NON-COMMUNICABLE DISEASES (NCDs) NATIONAL FORUM AT THE GREAT RIFT VALLEY LODGE, NAIVASHA, KENYA: AUGUST

24-26, 2011

The Political Economy of NCDs and Country Development

Klaus Hornetz, Atia Hossain, Anna Carin Matterson, GIZ Kenya

http://www.thecommonwealth.org/news/236456/090511ncdlancet.htm

• Economic Facts and Assumptions

• Some Case Studies

• Costing and Financing NCDs in Kenya

The Economics of NCDs and Country Development

• NCD’s affect and – for lower income countries threaten - economic and human development

Economic costs of NCD

• Life years lost

• Poverty enhanced

– Increased (“catastrophic”) out-of-pocket expenditure

– Decreased earning

• Productivity decreased (% of GDP)

• Resource allocation and spending – changed focus

• Poor/developing countries face challenges where NCDs become a major problem

- Indonesia’s private healthcare spending is projected to more than double by 2020, compared to 2005*

- India’s NCD mortality to cost USD237 Billion to the National Income by 2015**

• Social and economic costs of NCD are high:

- China will lose over $550 billion in productivity between 2005 and 2015*

- $84 billion of lost national output from 2006-2015 in 23 low-

and middle-income countries***

• NCDs share of all global healthcare costs = 75%****

Sources: * Dr Shin Young-soo, Director for Western Pacific. WHO. 2010. ** India Health Progress. 2010 /PRNewswire. *** The Rising Prevalence of NCDs: Implications for Health Financing and Policy. Charles Holmes, 2011. PEPFAR, USAID. **** Medtronic Innovation for Health.

• 1/3rd of people living on US$1-2 a day die prematurely of NCDs*

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

– Out of pocket expenses for treatment range from 4 to 34% of household income/expenditures**

– Cost of caring for a family member with diabetes can be 23% (Sudan) - 34% (India) of low-income household***

– Poorest households spend > 10% of their income on tobacco*

– Cost of essential drugs to treat and cure cancer - unaffordable for the poor*

Sources: * WHO, Economic and Social Council resolution High-level Segment 2009.; ** The Rising Prevalence of NCDs: Implications for Health Financing and Policy. Charles Holmes, 2011. PEPFAR, USAID. *** Self-reported social class, self-management behaviors, and the effect of diabetes mellitus in urban, minority young people and their families. Lipton R et al. Arch Pediatr Adolesc Med.2003.

Macro-economic impact of NCDs: lost national income

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100150200250300350400450500550600

Bra

zil

Ch

ina

Ind

ia

Nig

eria

Pak

ista

n

Ru

ssia

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atio

n

Tan

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ia

2005

2006-2015(cumulative)

bill

ion

$

WHO: "Heart disease, stroke and diabetes alone are estimated to

reduce GDP between 1 to 5% per year in developing countries

experiencing rapid economic growth“ (WHO Chronic Diseases Report, 2005)

Public Policy and the Challenge of Chronic Non-communicable Diseases. Olusoji Adeyi et al. 2007. World Bank.

Improving primary care for the prevention and treatment of people at risk of NCD’s, is cost effective and will reduce the burden on health systems

How much prevention How much medical care?

The Case of Northern Karelia

• Early Seventies men in Finland had the highest :mortality rates of coronary heart disease in the world,

• Intervention: a comprehensive prevention program to reduce the risk factor levels in the population through general lifestyle changes

• Results: over the years, great reductions in the population levels of the risk factors took place, associated with dramatic reduction in age-adjusted CVD mortality rates and improvement in public health.

“The experience of diminishing the prevalence of risk factors in the population is a powerful demonstration of how the CVD epidemic can be successfully confronted” National Institute for Health and Welfare (THL), FI-00271 Helsinki, Finland. pekka.puska@thl.fi

The Case of Northern Karelia

• First province of North Karelia as a pilot

(5 years), then national action (1972–77)

• Continuation is North Karelia as national demonstration

(1977–95)

• Good scientific evaluation to learn of the experience

• Comprehensive national action

Adapted from Pekka Puska , 2009`

The Case of Northern Karelia

Use of Butter on Bread (men age 30–59)

%

0

20

40

60

80

100

1972 1977 1982 1987 1992 1997 2002

North Karelia

Kuopio province

Southwest Finland

Helsinki area

Oulu province

Lapland province

Adapted from Pekka Puska , 2009`

Milk Consumption in Finland in 1970 and 2006 (kg per capita)

0

20

40

60

80

100

120

140

kg

1960 1970 1980 1990 2000 2010

Whole milk

Whole form milk

Low fat milk

Skim milk

Source: Pekka Puska , 2009

CHD Mortality in All Finland and in North Karelia, Men Aged 35-64

North Karelia

All Finland

start of the North Karelia Project

extension of the Project nationally

Source: Statistics Finland

- 85%

- 80%

0

100

200

300

400

500

600

700

69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06

Year

Per 100 000

Source: Pekka Puska , 2009`

Mortality Changes in North Karelia from 1969–71 to 2006 (Men 35–64 Years, Age Adjusted)

Rate (per 100.000) Change from

1969–71 2006 1969–71 to 2006

All causes 1509 572 - 62%

All cardiovascular 855 182 - 79%

Coronary heart disease 672 103 - 85%

All cancers 271 96 - 65%

Lung cancers 147 30 - 80%

Source: Pekka Puska , 2009

Source: OECD 2011 http://www.oecd.org/document/11/0,3746,en_2649_37407_47731659_1_1_1_37407,00.html

Morbidity is much more expensive than mortality. Once engaging in NCDs on larger scale will result in ever growing resource needs.

Germany

• Who’s Life?

Health care cost and age in Germany

12

13

14

15

16

17

18

19

1970 1975 1980 1985 1990 1995 2000 2005

Time [years]

Popula

tion >

65 y

ears

[%

]

9

10

11

12

13

14

New

-born

[‰

]

> 65 years New born

Demographic trends in Germany

Engaging on national level against NCDs is not only a diagnostic and therapeutic enterprise: Systems of social protection and care are to be developed in parallel to meet NCD related challenges i. a. to avoid catastrophic expenditures, need for long-term and for palliative care.

Chile

The individual in society is not an abstract entity: one is born, develops, lives, works, reproduces, falls ill, and dies in strict subjection to the surrounding environment, who different modalities create diverse modes of reaction, in the face of the etiologic agents of disease. This material environment is determined by wages, nutrition, housing, clothing, and culture… S. Allende

Chile: Health Care Expenditures 1970 - 2000

NCDs will not “go away” from national policy and political discourses. Those paying taxes and insurance premiums are the same citizen demanding adequate diagnostic and therapeutic infrastructure.

Who shall live

And who shall die

Who shall fulfil his days

And who shall die before his time….

Yom Kippur; Day of Atonement Prayer Book

La Historia de la Medicina en Mexico:

gente demanda mejor salud, 1953, Fresco, Hospital de La Raza, Ciudad de México

+++

poor

--

wealthy

+ +++

“diseases of

poverty”

“diseases of

affluence”

Disease dynamics in Kenya and the

Dilemma of Health Politics:

Demand Matrix

€

poor wealthy

€

“diseases of

poverty”

“diseases of

affluence”

Disease dynamics in Kenya and the

Dilemma of Health Politics:

Cost Matrix

Prevalence of overweight and obesity amongst Kenya women aged 15 – 49 years

BMI >25

0

5

10

15

20

25

DHS 1993 DHS 1998 DHS 2003

Perc

en

tag

e

BMI >25

Trends in 15 – 49 yr olds

Source: KIPPRA 2010

• NCDs today depend largely on domestic resources

• Despite the growing importance of NCDs for low and middle income countries, only 2-3 % of donor funding supports NCDs while 46% goes into the 3 big ones only.

Sector Budget paper 2011 (requirements as presented in sector budget hearing on 12 January 2011)

Millions KSHs - Education about 60% of total

Sub-sector 2011/12 2012/13 2013/14

Education 162,360 167,644 173,198

Labour 3,964 4,414 4,889

Medical

Services

56,740 60,704 63,067

Public health 35,846 40,189 45,411

Total 258,910 272,951 286,565

Total User fees (KES million) collected

Source: KIPPRA 2010

“Interventions for responding (to CDs) and NCD’s represent opportunities for improving health systems in low and middle income countries provided that such investments are planned to include these broad objectives at the onset. “

Thank You