The Challenge for public health: providing universal coverage and cost-effective treatment

Feisul Idzwan Mustapha MBBS, MPH, AM(M)Public Health Specialist

Disease Control DivisionMinistry of Health, Malaysia

MySPOR 2014 Conference9 March 2014Kuala Lumpur

dr.feisul@moh.gov.my

Ministry of Health Malaysia

There are Four Major Groups of Non-Communicable Diseases;Four major lifestyles related risk factors

Modifiable causative risk factors

Tobacco use Unhealthy diets

Physical inactivity

Harmful use of alcohol

Noncommunicable diseases

Heart disease and stroke

Diabetes

Cancers

Chronic lung disease

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The Causation Pathway For NCD

Underlying Determinants

•Globalisation•Urbanisation•Population Ageing

Common Risk Factors•Unhealthy diet•Physical Inactivity•Tobacco & Alcohol use•Age (non modifiable)•Heredity (non modifiable)

Intermediate Risk Factors•Overweight/obesity•Raised blood sugar•Raised blood pressure•Abnormal blood lipids

Main NCD•Heart Disease•Diabetes•Stroke•Cancer•Chronic resp. diseases

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ASYMPTOMATICTherefore these individuals do not come to health clinics

NCD prevention activities in health clinics (including screening) will not reach most

of the intended target groups.

Challenge #1

Overweight in adults, ASEAN Region, 2010

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Burden of Diabetes in Malaysia: Trends & Projections by 2020 (Adults age 18 years and above)

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UN Secretary-General:NCDs in developing countries are hidden, misunderstood and under-recorded

A rapidly rising epidemic in developed and developing countries…

… with serious socio-economic impacts, particularly in developing countries.

Workable solutions exist to prevent most premature deaths from NCDs and mitigate the negative impact on development.

The way forward: These solutions need to be mainstreamed into socio-economic development programmes and poverty alleviation strategies. 8

Non-Communicable Diseases:Socio-economic Impact• Macro-economic impact:

• World Economic Forum estimates high risk and likelihood of negative economic impact from NCDs.

• Heart diseases, stroke and diabetes alone estimated to reduce GDP between 1-5% in developing countries.

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Challenge #2

REDUCED ECONOMIC GROWTHThen how to initiate or sustain UHC?

Non-Communicable Diseases:Socio-economic Impact• Impact at household level:

• World Bank estimates that one-third of people living on US$1-2 a day die prematurely of NCDs.

• People in developing countries die younger from NCDs, often in their most productive years.

• Low-income households suffer from the cost of long term treatment and the cost of unhealthy behaviours:

• Cost of caring for a family member with diabetes: 20% of low-income household income

• Poorest households spend more than 10% of their income on tobacco

• Cost of essential drugs to treat and cure cancer makes them unaffordable for the poor

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Economic Burden of Diabetes

• Chronic diseases place a substantial economic burden on society. Estimates for the United States place the costs of chronic illness at around three-quarters of the total national health expenditure (Hoffman et al. 1996).

• Some individual chronic diseases, such as diabetes, account for between 2% to 15% of national health expenditure in some European countries (Suhrcke et al. 2005).

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Challenge #3

WHERE IS OUR DATA?We need Malaysian data

Cost of Diabetes in Malaysia

• People diagnosed with diabetes have access to diabetes care and treatment in Malaysia.

• Diabetes costs are estimated to account for 16% of the national Malaysian healthcare budget.• placing Malaysia among the top 10 countries in the world with

high percentage of healthcare budget spent on diabetes.• In 2010, an estimated RM 2.4 billion was spent on diabetes-

related healthcare.

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Zhang P. et al. Global healthcare expenditure on diabetes for 2010 and 2030. Diabetes researchand clinical practice. 2010; 87: 293– 301.

Cost of Diabetes in Malaysia

• In addition, an estimated 53% of people with diabetes are still undiagnosed.

• The rising prevalence and late diagnosis of diabetes continues to strain the public healthcare system and requires innovative public health interventions that address prevention as well as improved access to treatment for those already affected.

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NHMS II (1996) NHMS III (2006)

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Cost of Diabetes in Malaysia

• Cost of managing diabetes in Malaysia: ~RM19,000.00 per patient per year• Conservative estimate from a study we did in 2007• Not ideal treatment

• Data from NHMS 2011 estimates about 1.1 million patients are on follow up at MOH hospitals and clinics• 1.1 M x RM 19k = RM 20.9 billion!!

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Challenge #4

QUALITY OF CARE?Dichotomy between public – privateIncreasing number of patients in public health facilities

Complications drive costs!

• While there are no studies in Malaysia that outline the breakdown of diabetes costs, a study (CODE II) shows that up to 73% of diabetes-related healthcare costs result from hospitalisation and ambulatory care, as a result of complications due to poor blood sugar control.

• Only 7% of the total diabetes-related healthcare cost is spent on anti-diabetic drugs.

• Maintaining blood sugar levels close to normal can help delay or prevent diabetes complications and reduce the overall healthcare costs of diabetes care.

15Jonsson B. Revealing the costs of type 2 diabetes in the EU and findings from 8 EU countries.Diabetologia 2002;45:S5–S12.

Cost effective NCD interventions…

• What works, what can we afford, and what should we adopt?• The challenge? Identify interventions that:

• are effective;• can lead to measurable declines in NCD death rates quickly (e.g.

over 10 years);• are affordable; and• can easily be implemented and sustained.

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The Lancet. December 8, 2007 Volume 370:Gaziano T, Galea G and Reddy K. Scaling up interventions for chronic disease prevention: the evidence. pp 1939-1946.

The Lancet. December 15, 2007. Volume 370:Asaria P, Crisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. pp 2044-2053.Lim S, et. al. Prevention of cardiovascular disease in high-risk individuals in low-income and middle-income countries: health effects and costs. pp 2054-2061.

Cost effective NCD interventions…

• What is effective? The intervention must:• targets behaviours or risk factors that are causally associated with

NCDs; and• is proven, through evidence, to lead to favourable changes in

behaviours/risk factors, thereby reducing risk of death from NCDs.

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Cost effective interventions to address NCDs

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Population-based interventions addressing NCD risk factors 

Tobacco use  

- Excise tax increases - Smoke-free indoor workplaces and public places- Health information and warnings about tobacco - Bans on advertising and promotion

Harmful use of alcohol

- Excise tax increases on alcoholic beverages - Comprehensive restrictions and bans on alcohol

marketing- Restrictions on the availability of retailed alcohol

Unhealthy diet and physical inactivity

- Salt reduction through mass media campaigns and reduced salt content in processed foods

- Replacement of trans-fats with polyunsaturated fats- Public awareness programme about diet and physical

activity

Individual-based interventionsaddressing NCDs in primary care 

Cancer - Prevention of liver cancer through hepatitis B immunization

- Prevention of cervical cancer through screening (visual inspection with acetic acid [VIA]) and treatment of pre-cancerous lesions

CVD and diabetes

- Multi-drug therapy (including glycaemic control for diabetes mellitus) for individuals who have had a heart attack or stroke, and to persons at high risk (> 30%) of a cardiovascular event within 10 years

- Providing aspirin to people having an acute heart attack

Multi-disciplinary care team (in health clinics)

Post-basic training for paramedics

Clinical practice guidelines

Quality improvement programs

Clinical information

systems

Patient resource centres

Community empowerment

Strengthening Chronic Disease Management at the primary care level

Initiatives to Improve Clinical Outcome:• The formation of Diabetes Team which consists of Diabetic Educator, Medical

Officer, Family Medicine Specialist (FMS), Nutritionist and Pharmacist in every clinic as appropriate to their burden of diabetes patients.

• FMS or senior Medical Officer in the clinic to do regular audits on green book.

• Intensify and more frequent supervision especially by FMS of clinical staff to ensure compliance to CPGs and related guidelines.

• Regular training and CMEs on diabetes care for all clinic staffs, and the state office to monitor the numbers of training sessions conducted.

• Availability of module for health education for patients and a set of pre- and post-test for patients, as published by Disease Control Division, MOH.

• The usage of the Diabetes Conversation Map or similar tools.

• Further development of a Peer Support Group.

• Personalized care by Medical Officer in clinics with low to moderate burden of loads, as appropriate in the individual clinic settings.

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National Diabetes Registry

• Web-based application.• Went live on 1 January 2011.• Supports the implementation of the

annual “Diabetes Clinical Audit” and the “Diabetes Quality Assurance Programme” amongst Type 2 Diabetes patients in MOH Health Clinics.

• First report, “NDR Report, Volume 1, 2009-2012” was published in August 2013, available at the MOH website.

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Strategy 7 NSP-NCD: Policy & Regulatory Interventions• Main thrust of NSP-NCD• Health promotion and education will increase awareness and

knowledge• However changes in behaviour is strongly influenced by our

living environment

Awareness Knowledge Behavioural Change

Supportive living environment

Health promotion & educations

Policies & regulations22

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Financing NCD prevention and control programmes• Policy & regulatory interventions do not require a huge

budget.• What is more crucial is the political leadership and commitment.• Support from civil society is also essential.

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Summary• The issue is not should we spend more money (GDP) for

health• We already have universal health coverage• We subscribe to cost-effective treatment

• The question remains that if we were to spend more money (GDP) on health NOW, how can we be assured that especially for NCDs, we will get our money’s worth.

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A 25% relative reduction in the overall mortality from NCDs by year 2025.

Thank you

dr.feisul@moh.gov.myFacebook: Feisul Mustapha

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