertensionc. Almost 1 billion individuals are affected by 2-4 fold hypertension, which is a significant risk factor for cardiovascular increase from dying diseases, stroke and end-stage renal disease10,11 . from a heart leading disease causes of death • Heart disease and stroke are the leading causes of death for for people with people with kidney disease and acute and chronic kidney kidney disease (CKD) are major risk factors for CVD12,13 ,14. disease • Interventions in the 21st century have demonstrated that preventive health actions can reverse and improve circulatory health15. cHypertension is defined as systolic blood pressure ≥140 mmHg, and raised blood pressure as systolic blood pressure ≥110-115 mmHg.

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION WHITE PAPER FOR CIRCULATORY HEALTH BACKGROUND

CVDs are costly: 3. LET’S FOSTER BEST-BUY INTERVENTIONS! • By 2030, the total global cost of CVD is set to rise from approximately US$ 957 billion in 2015 to a US$ 1,044 billion. 55 percent are direct healthcare costs, and 45 percent are due to indirect costs, mainly losses US$ 1,044 of productivity16,17. billion • Heart disease and stroke-related care represents the largest proportion 2030 of diabetes health expenditures: 25 percent of diabetes inpatient costs are a result of heart disease and stroke. Conversely, diabetes is responsible for more than 25 percent of all CVD expenditure18. US$ 957 billion • The out-of-pocket cost of a month’s supply of combined therapy for in 2015 secondary prevention of CVD can reach as much as 18 days’ wages in low $ 19 income countries . global cost out of pocket cost • US$ 1 invested in reducing tobacco use can yield a return of US$ 7.43. Managing CVD and diabetes can yield a return of US$ 2.8, and reducing of combined therapy for CVD unhealthy diet can bring a return of US$ 12.82!20 secondary prevention of CVD can cost 18 days wages in • Keeping blood pressure under control significantly reduces the number low-income countries of cardiovascular events and deaths, making hypertension control one of the most cost-effective population-based interventions in public health.

CVDs can affect everyone: 4. LET’S PROMOTE A LIFE-COURSE APPROACH!

• Impr oving maternal and child health will make a difference for the circulatory health of future generations: the risks of CVD, diabetes, hypertension and kidney disease begin in utero and accrue throughout doubles every the life course21. 2 x decade after age 55 9 risk for CVD • Ag eing increases the risk of heart disease, stroke and other comorbidities. The risk of stroke doubles every decade after the age of 55. • 8-10 percent of the population worldwide suffers from chronic kidney Increasing to: disease. This figure increases to 20 percent in individuals in their 60s, 8-10% and to 35 percent in those aged 70 years and over22. of people suffer from chronic kidney 20% 35% disease globally population 60s 70s+ worldwide

Integrated strategies are scarce: • Approximately 75 percent of CVD is attributable to modifiable risk factors such as high blood pressure, diabetes, high cholesterol and obesity, 5. LET’S CLOSE THE GAP! tobacco use, alcohol consumption, physical inactivity and unhealthy diet 23. • Pr evention can yield positive results. Yet, although most countries have a national strategy that addresses either unhealthy diet, tobacco or diabetes, only 42 percent of countries have national strategies for all three issues24. • Worldwide, less than 1 in 3 countries have smoke-free environments in all indoor workplaces, public transport and indoor public places25, 26. 75%of risk factors are Only 20 percent of countries worldwide have set up an NCD surveillance modifiable • and monitoring system that includes data on mortality by cause and risk factor surveillance, and very few are in low-income countries27. • Scr eening for comorbidities in high risk patients leads to reduced costs, reduced cumulative incidence of grave disease progression and improved overall life expectancy, and should therefore be part of integrated national NCDs strategies and tailored to each setting according to available resources28,29,30. DRIVING SUSTAINABLE ACTION FOR CIRCULATORY HEALTH

PART 1_Background BACKGROUND

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION BACKGROUND THE GLOBAL COALITION FOR CIRCULATORY HEALTH

Cardiovascular disease (CVD), including heart disease, hypertension and stroke, and associated conditions such as kidney diseases and diabetes, are the leading cause of mortality worldwide, with more than 75 percent of these deaths occurring in low- and middle-income countries31. Yet this enormous burden is not being addressed with the priority required. 11 he Global Coalition date to meet the global target of for Circulatory Health REDUCE NCD a 25 percent reduction by 2025 in is the only network premature mortality from heart DEATHS disease and stroke, and on the of international, World Health Organization’s Global regional and national BY 2030 Hearts Initiative; Torganizations advocating for increased prevention, control • Pr omote common messaging by and treatment of all circulatory partner organizations and leverage STRENGTHEN their extensive networks to cascade diseases. Formed in 2017 to messages at regional and national drive the urgent action for THE VOICE OF levels in order to influence relevant circulatory health, the Global local policy- and decision-makers; Coalition aims to: PEOPLE • Str engthen the voice of people • Advocate for and support the living with heart disease, stroke achievement of the Sustainable PROMOTE and associated conditions by Development Goal (SDG) 3.4 of a including patients, their families and one-third reduction in premature communities in decision-making NCD deaths by 2030. The Coalition COMMON processes and in national, regional will build on the work done to MESSAGING and global advocacy. PARTPART 1_ 1_BackgroundBackground

PURPOSE OF THIS GLOBAL BURDEN WHITE PAPER

The present White Paper aims to inform a coherent policy approach to circulatory disease prevention, control and treatment at international, regional and national levels. It provides policymakers with key information and recommendations.

he White Paper is written Economic Growth), SDG 10 (Reduced It presents a range of success stories with sustainability in mind. Inequalities), and SDG 11 (Sustainable in various settings and lists a range This is why it is firmly Cities and Communities). of recommended actions in different fields, such as education and training, placed in the context The White Paper consists of two main universal health coverage, financing, of the United Nations’ parts: the first provides a situation infrastructure, access to medicines, TSustainable Development Goals analysis, the second focuses on and technology (SDGs) and in particular of SDG problem-solving. Target 3.4. of reducing by one This White Paper sheds light on the third premature mortality from global burden of CVD and the state 3.4 non-communicable diseases of circulatory health, and highlights through prevention and current gaps in policy. In addition to treatment and promoting mental providing an overview of the burden health and well-being by 2030. of the disease in terms of mortality, morbidity, disability-adjusted life Beyond target 3.4 and considering the years (DALYs), years of life lost (YLL), impact that circulatory diseases and and cost, it also gives people living NCDs have on health, productivity with circulatory diseases a voice. and the economy, improving Through their testimonies, individuals circulatory health is paramount from different backgrounds illustrate for SDG 1 (No Poverty), SDG 4 the daunting impact of circulatory (Quality Education), SDG 5 (Gender conditions on their daily lives. Equality), SDG 8 (Decent Work and The second part of this White Paper focuses on possible solutions.

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION WHITE PAPER FOR CIRCULATORY HEALTH GLOBAL BURDEN OF CIRCULATORY DISEASE

PART 2_The global burden of circulatory disease GLOBAL BURDEN

he cardiovascular system which are metabolic, behavioural, is composed of three environmental and occupational 32 main elements: the in nature . heart, blood vessels, Many of the risk factors for and blood, which deliver cardiovascular disease lead to Tnutrients and oxygen to all cells atherosclerosis, which is the in the body. The circulatory narrowing and thickening of arteries system consists of two circuits: that develops over the years without causing symptoms. It can happen pulmonary and systemic. The in any part of the body. When 2. pulmonary circuit brings blood atherosclerosis appears around the to the lungs to be oxygenated heart, it is known as coronary artery and then back to the heart. The disease. In the legs it is known as systemic circuit pumps blood to peripheral arterial disease. deliver oxygen and returns de- Atherosclerosis of the arteries is due oxygenated blood to the heart. to the deposition of fatty material, cholesterol and other substances Interruptions, blockages, or in the walls of blood vessels, also diseases that affect blood flow known as plaques. The rupture of can lead to heart disease and a plaque can lead to stroke or stroke. Such complications can a heart attack33. be caused by a variety of factors, 13 THE CIRCULATORY SYSTEM DRIVING SUSTAINABLE ACTION FOR CIRCULATORY HEALTH

PART 2_The global burden of circulatory disease ASSOCIATED CONDITIONS AND RISK FACTORS ASSOCIATED CONDITIONS AND METABOLIC RISK FACTORS

Cardiovascular diseases are People with kidney disease are up to ABNORMAL BLOOD LIPIDS: intrinsically linked with a range of 20 times more likely to die from a high total cholesterol, low-density lipoprotein other chronic conditions, such as heart attack or stroke than they are (LDL)-cholesterol and triglyceride levels, and to receive dialysis35 . diabetes, hypertension, obesity low levels of high-density lipoprotein (HDL)- and kidney disease. Each of these cholesterol increase the risk for coronary heart disease and ischaemic stroke. conditions affect each other in OBESITY: overweight and obesity may lead various ways, leading to a vicious to hypertension, diabetes and cycle of cause and consequence. PRE-ECLAMPSIA: atherosclerosis, which in turn increase which occurs in 3-5 percent of all the risk for heart disease, stroke and pregnancies worldwide, is an important, HYPERTENSION: kidney disease. yet often neglected, predictor of future CVD, is a major risk factor for heart attack, hypertension and kidney disease36. causing about 50 percent of ischaemic 14 strokes, and is a significant cause and consequence of kidney disease. The World Health Organization (WHO) rates hypertension as one of the most important causes of premature death worldwide. Peripheral Haemorrhagic Ischemic stroke DIABETES: vascular disease stroke multiplies the risk of developing CVD by 2 to 4 and contributes to 16.1 percent of the CVD burden. Conversely, heart disease and stroke are the leading cause of mortality for people with diabetes. Diabetes is the leading cause of end-stage kidney disease worldwide. Pre-eclampsia HYPERTENSION Heart failure CHRONIC KIDNEY DISEASE: OBESITY DIABETES reduced kidney function increases the risk for heart disease and stroke. It can lead to hypertension, which in turn is a major risk for heart attack and stroke. Conversely, high blood pressure can damage the blood vessels that carry Low Coronary blood to the kidney filters, and the kidney birth Kidney disease artery disease filters themselves. Severe hypertension weight can weaken and enlarge the heart muscle, which can cause kidney failure. Low glomerular filtration rate (GFR) contributes to 7 percent of cardiovascular deaths34.

d Adapted from a figure provided by Dr Valerie Luyckx, International Society of Nephrology.

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION GLOBAL BURDEN OF CIRCULATORY DISEASE

Number of Disability-Adjusted Life Years (DALYs) due to CVD, Global, both sexes, 2000 and 2016

CVD CAUSE 2000 RANK (% OF ALL) 2016 RANK (% OF ALL) 1. Ischemic heart disease 158,738,404.1 (52.1%) 208,846,775.3 (54.5%) 2. Stroke 100,757,889.8 (33.1%) 116,332,748.9 (30.4%) 3. Hypertensive heart disease 13,701,579.5 (4.5%) 15,450,446.6 (4.0%) 4. Other cardiovascular and circulatory diseases 10,101,831.6 (3.3%) 14,888,661.5 (3.9%) 5. Rheumatic heart disease 7,163,585.2 (2.4%) 9,542,474.7 (2.5%) 6. Cardiomyopathy and myocarditis 6,644,777.7 (2.2%) 6,239,513.3 (1.6%) 7. Atrial fibrillation and flutter 3,375,243.2 (1.1%) 5,407,780.4 (1.4%) 8. Aortic aneurysm 2,170,413.6 (0.7%) 3,728,304.7 (1.0%) 9. Endocarditis 1,667,716.7 (0.5%) 1,998,407.2 (0.5%) 10. Peripheral artery disease 503,394.0 (0.2%) 861,976.0 (0.2%) All CVD causes (total) 304,824,835.5 (100%) 383,297,088.4 (100%)

BEHAVIOURAL RISK FACTORS 15

TOBACCO USE: increases the risk of heart disease, stroke A diet high in sodium (salt) increases the risk for hypertension. and kidney disease, in particular in people who started young, and Estimates have shown that a reduction in dietary intake of sodium in heavy smokers. Passive smoking is an additional risk. It is estimated by about 1g of sodium a day, about 3g of salt, would lead to a that smoking increases the risk of stroke and coronary heart 22 percent drop in the number of deaths resulting from strokes and a 16 percent fall in the number of deaths from coronary disease by 100 percent. Smoking increases the risk of death from 38 undiagnosed coronary heart disease by 300 percent37. heart disease . Conversely, a diet rich in fruits and vegetables, wholegrain cereals and fish has a protective effect. As an example, low fruit and PHYSICAL INACTIVITY: can lead to obesity and vegetable intake accounts for about 20 percent of heart disease increases the risk of heart disease and stroke by 50 percent. and stroke worldwide. It is also a risk factor for both insulin resistance and CVD. Large amounts of sugar, in particular in sweetened soda beverages, have been linked to an increase in CVD mortality39. A diet high in saturated fat increases UNHEALTHY DIET: It is estimated that each US$ invested in reducing unhealthy diet the risk of heart disease and stroke. It is estimated to cause about 40 31 percent of coronary heart disease and 11 percent of stroke yields a return of investment of US$ 12.82 . worldwide. Compared to the typical diet of someone living in high-income countries, a diet low in saturated fats, which is rich in EXCESSIVE ALCOHOL USE: Harmful uses of alcohol fresh fruit and vegetables, reduces the risk of new major cardiac has been shown to damage heart muscle and increase the risk of events by 73 percent. stroke and cardiac arrhythmia. It is estimated that each US$ invested in reducing the harmful use of alcohol yields a return of investment of US$ 9.1341. PART 2_The global burden of circulatory disease OTHER MODIFIABLE FACTORS

Such as low birth weight and preterm births, constitute risk factors for CVD, LIFE-COURSE RISKS: hypertension, diabetes and kidney disease that could be modified through improved maternal and child health and nutrition42.

ENVIRONMENTAL RISK FACTORS: Environmental factors, such as exposure to ambient air pollution and particulate matters, play a significant and modifiable role in CVD and associated conditions43.

LOW SOCIOECONOMIC Poorer segments of the population are disproportionately affected by circulatory and stroke. A chronically stressful life, social isolation, anxiety STATUS: and depression also increase the risk44.

Awareness of CVD, CKD and diabetes within the population is low, hence LACK OF AWARENESS: these conditions are often only diagnosed once they have reached advanced stages and have caused irreversible damage.

16 NON-MODIFIABLE RISK FACTORS

ADVANCING AGE: Impact of associated conditions and selected risk Getting older constitutes a risk factor for circulatory disease. The risk 45 of stroke, for example, doubles every decade after age 55. factors on CVD deaths (2016)

SEX: RISK FACTOR NUMBER OF DEATHS CVD affects men more than pre-menopausal women. But once past All risk factors 15,256,450 the menopause, a woman’s risk is similar to a man’s. The risk of High systolic blood pressure 9,759,724 stroke is similar for men and women. Dietary risks 9,085,088 ETHNICITY: High total cholesterol 4,392,505 Individuals with African or Asian ancestry are at higher risks of Environmental/occupational risks 3,898,727 developing heart disease and stroke than other racial groups. In addition, some of these high-risk racial groups have less access to care. Tobacco 2,914,125 High body-mass index 2,850,587 HEREDITY OR FAMILY HISTORY: The risk increases if a first-degree blood relative has had coronary High fasting plasma glucose 2,840,891 heart disease or stroke before the age of 55 years (for men) or 65 Impaired kidney function 1,368,494 years (women)45. Alcohol use 797,869

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION WHITE PAPER FOR CIRCULATORY HEALTH GLOBAL BURDEN OF CIRCULATORY DISEASE

THE BURDEN OF CIRCULATORY DISEASE 2016 Disability-adjusted life years by country, Global CVD DALYs per 100,000 persons, 2016

DALYs per 100,000 2500 – 3500 3500 – 4500 4500 – 5500 5500 – 6500 >6500 17 Not applicable or data not available

Heart disease, stroke, diabetes and kidney disease are Diabetes affected 425 million Circulatory diseases major causes of premature death and chronic individuals and caused 4 million predominantly affect the poor 49 disability in all regions of the world. More people die deaths in 2017 . Hypertension and vulnerable, in particular (SBP ≥140 mmHg), a leading risk in low- and middle-income from heart disease and stroke worldwide than from factor for circulatory diseases countries56. Although age- any other cause. and associated conditions such standardized rates of heart as renal diseases, affects over disease and stroke mortality In 2016, there were an estimated 470 million cases of one billion people globally have dramatically dropped heart disease and stroke and 17.64 million deaths due and is linked to one in five in regions with high socio- deaths and seven percent of demographic indicators in the to heart disease and stroke. Of these deaths, 80 percent disability50,51,52. Chronic kidney past 25 years, only a gradual are due to heart attack and strokes, and about three disease affects 752 million decrease or no change has quarters occur in low- and middle-income countries48 . individuals worldwide and been observed at all in most caused at least 2.4 million other regions. deaths in 201653,54. Significant reductions in In 2016, the global burden of CVD, atherosclerotic vascular disease diabetes and kidney disease, mortality, an important success expressed in DALYs, amounted for public health, seem to have to almost half a billion years come to a halt in many regions (445,386,944.5)! World-wide, of the world, despite impressive CVD, diabetes, kidney disease, advances in technical capacity hypertension and obesity for preventing and treating heart amounted to 665,913,553 years disease and stroke57. Similar of life lost in 201655. concerns prevail for other associated conditions. DRIVING SUSTAINABLE ACTION FOR CIRCULATORY HEALTH

PART 2_The global burden of circulatory disease

In 2016, the global burden of CVD, diabetes and kidney disease, expressed in disability-adjusted life years, amounted to almost half a billion years (445,386,944.5)! World- wide, CVD, diabetes, kidney disease, hypertension and obesity amounted to 665,913,553 years of life lost in 201655.

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION GLOBAL BURDEN OF CIRCULATORY DISEASE

Change in CVD Disability-Adjusted Life Years (DALYs), 2000-2016, Global Percent change in CVD DALYs per 100,000 persons between 2000 and 2016

Percent Change >20% decrease 10-20% decrease 0-10% decrease 0-10% increase 19 10-20% increase Not applicable or data not available

Prevalence, deaths, Disability-Adjusted Life Years (DALYs)e 58, and Years of Life Lost (YLLs) in 201659

Prevalence Deaths DALYs YLLS CVD (incl. stroke) 470,811,346 17,646,585 353,120,871 319,638,664 Stroke alone 80, 065, 452 5,528,232 116,445,136 101,992,787 DM 383,453,015 1,437,706 57,233,688 28,650,003 Impaired kidney function/CKD 752.7 million 52 2,554,212 60,482,176 49,696,955 Obesity 432,822,019 4,525,095.23 135,381,335 100,463,112 Raised blood pressure 3,466,261,00053 10,455,860 212,105,088 190,901,236 SBP ≥110-115 mm H

eDALYs for a disease or health condition are calculated as the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for people living with the health condition or its consequences. PART 2_The global burden of circulatory disease COSTS OF CIRCULATORY DISEASE

In 2015, the global cost of CVD was estimated at US$ 957 billion. This cost Heart disease, stroke and related is likely to reach US$ 1,044 billion in 2030 – an increase of 22 percent. About conditions easily can lead to poverty, 55 percent of the global cost of CVD is due to direct healthcare costs and the especially in countries where out-of- pocket expenditure is high. It means remaining 45 percent to productivity loss from disability or premature death, that, for some parts of the population, 62,63 or time loss from work because of illness or the need to seek care . treatment becomes unaffordable. For example, the cost of combined therapy for secondary prevention in patients with established CVD was found to equal 18 days’ wages in some low- $956 BILLION income countriesf, 65. Global costs attributable to CVD and CVD incidence (in 1000s), 18 DAYS WAGES f 64 Secondary prevention: aspirin, betablocker, selected years: 2010-2030 angiotensin-converting enzyme inhibitor and statin.

Year Total cost (billions of US$) CHF Incidence IHD Incidence Stroke Incidence 2010 863 10,072 24,167 28,299 2015 906 10,821 25,933 30,370 20 2020 957 11,830 28,284 33,122 2025 1,002 12,754 30,369 35,571 2030 1,004 13,637 32,339 37,886 Total all years, 20,032 2010-2030

In addition, CVD-related care also represent large proportions of the health expenditure related to other diseases. For example, 25 percent of diabetes inpatient costs are a result of cardiovascular complications. At the same time, diabetes is responsible for more than 25 percent of all heart disease and stroke expenditure66. In 2015, 1 in 5 Medicare dollars in the United States of America (USA) were spent on patients with chronic kidney disease67. In the UK, annual costs due to kidney 68 $ 1,044 BILLION disease alone amount to approximately £1.44 billion .

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION WHITE PAPER FOR CIRCULATORY HEALTH LIVING WITH CIRCULATORY DISEASES

PART 3_Living with circulatory diseases

ithin the public associated conditions on the global health community, population. However, the multitude references to the of individual fates that make up these massive numbers shall not be number of deaths, forgotten – individual trajectories disability-adjusted that are made of distress, pain Wlife years, or years of life lost are and loss, but also hope, strength, very popular. solidarity, and courage. In this section, individuals from different Global figures, as presented in backgrounds, ages and countries tell 3. this White Paper, highlight the us how circulatory disease affects, massive global impact of CVDs and or may affect their lives. LIVING WITH CIRCULATORY 21 DISEASES DRIVING SUSTAINABLE ACTION FOR CIRCULATORY HEALTH

PART 3_Living with circulatory diseases

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION LIVING WITH CIRCULATORY DISEASES COMMUNITY VOICES

g Kevin’s life is not as exciting as it drive home, where he usually does some 23 should be when you’re 17 years old. homework and then plays online with KEVIN He lives with his parents in a small flat friends, drinking massive amounts of IMPACT ON in a crowded urban area. His weekly soda. Kevin used to play basketball down CIRCULATORY HEALTH: routine consists of a bowl of cereals for the block, but the last green patch in the breakfast and entire days spent at school. neighbourhood was replaced by a huge Unhealthy eating habits, smoking, lack At lunchtime, Kevin and his friends grab office building. What does this daily routine of exercise and overweight put Kevin’s a soda, a slice of pizza, a hotdog or a mean for his health? Kevin knows that he organs under stress. It is only a matter burrito, because “It’s cheaper and tastier is slightly overweight, but believes himself of time before one of them (the weakest than the daily ‘balanced’ menu they serve to be otherwise healthy. He is still young, one) gives way. If Kevin continues on there”. Before going back to class, they so he is not worried about the effects of too this path, hypertension, diabetes or usually sneak out and smoke a couple of much comfort food, smoking and lack of kidney disease are looming. So are cigarettes. After school, the same routine exercise on his body. heart disease or stroke. applies: a cigarette and then the bus

WHAT COULD HELP HIM?

Kevin is still in his early years. Yet, if nothing is done, he will not become a healthy young adult. His direct healthcare costs will be significant, and so will indirect costs translated in lack of energy, sickness and loss of productivity. The following interventions could make a difference for Kevin: • A healthy and balanced school nutrition programme, without sweet beverages; • A ban on tobacco advertising and sales to minors; • An infrastructure that fosters physical activity, such as a cycling lane that brings him safely to school, and outdoor sports facilities in his neighbourhood; • A systematic school screening programme (body mass index, blood pressure, smoking and other lifestyle habits, diabetes screening);

• A free counselling programme (for tobacco cessation, weight reduction). g This case does not represent a specific individual but illustrates a common disease trajectory and any resemblance to a specific individual is purely coincidental. PART 3_Living with circulatory diseases

MARIA hMaria’s life is a marathon: between going to the doctor is expensive for a IMPACT ON working full time, taking care of her struggling single mother, but was finally left house and raising three teenagers, with no choice. CIRCULATORY 24 she never seems to have a minute for HEALTH: herself. To make things worse, in the past Apart from being overweight, Maria was year she has been sleeping poorly, feeling diagnosed with hypertension and type II Maria lives a hectic life and does constantly tired, suffering from frequent diabetes and told that her kidney function not have much time to look after headaches, and craving food and drinks. was impaired, which might have been herself. Because most circulatory Maria put it all on her hectic life as a single, caused by her undiagnosed raised blood diseases are, at first, silent, she working mum. pressure and diabetes. She is now under was asymptomatic and did not medication and has to drastically change seek medical guidance. Maria Recently, however, she told a friend about her lifestyle. Otherwise, the doctor warned has therefore been suffering her constant fatigue, and was advised to that she would be a great candidate for from hypertension, diabetes and visit a doctor. Maria hesitated, because heart disease and stroke. impaired kidney function for months or even years without being aware that her body was struggling. As a result, she is now a high-risk WHAT COULD HELP HER? candidate for heart disease and stroke and will need to drastically Maria is a very busy and active woman. However, because she delayed seeking change her lifestyle in order to medical guidance, she allowed her condition to worsen. The direct costs of her maintain her quality of life and treatment will now be significant. There is hope, however. By strictly adhering to her to prevent any aggravation of her treatment, Maria will be able to limit indirect costs and continue her life and work as circulatory diseases. before. The following interventions could make a difference for Maria: • A free community-based screening programme (body mass index, blood pressure, diabetes screening, urine test for proteinuria screening, smoking and other lifestyle habits); • UHC that includes screening and management of circulatory diseases; • A free individual counselling programme to help her change her dietary habits and to quit smoking; • Free or affordable access to medicines that will allow her to maintain her medical condition.

hThis case does not represent a specific individual but illustrates a common disease trajectory and any resemblance to a specific individual is purely coincidental.

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION WHITE PAPER FOR CIRCULATORY HEALTH LIVING WITH CIRCULATORY DISEASES

Letlhogonolo was in her teens when she school. She did not think it would take years to suffered a stroke during a school for a choir recover from her stroke. The reality was much workshop. She did not experience any of the bleaker, though. Letlhogonolo’s first three LETLHOGONOLO usual symptoms, such as face drooping, arm years of rehabilitation were tough: she kept weakness or speech difficulties. Instead, she struggling with what happened and thinking was about to start warming up with her friends of her friends progressing with their education. when she suddenly started feeling strange. Having a stroke at such a young age made She ran out of the room and sat, but shortly things more difficult to understand. “When you afterwards found herself lying on the floor, with have plans with your friends for your future, her eyes closed. Letlhogonolo heard her friends and when you see that your dream becomes calling her mother. One of them was crying. She impossible, it hurts… a pain you wouldn’t wish was brought to hospital, but a lot of time was upon anyone. Without such great support from wasted travelling to different hospitals because family and friends, life would have been harder only one had the necessary equipment. and acceptance almost impossible. I probably Through it all, Letlhogonolo hoped that she would’ve taken longer to get to where I currently would soon be discharged from hospital, where am in my journey to recovery. Nobody should go she was undergoing rehabilitation, and get through this alone,” says Letlhogonoloi. back to school to finish her final year of high i Testimony provided by and adapted from the World Stroke Organisation.

Nick was just 39 when, just after New Year’s hospital and didn’t even have a GP! When he was Eve, he had to take sick leave from work. given the heart failure diagnosis, he felt like he He had previously been feeling lethargic, which had been hit by a boxer; his life felt as though it NICK had only got worse over the festive period, and had fallen apart. “A good analogy is: before I was had been having difficulty walking up the hill diagnosed my life was a jigsaw, nearly complete. to his office in Manchester. Although he had no After diagnosis, it is a mess of pieces. So self- appetite, Nick was also putting on weight. At a management is all about finding those corners and first visit to the general practitioner (GP), he was colour combinations,” says Nick. prescribed cough syrup. When that had no effect, a second appointment resulted in a diagnosis of Approximately five months after he was chest infection and a prescription of antibiotics. diagnosed, he decided to set up a support organisation for people diagnosed with heart Yet his symptoms worsened to the extent that he failure. This is because, while Nick received great could not walk five yards. Blood tests revealed a support and advice from health professionals, he 25 possible liver or kidney infection. He was feeling was lacking to some extent the personal patient so unwell that he was finally admitted to hospital. touch. The Pumping Marvellous Foundation, the Almost one week later, a doctor finally said ‘It’s your organization Nick founded, was meant to be a heart’. He was then diagnosed with heart failure. local patient support group but quickly grew into a national organisation which supports patients Before, Nick was relatively fit and active, and ate in the management of their condition and helps a healthy diet. He had never been admitted to them to advocate for their rights69.

JAMES away and James did not go for health follow- when climbing stairs and is awaiting a second ups frequently. Poor roads in the winter made kidney transplant for a new chance at life. access to healthcare even more challenging. In addition, James felt fine and thought his family doctor was exaggerating the risks that The following interventions could make diabetes posed. a difference for James: James developed high blood pressure in his • Community and family engagement and mid-20s. By his early 30s, he developed kidney support, especially for adolescents for whom failure. He was initially treated with dialysis and adherence tends to be challenging; then was fortunate to get a kidney transplant. The transplanted kidney lasted for more than • Early detection and management jJames is a 46 year-old man from rural 10 years but eventually failed, forcing James to of diabetic kidney disease through urine Canada. He developed type 1 diabetes at go back on haemodialysis. protein screening, control of blood age 12 and since then has had to take daily pressure, use of angiotensin-converting Dialysis is time consuming and means he can measurements of his blood sugar, monitor enzyme inhibitors; his diet and inject himself with insulin. During no longer work. After a year on dialysis, James his teenage years and early adulthood, James developed a foot infection after getting a • Access to frequent health follow-up; blister from a new pair of shoes and required was too busy with his friends and with his • Tobacco control programmes; construction business to worry too much an amputation of his lower leg. True to form, about his diabetes. he soon learned to walk with a prosthesis and • Promotion of deceased donation regained his independence. for transplantation. He also smoked a pack of cigarettes per day. The family doctor was in a town 1.5 hours He has subsequently required a cardiac bypass after noticing worsening shortness of breath

j This case does not represent a specific individual but illustrates a common disease trajectory and any resemblance to a specific individual is purely coincidental. DRIVING SUSTAINABLE ACTION FOR CIRCULATORY HEALTH

PARTPARTPART 4_ 3_ 1_SuccessPatientBackground Voicesstories SUCCESS

ublic health interventions The following case studies present can be implemented a series of public health interventions at several levels, with that have made a positive contribution to the prevention and varying degrees of impact. control of circulatory diseases in They range from taking different settings. They are meant Paction at the population level to to illustrate the wide spectrum of targeting individuals. positive initiatives around the world 4. rather than be an exhaustive list. STORIES 26

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION SUCCESS STORIES SUCCESS STORY : 1 THE EXCISE TAX REFORM IN THE PHILIPPINES

CHALLENGE OUTCOMES The reform scaled up financing Country: Philippines Up until 2012, cigarette prices in the Philippines for health care, nearly doubling Government were very low. Falling real taxes and growing the Department of Health’s Initiator: budget. It funded the extension of incomes meant that tobacco and alcohol products Instrument: Fiscal policy were widely accessible and affordable. In addition, fully subsidized health insurance the multi-tier excise regime was complicated and to the poorest 40 percent of the created perverse incentives. The system needed to population. From 2013 to 2015, be simplified and modernised. the number of poor and near- poor families enrolled expanded from 5.2 million to 15.3 million, almost tripling the coverage of the poor and near-poor. Excise tax revenues were also subsequently RESPONSE used to subsidize the insurance coverage of senior citizens, further The Philippines’ excise tax expanding access to care among reform was conceived to the most vulnerable. simplify and increase tobacco and alcohol excise taxes. Retail prices for cigarettes 27 Simultaneously, increases in increased significantly because of revenue were earmarked to the reform, prompting consumers fund universal health care. to cut down and even stop smoking. Increased taxation has Enacted in December 2012, the led to a significant decrease in reform raised and simplified smoking prevalence among adults, tobacco and alcohol excises, with from 29.7 percent in 2009 to 23.8 increased government revenues percent in 2015 (from 49.5 percent and reduced smoking. Within one to 41.9 percent among men; from year, excise tax collections from 10.1 percent to 5.8 percent among tobacco and alcohol products women). This represents a 19.9 increased by approximately percent relative decline of the US$ 2.44 billion, i.e., an 86 percent tobacco use prevalence70,71 . increase compared to the pre-reform years. The 2012 Philippines Excise Tax Law (ETL) brought about long- overdue reforms to tobacco and

alcohol taxation to promote better health. This reform exemplifies

how the Philippines made a tangible difference in the lives of millions of Filipino citizens. Many thought it was impossible to pass the Excise Tax Reform Bill: “ the enemy is strong, loud, organized, and has deep pockets. But, as we have proven time and again, nothing is impossible with the Filipino nation rowing in one direction, heart in the right place, “ and ready to stand up for its principles.

President Benigno Aquino PART 4_Success stories SUCCESS STORY : 2 PRIMARY CARE PREVENTION OF HEART DISEASE AND STROKE IN THE SEYCHELLES CHALLENGE The main features of this heart disease and stroke prevention Country: Seychelles programme included: An epidemiological study conducted in the 1980s in Government the Seychelles revealed worrying results: the rates of Initiator: • Awareness-raising campaigns cerebrovascular diseases were higher than in most through the use of media, Instrument: Primary care European countries and the medium rates of ischaemic especially radio and television; prevention heart disease were similar to those in southern European countries, especially in young and middle- • Screening of risk factors in aged men. The prevalence of hypertension and diabetes • Establishing a national register schools within routine school was also high in the adult population, and a substantial for hypertension and diabetes, medical visits for children aged proportion of children were overweight. The high which recorded blood pressure, 5, 9, 12 and 15; burden of heart disease and stroke in the Seychelles body mass index, total was also associated with rapid lifestyle changes, such cholesterol, HDL cholesterol, • Organising health education as increased consumption of saturated fatty foods, glucose levels, smoking, previous activities in the frame of the increased intake of salt and calories, and growing stroke and myocardial infarction World No Tobacco Day, Diabetes prevalence of smoking and sedentary lifestyles. and fed back information to Day and Heart Day programmes. health centres. For example, the lists of diabetic patients In a second phase, the 28 were sent to ophthalmology Seychelles heart disease and departments to promote RESPONSE stroke prevention programme screening and treatment of was scaled up to include A national programme on the eye diseases. not only health-promotion prevention of heart disease activities, but also interventions and stroke was initiated in targeting high-risk individuals 1991 under the umbrella of OUTCOMES such as: the Unit for the Prevention More than 90 percent of adults and Control of Cardiovascular • Risk-factor screening in public aged 35–65 years have good Disease (UPCCD) of the Ministry places and work sites, including knowledge of heart disease of Health, in collaboration follow-up visits for suspected and stroke and are aware of the with the University Institute cases of hypertension, diabetes main activities offered within of Preventive Medicine of and dyslipidaemia. the prevention programme. Lausanne, Switzerland. The prevalence of smoking • Setting-up community-based decreased, and the prevention The programme was community- health clubs for high-risk programme contributed to based and involved non-physician individuals in primary healthcare attenuate increases in blood healthcare workers. In an centres or in district community pressure and cholesterol levels in attempt to prevent and control centres, to build the skills needed the population. premature morbidity from heart for the adoption of a healthy disease and stroke, diabetes and lifestyle, such as healthy In addition, the involvement of smoking, it aimed at promoting cooking, and to increase community members generated healthy lifestyles and controlling adherence to treatment; a broad coalition among the risk factors. public, authorities and other organisations that will be used to develop new health interventions and policies72,73.

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION WHITE PAPER FOR CIRCULATORY HEALTH SUCCESS STORIES SUCCESS STORY : 3 NURSING STEPPING UP TO CURB NCDS IN TONGA

CHALLENGE OUTCOMES Country: Tonga NCDs accounted for 75 per cent of all deaths in This nurse–led initiative has already Tonga in 2008. According to the Minister of Health, enhanced the accuracy of data Initiator: Government collection on NCDs; improved 99 percent of the Tongan adult population is at Instrument: Community-based medium to high risk of developing a NCD. diabetes and cardiovascular NCD nurses disease monitoring and treatment; enhanced community participation in exercise and nutrition programmes; and reduced the need RESPONSE for amputations74. The focus on NCDs in Tonga began in 2003 with the development of a comprehensive NCD strategy (2004–2009). From the inception of the programme, nurses were seen as having a central role to play. The next NCDs strategy (2010– 29 2015) focused on improving data collection and implementation.

Several years earlier, reproductive health nurses had been specifically educated and stationed in each community health centre, resulting in a significant reduction in maternal and infant mortality, morbidity and rise in immunisation rates. It was felt that this community–based, nursing– led model might also work with NCDs if a role could be introduced which would combine health promotion, early detection, illness prevention, treatment adherence, rehabilitation and palliation.

A pilot was set up in 2012 in five community centres which quickly confirmed the efficacy and acceptance of this programme. Funding was sought for rolling the NCD nurse programme out to 20 community centres and selected community nurses were specifically trained. DRIVING SUSTAINABLE ACTION FOR CIRCULATORY HEALTH

PART 4_Success stories

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION SUCCESS STORIES

SUCCESS STORY : 4 SMART HEALTH FOR BETTER CARDIOVASCULAR HEALTH IN INDIA CHALLENGE Physicians can share their diagnosis and management plan Country: India with community health workers Rural India is home to 750 million people living in through their devices. In addition, George Institute for 650,000 villages. Most premature deaths in adults Initiator: the system can also disseminate Global Health are due to chronic conditions, such as heart disease text or voice messages to promote and stroke. The doctor to patient ratio in rural India healthy behaviours and treatment Instrument: Mobile technology is 10 times greater than that for India as a whole. As adherence, which helps overcome a result, most people with chronic conditions have illiteracy/language barriers. little or no access to simple, affordable preventive treatments. Efforts are therefore necessary to diagnose individuals at high risk of heart disease OUTCOMES and stroke and offer treatments to lower that risk. The use of technology has helped overcome system level barriers such as workforce shortage via task-shifting.

RESPONSE The availability of a uniform, 31 evidence-based clinical decision SMART Health (Systematic support mechanism, electronic Appraisal Referral and Treatment medical records and a reliable system) has been developed community-based disease registry by the George Institute of have contributed to improvements Public Health researchers in in quality assurance. India, Australia and the UK to strengthen the capacity of The tool was easy to integrate primary care physicians and into the workflow of healthcare community health workers. The workers, making it a feasible and intervention employed a mobile acceptable mobile technology. device-based, clinical decision, The clinical impact of the mHealth support system that uses a platform is currently being guideline-based screening and evaluated based on over 16,000 management algorithm aimed individuals at high risk of heart at improving blood pressure disease and stroke who have control in high risk individuals. been screened75,76.

In short, community health workers screen individuals in the community using the SMART Health application which has been previously loaded on a tablet device. The information collected is then uploaded via a 2G or 3G network to a secure, cloud-based, open-source electronic medical record system. Community health workers can then make electronic referrals to primary care physicians. PART 4_Success stories SUCCESS STORY : 5 REDUCED MORTALITY THROUGH SYSTEMATIC SCREENING AND TREATMENT 77 CHALLENGE OUTCOMES Country: Australia, Tiwi Islands Australian Aborigines in remote areas have high The introduction of a systematic University of rates of all-cause mortality, of cardiovascular deaths screening and treatment Initiator: and of end-stage kidney failure. People living in programme led to an estimated Queensland the Tiwi Islands were particularly exposed. In the 50 percent reduction in the Instrument: Systematic screening 1990s, the Tiwi community had a three- to five-fold rate of natural deaths and and treatment increase in death rates and an annual incidence of 57 percent reduction in the treated end-stage kidney disease (ESKD) of 2,760 rate of renal failure. per million. 25 percent of natural deaths in Tiwi adults were renal deaths, 42 percent had a primary Increased awareness, improved or underlying cardiovascular cause, and 43 percent health education and better were of neither renal nor cardiovascular cause. metabolic management all Costs for treating ESKD in particular were spiraling contributed to the success of out of control. the programme. However, what made the programme successful was the provision of adequate medication for renal and 32 cardiovascular protection. The fall RESPONSE in blood pressures, the reduced progression of albumin- In order to halt this negative to-creatinine ratio and the spiral, a formal programme reduction in the loss of GFR led to was introduced to alter renal a reduction in renal and all-cause and cardiovascular disease natural deaths. outcomes. A systematic screening and treatment programme In addition, looking at the was introduced for adults with avoidance of dialysis alone, confirmed hypertension, diabetics millions of dollars were saved. with microalbuminuria or overt More generally, the reduction in albuminuria, and people with premature death is the greater overt albuminuria, regardless benefit. This chronic disease of blood pressure and diabetes. programme was shown to be Aside from a health education highly effective in such a high- component, the programme risk community, leading to a mostly focused on providing significant reduction in all-cause adequate treatment to all adults mortality and in considerable affected. Treatment focused on savings due to the avoidance of the use of angiotensin-converting costly treatments like dialysis. enzyme inhibitors with other medications as needed to reach defined blood pressure goals and attempts at control of glucose and lipid levels.

THE INTRODUCTION OF A SYSTEMATIC SCREENING AND TREATMENT PROGRAMME LED TO AN ESTIMATED 50 PERCENT REDUCTION IN THE RATE OF NATURAL DEATHS AND 57 PERCENT REDUCTION IN THE RATE OF RENAL FAILURE.

CHALLENGE While all socioeconomic groups bought fewer taxed beverages, Country: Mexico households of low socioeconomic In Mexico, one in three children and adolescents status decreased their beverage Initiator: Government aged 2-18 is overweight. Among adults, the purchases by 17 percent by prevalence of overweight and obesity is higher Instrument: Tax on sugar- December 2014 compared with than 70 percent. The prevalence of diabetes in sweetened beverages pre-tax trends. Over the same Mexico is the highest among countries belonging period, sales of bottled plain water to the Organization for Economic Co-operation increased by 4 percent. and Development (OECD) and ischemic heart disease and diabetes are the two leading causes A 2016-modelling study of mortality. Concomitant with the rise in obesity projected that a reduction of and diabetes are significant increases in the 10 percent in the consumption consumption of sugar-sweetened beverages (SBB) of sugar-sweetened beverages among Mexicans. In 2011, Mexico had the largest per among adults in Mexico would capita (163 litres) consumption of soft drinks. prevent 189,000 cases of type 2 diabetes, 20,400 incidents of stroke and myocardial RESPONSE infarctions, and 18,900 deaths 33 between 2013 and 202281. In September 2013, as part of Encouragingly, the study the federal budget, the Mexican estimated the biggest health congress passed an excise tax on gains from the SSB tax in young sugar-sweetened beverages and adults aged 35 to 44 years old. a sales tax on several energy dense foods. Similar trends were observed in other countries which also A specific excise tax of 1 peso/L introduced excise taxes: (approximately a 10 percent price increase) on non-dairy and • In France, a 6.7 percent decline non-alcoholic beverages with in demand for regular cola was added sugar and an ad valorem observed in the first two years tax of 8 percent on a defined list of after the SSB tax was introduced. non-essential highly energy dense foods (containing ≥275 calories • In low-income neighbourhoods (1151kJ) per 100 g) came into effect in Berkeley, USA, sugary drink on 1 January 2014. Agencies collect consumption declined by 21 the excise tax on sugar-sweetened percent after an SSB tax was beverages from the manufacturers, introduced. Conversely, sales of and this tax is passed on to untaxed beverages rose. consumers at the point of sale.

OUTCOMES

Following the introduction of the tax on SSB, the price of sugary FOR MORE drinks increased by around 10 SUCCESS percent and consumption fell by around 6 percent. By December STORIES 2014, soda sales were down 12 percent from December CLICK HERE 2013, and the drop was greatest among the poorest Mexicans. DRIVING SUSTAINABLE ACTION FOR CIRCULATORY HEALTH TAKING ACTION

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION TAKING ACTION

PART 2_The global burden of circulatory disease TAKING ACTION WHY ARE HEART DISEASE 5. & STROKE A PUBLIC HEALTH ISSUE?

Circulatory diseases are an issue of public health relevance because they: 35 Disproportionately affects vulnerable segments of the + population Pose a large and increasing burden and cost on society

Can be influenced by preventive strategies that are + not yet in place Public health issue = PART 5_Taking action TAKING ACTION Heart disease, stroke, diabetes, hypertension, kidney disease, and other NCDs share a range of modifiable risk factors. Policies that include comprehensive and inclusive strategies to reduce the risk of NCDs and create environments that are conducive to healthy habits are needed. In addition, health systems must be shaped in a way that allows early detection and management of heart disease, stroke and related NCDs. Promoting and maintaining good circulatory health necessitates a combination of both prevention and treatment approaches.

n 2015, the United Nations These recommendations: Member States have adopted SUSTAINABLE DEVELOPMENT GOALS the Sustainable Development • Are grounded in evidence with regard Goals (SDGs) for 2030. Those to their effectiveness and cost- effectiveness; include several targets that By 2030, reduce by one third premature Iare related to NCDs, and hence • Are globally relevant, taking into 3.4 account that regional or national mortality from non-communicable diseases through to circulatory health. Specifically, differences may exist; prevention and treatment and promote mental health Goal 3 “Good Health and Well- • Reinforce recommendations that and well-being. being” include several targets stem from the Third High-level that are closely linked with NCDs Meeting on NCDs, but also look and circulatory health. Beyond beyond the UN HLM to drive action 3.5 Strengthen the prevention and treatment of Goal 3, circulatory diseases are on circulatory health for the years substance abuse, including narcotic drug abuse and affected by, and can contribute to come; harmful use of alcohol. to, each and every SDG. • Can be acted upon by members of the Global Coalition for Circulatory The recommendations below rely on Health and their global, regional and 36 Achieve universal health coverage, including four main pillars. Together, they aim national networks; 3.8 financial risk protection, access to quality essential to drive action to achieve the health- health-care services and access to safe, effective, related SDG objectives. Based on these Each recommendation is quality and affordable essential medicines and four top-line fields of action, the Global accompanied by a range of actions vaccines for all. Coalition has identified selected strong which the Global Coalition and its recommendations which governments members can undertake to support are called upon to implement as governmental authorities and intergovernmental agencies in their a priority. Strengthen the implementation of the World implementation efforts. 3A Health Organization Framework Convention on Tobacco Control in all countries, as appropriate.

3B Support the research and development of vaccines and medicines for the communicable and non-communicable diseases that primarily affect developing countries, provide access to affordable Prioritizing Fostering essential medicines and vaccines. multisectoral, access to cost-effective prevention interventions and care 3C Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States. Mobilizing resources for Measuring circulatory progress 3D Strengthen the capacity of all countries, in health particular developing countries, for early warning, risk reduction and management of national and global health risks.

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION WHITE PAPER FOR CIRCULATORY HEALTH TAKING ACTION

PRIORITIZING MULTISECTORAL, PILLAR 1: COST-EFFECTIVE INTERVENTIONS

irculatory diseases In the field of primary prevention, • Advance the implementation can largely be the Global Coalition considers that of the HEARTS package, which prevented and the following actions should be provides a comprehensive prioritized: approach to improving managed through • Fully implement the WHO circulatory health in primary effective and efficient Framework Convention on health care settings using an Cprevention and early Tobacco Control (FCTC). integrated approach to the detection mechanisms. Actions include raising tobacco management of NCDs that Priority actions should taxes, comprehensive bans promises to reduce deaths from hypertensive disorders such as therefore focus on on tobacco advertising and heart disease, stroke, kidney fostering circulatory sponsorship, placing large health warnings on packaging disease and others. disease prevention and and legislating for smoke-free • Treat all patients with early detection as well as environments; hypertension and high-risk on promoting affordable • Comb at obesity, with patients with statins and aspirin. medications for the a particular focus • Acknowledg e the importance prevention and treatment on implementing of integrated management of heart attacks, strokes, recommendations from the of CVD and associated NCDs hypertension, diabetes and WHO Ending Childhood Obesity to improve access to care 37 (ECHO) report; and efficiency, as well the kidney disease. • Introduce taxation on need to reinforce integration with existing communicable The Global Coalition therefore unhealthy products; disease programmes (e.g. HIV, urges governments to shape • Support food reformulation Tuberculosis). policies that ensure an efforts, in particular with environment that is conducive regard to reducing sodium and to healthy living. Governments eliminating artificial trans-fat. can do so through legislative kThe Recommendations refer action, policies and programmes With regard to secondary to the following clauses in that encompass tobacco, alcohol prevention, the Global the Political Declaration of and unhealthy foods, that Coalition strongly supports the Third United Nations promote clean air and a built the following actions: High-Level Meeting on Non- environment which fosters safe Communicable Diseases: physical activity. • Prioritise the WHO best-buy OP1; OP2; OP3; OP4; OP5; of providing counselling and OP6; OP7; OP15; OP16; OP18; multi-drug therapy (including OP20; OP23; OP26; OP28. glycaemic control for diabetes mellitus and control of hypertension using a total risk approach) for people with a high risk of developing heart attacks and strokes (including those with established CVD82).

K The recommendations and clauses refer to the draft Political Declaration released in August 2018. DRIVING SUSTAINABLE ACTION FOR CIRCULATORY HEALTH

PART 5_Taking action

FOSTERING ACCESS TO THE PREVENTION PILLAR 2: AND CARE OF CIRCULATORY DISEASES

o live full and healthy collaborations between all of diagnostic tools, such as blood • Strengthening and stressing the lives, people at-risk their relevant departments, as pressure measurement, basic fundamental role of primary of or living with well as work together with civil blood laboratory tests, urine health care in circulatory health society and the private sector to protein testing, ECG, cardiac at all levels, from self-care circulatory diseases address the social determinants and arterial/carotid ultrasound, to palliative care to ensure need strong health of health. One key area is that of brain-CT; continuity over time; Tsystems that are designed Access to Medicines. • Fostering the implementation • Strengthening the contribution to deliver universal health of innovative information of interdisciplinary primary coverage and to ensure This is why the Global systems, such as mobile-health care and task sharing with Coalition access to prevention, strongly supports technologies and telehealth non-physician and community- the recommendation that programmes. based health workers; screening, and care for all. governments and private sector • Developing locally applicable But strengthening health entities should ensure access As an entity which represents practical guidelines for both systems in not enough in to affordable, quality-assured millions of healthcare workers, specialist and non-specialist essential medicines. the absence of financial the Global Coalition emphasizes health professionals. In protection, good nutrition, that access to essential addition, clinical support Priority actions therefore medicines also means that systems can be used to improve education, and affordable include: transportation to healthcare, medicines are prescribed drug prescriptions and promote 38 by adequately trained staff. cost-effective treatment; to name just a few. • Improving access to proven Therefore, specific attention • Building local research capacity drugs, including low-cost should be given to optimizing the to determine local health Putting all these in place requires combination pills, as part health workforce and enabling burdens, risk factors and an innovative, multi-sectoral of a package of essential health workers to work to their provide data for regional and approach which turns every treatment and services to full scope of practice, i.e., in the local prioritization of services. minister — be it in Finance, control heart disease and areas where they are educated, Agriculture, Education or stroke. Specifically, aspirin, authorized and competent Transportation — into a health clopidogrel, ACE inhibitors, to perform. minister. An effective health- angiotensin receptor in-all policy approach extends antagonists, beta-blockers, Recommended actions beyond the walls of governments calcium channel antagonists, include: into collaborations with external diuretics, statins and a basic The Recommendations organizations, from carefully range of short and long- refer to the following clauses selected private sector partners • Reinforcing education and acting insulins and oral anti- training programmes to in the Political Declaration to civil society and community- diabetics must be generally of the Third United Nations based organizations. build the national capacity available and affordable; of health professionals and High-Level Meeting on Non-Communicable Diseases: Therefore, the Global • Fostering access to relevant non-physician health workers in technology, notably by circulatory health and disease OP1; OP2; OP14; OP19; OP20; Coalition recommends that OP22; OP24; OP25. governments initiate and sustain increasing the availability of prevention; basic and evidence-supported

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION TAKING ACTION

MOBILIZING RESOURCES PILLAR 3: FOR CIRCULATORY HEALTH

nce every minister The Global Coalition strongly United Nations Children’s Fund starts thinking like a encourages governments and (UNICEF) and the United Nations health minister, the intergovernmental agencies to Populations Fund (UNFPA), mobilise sufficient resources to which would “seek to scale-up financial argument combat NCDs, and circulatory support to LMICs in their efforts becomes clear: diseases in particular. to meet SDG 3.4”89. Oinvesting in the fight against circulatory diseases and • Specifically, the Global • Lastly , the Global Coalition associated conditions is Coalition strongly supports encourages each country to the mobilise sufficient resources at $ paramount for a healthy taxation of unhealthy products such as alcohol, national level, in particular by and productive population. tobacco, unhealthy foods and enforcing adequate taxation For one, it is strikingly non-alcoholic beverages (such policies and by entering into affordable: investing as sugar-sweetened beverages), carefully selected public- US$ 1.27 per person per year and encourages the use of private collaborations. INVESTING in low- and middle-income these revenues for advancing the prevention and control of countries until 2030 can save circulatory diseases. an estimated 8.2 million The Recommendations $1.27 lives, decrease premature The evidence in support of refer to the following 39 per person per mortality from NCDs by taxation and redistribution of clauses in the Political year in low- and 15 percent, and yield a revenues in overwhelming, as the Declaration of the Third return on investment of at success of the excise tax reform United Nations High-Level in the Philippines, the sugar tax Meeting on Non-Communi- middle-income 83 least US$ 7 . in Mexico or the tobacco tax in cable Diseases: OP3; OP5; countries until the Gulf countries and in South OP8; OP30. 2030 can save And it also helps:84,85,86. Africa have demonstrated. When • Save US$ 47 trillion, the designed and implemented an estimated estimated lost gross domestic effectively, taxation programmes product globally attributed reduce consumption of unhealthy to underfunding programmes products and allow governments 8.2 million to prevent and manage NCDs to expand national insurance lives between 2011 and 2025, of programmes and enhance which 50 percent is attributable financial protection for the most 87 to CVD; vulnerable . • Prevent catastrophic health Evidence from China and Thailand expenditure for low-income SAVE suggests that, in doing so, patients suffering from CVD taxation programmes benefit and stroke. For example, in low-income consumers 88. Tanzania and China, investing $47 trillion in the fight against CVD could • Further, the Global Coalition for estimated lost product prevent catastrophic health Circulatory Health encourages expenditure among 92 and 72 globally due to the development of innovative percent of patients respectively. financing mechanisms to underfunding • Keep 100 million people a ensure that sufficient funds are year from falling into extreme available to achieve objectives. programmes to prevent poverty because of unaffordable One such example is the and manage NCDs health costs; creation of a multi-donor fund • Avoid loss of employment for non-communicable diseases and productivity, measured and mental health, consisting in gross domestic product, of WHO, the World Bank, the household income and number United Nations Development of working days. Programme (UNDP), the PART 5_Taking action

MEASURING AND PILLAR 4: TRACKING PROGRESS

easuring and tracking The Coalition strongly • The development of reliable progress are essential supports: health information systems to monitor health behaviours, elements in order • The implementation of risk factors, and morbidity and reliable, simple, and fit-for- to shape priorities, mortality; adapt strategies, purpose surveillance systems for monitoring the burden • The implementation of the WHO Mprogrammes and projects, Global Monitoring Framework; of circulatory diseases, identify what works and what prevalence of risk factors, • An agreement among doesn’t, justify the allocation and treatment of circulatory governments and of resources, among others. diseases at national and global intergovernmental agencies upon This is why the Global Coalition levels. At national level, these international standards. for Circulatory Health strongly systems could leverage existing supports the introduction of monitoring mechanisms for non-communicable diseases, instruments which reinforce such as population-based accountability mechanisms registries. Globally, accountability to track progress on NCDs in systems for NCDs in general and The Recommendations refer 40 general, and on circulatory circulatory diseases in particular to the following clauses in the diseases in particular, in a clear, could be modelled on the Political Declaration of the Countdown to 2030 for Women’s, Third United Nations High- timely and transparent fashion. Children’s and Adolescents’ Health, Level Meeting on Non- a multi-sector initiative that Communicable Diseases: tracks progress and drives action OP10; OP11; OP29; OP32. to achieve the SDG targets for ending preventable maternal, new born, and child mortality.

PERFORMANCE

CONTENTS EXECUTIVE SUMMARY BACKGROUND GLOBAL BURDEN LIVING WITH CIRCULATORY DISEASES SUCCESS STORIES TAKING ACTION WHITE PAPER FOR CIRCULATORY HEALTH TAKING ACTION

THE GLOBAL COALITION FOR CIRCULATORY HEALTH COMMITS TO:

PILLAR 1 PILLAR 2 PILLAR 3 PILLAR 4 Prioritizing cost-effective Fostering access to Mobilising resources for Measuring and interventions prevention and care for circulatory health tracking progress n Action our network of circulatory diseases n Adv ocate for the taxation n Adv ocate for the use of members and partners n Action our networks of of unhealthy products evidence-based approaches to advocate for the members and partners to (tobacco, alcohol, sugar) whenever data is collected, implementation of these advocate for the improved at global, regional and analysed and disseminated. recommendations at global, availability and affordability national levels through its n Help collect, monitor and regional and national levels. of essential circulatory network of members and disseminate data to track disease medicines at global, partners. n Support staff education progress of circulatory regional and national levels. and training through its n Collect and disseminate disease-related objectives wide network of members n Adv ocate for a prioritization of examples of best practices through our wide networks and partners. circulatory diseases in Universal and success stories with of members and partners. Health Coverage plans. regard to taxation issues 41 n F oster and support optimal and innovative financing n Activ ely support a health workforce utilization. n Support the education mechanisms. Countdown to 2030 for and training of healthcare NCDs and contribute as n Collect and disseminate workers to foster optimal deemed fit. education materials, best prescription of essential practices and success medicines and adherence stories across disciplines to treatment. and regions. n Seek collaborations n Contribut e to raising with potential donors, awareness through to implement integrated international disease days programmes aimed at and other impactful events. improving circulatory health.

n Collect and disseminate examples of best practices and success stories across disciplines and regions. DRIVING SUSTAINABLE ACTION FOR CIRCULATORY HEALTH THE GLOBAL COALITION FOR CIRCULATORY HEALTH The Leadership Group sets the strategy and workplan for the Coalition. It comprises partner organizations with an interest in heart disease and stroke, which also hold Official Relations Status with the World Health Organization.

The Leadership Group is currently made up of the following organizations:

Framework Convention Alliance for Tobacco Control International Society of Nephrology International Alliance of Patients’ Organizations World Federation of Public Health Associations International Council of Nurses World Heart Federation International Diabetes Federation World Hypertension League World Organization of Family Doctors World Stroke Organization

The following organizations are the current members of the Global Coalition:

Cuban Society of Cardiology International Council of Cardiovascular Prevention and Rehabilitation 42 European Heart Network International Primary Care Cardiovascular Society European Primary Care Cardiovascular Society International Society of Behavioural Medicine (ISBM) FemSansCancer Iranian Heart Foundation Health Related Information Dissemination Amongst Youth (HRIDAY) Nepal Development Society Heart Friends Around the World Polish Lipid Association Heart & Stroke Foundation of Canada Preventive Cardiovascular Nurses Association Instituto Nacional Cardiovascular Incor EsSalud Rural Clinical School, University of New South Wales InterAmerican Heart Foundation Shenyang First People’s Hospital International Atherosclerosis Society South African Heart Association International Society of Hypertension Stroke Association Support Network-Ghana Ukrainian Association of Cardiology

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1 World

GLOBAL COALITION FOR CIRCULATORY HEALTH 44

GLOBAL COALITION FOR CIRCULATORY HEALTH Secretariat 32, Rue de Malatrex 1201 Geneva Switzerland