policy makers and regional health institutions response to ncds and the link with civil society

Policy Makers and Regional Policy Makers and Regional HealthHealth

Institutions Response to NCDs Institutions Response to NCDs and the Link with Civil Society and the Link with Civil Society

Healthy Caribbean Coalition ConferenceHealthy Caribbean Coalition ConferenceBarbados, October 2010Barbados, October 2010

C. James HospedalesC. James HospedalesSenior Advisor and Coordinator, NCD Prevention & ControlSenior Advisor and Coordinator, NCD Prevention & Control

Pan American/World Health OrganizationPan American/World Health Organization

What’s the role of Civil Society and What’s the role of Civil Society and NGOs in the prevention & control of NGOs in the prevention & control of

NCDs?NCDs?

Advocacy, creating mass /popular movementsAdvocacy, creating mass /popular movements Monitoring/watchdog roleMonitoring/watchdog role Providing education and trainingProviding education and training ResearchResearch Service provision for people with NCDs or risk Service provision for people with NCDs or risk

factors; screening, preventive care, etc.factors; screening, preventive care, etc. Health promotion and prevention interventionsHealth promotion and prevention interventions Other?Other?

Burden of NCDs in the Americas, mid-Burden of NCDs in the Americas, mid-2000s2000s

Of a total of 5.2 million deaths, 3.2 million Of a total of 5.2 million deaths, 3.2 million (62%) were due NCDs (51% males, 49% (62%) were due NCDs (51% males, 49% females)females)

97% in high and upper middle-income countries97% in high and upper middle-income countries

Leading causes (per 100,000): Leading causes (per 100,000): – CVD (192), or 1.6M deathsCVD (192), or 1.6M deaths– Cancer (121)Cancer (121)– Chronic resp disease (52)Chronic resp disease (52)– Diabetes (26) Diabetes (26)

In 2004, approximately 598,000 people died In 2004, approximately 598,000 people died prematurely from NCDs before age 60 yearsprematurely from NCDs before age 60 years

wb_income (group) / agegroup

Low, Lower-middle Upper-middle High

year 1 < years 4 -1 years 9 -5 ..yea 29 -10 ..yea 49 -30 ..yea 69 -50 and over 70year 1 < years 4 -1 years 9 -5 ..yea 29 -10 ..yea 49 -30 ..yea 69 -50 and over 70

year 1 < years 4 -1 years 9 -5 ..yea 29 -10 ..yea 49 -30 ..yea 69 -50 and over 70

0%

10%

20%

30%

40%

50%

60%

Proportion of deaths

cause (group)

Sign symptoms ill-defined

Chronic non-communicable diseases

Communicable, maternal, perinatal, nutritional diseases

External causes

MORTALIDAD EN PAISES AGRUPADOS SEGUN INGRESOS REGION DE LAS AMERICAS

USA, Can, T&T, Bar,

Some OTs

Guy, Hai, Hon,

Nic, Bol, Guat

All others

Risk Factors for Chronic DiseasesRisk Factors for Chronic Diseases in in the Americas regionthe Americas region

145 million people >15 years are current smokers145 million people >15 years are current smokers

Prevalence of hypertension: 13-34% Prevalence of hypertension: 13-34%

Low fruit & vegetable intake in females >18 Low fruit & vegetable intake in females >18 years: 56-94%; and 57-92% in malesyears: 56-94%; and 57-92% in males

Low physical activity in adults >18 years: 14-Low physical activity in adults >18 years: 14-46% 46%

Projected that persons >15 years with obesity will Projected that persons >15 years with obesity will increase from 139 million in 2005 to 289 million in increase from 139 million in 2005 to 289 million in 2015! Majority females2015! Majority females

Economic Issues:Economic Issues:

NCDs reduce the economy of LAC by 2% a yearNCDs reduce the economy of LAC by 2% a year Expenditure for diabetes ‘07 = $131 billionExpenditure for diabetes ‘07 = $131 billion 40% of patients with kidney failure pay from 40% of patients with kidney failure pay from

their pocket $99/dialysis session, $15,500/yeartheir pocket $99/dialysis session, $15,500/year Treatment/care of NCDs cause catastrophic Treatment/care of NCDs cause catastrophic

health expenses because of out-of-pocket health expenses because of out-of-pocket expenditure, worsening poverty and increasing expenditure, worsening poverty and increasing health inequitieshealth inequities

Access for low-income persons hindered by 39-Access for low-income persons hindered by 39-63% of the population having to pay full cost of 63% of the population having to pay full cost of basic medications for diabetes and hypertensionbasic medications for diabetes and hypertension

Some Examples of basic strategies Some Examples of basic strategies that can help reduce the burden of that can help reduce the burden of NCDsNCDs

Reduce tobacco use by 20%; salt intake Reduce tobacco use by 20%; salt intake by 15%; and use simple multidrug by 15%; and use simple multidrug regimens for patients at high-risk of regimens for patients at high-risk of cardiovascular disease to prevent more cardiovascular disease to prevent more than 3.4 million deaths from chronic than 3.4 million deaths from chronic diseases in the Region over 10 years at diseases in the Region over 10 years at reasonable cost.reasonable cost.

Two interventions (20% tobacco and 15% Two interventions (20% tobacco and 15% salt intake reduction) would be less than salt intake reduction) would be less than $0.40 per person/year in low- and lower $0.40 per person/year in low- and lower middle-income counties, and $0.50-1.00 middle-income counties, and $0.50-1.00 in upper middle-income countries.in upper middle-income countries.

What are the policy What are the policy makers doing in makers doing in countries and regional countries and regional institutionsinstitutions

NCD Progress Indicator Status / Capacity by Country in Implementing NCD Summit Declaration - NCD Progress Indicator Status / Capacity by Country in Implementing NCD Summit Declaration -

September 2010September 2010 POS NCD #

NCD Progress Indicator

A N G

A N T

B A H

B A R

B E L

B E R

B V I

C A Y

D O M

G R E

G U Y

H A I

J A M

M O N

S K N

S T L

S V G

S U R

T R T

T C I

COMMITMENT 1,14 NCD Plan X X ± ? ± ? ± X ? ? ? X ? ? ? ± ± ? 4 NCD budget X X X ? ± X X X ± X ± X X X ? X X ? 2 NCD Summit convened X X X ? X ? ? X ? ± ? X ? X ? X ? 2 Multi-sectoral NCD Commission

appointed and functional X X X ? ± ? ? X X ? ? X ± X ? X ± ?

12 NCD Communications plan X X ± ± X ? X X ± ± ? X ± X ± X X ? TOBACCO

3 FCTC ratified * ? ? ? ? * * ? ? ? ? X ? * ± ? ? ? ? * 3 Tobacco taxes >50% sale price X X X ? X ± X ? X ? ± X X ? X 3 Smoke Free indoor public places X ? X ? ± ? ? ? ? ? X ± X ? X ± ? 3 Advertising, promotion & sponsorship bans X X X ± X ? ? ? X ± X ? X X X ± ?

NUTRITION 7 Multi-sector Food & Nutrition plan

implemented ? ? ? ± ± X ? X ? ? ? X ? ? ± X ? X ± ?

7 Trans fat free food supply X X ± X X X 7 Policy & standards which promote healthy

eating in schools implemented ? ? ± ? X ± ± ? ± X X ±

8 Trade agreements utilized to meet national food security & health goals

± X ± X X X ?

9 Mandatory labeling of packaged foods for nutrition content

X X ± ± ± X X ± X

PHYSICAL ACTIVITY 6 Mandatory PA in all grades in schools ? ? ± ? ± X X X ? 10 Mandatory provision for PA in new housing

developments ? ? X X X X X

10 Ongoing, mass Physical Activity or New public PA spaces

X X ? ? ? ? X ± ? ? ? ? ? ? ? ?

EDUCATION / PROMOTION 15 CWD multi-sectoral, multi-focal celebrations ? ? ? ? ? ? ? ? ? ? ? X ? ? ? ? ? ? ? ? 10 ?50% of public and private institutions with

PA & diet) programmes X X X X ± ± X X X

12 ?30 days media broadcasts on NCD control / yr (risk factors and treatment)

? ? X ? X ± ? ? ? ± X X X

SURVEILLANCE Surveillance: - STEPS or equivalent survey X X ? ? ? ± ? X ? ± ± X ? ? ± X ± ± - Minimum Data Set reporting X X X X X ? ? X ? X X X X X X X ? ? X X - Global Youth Tobacco Survey X ? ? ? ? X ? ± ? ? ? ? ? ± ? ? ? ?

11, 13, 14

- Global School Health Survey ? ? ? ± ± ? ± ? ? X ? ± ? ? ? ? TREATMENT

5 Chronic Care Model / NCD treatment protocols in ? 50% PHC facilities

X ? ? ± ± ± X ± X ± ± X ? X ? X X ?

5 QOC CVD or diabetes demonstration project

± ? ? ± ± ± ? X ? ? ± ? ±

? X ? ?

ROLES OF CARIBBEAN REGIONAL INSTITUTIONS AND PAHO/WHO ROLES OF CARIBBEAN REGIONAL INSTITUTIONS AND PAHO/WHO IN SUPPORT OF CHRONIC DISEASE PREVENTION AND CONTROL, IN SUPPORT OF CHRONIC DISEASE PREVENTION AND CONTROL, AND OTHER FINANCING ORGANIZATION AND OTHER FINANCING ORGANIZATION (UNICEF, UNFPA, CDC, PHAC, IADB, WORLD BANK)(UNICEF, UNFPA, CDC, PHAC, IADB, WORLD BANK)

CARPHA

Line of Action CEHI CFNI CHRC CRDTL CAREC

CARICOM PAHO/WHO OTHER PARTNERS

UWI

Civil Society

Public Policy and Advocacy

X X X X X X X X

Building capacity for legislation

X X X X X X CDC PHAC

UNICEF UNFPA

X X

CARICOM Regional plan for the prevention and control of NCDs

X X X X X CDC PHAC

UNICEF UNFPA

X X

Food child marketing X X X X CDC PHAC

UNICEF

X

Tobacco legislation X X X X CDC PHAC

UNICEF

X

Establishment of National NCD Commissions

X X X

Surveillance X X X Surveillance of risk

factors X X X X CDC X

Mortality and Morbidity surveillance

X X CDC

Health Promotion and Disease Prevention

X X X X

Comprehensive NCD education/awareness campaign

X X X X CDC PHAC

UNICEF UNFPA

X X

Healthy lifestyles X X X X X CDC PHAC

UNICEF UNFPA

X X

Healthy workplace X X X ILO X X

Healthy schools X X X X UNICEF X X

NCD Capacity Survey NCD Capacity Survey 2010 - Main Highlights2010 - Main Highlights

32 countries; 332 countries; 3rdrd survey since 2001 survey since 2001 Most countries have a capacity installedMost countries have a capacity installed Financial resources mainly allocated for treatment Financial resources mainly allocated for treatment Some have tobacco and alcohol taxes; most not earmarked for Some have tobacco and alcohol taxes; most not earmarked for

NCDsNCDs Most countries have not yet developed specific policies on NCDsMost countries have not yet developed specific policies on NCDs However, most have policies on tobacco, diet and physical However, most have policies on tobacco, diet and physical

activityactivity Most countries have mortality surveillance systemsMost countries have mortality surveillance systems But limited information on NCDs incidence and risk factorsBut limited information on NCDs incidence and risk factors Most countries reported addressing NCDs and risk factors with a Most countries reported addressing NCDs and risk factors with a

primary health care approachprimary health care approach Most reported having established a partnership/ collaborationMost reported having established a partnership/ collaboration Although most reported having financial resources for health Although most reported having financial resources for health

promotion, it seems most not implementing health promotion promotion, it seems most not implementing health promotion activitiesactivities

PUBLIC INFRASTRUCTUREPUBLIC INFRASTRUCTURE

CountryCountryHigh IncomeHigh Income Upper Middle IncomeUpper Middle Income Lower Middle Lower Middle

IncomeIncome UndeterminedUndetermined

BARBAR TRTTRT JAMJAM SCNSCN SALSAL SURSUR BELBEL GUYGUY ANGANG BVIBVI MONMON

Per capita health expenditurePer capita health expenditure 1,5351,535 785785 224224 622622 360360 360360 174174 185185 N/AN/A N/AN/A N/AN/A

All NCDs mortality rates/100,000All NCDs mortality rates/100,000 577577 496496 N/AN/A 519519 353353 294294 225225 349349 266266 280280 866866

There is unit/branchThere is unit/branch √√ √√ √√ √√ √√ √√ √√ √√ √√

IncludesIncludes

PlanningPlanning √√ √√ √√ √√ √√ √√ √√ √√ √√ √√

Coordination of implementationCoordination of implementation √√ √√ √√ √√ √√ √√ √√ √√ √√ √√

Monitoring and evaluationMonitoring and evaluation √√ √√ √√ √√ √√ √√ √√ √√ √√ √√

Funding available:Funding available:

Treatment and controlTreatment and control √√ √√ √√ √√ √√ √√ √√ √√ √√

Prevention and health promotionPrevention and health promotion √√ √√ √√ √√ √√ √√ √√ √√

Surveillance, monitoring an Surveillance, monitoring an evaluationevaluation √√ √√ √√ √√ √√ √√ √√

Fiscal interventions to influence Fiscal interventions to influence behavior changebehavior change √√ √√ √√ √√ √√

Earmarked taxes on Earmarked taxes on alcohol/tobaccoalcohol/tobacco √√

POLICIES, STRATEGIES AND ACTION PLANS POLICIES, STRATEGIES AND ACTION PLANS

CountryCountryHigh IncomeHigh Income Upper Middle IncomeUpper Middle Income

Lower Lower Middle Middle IncomeIncome

UndeterminedUndetermined


Integrated NCD Integrated NCD policy/strategy/action planpolicy/strategy/action plan √√ √√ √√ √√ √√

but not operational/more info but not operational/more info needed for current statusneeded for current status √√ √√

Integrated NCD policy/strategy/action plan combines the following:Integrated NCD policy/strategy/action plan combines the following:

Harmful alcohol consumptionHarmful alcohol consumption √√ √√ √√ √√ √√

Unhealthy dietUnhealthy diet √√ √√ √√ √√ √√ √√ √√ √√ √√

Physical activityPhysical activity √√ √√ √√ √√ √√ √√ √√ √√ √√

TobaccoTobacco √√ √√ √√ √√ √√ √√ √√ √√

Policies/strategies/action plan combining early Policies/strategies/action plan combining early detection, treatment and care, rehabilitationdetection, treatment and care, rehabilitation

CountryCountry

High High IncomeIncome Upper Middle IncomeUpper Middle Income




CancerCancer √√ √√ √√ √√

Cardiovascular diseasesCardiovascular diseases √√ √√ √√ √√

Chronic respiratory Chronic respiratory diseasesdiseases

√√ √√

DiabetesDiabetes √√ √√ √√ √√

HypertensionHypertension √√ √√ √√ √√

Overweight/obesityOverweight/obesity √√ √√ √√ √√

Abnormal blood lipidsAbnormal blood lipids √√ √√

Cont…Cont…Policies/strategies/action plan combine early Policies/strategies/action plan combine early detection, treatment and care, rehabilitationdetection, treatment and care, rehabilitation

CountryCountry





Specific policies on:Specific policies on:

Harmful alcohol Harmful alcohol consumptionconsumption √√ √√ √√ √√

Unhealthy dietsUnhealthy diets √√ √√ √√√√

√√ √√

Physical inactivityPhysical inactivity √√ √√ √√ √√ √√ √√

Tobacco consumptionTobacco consumption √√ √√ √√ √√ √√ √√

Health Information Systems, Surveys and Health Information Systems, Surveys and Surveillance; Registry on Risk FactorsSurveillance; Registry on Risk Factors

CountryCountry





Cause-specific mortality Cause-specific mortality related to NCDrelated to NCD √√ √√ √√ √√ √√ √√ √√ √√ √√ √√

Morbidity related to NCDMorbidity related to NCD √√ √√ √√ √√ √√ √√ √√

Existence of disease registryExistence of disease registry

CancerCancer √√ √√ √√ √√ √√ √√

DiabetesDiabetes √√ √√ √√ √√ √√ √√ √√

Cardiovascular diseaseCardiovascular disease √√ √√ √√

Cerebrovascular diseaseCerebrovascular disease √√ √√

Health Information Systems, Surveys and Health Information Systems, Surveys and Surveillance; Risk FactorsSurveillance; Risk Factors

CountryCountry





Risk factor surveys on:Risk factor surveys on:

Harmful alcohol useHarmful alcohol use √√ √√ √√ √√ √√

DietDiet √√ √√ √√ √√

Physical inactivityPhysical inactivity √√ √√ √√ √√

Tobacco useTobacco use √√ √√ √√ √√ √√ √√ √√

Raised blood Raised blood glucose/diabetesglucose/diabetes √√ √√ √√ √√ √√

Abnormal blood lipidsAbnormal blood lipids √√ √√ √√ √√ √√ √√

Raised blood Raised blood pressure/hypertensionpressure/hypertension √√ √√ √√ √√ √√

Overweight/obesityOverweight/obesity √√ √√ √√ √√ √√

Health System Capacity for Prevention, Early Health System Capacity for Prevention, Early Detection, Treatment and Care within the Primary Detection, Treatment and Care within the Primary Health Care SystemHealth Care System

CountryCountry





Primary prevention/health Primary prevention/health promotionpromotion √√ √√ √√ √√ √√ √√ √√ √√ √√ √√

Risk factor detectionRisk factor detection √√ √√ √√ √√ √√ √√ √√ √√ √√

Risk factor and disease Risk factor and disease managementmanagement √√ √√ √√ √√ √√ √√ √√ √√ √√ √√ √√

Support for self help and Support for self help and self-careself-care √√ √√ √√ √√ √√ √√ √√

√√

Home-based careHome-based care √√ √√ √√ √√ √√

Surveillance reportingSurveillance reporting √√ √√ √√ √√ √√ √√ √√

Does your health system have guidelines/protocols or Does your health system have guidelines/protocols or norms for prevention and management of: norms for prevention and management of:

GuidelinesGuidelines % of Countries% of Countries(sample size (sample size

24)24)

Hypertensión Hypertensión 2323

Diabetes Mellitus Diabetes Mellitus 2323

Heart Diseases Heart Diseases 1717

Cerebrovascular Cerebrovascular diseasedisease

1313

Cancer Cancer 2020

Chronic Respiratory Chronic Respiratory Diseases Diseases

1414

Smoking Cessation Smoking Cessation 1313

Weight Control Weight Control 1212

Nutrition Nutrition 1919

Physical ActivityPhysical Activity 1313

Other diseasesOther diseases 99

Source: PAHO. National Capacity for the Management of Chronic Diseases in Latin America & the Caribbean, Washington, 2010

Price and access to medicines Price and access to medicines for chronic diseasesfor chronic diseases

NameName Cost Cost % out of % out of pocket pocket

In essential In essential list of medslist of meds

Insulin Insulin $10.30$10.30 62.362.3 2323

Aspirin(100 Aspirin(100 mg) mg)

$0.05$0.05 42.842.8 2121

Metformin Metformin $0.11$0.11 41.541.5 2222

GlibenclamidGlibenclamide e

$0.08$0.08 43.543.5 2222

Thiazide Thiazide diuretics diuretics

$0.09$0.09 38.638.6 2222

ACE ACE InhibitorsInhibitors

$0.14$0.14 38.638.6 2121

Ca C Ca C Blockers Blockers

$0.86$0.86 38.638.6 2121

B Blockers B Blockers $0.12$0.12 38.638.6 2121

Statins Statins $0.58$0.58 35.235.2 1616

TamoxifenTamoxifen $1.23$1.23 31.631.6 1414

ChemotheraChemotherapy py

$1,188.44$1,188.44 18.518.5 1313

Source: PAHO. National Capacity for the Management of Chronic Diseases in Latin America & the Caribbean, Washington, 2010

Health Promotion and Health Promotion and CollaborationCollaboration

CountryCountry





Partnerships/collaborations Partnerships/collaborations for implementing key for implementing key activitiesactivities

√√ √√ √√ √√ √√ √√ √√ √√ √√ √√ √√

Health promotion activities implemented:Health promotion activities implemented:

Fiscal interventions to Fiscal interventions to influence behavior changeinfluence behavior change √√ √√ √√ √√ √√

Implementing 1 or more Implementing 1 or more community/empowerment community/empowerment approachesapproaches

√√ √√ √√ √√ √√ √√ √√

implementing 1 or more implementing 1 or more evaluated health promotion evaluated health promotion campaigns to change campaigns to change individual behaviorsindividual behaviors

√√ √√ √√ √√

Initiatives that regulate the Initiatives that regulate the marketing of foods to marketing of foods to childrenchildren

√√ √√

Health promotion activities implemented:Health promotion activities implemented:TypeType

BARBAR TRTTRT DOMDOM JAMJAM SCNSCN SALSAL SURSUR BELBEL GUYGUY ANGANG BVIBVI MONMON

Implementing 1 or more Implementing 1 or more community/empowerment community/empowerment approachesapproaches

√√ √√ √√ √√ √√ √√ √√ √√

In SchoolsIn Schools √√ √√ √√ √√ √√ √√ √√

In workplace wellnessIn workplace wellness √√ √√ √√ √√ √√ √√ √√

In healthy cities / In healthy cities / municipalitiesmunicipalities √√ √√ √√ √√ √√ √√

Conclusions & Next Conclusions & Next StepsSteps Despite the major gains made by Member Despite the major gains made by Member

States on their national chronic disease States on their national chronic disease programs, the attention and resources programs, the attention and resources devoted to this public health issue are not devoted to this public health issue are not commensurate with the extent of the commensurate with the extent of the disease burden and economic costs. disease burden and economic costs.

Continue working together to promote Continue working together to promote inter-sectoral policy changes before, inter-sectoral policy changes before, during, and after the high-level meeting during, and after the high-level meeting of the United Nations on NCDs in of the United Nations on NCDs in September 2011.September 2011.

Next StepsNext Steps

Member States and PAHO should make a Member States and PAHO should make a concerted effort to:concerted effort to:– build competencies and capacity for build competencies and capacity for

comprehensive, integrated prevention and control comprehensive, integrated prevention and control of chronic diseases at all levels (training), of chronic diseases at all levels (training),

– Improve surveillance, Improve surveillance, – policy, policy, – tobacco control, tobacco control, – salt reduction, salt reduction, – healthy diets and physical activity, healthy diets and physical activity, – improved disease management, and improved disease management, and – multi-stakeholder engagement mechanisms with a multi-stakeholder engagement mechanisms with a

strengthened stewardship role of Ministries of strengthened stewardship role of Ministries of Health.Health.


Continue to scale up access to Continue to scale up access to medicines and quality health services medicines and quality health services for screening, early detection, and for screening, early detection, and control of chronic diseases.control of chronic diseases.

Continue to improve the quality and Continue to improve the quality and timeliness of health information timeliness of health information designed to guide policy, planning, and designed to guide policy, planning, and evaluation, especially risk factor evaluation, especially risk factor information, pursue gender-based information, pursue gender-based analysis and novel approaches and analysis and novel approaches and technologiestechnologies


Strengthening national & subregional inter-Strengthening national & subregional inter-sectoral efforts, partnerships, and alliances as a sectoral efforts, partnerships, and alliances as a key cross-cutting strategy key cross-cutting strategy

Support the CARMEN Network and Partners Forum Support the CARMEN Network and Partners Forum as innovative mechanisms to support country as innovative mechanisms to support country efforts to engage private sector and civil societyefforts to engage private sector and civil society

Review their legislation and norms for addressing Review their legislation and norms for addressing chronic diseases and tobacco controlchronic diseases and tobacco control

Implementation of WHO guidelines on marketing Implementation of WHO guidelines on marketing foods and non-alcoholic beverages to children, as foods and non-alcoholic beverages to children, as approved at the 63rd World Health Assembly.approved at the 63rd World Health Assembly.

What’s the role of Civil Society and What’s the role of Civil Society and NGOs in the prevention & control of NGOs in the prevention & control of

NCDs?NCDs?

Advocacy, creating mass movementsAdvocacy, creating mass movements Monitoring/watchdog roleMonitoring/watchdog role Providing education and trainingProviding education and training ResearchResearch Service provision for people with NCDs or Service provision for people with NCDs or

risk factors; screening, preventive care, etc.risk factors; screening, preventive care, etc. Health promotion and prevention NGOsHealth promotion and prevention NGOs OtherOther

Thank youThank you

policy makers and regional health institutions response to ncds and the link with civil society

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