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1 THE ECONOMIC COSTS OF NON communicable DISEASES IN THE pacific ISLANDS. A Rapid Stocktake of the situation in Samoa, Tonga and Vanuatu Final Report November 2012. Page | i Exchange Rates Exchange rates at 30 June 2012 1 Samoan Tala = US$ 1 US$ = Samoan Tala 1 Tongan Pa anga (TOP) = US$ 1 $US = Tongan Pa anga (TOP) 1 Vanuatu Vatu (Vt) = US$ 1 $US = Vanuatu Vatu (Vt) 93 Currency in $ All $ are current United States dollars, unless otherwise specified Page | ii Table of Contents Acknowledgements .. iv Abbreviations .. v Executive Summary .. vi Chapter One: context and purpose of this report.

2 1 NCDs as an international development issue .. 1 Why NCDs are a development challenge in the South pacific .. 2 The objective, intended audience and status of this report .. 3 Definitional issues and data limitations in estimating financial and ECONOMIC COSTS of NCDs in this report .. 4 Chapter Two: the overall country context in Samoa, Tonga and Vanuatu .. 7 Economies and per capita income .. 9 Population and age structure .. 10 Health indicators .. 10 Health financing .. 10 Chapter Three: Update on NCDs prevalence and risk factors in the pacific .. 12 Prevalence of NCDs in Samoa, Tonga and Vanuatu.

3 12 NCDs as the major cause of death .. 12 The role of cardiovascular disease .. 14 High rates of premature NCD deaths .. 15 Specific country data on NCDs .. 17 Underlying Risk Factors for NCDs .. 17 Obesity and overweight .. 18 Changing diets .. 20 Physical inactivity and urbanisation .. 20 Tobacco and alcohol use .. 21 Combined risk factors .. 22 Type 2 Diabetes: a particularly significant NCD in the pacific .. 25 Country responses to NCDs .. 27 Chapter Four: Financial and ECONOMIC COSTS of NCDs.. 30 Recent estimates of the COSTS of NCDs from the international literature .. 30 Estimating ECONOMIC COSTS of NCDs in the pacific .

4 31 Estimating COSTS through National Health Accounts .. 31 Previous estimates of COSTS of NCDs.. 33 Page | iii Previous studies on the COSTS of treating Type 2 diabetes in Vanuatu .. 36 New estimates of the cost of drug treatment for diabetes and hypertension in Vanuatu .. 37 New estimates of the cost of kidney dialysis in Samoa .. 38 Overseas Treatment COSTS .. 39 Chapter Five: Broad implications for Ministers of Health, and Ministers of Finance and Planning .. 40 Implications for Ministers of Health .. 40 Implications for Ministers of Finance, and Planning, and their Ministries.. 42 Implications for both Ministers of Health, and Ministers of Finance: a convergence of public health and public expenditure and possible win wins.

5 51 Chapter 6: Initial Recommendations and Possible Next Steps .. 54 Initial recommendations for discussion with Governments and development partners.. 54 Possible next steps .. 56 Annex One: pacific Islands Indicators of Non communicable Diseases and Risk Factors in 2008 .. 57 Annex Two: Health expenditure statistics for Samoa, Tonga and Vanuatu, 2010 .. 58 Annex Three: Health Expenditure Samoa, Tonga and Vanuatu compared to Income Groups .. 59 Annex Four: Crude death rates from Non communicable Diseases in the pacific Island region .. 60 Annex Five: Recent estimates of the ECONOMIC COSTS of NCDs from the international literature.

6 61 Annex Six: Financial cost to Government of Samoa of the National Kidney Foundation .. 65 Annex Seven: First draft of a possible policy briefing note for a hypothetical pacific Minister of Health, and Minister of Finance .. 73 References .. 75 Page | iv Acknowledgements This report was prepared by Ian Anderson, independent consultant, under the direction of Dr Eva Jarawan, Lead Health Specialist, East Asia and pacific Region, The World bank , and Task Team Leader for this project. Helpful comments and inputs were received on earlier drafts from several sources. Senior staff of The World bank including S Chao, S Ivatts, J Langenbrunner, P Marquez, T Palu, and A Yazbeck made numerous constructive suggestions.

7 M Lee of the World bank assisted in finalization of the report. Helpful comments were also received from C Bell, J McKenzie, and T Waqanivalu of the World Health Organisation, and W Snowdon of Deakin University. Consultations were held with senior Government officials, and their development partners, in Samoa, Tonga and Vanuatu during October 2012 that generated valuable comments and suggestions. This analysis and report were made possible through financial support provided by the Government of Australia and the Government of New Zealand. Such support is greatly appreciated. Page | v Abbreviations ALOS Average Length of Stay (in days, in a hospital)BMI Body Mass Index.

8 A measure of weight for height, calculated as a person s weight in kilograms divided by the square of the persons height in metres: kg/m2. WHO define BMI equal to or greater than 25 as overweight, and BMI equal to or greater than 30 as obese. There is ongoing research about how appropriate these cut off points are in the pacific . COPD Chronic Obstructive Pulmonary disease ( respiratory and lung disease ) CVD Cardiovascular diseaseICD 10 International Classification of disease , 10thseries. IDF International Diabetes FederationNKF National Kidney Foundation of SamoaMNCH Maternal, newborn and child health.

9 NCDs Non communicable diseases (see box one)NHA National Health AccountOPD Outpatient Department of a hospitalPEN Package of Essential Non communicable (PEN) disease Interventions for Primary Health Care in Low Resource Settings. (And initiative of the WHO) SAT Samoan Tala SNAP Smoking, Nutrition, Alcohol, Physical inactivitySPC Secretariat for the pacific CommunitySTEPS Not an acronym. It is the term used for the WHO stepwise approach to surveillance of risk factors TOP Tongan Pa anga currencyWHO World Health Organisation Page | vi Executive Summary There are three main messages running throughout this report.

10 First, Non communicable Diseases (NCDs) can impose large health, financial and ECONOMIC COSTS on countries. This is particularly important in the pacific where Government already finances and provides the bulk of health services. Second, risk factors in the pacific are feeding a pipeline of potentially expensive to treat NCDs, including diabetes and heart disease , but governments are already fiscally constrained in how much more they can provide to the health system. Third, from public health and public finance perspective, many of the NCDs are avoidable or their health and financial COSTS can at least be postponed through good primary and secondary prevention.