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Vision in a World of NCDs

Prof K Srinath Reddy President, Public Health Foundation of India Bernard Lown Professor of Cardiovascular Health, Harvard School of Public Health. Vision in a World of NCDs. Sir John Wilson Lecture. (Why) are NCDs (Finally) receiving policymaker attention at Global Level?

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Vision in a World of NCDs

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  1. Prof K Srinath Reddy President, Public Health Foundation of India Bernard Lown Professor of Cardiovascular Health, Harvard School of Public Health Vision in a World of NCDs Sir John Wilson Lecture

  2. (Why) are NCDs (Finally) receiving policymaker attention at Global Level? • Why is ‘Eye Health’ not part of the UN/WHO NCD package? • How will Ageing and NCDs impact on Eye Health in the 21st Century? • How should Eye Health position itself in the broader ‘Health System’ framework and ‘Rights’ discourse? QUESTIONS THIS TALK WILL ADDRESS

  3. Global Challenge of NCDs APATHY (2000) ATTENTION (2011) ACTION ?

  4. Is NCD a global crisis? YES! Source: Beaglehole R, Bonita R, Alleyne G, et al for the Lancet NCD Action group. UN HLM on NCDs: Addressing four questions. Lancet 2011 POL June 13 2011

  5. 347-390 391-426 391-426 427-464 542-722 723-1030 Cardiovascular disease(Age-standardized death rate per 100 000, males) 138-205 206-281 282-346 347-390 391-426 427-464 465-541 542-722 723-1030 No Data 723-1030 Yach D., 2009

  6. Projected global numbers of deaths by cause for high, middle and low income countries (WHO, 2008)

  7. Is NCD a development issue? YES!(and the case for investment is strong) • NCDs are a cause and consequence of poverty • NCDs entrench poverty-cycle of debt • Costs of loss of productivity and care will increase as the burden rises • Inaction will pose problems on fragile health systems • And… action on NCDs will contribute to progress for other global priorities, e.g. MDGs

  8. NCDs: Economic Impact • NCDs accounted for five of the six top causes of economic loss in 2008 • Heart disease : $752bn • Stroke: $298bn • Diabetes: $204bn NCDs cost developing countries up to 6.77% of GDP; this economic burden is more than that caused by Malaria (1960’s) or AIDS (1990’s) - IOM Report 2010 NCDs will lead to a loss of 30 Trillion Dollarsglobally up to 2030 representing 48% of global GDP in 2010 – Harvard + WEF Study 2011

  9. Are affordable cost-effective interventions available? YES! Source: Cecchini M, Sassi F, Lauer J et al. Tackling unhealthy diets, physical inactivity and obesity: health effects and cost-effectiveness. Lancet 2010

  10. UN “ADOPTS” NCDs! • UNHLM – September 2011 (New York) • Political Resolution Adopted • Global Target Set For 2025 – 25% Reduction in NCD Related Mortality Below 70 Yrs. 25 By 25

  11. What are NCDs? • Why Only Four? (CVD; DM; Cancer: COPD) Linked by Common Risk Factors • What About: - Mental Health? - Oral Health? - Eye Health? - Renal Diseases? - Genetic Disorders? • Where Do Injuries and Disabilities Fit In?

  12. UN Political Resolution 2011:Disease Burden & Determinants • High and Rising Health Burden • Advancing in LMIC • Preventable Premature Deaths • Common Risk Factors : ↑Prevalence • Social Determinants Recognized • Economic Cost of Neglect : Huge

  13. Risk Factors • Tobacco • Unhealthy Diet • Physical Inactivity • Harmful Use of Alcohol Others Mentioned: - Indoor Smoke - Breast Feeding - Infections

  14. Global causes of blindness due to eye diseases, excluding refractive errors (2002) Source: Eggleston K and Tuljapurkar S. Aging Asia The Economic and Social Implication of Rapid Demographic Change in China, Japan and South Korea

  15. How will vision fare in the 21st century? • Ageing • NCDs • Injuries • Climate Change

  16. SILVER TSUNAMI GLOBAL GRAYING VERY ELDERLY ELDERLY AGEING DEMOGRAPHIC TRANSITION

  17. 0 to 9 Global Ageing Trends (2012) 10 to 19 25 to 29 30 or over Per centage 60 or over 20 to 24

  18. Global Ageing Trends (2050)

  19. Ageing in LMIC • By 2050, 80% of older people will live in LMIC • Chile, China and Iran will have a greater • proportion of older people than USA. • By 2050, 400 million persons over 80 years; • 100 million in China alone

  20. Age Related Eye Problems • Cataract • Age Related Macular Degeneration • Vitreous Degeneration • Glaucoma

  21. Risk Factors: Tobacco Use on the Rise in Developing Countries

  22. Smoked Tobacco And The Eye

  23. Smokeless Tobacco And The Eye • Raju et al (2006) – • O.R. for Nuclear Cataract = 1.67 • (9.5% CI, 1.16 – 2.39) • Iyamu et al (2002) – • SLT Raises Intra – Ocular Pressure

  24. Prevalence of Diabetes in Asia-Pacific Countries Source: For China, Yang et al. 2008. For all other countries, International Diabetes Federation Diabetes Atlas, www.diabetesatlas.org/content/regional-data

  25. Rising Prevalence of Diabetes in Urban India Over 14 years, DM prevalence increased by 72.3% NUDS CURES Prevalence rate – age standardized for Chennai Census 1991 Mohan et al, Diabetologia, 2006; 49: 1175 Ramachandran et al, Diabetes Care, 2008; 31: 893

  26. The “TOP 10”

  27. Diabetes And The Eye “People with Diabetes Are 25 Times More Likely To Go Blind From Diabetic Retinopathy And Cataract Than Those Without Diabetes” - Patel and Ireland (Sightsavers)

  28. Blood Pressure and Eye • Hypertensive Retinopathy • Interaction Between HBP And Diabetes • Interaction Between HBP And Tobacco

  29. CVD and Eye • CVD WITH OCULAR EFFECTS • Stroke/ TIA • Arrhythmias • Vasculitis • Drug Effects • B. COMORBIDITIES • Assessment of surgical risk

  30. Cancer and Eye • Tumours • Primary • Metastatic • Treatment • Steroids • Radiotherapy

  31. SOCIAL DETERMINANTS (OF HEALTH & NUTRITION) HEALTH SYSTEM PEOPLE

  32. Implications for the Health System • Clinical • Changing Spectrum • Increased Caseload • Public Health • Services • Continuity of Care • Workforce • Awareness • Policy • Integration • Financing

  33. Remain a Vertical Programme • Be part of a Horizontal Integration of many Programmes? • Seek a Diagonal Approach? Should Eye Health…..

  34. Health Workforce • Primary Care: • Physicians • Non Physician Health Care Providers • Task Shifting • Task Sharing • Outreach Services (IT enabled) • Secondary Care: • Ophthalmologists + Allied Health Professionals • Other Physicians • Tertiary Care: • Specialists • Referral Services • Supportive Supervision

  35. Universal Health Coverage Equity Rights 21st Century Health System Social Determinants Economy Human Resources Sustainable Development

  36. The Global Path to Universal Health Coverage INDIA, 2012 South Africa, 2011/12 Philippines, 1995; Taiwan, 1995; Thailand,2002; Vietnam, 2009 Mexico, 2001 Rwanda, 2003; Ghana, 2004 Spain, 1986; Brazil, 1988; Columbia, 1993 Australia, 1975, Italy 1978 South Korea; 1989 NHIF, Kenya, 1966 Scandinavia: Norway, 1912; Sweden, 1955; Denmark, 1973; Canada, 1966 Chile, 1952 UK, 1948 (NHS) Sri Lanka, 1950 Germany, 1941 Japan, 1938 New Zealand, 1938 Bismarck Model 1883 Beveridge Model, 1942

  37. DEPTH BREADTH UNIVERSALITY COVERAGE EQUITY BRIDGING GAPS HORIZONTAL VERTICAL

  38. - Margaret Chan, DG of WHO (2012) “Universal Health Coverage Based On People Centric Primary Care’’

  39. 20th Century Health Care • Clinician Centred • Focus on Benefits of Treatment • Increase Quality • Patient as Passive Complier • Good Care for Known Patients • Hospital as Focus • Operates Through Bureaucracy • Driven by Finance • High Carbon Usage • Challenges met by Growth • 21st Century Health Care • Patient-Centred • Focus on Prevention of Disease and Harm • Reduce Waste and Increase Value • Patient as Co Producer • Equitable Care for Populations • Focus on systems • Operates Through Networks • Driven by Knowledge • Low Carbon Usage • Challenges met by Transformation -Sir Muir Gray (2007)

  40. How Do we then gather more strength In our advocacy for adoption and advancement of policies for eye health?

  41. A Framework for Determinants of ‘Issue Attention’ in Global Health • The collective strength of the actors mobilising around an issue; • The ideas they use to portray and position the issue; • (iii) The issue characteristics that pertain to inherent features of the issue; and • (iv) The nature of the political context or features of the environment that individuals confront as they seek to advance attention of the issue, including other actors who do not work on the issue • (Jeremy Shiffman, 2010)

  42. The Economic Argument • Cause and Consequence of Poverty • Productivity Losses • Cost-Effective Treatments (‘Best Buys’) Global cost of Visual Impairment and Blindness = USD 3 Trillion Patel and Ireland (Sightsavers)

  43. ‘Value’ of Vision • Vision Impairment is the 6th largest cause of DALY loss (3%) • - WHO • How is ‘Vision Loss’ weighted for estimation of Disability? • - Perspective of Physicians • - Perspective of Patients • - Perspective of ‘People’ • ‘Quality of Life’ is an important message to convey

  44. Economic arguments work • BUT there are competing demands (within and beyond the Health Sector) • Voice of Patients and Civil Society needed • - e.g. HIV-AIDS, Tobacco Control Why Do We Need A ‘Rights’ Argument

  45. Bentham Rawls Sen • Capability Right • Utilitarian Justice “A well ordered society would ensure that all individuals have the capability to be healthy and at a level that is commensurate with human dignity in the modern world, which is their right” HEALTH EQUITY: PHILOSOPHICAL CONSTRUCT - Sridhar Venkatapuram. Health Justice; Polity (2011)

  46. WHAT NEXT? • Post 2015 UN Agenda:Sustainable Development Goals (SDH) • Four Pillars • - Inclusive Economic Development • - Inclusive Social Development • - Environmental Sustainability • - Peace and Security • Nine Thematic Working Groups • Inter-Governmental Leadership Group (UK, Indonesia, Liberia) Position Eye Health Wherever Possible

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