2- NCD Policy Notes Presentation YEO Baguio Nov 08 2

Noncommunicable Diseases (2005-2015)

Why Address NCDs?

• 60% of global deaths are due to NCDs (and still increasing)

• 40% of cancer is preventable• 80% of cardiovascular disease, stroke

and diabetes is preventable• A large part of chronic respiratory

diseases is preventable• Cost-effective secondary prevention

interventions exist and have worked in many countries

Projected Forgone National Income due to Heart Disease, Stroke and DM in Selected Countries, 2005-2015 (in billion dollars)

Brazil Canada China India UK Nigeria Russia

Estimated Income Loss 2005

2.7 0.5 18.3 8.7 1.6 0.4 11.1

Estimated Income Loss 2015

9.3 1.6 131.8 54 6.4 1.5 66.4

•The extent of the NCD problem

•in the Western Pacific Region

AFR EMR EURSEAR WPR AMR

Noncommunicableconditions

Injuries

25

50

75%

Most Life Years Lost in Western Pacific Region are due to NCD (DALYs lost, 1999)

DALY = Disability-Adjusted Life YearSource: World Health Report, 1999

Communicable diseases, maternal and perinatal conditions and nutritional deficiencies

Chronic diseases in Western Pacific, deaths, all ages, 2005(total deaths 12,397,000)

Chronic respiratory

disease14%

Injuries10%

Communicable, maternal and

perinatal, nutritional

deficiencies 12%

Other chronic diseases

9%

Diabetes2%

Cancer20%

CVD33%

Projections for Chronic Disease in WPR next 10 years

• 106 million people will die • Deaths from infectious diseases, maternal

and perinatal conditions, and nutritional deficiencies combined will increase by 1%.

• Deaths will increase by 20% - deaths from diabetes will increase by 51%.

<< Inactivity

<< Tobacco

Alcohol >>

Top Risk Factors in this Region

Unhealthy Diet >>

Why Address NCDs?

Major NCDs have shared preventable risk factors:

• Tobacco use• Unhealthy diet• Physical inactivity• Harmful use of

alcohol

Philippines NCD Situation

The Philippines is one of the 23 selected countries contributing to around 80% of the total mortality burden attributable to chronic diseases in developing countries, and 50% of the total disease burden caused by non-communicable diseases worldwide.

(Source: Lancet, 2007)

MORTALITY: TEN LEADING CAUSES BY SEXNumber, Rate/100,000 Population and Percent Distribution

Philippines, 2004

Cause Male Female Both Sexes

Number Rate Percent*

1. Heart Diseases 40,361 30,500 70,861 84.8 17.6

2. Vascular System Diseases 28,930 22,750 51,680 61.8 12.8

3. Malignant Neoplasm 21,395 19,129 40,524 48.5 10.1

4. Accidents** 28,041 6,442 34,483 41.3 8.6

5. Pneumonia 15,822 16,276 32,098 38.4 8.0

6. Tuberculosis, all forms 17,841 8,029 25,870 31.0 6.4

7. Ill-defined and unknown causes of mortality 10,916 10,362 21,278 25.5 5.3

8. Chronic lower respiratory diseases 13,084 5,891 18,975 22.7 4.7

9. Diabetes Mellitus 7,970 8,582 16,552 19.8 4.1

10. Certain conditions originating in the perinatal period

7,809 5,371 13,180 15.8 3.6

Source: The 2004 Philippine Health Statistics* percent share from total deaths, all causes, Philippines** External Causes of MortalityLast Update: February 11, 2008

Top Ten Leading Causes of Morbidity 2006

Overall (both sexes and all ages)

Rank 4. Hypertension

Rank 7. Diseases of the HeartSource: FHSIS, 2006

Risk Factors

90% of Filipinos has one or more of these 6 prevalent risk factors:

Physical inactivity 60.5% Smoking 34..8% Hypertension 22.5% Hypercholesterolemia 8.5% Overweight 20% Obesity 4.9% Diabetes 4.6%

Source: (NNHeS, FNRI 2003)

Low and Fruits Consumption Among Filipinos

• Dangerously low fruit & vegetable intake– Only 19% of national population eat fruit

& vegetables more than four times a day– Recommended standard: 100% eating

FIVE servings DAILY– Total daily requirement must be

400g/capita– Actual consumption is only 111g/capita

Increasing Diabetes Morbidity

• Diabetes prevalence has increased significantly over the years to 20.06% among Filipino adults (20 y/o and above)

• Adult incidence of diabetes from 1998 to 2007 is likewise alarming at 8.5%.(Source: Philippine Cardiovascular Outcome Study – Diabetes Mellitus, 2008)

0.40.6

0

0.4 0.4

0

1

0.8

1.41.3

2

1.6

0

0.5

1

1.5

2

2.5

Pe

rce

nt

1993 1996 1998 2001 2003 2005Year

0-5

6-10

Trends in overweight among children 0-10 years old

2.22.5 2.5

3.1

4.2

3.4

5.8

4.4

0

1

2

3

4

5

6

7

Perc

en

t

1993 1998 2003 2005

Year

11-12

13-19

Trends in overweight among adolescents

Current Use of Tobacco Product Among Adolescents Both Sexes: 22% (20% in

2003)

Boys: 34% (27% in 2003)

Girls: 14% (13% in 2003)(Source: GYTS 2007)

Tobacco Use Among Youth

Alcohol Use

11% of Filipinos 15-74 years regularly drink alcoholic beverages (>4 days/week)

24% of Filipinos 15-19 years are current drinkers (2001 survey n=10,240)

42% of Filipinos 15-27 years are current drinkers (2002 survey n=20,000)

Mean value of pure alcohol consumed per day: 4.8 grams (2003 World Health Survey n=4951)

Smoking-related Diseases

Health Care Costs

Productivity Losses from

Death

Productivity Losses from

DiseaseTotal Costs

Lung Cancer 9,188,871 189,709,987 3,407,151 202,306,009

CVD 507,315,052 2,930,533,343 38,910,556 3,476,758,951

CAD 236,888,476 1,312,836,695 88,922,515 1,638,647,686

COPD 104,561,119 569,530,925 54,043,648 728,135,692

All 4 Diseases 857,953,518 5,002,610,950 185,283,871 6,045,848,339

Summary of Economic Costs in US$)* for Four Smoking-related Diseases

(2003, using SAMMEC methodology figures)

*$1=PhP 52.Source: Tobacco and Poverty Study in the Philippines,2006.

DOH Early Actions on NCD Prevention and Control

• Non-communicable Disease Prevention and Control Service established 1986 with EO 119 reorganizing the Department of Health

• Developed vertical programs in early 1990s– Cardiovascular Disease Prevention

and Control Program– National Cancer Control Program– Diabetes Prevention and Control

Program

Non-communicable Disease Prevention and Control Service

Launched advocacy and IEC campaigns against known risk factors

YOSI KADIRI –anti smoking

EDI EXERCISE/HATAW /THE GREAT FILIPINO WORKOUT – regular physical activity

TIYA KULIT/ IWAS SAKIT DIET – low salt, low fat, high fiber diet

DOH Milestones on NCD Prevention and Control

Year 2000External evaluation study on existing programs as basis for integration conducted;Degenerative Disease Office under NCDPC mandated to manage NCDs; The Health Sector Reform Agenda was introduced advocating changes of service delivery, governance, financing and regulations, which facilitated the integration of NCDPC-related efforts


2001Integrated Community-Based NCDPC Demonstration Project in Pateros and Guimaras started. Framework for the Integrated Community-Based NCD prevention and control program (NCDPCP) formulated;Training Module on the Integrated CB- NCDPCP developedNational Mental Health Policy


2002Healthy Lifestyle (HL) approach (focusing on 3 major risk factors: physical inactivity, tobacco use and unhealthy diet) was mainstreamed;National advocacy program on HL developed with Philippine Heart Association;

2003“Mag HL Tayo Campaign” was launched;Nationwide training of Regional NCDPC Coordinators and Training staff/HEPOs on the promotion of HLAnti-Tobacco Law (RA 9211) was passed.


2004 Philippine Coalition for the Prevention of Non-Communicable Diseases established; Advocacy with commercial food establishments to offer healthier menu options to the public started;2005Training of national government agencies on HL (DILG, DepED, DSWD, DOT, etc.) Policy Development Study completed identifying policy agenda in support to the integrated NCDPC Program; Demonstration project in Guimaras and Pateros was assessed and results show very promising results.Revision of National Mental Health Plan


2006 Breast Cancer Intervention Study in Pateros and Chronic Respiratory Disease Study in Guimaras; 3rd Public Health Convention on NCD Prevention and Control on local initiatives to promote HL

2007 Post NCD impact survey in Guimaras and Pateros DOH-NCDPC adaptation of the WHO NCD Framework for Action for the Philippines National Policy on Injury Prevention ProgramOperational Framework for Sustainable Establishment of Mental Health Program


2008 4th Public Health Convention on NCD Prevention and Control accelerating NCD actions Finalization of manual of operations for community-based NCD prevention and control

Framework for NCD Prevention and Control Action

• Follows the causation pathway of NCDs and supports the following actions:– Environmental Interventions– Lifestyle Interventions– Clinical Interventions– Advocacy– Research and Surveillance– Political and Community Leadership,

Intersectoral Partnerships and Community Mobilization

– Health systems strengthening

Causation Pathway

Causation Pathway

Intervention Pathway

Advocacy

Research, Surveillance, Evaluation

“Whole of society” responseCommunity leadership

Intersectoral partnerships

Community mobilization

Health Systems Response(Health Systems Strengthening)Health workforce developmentHealth services organization/deliveryFinancingPeople-centred systems of careFocus on prevention

Health Sector ResponseHealth sector governanceHealth sector leadershipIntegration of NCD prevention and control into national health strategy

“Whole of government” responsePolitical willPolitical leadershipHealthy public policies and laws

Strategic Approach

76

54

11

322

Integrated NCD Prevention and Control Program

Vision: Improved quality of life for all Filipinos

Mission: To ensure that quality prevention and control NCD services are accessible to all, especially to the vulnerable and at-risk population.

Goal: To reduce mortality, disability and morbidity due to NCDs (CVDs, CA,COPD,DM).

Integrated NCD Prevention and Control Program

Objectives:– To reduce the exposure of population to

risks related to NCDs primarily smoking, unhealthy diet, physical inactivity and alcohol use.

– To increase the proportion of NCD cases given appropriate treatment and care.

Policy Statement No. 1

• The Integrated NCD Prevention and Control Action follows the causation pathway of NCDs as a framework for action

• It supports the WHO Global and Regional Strategy for NCD Prevention and Control.

Policy Statement No. 2• Adoption of an integrated, comprehensive and

community based response to NCD prevention and control – Focuses on common risk factors guided by a life

course perspective;– Encompasses the three levels of disease prevention:

primary, secondary and tertiary level;– Emphasizes strategies which would benefit entire

population or large packets of population, but also takes care of high-risk populations;

– Integrates across settings; such as health centers, schools, workplaces and communities;

– Makes explicit links to other government programmes; – Emphasizes intersectoral action


• Intensify health promotion to effect changes that lead to significant reduction in mortality and morbidity due to NCDs– Changing lifestyles– Changing the environment– Reorienting the health system from

the curative mode to the preventive or wellness mode


• Foster complementary accountabilities in the implementation of an Integrated NCD Prevention and control program– DOH – LGU– Other GOs/NGAs– Other Sectors, including Private sector and

other stakeholders

Guiding Principles

• Equity• Sustainability• Rights based• Continuum of care throughout the life

cycle• Evidence based

Current Issues and Challenges:Governance

• A core national coalition of stakeholders is established but mostly from the health sector.

• There is a need to expand partnerships to other sectors, including the private sector.

• Whole of government and whole of society approach is needed to build momentum and sustain gains.

Coalition Building for NCDs


• Integrated and comprehensive approach is established but there is a need to further advocate among the health workforce and stakeholders on effectiveness of this approach.

• Human resource, both in quantity and capacity


• Surveillance System for NCDs and risk factors is available but currently limited.

• Main sources of data are from the Philippine Health Statistics, national prevalence surveys, a cancer registry and other registries from NGOs and professional groups.

• NCD data from FHSIS and hospitals are very limited • PHilHealth could have been a very good source of data• DOH should enhance information systems to generate

timely and relevant data for continuing policy enhancement and program response.

• Health promotion and education is conducted nationally mostly by the health sector.

• Health services and products addressing NCD needs are available in the field at varying levels, depending on local government resources and priorities.

• Suggested NCD package of services are established but need to be advocated, adopted, implemented and monitored at all levels of care.

• Referral systems should be enhanced to effectively prevent and manage NCDs.

Current Issues and Challenges:Service Delivery

• Some policies and legislations are already in place to facilitate implementation of relevant NCD interventions.

• Republic Act 9211 is in place, but needs more strict enforcement

• Ensuring affordability and accessibility of essential medicines and diagnostic services

• There is a need to come up with additional regulatory mechanisms, e.g. nutrition labeling, to support and strengthen current initiatives on NCD prevention and control.

Current Issues and Challenges:Regulation

• NCDs often result to catastrophic expenditures, plunging many families deeper into poverty.

• Many are often not able to continue with treatment and care, contributing to the growing burden of diseases due to NCDs.

• About three-fourths of the diabetes patients had given up diabetes care because of financial difficulties at one time in the past.

• 67% experienced shortage of money because of diabetes-related expenditure, and borrowed money or pawned assets.

• Philhealth coverage was lowest among the informal sector at 15%. (Source: Costs, Availability, and Affordability of Diabetes Care in the Philippines, Higuchi, et all, WHO, 2008)

Current Issues and Challenges:Financing

Study on an “Outpatient Prescription Drug Benefit for PhilHealth Members with Hypertension”

• Lack of affordable access to outpatient antihypertensive medicines leads to avoidable disease progression and costly inpatient admissions.

• Inpatient care for hypertension and its sequelae is expensive and hypothesize that many hospitalizations could be avoided with appropriate antihypertensive therapy provided in ambulatory care.

• Avoiding expenditures for one hospitalization could pay for one year of anti-hypertensive medicine treatment for three (3) patients.

• Operationalize and promote integrated approach to NCD prevention and control at the local level.

• Ensure access and availability of relevant services and products, including NCD drugs, in the communities and among affected and vulnerable populations.

• Enhancing referral systems will provide for the continuum of care along the spectrum of non-communicable diseases. .

Way Forward

Way Forward

• Strengthen linkages with relevant government and nongovernment agencies

• Awaken social accountability of various stakeholders and sectors to address the NCD related problems

• Utilize the whole of society and whole of government approach

Way Forward

• Improve the surveillance system on NCDs.• Information systems that will link various

sources of data (private/public health facilities, hospitals, PHIC, NGO’s, Professional Groups, etc) should be established and harmonized

• Efforts to disseminate and utilize data for policy enhancement and program management should be continually pursued

Way Forward

Health promotion and advocacy are cross-cutting interventions that the broad network of stakeholders can collaboratively engage in as part of social responsibility.

Such should be consistently provided as support to other interventions to change behavior.

Way Forward

• Ensure sustainable financing. Different financing mechanisms such as funding, resource allocation, contracting and reimbursement can be utilized.

• Local governments should be encouraged to increased their resources and investments for NCD prevention and control.

• Improve social health protection through the enhancement PhilHealth’s benefit package to cover lifestyle diseases, to increase the benefit package’s support value and to improve the coverage of the indigents and those in the informal economy.

• Improve access to, availability of and reliance on low cost medicines– Strengthen Botika ng Barangay

Improve physical accessibility Improve procurement of medicines and

availability of medicines Promote public reliance on quality assurance

of low cost medicines

Way Forward

Invest in cost-effective interventions

Deaths Averted

Intervention Deaths Averted

Salt Reduction

8.3 million

Tobacco Control

5.5 million

Multi-drug Treatment

17.9 million

TOTAL 31.7 million

Cost per head

Intervention Cost per head (US$)

Salt Reduction 0.36(0.14-0.38 low-mid

income)(0.52-1.04 High mid

income

Tobacco Control

Multi-drug Treatment

1.08(0.75-1.40)

TOTAL 1.44(0.89-1.78 low-

mid income)(1.27-2.88 high

mid income)

31.7 million ÷ 36 million =

88% of global goal

Health Benefits and Costs of 3 Interventions Combined

Way Forward

• Pursue the policy agenda on the following:

(1) Lowering of saturated fat and lower salt content in food offerings; 2) Mandating fast food chains and restaurants to keep public informed of the nutritional value of food offerings; 3) Providing subsidies/ tax breaks to encourage manufacture and sale of healthier food options; 4) amendment of the Food Fortification Law; (5) legislation of graphic health warnings on tobacco packages, etc

• Fulfill the research and development agenda in collaboration with government agencies and private organizations to fill in program data needs:

Way Forward

The integrated approach would provide for harmonized NCD prevention and control policies and programs, delivery of services and health care financing thereby creating a “seamless and smooth system” to achieve good health outcomes and coverage.

However, commitment of all public and private stakeholders and integrated planning must be set in place before objectives can be fully realized.

Key Strategies for Local Implementation

• Localize healthy public policies• Build coalitions and partnerships• Enhance community participation• Create a supportive organizational

and physical environment• Intensify health education and

public information

Key Strategies for Local Implementation

• Institutionalize local assessment and planning

• Build or expand local capacities• Reinstall supervision• Establish financing schemes• Install regulatory mechanisms• Unify monitoring and evaluation

efforts

Lessons on Local Implementation

• National policies are useless if not locally adapted

• Success lies largely in the hands of implementing units

• Experience with PIPH-AOPs shows that effective strategies for NCDS are not fully utilized.

• Operationalizing this policy at the local level will ensure effective prevention and control efforts for NCDs

• “We cannot afford to say ‘we must tackle other diseases first – HIV/AIDS, malaria, tuberculosis – then we will deal with chronic disease’. If we wait even 10 years, we will find that the problem is even larger and more expensive to treat”

• Olusegun Obasanjo, President , Federal Republic of Nigeria.

Recent and Current Evidence showed that....

• Preventing and controlling major risk factors in an integrated manner and employing health promotion across the life course at the level of family and community is thus most cost-effective

2- NCD Policy Notes Presentation YEO Baguio Nov 08 2

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