Prepared by: Dr. Faisal A/Latif Director NCDs Programs January 2010 Lausanne

1. Palestinian National Authority Ministry of HealthTowards Better Prevention and Management of Non Communicable Diseases (NCDs) Prepared by: Dr. Faisal A/Latif Director NCDs Programs January 2010 Lausanne

2. Jerusalem – The holy city

3. Presentation outlines • Background and Demography • Why NCDs? • NCDs magnitude Global Vs. Local • National facts on NCDs • Challenges, opportunities and constrains • Commitments • Specific MOH interventions: • NCDs Department • National Center for Prevention and Management of NCDs funded by the Austrian Government Establishment of thematic working group • Integration of programs • Conclusions and recommendations

4. Background • Longstanding conflict and ongoing occupation • Challenges to maintain up to date knowledge and skills and continuous education programs • Ministry of Health responsibility, efforts and coordination • The separation wall and its negative impact • Trends of care and raised hospital orientation • Services offered in PHC centres • Population: 3.9 million; 2.4 million in the West Bank and 1.4 million in Gaza (Palestinian Central Bureau for Statistics (PCBS), Palestine in Figures 2007)

5. Why focus on NCDs? • Rise in life expectancy, gradual adoption of unhealthy behaviors including tobacco use, physical inactivity and unhealthy diet, aggravated by poor psychosocial wellbeing due to a longstanding political conflict has resulted in a growing burden of NCDs in Palestine. • 50 % of deaths is attributed to cardiovascular disease, cancer, DM and COPD • This represents a major public health challenges to the national economy and social development as well as lives and health of people • Palestine is witnessing a status of epidemiological transition that shaped the national task to address simultaneously both: “diseases of underdevelopment“ as well as "diseases of development,“ • The NCDs rate in the Middle East including Palestine is considered as the highest in the world

6. Burden of NCDs Global • 60% of all deaths over the world • 75% in the developing countries • 25% in the developed world • 47% of the burden of diseases Regional - Middle east • 52% of all Deaths • 47% of the Burden similar of the global figure “The World Health Report 2006” 

7. Burden of NCDs in the developing countries 1995 - 2020 1990 2020 ) Communicable diseases, maternal conditions and nutritional deficiencies Non Communicable Diseases Neuro psychiatric and OA Disorders Injuries Extracted from WHO reports

8. Where are we in Palestine ? Prevalence of NCDs – Estimation NCDs Prevalence • Cardiovascular Diseases 14% above 18 years • Diabetes mellitus 10 % all ages (old study 2000) • Neoplasm 4.5 % • COPD 3.5%

9. Where are we in Palestine ?Leadings causes of death – Estimations Causes of Death Rate • Cardiovascular Diseases 40% • Malignancies 18% • Accidents 17% • Diabetes Mellitus 06% • All others 19%

10. Where are we in Palestine ? Prevalence of Major NCDs Risk Factors- Estimation Risk Factor Percentage Modifiable: • Low fruit and vegetable 25% - (relatively low) • Tobacco use 28% • Physical Inactivity 50% - (urbanization) Intermediate: • Overweight &Obesity 32% • Abnormal lipids Profile 25% • Hypertension 12% • Diabetes Mellitus 10% - (old studies (2000)

11. Facts on NCDs in Palestine (PCBS) • Prevalence: • One out of every ten has at least one NCD • 25% of citizens above 60 are diabetics • Expenditure : 45% of health expenditure goes on NCDs • Health insurance: 60% of the Palestinian population is covered by the existing insurance system and those not covered usually register for coverage upon diagnosis of NCDs in order to obtain subsidized prescriptions and other implications • Quality of care: at this point, no consistent implementation of service delivery protocols • Tracking of the clinical indicators and risk factors not available

12. Studies related to NCDs • Only two and old - 2000 : one by Birzeit university in cooperation with Oslo university - 1996- 1998 and the other is by Al-Quds university in cooperation with MOH and PCBS • Findings : • Prevalence: • DM was approximately 10 % ? ( projecting to ----?) • Heart diseases was approximately 8 % ( doubled now16%) • Comparing to regional finding : • Close to reported results in Jordan, Iraq and Tunisia • Less than in Saudi Arabia and Oman • Under reporting: • Big and significant gap between the expected prevalence of DM and cases under supervision • Recommendations: • Screening and consequently early detection would allow more realistic estimation of the prevalence of the disease and insure appropriate evaluation and management of the problem.

13. Challenges and Opportunitiesin the developing world

14. Double burden of diseases in low income countries DALYs High incomeLow income Communicable, Maternal and Peri-natal Conditions Nutritional Deficiencies Non Communicable Diseases

15. Cardiovascular Deaths Projected to 2020 Millions Non Communicable Diseases Communicable, MCH Conditions and Nutritional Deficiencies

16. Challenges Vs. OpportunitiesGAPS • Adequate scientific knowledge but not sufficient information , policies, strategies and actions • Limited resource and actual need to invest in NCDs prevention and health promotion KnowledgeE Action TION

17. Main and progressing constraints • Resource limitation • Confusions: (Behaviours Vs. Public Health problem, Treatment Vs. Prevention, Modernization, globalization Vs. local problem ) • Myths about the nature and impact of NCDs • Lack of surveillance system • Fragmented and uncoordinated care • Few clear policies and strategies • Inadequate adherence to standardized guidelines • Severe lack of investment in research • Political instability

18. Our commitment • Addressing NCDs risk factors: • Conduct STEP wise risk factors surveillance • Targeting the modifiable risk factors: unhealthy food, obesity, smoking and physical inactivity • Preventive measures: • Health education and promotion , screening and early detection , counseling and messages smoking cessation, obesity control, breast feeding promotion. and retinopathy screening has been recently considered • Curative measures: • PHC Clinics, guidelines, training of service providers , • Referral policies • Secondary care settings • Cooperation at national and international levels: • We in the MOH work with stakeholders at all levels and provide national leadership in prevention and control of NCDs through an effective and functioning NCDs thematic working group • Focus on the role of PHC and the importance of integration: • The MOH gave special attention to PHC in prevention, control of NCDs and proceeding in further integration of all NCD's programs

19. Thematic Working group Purpose: “The NCDs thematic working group has been established by a Minister decision mainly for the Development of the National Policy and Strategy for Prevention and Management of NCDs aiming improving the health status of Palestinian population” Structure: • Chair by the MOH • Co-chaired by the Austrian Development Agency (ADA) - main donor • WHO: technical advisor • Members: UNRWA, NGOs, donors community and academic institutions

20. Specific Intervention Establishment of NCDs cells and bodies ( 2008-2009) • Department for NCDs/ PHC : Works with other departments and stakeholders at all levels and provide national leadership in prevention and control of NCDs through: • Leading the work of the thematic group • Development of surveillance system • Upgrade and disseminate knowledge and skills of service providers with focus on the preventable nature of NCDs and importance of early detection of cases • Integrating programs • National Center for Prevention and Management of NCDs – funded by ADA

21. National Center for Prevention and Management of NCDs – Austrian FundSite: Ramallah City

22. Center for Prevention and Management of NCDs Vision “Palestinian people living healthy and free from the devastation of NCDs” Mandate • Support the Development of the National Policy and Strategic Plan for Prevention and Management of NCDs • Lead the implementation of quality prevention and care programs utilize evidence based practices Expected ultimate impacts of the project interventions • Prevalence of NCDs - Decreased • Early detection of cases - Enhanced • Quality of life of sick people - Improved • Number of referrals abroad -Reduced • Economic burden and cost of management of NCDs –Reduced • Partnership among stakeholders- Enhanced

23. Work done so far: • Developed the process for the development of the National Policy and Strategy for NCDs as follows: • Situation analysis and data collection – done • Identification of gaps – done • Setting priorities – done • Formulate objectives - done • Develop strategies that achieve objectives – done • Develop action plans – ongoing • Monitoring and evaluation - ongoing

24. First step Situation Analysis and Data Collection

25. Situation analysis and data collection • Scope of work : • Health information, research, surveys related to NCDs • Organization, delivery, quality and costing of services related to NCDs • Community based interventions and empowerment and legislative, regulatory and inter-sectoral measures related to NCDs • Surveys: • Health Facility Assessment – Done • NCDs risk factors surveillance – ongoing

26. Health Facility Assessment Purpose: “Assess the capacity of identified health facilities to prevent and manage major NCDs in primary care centres” Tool : “WHO global assessment tool” Steps undertaken: • 60 PHC randomly selected representing all care providers • An assessment team assigned representing care providers • Orientated the team on the tool content , data needed and reporting mechanisms • All centers were visited , assessed and questionnaire filled in • Data collected were downloaded • Downloaded submitted to WHO for analysis

27. NCDs Risk Factors Surveillance Rational: • Huge burden of NCDs on the care system as well the national economy and social development in Palestine • Lack of reliable information on the level of NCDs and its risk factors hinders successful planning, intervention and consequently the control of NCDs Goal:Assess the magnitude of risk factorsamong population • Behavioral factors: tobacco consumption ,unhealthy food habits , physical inactivity and obesity • Biological factors: raised blood sugar , B.P and cholesterol Approach:STEP wise global approach adopted by WHO as a flexible tool that consist of three main steps and each include core and expanded items in cooperation with PCBS • Step I: key information on risk factors • Step II: simple physical measurements • Step III: blood sampling for biological analysis

28. NCDs Risk Factors Surveillance • Sampling: • Target: age groups15 to 64 years • Size: 7200 citizens • Data manipulation: • Collecting downloading and analyzing data • Results and reports would be used by the ministry for the purpose of developing the final National Policy and Strategy for NCDs and then for continues monitoring • Resources allocated: • National NCDs center project budget – Austrian fund • Ministry of Health capacities • Technical support from WHO

29. Conclusion • NCDs issue is a top priority: CVD- Cancer- COPD and DM • These major NCDs share common risk factors: tobacco use, unhealthy diet, physical inactivity, alcohol abuse • Reliable information and surveillance is power • Prevention , integration of programs and population approach are the keys • No nation is immune to the rising burden of NCDs • Their burden can be dramatically reduced but ONLY if governments and health care leaders decide to do so.

30. Recommendations It is time to take action • Increasing awareness • Marketing and advocacy of NCDs prevention • Developing National Policy and Strategy • Integrating , further cooperation • Capacity building and training • Enhancing research

31. Thank you