Plenary Session 2 - Preventing Chronic Non-Communicable Lifestyle Related Diseases

Preventing Chronic Non-Communicable Lifestyle RelatedDiseases: A Vital

Investment

Ms. Frances Prescilla CuevasChief Health Program OfficerDegenerative Disease Office

National Center for Disease Prevention and ControlDepartment of Health

Outline of the Presentation

• Global Situation

• Framework for Intervention

• Country Situation

• Way Forward for the Philippines

• Implications to Nursing

MISUNDERSTANDINGS ABOUT CHRONIC DISEASES HAVE CONTRIBUTED TO THEIR GLOBAL NEGLECT

16

Economic Burden of NCDs

Share of Disease Burdens Falling Between Ages

15-69 in Low- and Middle-Income Countries, 2005•A large share of the burden of

NCDs occurs in populations of

working age

•NCDs impose a significant burden

not just on patients, but also on

households, communities,

employers, health care systems,

and government budgets

•E.g., costs associated with

tobacco and obesity in China and

India are about 1-2% of GDP

Source: Lopez and others. 2006. Global Burden of Disease and Risk Factors. New York: Oxford University Press. Data also available World Health Organization. “Burden of Disease Project.” World Health Organization. http://www.who.int/healthinfo/bodproject/en/index.html.

Disease category % Deaths

15-69

% DALYs

15-69

All causes 46% 54%

All NCDs 43% 74%

-Cardiovascular

diseases

38% 72%

-Cancers 62% 81%

All communicable

diseases

35% 32%

Office of the WHO Representative in the Philippines

Macro-economic impact:

• World Economic Forum estimates high risk and

likelihood of negative economic impact from

noncommunicable diseases

• Heart disease stroke and diabetes alone estimated

to reduce GDP between 1-5% in developing

countries

Noncommunicable 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 noncommunicable diseases

• People in developing countries die younger from noncommunicable diseases, 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

Noncommunicable Diseases

Socio-economic Impact

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

• 1st part: Analyzed 3.5-year claims data from 2002-2005

• 2nd part: Conducted a survey of identified PhilHealth beneficiaries with hypertension based on claims data

• Specific aims of the study:

1. Describe the frequency of use of inpatient care for hypertension and costs reimbursed by PhilHealth, using existing claims data on all PhilHealth members admitted for hypertension treatment from 2002 – 2005

2. Assess pre and post-hospitalization medicines access and use and willingness to pay for outpatient medicines of PhilHealth members discharged in 2005 after treatment for hypertension


• Conclusion:

• 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.


• Recommendation:

PhilHealth to explore options for providing outpatient medicines and care benefits for chronic conditions such as hypertension.

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

• Sixty seven percent (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%.

Costs, Availability, and Affordability of Diabetes Care in the Philippines

by Higuchi, et all, WHO, 2008

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” response

Political willPolitical leadershipHealthy public policies and laws

Strategic Approach

76

54

11

322


Cost-effective strategies exist

28

The Cost-Effectiveness of NCD Interventions Covers a Wide Range

Selected Cost-effectiveness Ratios for Interventions against NCDsTaxation of tobacco products

DALYs averted per U

S$1

million spent

Cost per D

ALY

Treatment of acute myocardial infarction or heart attach with an

inexpensive set of drugs (aspirin and beta-blocker)

Treatment of acute myocardial infarction with inexpensive drugs plus

streptokinase (costs and DALYs for this are in addition to what

would have occurred with inexpensive drugs only)

Lifetime treatment of heart attack and stroke survivors with a daily

polypill combining four or five off-patent preventive medications

Coronary artery bypass gaft or bypass surgery in specific identifiable

risk cases, such as disease of the left main coronary artery

(incremental to 4)

Bypass surgery for less severe coronary heart disease and lifetime

treatment (incremental to 4)

3-50 20,000-330,000

10-25

600-750

700-1,000

>25,000

Very high

40,000-100,000

1,300-1,600

1,000-1,400

<40

Very small

Source: Jamison and others. 2006. Priorities in Health. Washington, DC: World Bank.


There are low cost interventions to prevent

NCDs…

Country 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.

Fig. 1. Ten Leading Causes of Mortality:

Philippines 1999-2005

0

10

20

30

40

50

60

70

80

90

100

1999 2000 2002 2003 2004 2005

Ra

te

s/1

00k

P

op

ulatio

nDiseases of the Heart

Diseases of the Vascular

system

Malignant Neoplasm

Pneumonia

Accidents

Tuberculosis, all forms

Chronic low er respiratory

diseases

Diabetes Mellitus

Certain conditions originating

in the perinatal period

Nephritis, nephrotic syndrome

and nephrosis

Source: FHSIS-DOH

Prevalence of hypertension, hyperglycemia, dyslipidemia & overweight

1998, 2003 and 2008 Philippine NNS, FNRI

Risk factors1998 2003 2008 Basis

Hypertension 21.0 22.5 25.3 SBP ≥ 140, DBP ≥ 90

Hyperglycemia 3.9 3.4 4.8 FBS > 126 mg/dL

Total cholesterol 4.0 8.5 10.2 ≥ 240 mg/dL

LDL-c 8.1 11.7 11.8 ≥ 160 mg/dL

HDL-c 76.6 54.2 64.1 < 40 mg/dL

Triglycerides 8.7 9.4 14.6 ≥ 200 mg/dL

BMI (Overweight) 20.2 24.0 26.6 BMI ≥ 25.0

Distribution of population by physical inactivity Philippine NNS, FNRI

Physical Inactivity Domains 2003(%)

2008(%)

P-value

Males

Occupational 67.0 76.3 0.0000

Travel-related 91.0 93.8 0.9999

Leisure time physical activity < 2 times per week

90.0 89.1 0.1269

Females

Occupational 82.1 76.2 0.0035

Travel-related 94.3 95.2 0.6022

Leisure time physical activity < 2 times per week

95.5 95.7 0.0001

Current smoking Prevalence

Hazardous alcohol intake

From Pedro, Benavides, & Barba, 2006

CURRENT NCD SITUATION

• STATISTICS SHOWS THAT PREVALENCE OF NCDs and its major RISK FACTORS CONTINUES TO RISE

• THIS SITUATION IN THE COUNTRY IS UNACCEPTABLE

• WHAT WE HAVE BEEN DOING IS NOT ENOUGH

• DRASTIC MEASURES NEED TO BE DONE

PHILIPPINE COMMITMENT

INCLUSION OF NCD PREVENTION

AND CONTROL TO MDG

COMMITMENT OF THE COUNTRY

THROUGH THE MDGMAX INITIATIVE

Announced by the Secretary of Health, Dr. Francisco T. Duque III, during

the 4th Public Health Convention on NCD Prevention and Control last July 2008 convened by the PCPCNCD and affirmed by an Administrative Order operationalizing the Prevention and Control of Lifestyle Related NCDs, the goal is to reduce NCD mortality by 2% per year.


Framework for Action,

Philippines

Adoption of an integrated, comprehensive and community based response to NCD prevention and control:

• Focuses on common risk factors

• Encompasses the three levels of disease prevention

• Emphasizes strategies which would benefit entire population

• Integrates across settings

• Makes explicit links to other government programmes and community based organizations

• Emphasizes intersectoral action

Strategic Approach For The Prevention And Control Of Lifestyle Related Diseases

1. Environmental Interventions

2. Lifestyle Interventions

3. Clinical Interventions

4. Advocacy

5. Research, Surveillance, Monitoring and Evaluation

6. Networking and Coalition-Building

7. Health Systems Strengthening

Environmental Intervention:

• Governance

• Policy and legislation

• Creating supportive built environments

Lifestyle Intervention:

• Information and Education

Clinical Intervention:

• Provision of clinical preventive service packages

• Provision of Acute Care, Chronic Care, Rehabilitation Care, and Palliative care

Advocacy:

• Further develop, implement and sustain health promotion initiatives on healthy lifestyle

• Utilize media and social marketing

Research, Surveillance, Monitoring and Evaluation:

• Inclusion of lifestyle-related diseases in the national unified health research agenda

• Development of evidence based interventions

Networking and Coalition Building:

• Collaborate with LGUs, private sector and other partners

Health Systems Strengthening:

• Establish program structure and provide funding for addressing lifestyle-related diseases

• Strengthen human resources capacity

• Facilitate resource mobilization and establish sustainable financing mechanisms

• Strengthen referral mechanism

Healthy City-NCD-Cherian Varghese-China-July 200910/28/2010

Changing times- Need social

engineering

http://intranet.wpro.who.int/

WPR Meeting on NCD Prevention and Control; 3-7 August 200910/28/2010

THE MEDICAL MODEL

DIAGNOSE

TREAT

(FIX)

SCREEN

Focus on Disease.

Individual

Lifestyle



THE HEALTH PROMOTION MODEL

PREVENT

SUSTAIN

PROMOTE

Focus is on Health

ENABLING

ENVIRONMENT


How then should we educate our nurses?

• Train nurses in health promotion with expertise on population based approaches and not only on the highly clinical individual focused interventions.

• Philippines: link with ADPCN and UP College of Nursing to strengthen and enhance teaching of health promotion and NCD prevention and control in the BSN curriculum

• Train nurses to become highly skilled in policy advocacy, networking and negotiation.

Investing in Nurses

• Dr. Patricia Benner: Educating Nurses –Creating a New Future, Global Alliance for Nursing and Midwifery WHO CC Elluminate Distinguished Lecturer Series advocates on reverting back to educating nurses in Primary Health Care – Public Health- Health Promotion Model.

• Oct 13, 2010 Elluminate Conference

Nursing Coming of Age Globally

• Nurses are knowledge workers who are educationally equipped to deliver knowledgeable health education and care, health promotion and illness prevention in all settings.

• Their work needs to be in Community Health Centers, Primary Health Care, and thus, be enabled to spend less time in higher technology tertiary care centers in order to prevent illness and improve the health of nations.


Upstream interventions

NCDs

Policies/

lack of it

in other

sectors



• Cross over

• All sectors to

work for health

• Health in all

policies

• Back to

Primary Health

Care and

Health

Promotion


GUINNESS WORLD RECORDSThe largest aerobics display involved 48,188 participants at Luneta Park

Manila, Philippines, February 16, 2003

Thank you!

Documents

Plenary Session 2 - Preventing Chronic Non-Communicable Lifestyle Related Diseases