addressing the challenge of ncds in lac: brazil country case study isabella danel christoph kurowski

Addressing the Challenge of NCDs in LAC:Brazil Country Case Study

Isabella Danel

Christoph Kurowski

Brazil Country Case Study

To inform policy dialogueLessons learned from developed countries and the

potential applicability of the most CE strategies in BrazilPotential impact of expanding health promotion and

improved NCD management on health outcomesCosts and returns from expanding health promotion and

improved NCD management activities

To inform current and future health project (VIGISUS 2 and 3, FHP)

To develop and pilot a model for assessing NCD prevention and control issues in other countries

Objectives:

Brazil Overview

Largest country in LAC Population 186 million; 80% urban Large health disparities Universal health system since 1990 Decentralized Family Health Program % of GDP spent on health: 7.6 Basic health indicators:

• LE: 69 / aging population• TFR: 2.2 • IMR: 30 (48 in 1990)• HALE at birth: 57/62 (male/female)

Burden of Disease by Major Disease Groups, Brazil 1998

0

5,000

10,000

15,000

20,000

25,000Communicable,Maternal, Perinatal,and NutritionalConditionsNon-CommunicableDiseases

Injuries

Source: BOD study 2002

Thousands of Disability-Adjusted Life Years

24%21%

55%

Burden of Disease, Brazil 1998

0

5,000

10,000

15,000

20,000

25,000

Communicable, maternal,perinatal, nutritional

Non-communicable Injuries

Disability,YLDs

Deaths,YLLs

Source: BOD study 2002

Thousands of Disability-Adjusted Life Years, Divided into YLLs and YLDs

Comparison of Years of Life Lost Among Several Diseases

Thousands Years of Life Lost due to Premature Mortality

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

Ischemic heartdiseaseCerebro-vasculardiseaseChronic ObstructivePulmonary DiseaseLung cancer

HIV

Source: BOD study 2002

Avoidable DALYs: Brazil compared to Amer-A*

Brazil Ameri-A

Causes Rate / 1000 Rate / 1000

ALL 270 142

Communicable Maternal Perinatal, Nutritional

Infectious, parasitic

Respiratory infection

Maternal

Perinatal

Nutritional

65

32

8

5

15

5

10

4

1

<1

2

1

Non-communicable

Cancer

Diabetes

Neuro-psychiatric

Cardiovascular

Chronic respiratory

Other

148

15

13

38

31

18

34

118

17

4

42

21

9

25

Injuries

Unintentional

Intentional

56

45

11

14

9

5

* Very low child and adult mortality: Canada Cuba, USA

Prevalence of risk factors in Brazil

Study on nutrition / obesity data is national; all others are smaller studies

Behavioral Risk Factor Survey in most capital cities has been completed – data not yet available

Multiple studies showing wide ranges:Tobacco – 35-50% for men; 20-33% for women Inactivity – 45-60% in men; 60-80% in womenObesity – 10% in adults in ’89 (national survey)Hypertension – 20-30% in adults; higher among lower SES

TendenciesObesity increasing: 6% among adults in ’75; 10% in ’89; also increasing among the poor: 3.6% for lowest female

tercile in ’75, 9.7% in ’89Diabetes increasing: 7.6 / 100,000 for < 15 years old in ’93

(SP); 12.7 in ’98

The challenge of NCD’s in Brazil

Preliminary results of an economic evaluation

Objectives

For a subset of largely preventable NCDs, to estimate the financial costs of treatment and care; estimate the future burden of disease; estimate the future financial and economic costs; and estimate the financial costs of health promotion in

comparison with the financial and economic benefits.

Model (I)

Diabetes mellitus

Ischaemic heart disease

Ischaemic stroke

Chronic obstructive pulmonary disease

Cancer (trachea, bronchi, lungs)

Physical inactivity

Arterial hypertension

Smoking

Current costs of treating a subset of NCD’s [2002/03]

Risk factor Sec. Disease USD 2000 [billion]

Physical inactivity IHD, CVD*, DM 3.4

Arterial hypertension

IHD, CVD 3.2

SmokingIHD, COPD, “lung” cancer

3.5

Total 10.2

Future burden of disease 2005/2010

2005 2010 2015 2020

LE

Future burden of disease – selected conditions by risk factor: 2005 to 2010

Risk factor Sec. Disease BoD 05-10 [DALY, million]

Physical inactivity IHD, CVD*, DM 4.9

Arterial hypertension

IHD, CVD 12.6

SmokingIHD, COPD, “lung” cancer

3.7

Total 21.2

Future costs due to NCD’s 2005/2010

Future costs (status quo persists): Financial costs:

Costs of treating secondary diseases Economic costs:

Financial costs plusproductivity losses due to disability and premature mortality

Future economic costs due to NCD’s: 2005/2010

Risk factor Sec. Disease Economic costs 05-10 [ USD, 2002, billion]

Physical inactivity IHD, CVD*, DM $130.0

Arterial hypertension

IHD, CVD $215.2

SmokingIHD, COPD, “lung” cancer

$122.0

Total $467.2

Model II

Physical inactivity

Arterial hypertension

Smoking

Scaling up of AGITA SAO PAULO

Treatment of 25% of population c hypertension

10% increase in prices of cigarettes

Medical counseling for 25% of smokers

Scaling up of AGITA SAO PAULO

Intervention: Expansion of program to 25% of population

Financial costs of providing intervention

131 million

DALY’s averted 127,000

Financial costs in care of secondary diseases averted

572 million

Losses in productivity averted 452 million

Benefit cost ratio 7.8

Costs in USD 2000

Benefit cost ratios

Scaling up of AGITA SAO PAULO

Treatment of 25% of population c hypertension

10% increase in prices of cigarettes

Medical counseling for 25% of smokers

7.8

1.2

2.9

0.1

Conclusions

NCDs consume a large share of Total Expenditure on Health

Future economic costs accruing over the period of 2005/2010 equal approximately 70% of GDP in 2002

Effective interventions to prevent NCD’s exist. Some are financially and economically highly attractive.

Ministry of Health Response to Health Transition

Fragmented national policies: National policy to reduce injuries and violence National anti-tobacco and anti-drug policy National Food Security policy National and State Cancer Control policies National and State Occupational Health policies

Policies not yet operationalized in national / state / municipal health plans

Health Muncipalities project, 2002, UNSP

Ministry of Health Structure

Executive Secretariat responsible for establishing health promotion policies and coordinating cross-cutting program

Fragmented national structure: No one unit responsible for health promotion

activities Four secretariats involved

Greater activity in some states e.g. Sao Paulo

Ministry of Health:primary health care

Eight Family Health Program priorities include: Control of hypertension and diabetes Health promotion

National plan and guidelines available for hypertension and diabetes detection and control, but not health promotion

Plan has been implemented through training, IEC campaigns, community work

Performance measures on hospitalization and mortality; none for risk factors or HP activities

In process of defining policies to promote healthy lifestyles, health promotion and risk prevention.

Interventions in tobacco

National Tobacco Control Program established, 1987 Advisory Board on Tobacco Use Control established,

1987 Warning on cigarettes, 1988; bolder in 2001 Restricted tobacco advertising, 1994 Smoking banned in MOH, 1998 Tobacco considered drug and regulated by ANVISA,

1999 Various media campaigns Tobacco advertising only at point of sale, 2000 Tobacco use education and control programs in the

workplace, schools, and health units

Next steps

National health promotion plan -- involvement of multiple sectors; address issues at various levels

Clearly defined priorities and targets Commitment to financing Structure that facilitates action Scale up cost-effective interventions shown to

work in Brazil Piloting interventions found to be cost-effective in

other countries based on priorities HP performance measures include in pactos Information systems to monitor impact and trends