ACCELERATING NON- COMMUNICABLE DISEASE PREVENTION AND CONTROL

1. ACCELERATING NON- COMMUNICABLE DISEASE PREVENTION AND CONTROL DR. YOLANDA E. OLIVEROS Director IV National Center for Disease Prevention and Control Department of Health

2. Noncommunicable Diseases (2005-2015) NCDs especially CVD, cancers, CRDs, and DM caused 60% of all deaths globally in 2005 (estimated at 35 M deaths). Total deaths from NCDs are projected to increase by a further 17% over the next 10 years. Low and middle-income countries, primarily from Africa, Middle East, and Asia, are the worst affected by these diseases. The rapidly increasing burden of these diseases is affecting poor and disadvantaged populations disproportionately, contributing to widening health gaps between and within countries.NCDs especially CVD, cancers, CRDs, and DM caused 60% of all deaths globally in 2005 (estimated at 35 M deaths). Total deaths from NCDs are projected to increase by a further 17% over the next 10 years. Low and middle-income countries, primarily from Africa, Middle East, and Asia, are the worst affected by these diseases. The rapidly increasing burden of these diseases is affecting poor and disadvantaged populations disproportionately, contributing to widening health gaps between and within countries.

3. Why Address NCDs? 60% of global deaths are due to NCDs (and still increasing) 40% of cancer is preventable 80% of cardiovascular disease, stroke and diabetes is preventable A large part of chronic respiratory diseases is preventable Cost-effective secondary prevention interventions exist and have worked in many countries

4. Projected Forgone National Income due to Heart Disease, Stroke and DM in Selected Countries, 2005-2015 (in billion dollars)

6. Most Life Years Lost in Western Pacific Region are due to NCD (DALYs lost, 1999)

7. Chronic diseases in Western Pacific, deaths, all ages, 2005(total deaths 12,397,000)

8. Projections for Chronic Disease in WPR next 10 years 106 million people will die Deaths from infectious diseases, maternal and perinatal conditions, and nutritional deficiencies combined will increase by 1%. Deaths will increase by 20% - deaths from diabetes will increase by 51%.

10. Top Risk Factors in this Region

11. Why Address NCDs? Major NCDs have shared preventable risk factors: Tobacco use Unhealthy diet Physical inactivity Harmful use of alcohol

13. This is our 2004 mortality statistics…it shows that diseases of the heart and the vascular system are still the top leading causes of deaths in the country today.This is our 2004 mortality statistics…it shows that diseases of the heart and the vascular system are still the top leading causes of deaths in the country today.

14. Top Ten Leading Causes of Morbidity 2006 Overall (both sexes and all ages) Rank 4. Hypertension Rank 7. Diseases of the Heart Source: FHSIS, 2006

16. Low and Fruits Consumption Among Filipinos Dangerously low fruit & vegetable intake Only 19% of national population eat fruit & vegetables more than four times a day Recommended standard: 100% eating FIVE servings DAILY Total daily requirement must be 400g/capita Actual consumption is only 111g/capita

17. Increasing Diabetes Morbidity Diabetes prevalence has increased significantly over the years to 20.06% among Filipino adults (20 y/o and above) Adult incidence of diabetes from 1998 to 2007 is likewise alarming at 8.5%. (Source: Philippine Cardiovascular Outcome Study – Diabetes Mellitus, 2008)

23. DOH Early Actions on NCD Prevention and Control Non-communicable Disease Prevention and Control Service established 1986 with EO 119 reorganizing the Department of Health Developed vertical programs in early 1990s Cardiovascular Disease Prevention and Control Program National Cancer Control Program Diabetes Prevention and Control Program

24. Non-communicable Disease Prevention and Control Service Launched advocacy and IEC campaigns against known risk factors YOSI KADIRI –anti smoking EDI EXERCISE/HATAW / THE GREAT FILIPINO WORKOUT – regular physical activity TIYA KULIT/ IWAS SAKIT DIET – low salt, low fat, high fiber diet

31. Framework for NCD Prevention and Control Action Follows the causation pathway of NCDs and supports the following actions: Environmental Interventions Lifestyle Interventions Clinical Interventions Advocacy Research and Surveillance Political and Community Leadership, Intersectoral Partnerships and Community Mobilization Health systems strengthening

32. Common risk factors underlie NCDs. Globalization and urbanization serve as conduits for the promotion of unhealthy lifestyles and environmental changes that make otherwise diverse communities within the Region susceptible to tobacco and alcohol use, unhealthy diets, and physical inactivity. These common risk factors give rise to intermediate risk factors such as high blood pressure, elevated blood glucose, abnormal lipid profiles and obesity. In turn, the intermediate risk factors predispose individuals to the “fatal four” – cardiovascular diseases, cancer, chronic respiratory diseases and diabetes. Ironically, every one of the risk factors for these diseases, with the exception of age and heredity, is preventable. An estimated 80% of premature heart disease, stroke, and type 2 diabetes, and 40% of cancer, could be avoided through healthy diet, regular physical activity, and avoidance of tobacco use. Yet, the prevalence of these risk factors in the Western Pacific Region remains unacceptably high, and, in many countries, continues to increase. Clearly, it is time to act.Common risk factors underlie NCDs. Globalization and urbanization serve as conduits for the promotion of unhealthy lifestyles and environmental changes that make otherwise diverse communities within the Region susceptible to tobacco and alcohol use, unhealthy diets, and physical inactivity. These common risk factors give rise to intermediate risk factors such as high blood pressure, elevated blood glucose, abnormal lipid profiles and obesity. In turn, the intermediate risk factors predispose individuals to the “fatal four” – cardiovascular diseases, cancer, chronic respiratory diseases and diabetes. Ironically, every one of the risk factors for these diseases, with the exception of age and heredity, is preventable. An estimated 80% of premature heart disease, stroke, and type 2 diabetes, and 40% of cancer, could be avoided through healthy diet, regular physical activity, and avoidance of tobacco use. Yet, the prevalence of these risk factors in the Western Pacific Region remains unacceptably high, and, in many countries, continues to increase. Clearly, it is time to act.

33. The causation pathway for chronic diseases provides the framework for elucidating key components of a regional prevention and control strategy . Environmental – macroeconomic, structural and policy - interventions address the broad determinants of NCD risk. Lifestyle interventions impact on the common modifiable risk factors, and, to a certain extent, the intermediate risk factors for chronic disease. Clinical interventions effect change at the level of intermediate risk factors and overt disease. Environmental and lifestyle interventions target the entire population, while clinical interventions target high-risk individuals. These 3 main components form the intervention pathway for NCD prevention and controlThe causation pathway for chronic diseases provides the framework for elucidating key components of a regional prevention and control strategy . Environmental – macroeconomic, structural and policy - interventions address the broad determinants of NCD risk. Lifestyle interventions impact on the common modifiable risk factors, and, to a certain extent, the intermediate risk factors for chronic disease. Clinical interventions effect change at the level of intermediate risk factors and overt disease. Environmental and lifestyle interventions target the entire population, while clinical interventions target high-risk individuals. These 3 main components form the intervention pathway for NCD prevention and control

34. The Regional Approach seeks to effect change simultaneously at 3 levels: At the environmental level, through policy and regulatory interventions; At the level of common and intermediate risk factors, through population-based lifestyle interventions; At the level of early and established disease, trough clinical interventions targeted at high risk individuals. Advocacy, research and surveillance, political and community leadership, intersectoral partnerships and community mobilization and health systems strengthening underpin each of these levels where action is needed, and comprise the remaining 4 action areas. The Regional Approach seeks to effect change simultaneously at 3 levels: At the environmental level, through policy and regulatory interventions; At the level of common and intermediate risk factors, through population-based lifestyle interventions; At the level of early and established disease, trough clinical interventions targeted at high risk individuals. Advocacy, research and surveillance, political and community leadership, intersectoral partnerships and community mobilization and health systems strengthening underpin each of these levels where action is needed, and comprise the remaining 4 action areas.

36. Integrated NCD Prevention and Control Program Vision: Improved quality of life for all Filipinos Mission: To ensure that quality prevention and control NCD services are accessible to all, especially to the vulnerable and at-risk population. Goal: To reduce mortality, disability and morbidity due to NCDs (CVDs, CA,COPD,DM).

37. Integrated NCD Prevention and Control Program Objectives: To reduce the exposure of population to risks related to NCDs primarily smoking, unhealthy diet, physical inactivity and alcohol use. To increase the proportion of NCD cases given appropriate treatment and care.

38. Policy Statement No. 1 The Integrated NCD Prevention and Control Action follows the causation pathway of NCDs as a framework for action It supports the WHO Global and Regional Strategy for NCD Prevention and Control.

39. Policy Statement No. 2 Adoption of an integrated, comprehensive and community based response to NCD prevention and control Focuses on common risk factors guided by a life course perspective; Encompasses the three levels of disease prevention: primary, secondary and tertiary level; Emphasizes strategies which would benefit entire population or large packets of population, but also takes care of high-risk populations; Integrates across settings; such as health centers, schools, workplaces and communities; Makes explicit links to other government programmes; Emphasizes intersectoral action

40. Policy Statement No. 3 Intensify health promotion to effect changes that lead to significant reduction in mortality and morbidity due to NCDs Changing lifestyles Changing the environment Reorienting the health system from the curative mode to the preventive or wellness mode

41. Policy Statement No. 4 Foster complementary accountabilities in the implementation of an Integrated NCD Prevention and control program DOH LGU Other GOs/NGAs Other Sectors, including Private sector and other stakeholders

42. Guiding Principles Equity Sustainability Rights based Continuum of care throughout the life cycle Evidence based

43. Current Issues and Challenges:Governance A core national coalition of stakeholders is established but mostly from the health sector. There is a need to expand partnerships to other sectors, including the private sector. Whole of government and whole of society approach is needed to build momentum and sustain gains.

44. Current Issues and Challenges:Governance Integrated and comprehensive approach is established but there is a need to further advocate among the health workforce and stakeholders on effectiveness of this approach. Human resource, both in quantity and capacity

45. Current Issues and Challenges:Governance Surveillance System for NCDs and risk factors is available but currently limited. Main sources of data are from the Philippine Health Statistics, national prevalence surveys, a cancer registry and other registries from NGOs and professional groups. NCD data from FHSIS and hospitals are very limited PHilHealth could have been a very good source of data DOH should enhance information systems to generate timely and relevant data for continuing policy enhancement and program response.

46. Health promotion and education is conducted nationally mostly by the health sector. Health services and products addressing NCD needs are available in the field at varying levels, depending on local government resources and priorities. Suggested NCD package of services are established but need to be advocated, adopted, implemented and monitored at all levels of care. Referral systems should be enhanced to effectively prevent and manage NCDs. Current Issues and Challenges:Service Delivery

47. Some policies and legislations are already in place to facilitate implementation of relevant NCD interventions. Republic Act 9211 is in place, but needs more strict enforcement Ensuring affordability and accessibility of essential medicines and diagnostic services There is a need to come up with additional regulatory mechanisms, e.g. nutrition labeling, to support and strengthen current initiatives on NCD prevention and control. Current Issues and Challenges:Regulation

48. NCDs often result to catastrophic expenditures, plunging many families deeper into poverty. Many are often not able to continue with treatment and care, contributing to the growing burden of diseases due to NCDs. About three-fourths of the diabetes patients had given up diabetes care because of financial difficulties at one time in the past. 67% experienced shortage of money because of diabetes-related expenditure, and borrowed money or pawned assets. Philhealth coverage was lowest among the informal sector at 15%. (Source: Costs, Availability, and Affordability of Diabetes Care in the Philippines, Higuchi, et all, WHO, 2008) Current Issues and Challenges:Financing

49. FINDINGS: 1st part of the studyFINDINGS: 1st part of the study

50. Operationalize and promote integrated approach to NCD prevention and control at the local level. Ensure access and availability of relevant services and products, including NCD drugs, in the communities and among affected and vulnerable populations. Enhancing referral systems will provide for the continuum of care along the spectrum of non-communicable diseases. .

51. Way Forward Strengthen linkages with relevant government and nongovernment agencies Awaken social accountability of various stakeholders and sectors to address the NCD related problems Utilize the whole of society and whole of government approach

52. Way Forward Improve the surveillance system on NCDs. Information systems that will link various sources of data (private/public health facilities, hospitals, PHIC, NGO’s, Professional Groups, etc) should be established and harmonized Efforts to disseminate and utilize data for policy enhancement and program management should be continually pursued

53. Way Forward Health promotion and advocacy are cross-cutting interventions that the broad network of stakeholders can collaboratively engage in as part of social responsibility. Such should be consistently provided as support to other interventions to change behavior.

54. Way Forward Ensure sustainable financing. Different financing mechanisms such as funding, resource allocation, contracting and reimbursement can be utilized. Local governments should be encouraged to increased their resources and investments for NCD prevention and control. Improve social health protection through the enhancement PhilHealth’s benefit package to cover lifestyle diseases, to increase the benefit package’s support value and to improve the coverage of the indigents and those in the informal economy.

55. Improve access to, availability of and reliance on low cost medicines Strengthen Botika ng Barangay Improve physical accessibility Improve procurement of medicines and availability of medicines Promote public reliance on quality assurance of low cost medicines Way Forward

56. Invest in cost-effective interventions Deaths Averted Cost per head

57. Way Forward Pursue the policy agenda on the following: (1) Lowering of saturated fat and lower salt content in food offerings; 2) Mandating fast food chains and restaurants to keep public informed of the nutritional value of food offerings; 3) Providing subsidies/ tax breaks to encourage manufacture and sale of healthier food options; 4) amendment of the Food Fortification Law; (5) legislation of graphic health warnings on tobacco packages, etc Fulfill the research and development agenda in collaboration with government agencies and private organizations to fill in program data needs:

58. Way Forward The integrated approach would provide for harmonized NCD prevention and control policies and programs, delivery of services and health care financing thereby creating a “seamless and smooth system” to achieve good health outcomes and coverage. However, commitment of all public and private stakeholders and integrated planning must be set in place before objectives can be fully realized.

59. Key Strategies for Local Implementation Localize healthy public policies Build coalitions and partnerships Enhance community participation Create a supportive organizational and physical environment Intensify health education and public information

60. Key Strategies for Local Implementation Institutionalize local assessment and planning Build or expand local capacities Reinstall supervision Establish financing schemes Install regulatory mechanisms Unify monitoring and evaluation efforts

61. Lessons on Local Implementation National policies are useless if not locally adapted Success lies largely in the hands of implementing units Experience with PIPH-AOPs shows that effective strategies for NCDS are not fully utilized. Operationalizing this policy at the local level will ensure effective prevention and control efforts for NCDs

62. “We cannot afford to say ‘we must tackle other diseases first – HIV/AIDS, malaria, tuberculosis – then we will deal with chronic disease’. If we wait even 10 years, we will find that the problem is even larger and more expensive to treat” Olusegun Obasanjo, President , Federal Republic of Nigeria.

63. Recent and Current Evidence showed that.... Preventing and controlling major risk factors in an integrated manner and employing health promotion across the life course at the level of family and community is thus most cost-effective