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IntegratedDiseaseManagement

ChaisriSupornsilaphachai
DepartmentofDiseasesControl;MOPH;Thailand PresentedinMeetingtheChronicDiseaseChallenge HighLevelRegionalWorkshop Jakarta,Indonesia June2021,2011

What is Integrated Diseases Management ? Why is it important ? What have we already developed How about the role of partnerships ? What next ?

What is Integrated Diseases Management ?


International ThaiContext

The word integration stems from the Latin verb integer, that is, to complete. The adjective integrated means organic part of a whole, or reunited parts of a whole. It is mostly used to express the bringing together or merging of elements or components that were formerly separate. The idea of comprehensiveness overlaps with that of integration

Integration is used by different


people to mean different things. Combined with the fact that this is an issue which arouses strong feelings, there is clearly much scope for misunderstanding and fruitless polarization.

World Health World Health Organization Organization

The meaning implied in the WHO quotation Integrated, Integrated health service, Integrated Service, Integration .can be summarized as:

The management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system.

Characters of Chronic conditions in Chronic Diseases


People with chronic conditions (risks, illnesses and disabilities)
often have a mix of acute and long-term care needs that require multiple providers, organizations, and systems of care to address.

Chronic disease prevention and management consists of a group of coherent interventions, designed to prevent or manage one or more chronic conditions using a community wide, systematic and structured multidisciplinary approach potentially employing multiple treatment modalities.

The management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system.
Key questions under this definition are:
What interventions should be packaged together? How are management support systems best organized to service these interventions?

TheGoalofChronicDiseasePrevention andManagement:
toidentifypersonswithoneormorechronic conditions, topromoteselfmanagementbypatients toaddresstheillnessorconditionsaccordingto diseaseseverityandpatientneedsandbasedonthe bestavailableevidence,maximizingclinical eectivenessandeciencyregardlessoftreatment setting(s)ortypicalreimbursementpatterns. toallowroutineprocessandoutcomemeasurements forfeedbacktoallthoseinvolved,aswellastoadapt theprogramme.

Why is it important?
- Rapid growing threat and impact of chronic diseases - The natural course of chronic diseases - How to start and mobilize our health system to response

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND


Source: Bureau of Health Policy and Plan, MOPH

Health Status : Lower Mortality Middle Income country

Source:Thai Burden of Disease (BOD) Study

TrendofDiabetesandHypertensionPrevalence

WhyPreventionmore Focused

BNCD/Chai/ 23-10- 06 BNCD/Chai/ 8-11- 48

1998

HT 5+ Million times DM 2+ Million times

Stroke/Renal Failure/ISHD

Suspected Case

HT 6+ million 2from 3 of HT and DM suspected population working1.9 million population DM Is in

THAILAND

HBP, HT HBS, DM

Stroke/Renal Failure/ISHD

BNCD/Chai/ 27-9-48

BNCD/Chai/ 23-10- 06 BNCD/Chai/ 8-11- 48

2004

HT 8+ Million times DM 4+ Million times

Stroke/Renal Failure/ISHD

Suspected Case

HT 9+ million 2from 3 of HT and DM suspected population Is DM in working populationmillion 2+ . children

THAILAND

HBP, HT HBS, DM

Stroke/Renal Failure/ISHD

BNCD/Chai/ 27-9-48

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

Productivity loss from 12 BOD Estimated in 2005


Million Baht
Productivity loss from 12 BOD - Premature death - Absenteeism OP - Absenteeism IP Total % of GDP in 2548 % of total health expenditure 2548
Male 175,028 7,422 1,123 183,573 Female 33,259 2,414 314 35,987 Total 208,287 9,836 1,437 219,560 3.1% 88.5%

percentage
Male female 80% 3% 15% 1% Total 95% 4% 1% 100%

0.5% 0.1% 84% 16%

Total productivity loss from 12 BOD = 219,560 million baht ~ 3.1% of GDP in 2005 Note: GDP in 2548 = 7,104,228 million baht

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

Ratio of Doctors in 1,000 Population; Compared among the countries in the near economic level

Country
Latin America & Caribbean Europe & Central Asia Malaysia Thailand Phillippine Vietnam

GDP/Capita
6950 6900 8500 6890 4450 2300

Physician/1000
1.4 3.1 0.7 0.4 1.2 0.5
Why Prevention more Focused

Source: World Development Indicator 2004

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

Sritara P et al.

Why Prevention more Focused

Population with Specific Important Risk Factors 2004-2005


Risk Factors ** MiIllions
Low fruits and vegetable Diet Physical Inactivity Tobacco Consumption Heavy Alcohol Consumption Overweight and Obesity Hypertensive Diseases Diabetes
: (.2549) * TBRFSS2548 ** TNHEXAM2546

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

38 19 10.7 1.7 16.1 ~ 7.4 ~ 3.3


Why Prevention more Focused

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

Table: Percentage of Population who have Risk Factors by Age, Sex, Numbers of Risk Factors
Numbers of Risk Factors 1 Risk Factor 2 Risk Factors 3 Risk Factors >= 4 Risk Factors 1 Risk Factor Age (Year) 15-29 30-44 45-59 60-6 70-79 9 Male (N=18934) 80+

42.8 48.0 39.2

40. 41. 6 6 10.8 20.7 28.4 28. 2 29.9 3.1 6.7 11.9 12.0 9.1 0.3 1.8 3.4 3.4 1.6
Female (N=20356)

46.1 26.7 7.2 0.9

43.7 20.0 7.1 1.7

21.4 37.2 36.6 32.4 35.2 44.4 32.0 2 Risk Factors RiskFactors:Hypertension,Hypercholesterolemia,Diabetes,Overweight,RegularSmoker 5.4 12.4 24 25.5 27.3 22.6 14.7 : 3 Risk Factors 0.6 3.7 11.2 14.7 10.7 0.7 5.6 TNHEXAM2546
>= 4 Risk

N.B. : a Treatment of infectious disease can lead to prevention of further cases if it interrupts transmission. An example: Distal socioeconomic causes include income, education and occupation, all of which affect levels of proximal factors such as inactivity, diet, tobacco use and alcohol intake; these interact with physiological and pathophysiological causes, such as blood pressure, cholesterol levels and glucose metabolism, to cause cardiovascular disease such as stroke or coronary heart disease. The sequelae include death and disability, such as angina or hemiplegia.

Family health, Health Learning, Health services, Social Services

Health care System:

Physical Environment

Lifestyles Modification Intervention Health and Disease Continuum


Information and Environmental Early Diseases Supports for Primary Prevention Detection Risk Screening and Diseases risk management and Management Information support

Social and Economic Environment

Population level

Individual level

Care for Health


280

What have we already developed ?


Healthsystemrelatedbefore2004 Whatwehavealreadydeveloped 20042009

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

Service Problems in NCDs Prevention and Control before 2004


Overload Huge burden in Thai commuinties Expensive service for treatment Acute care management can not solve chronic care problems Unclear for prevention and control model
Confusion in every level Not effectiveness for prevention and control service Difficult to determine resources to support efficiently Etc.

National NCD Program Move to Department of Diseases Control in 2003

Health Reform
Reform Government System Provincial and local government Policy Thailand NCD Civil society
Policy

Decentralization

Universal Coverage Insurance

MOPH

Thai Health Foundation Fund

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

Disease Treatment and Care

Disease and Risk Prevention and Control


Normal.Risk.. Disease...Sick Population Average

Normal.Disease/Sick Individual level

Acute

Chronic / Subacute /Acute


System and coordinated group of Service activities

Separated Service activities

Vertical Program
Monitoring and Control

Comprehensive and Integrated Program

Monitoring and Support

Area

Social Organization

Health care net Regulation and Law enforcement for protection from risk Support for quality of prevention and control (focused on risk reduction and qulity improvement process)
Development needed Mechanism for prevention and control

Social mobilization and campaign For awareness and risk reduction

PCU/ CHC

CEO and Provincial Managerial Organization

Hlth Provincial Office

Consulting/ Collaboration and cooperation/ Monitoring and support/Regional evaluation


Central and Regional System

ODC

DDC.. With Other Depts,

Surveillance and Information Development

Development of social and campaign process

Law Development and Enforcement

Services System Quality Development

BNCD

Development & Research

HMR Development

Policy and Plan Development

National Goal/Strategic Outline/Main Strategic Collaboration (Disease Control System: quality/ standard/ strength/transparency etc.)
2547

Countries

20

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

Review, Rethink and Reestablish


3 Main Activities of Diseases Control Process
Surveillance Activities
surveillance for community situation Warning back to community Suggestion for community measures for risk reduction

Prevention Activities
Focused on risk prevention and control and risk opportunities

Control Activities
Disease Control for prevention repeated attack and complication and consequences prevention

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

Input Resources (1)


1. Comprehensive concept and preliminary outline of prevention and control activities and roles at every levels of provincial health care system Natural course of diseases; paradigm and service delivery targets of 3 main prevention and control activities Essential contents, suggested technique, examples of expected characteristic and innovation and designs for adding and adjusting in the model such as information service for risk reduction etc Continuous quality improvement process and how to connect and integrate with existing standard services and knowledge in the community 2. 3.

4.

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

Input Resources (2)


5. 6. 7. 8. 9. Informing about the factors that influence services arrangements, service adaptation and development. Informing how important it is for evaluation for services development Forum for learning together Monitoring, supporting and consultation Seeding money for innovation, quality improvement process and evaluation

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

Many Challenges
1. 2. Knowledge, technique and guide Population and community characteristics such as local culture, proportion of migration population in the area etc Information system that support surveillance and management Inadequate needed resources Other supporting system

3. 4. 5.

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

Paradygm shift in health workers

Study of Communitys information Information of NCDs situation

Project introduction for civil society


Floor to conclude lesson learned Provincial level

Learning from work and success

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND -

Stroke Fast Track Policy (policy/ target/KPI (ministry/ national monitoring)) Financial support for other supporting system Stroke risk (Universal coverage insurance, social insurance, local budget, etc)

Consequence Results in PHC:

screening service - risk reduction service

(Health guide, CPG) Finance

Level of service units/ age specific

Settings, local specific population and area target

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

Trend of Crude Death rate (per 100,000) in Thailand from Stroke and Key activities in 1995-2007

Hypertension & Diabetes Mellitus Screening

Hypertension Quality Standard Stroke Awareness NonHT & DM & Comprehensive Awareness pharmacologic Screening CVD Screen Care Increase Communication Thru Salt Net Campaign
Start CBI for Comprehensive risk reduction

Start 2009 Source: BNCD (.2006) and edited inNational Exercise

World Health Organization

&

& . 290251

50

Community
Resources and Policies
SelfManagement Support Delivery System Design

Health System
Health Care Organizations
Decision Support Clinical Information Systems

Informed, Activated Patient

Productive Prepared, Proactive Interactions Practice Team

Improved Outcomes

Source:BureauofPolicyandStrategy,MoPH

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

Trends of major physiological /behavioral risk factors


(Aged >= 15 Yrs)

Prevalence (%) NHES Obesity* Waist circumference** Regular Smokers Alcohol consumption (harmful) Fruit & Vegetable Low Intake*** Physical Inactivity

Male III 22.5 15.4 45.9 16.6 IV 28.4 18.6 38.7 13.2 III

female IV 40.7 45.0 2.1 1.6 III 34.4 36.1 2.3 2.1

Total IV 34.7 32.1 19.9 7.3 28.7 26.1 23.3 9.1

80 20.7

83.1 16.8

76.4 24.2

81.5 20.2

78.1 22.5

82.3 18.5

* BMI >25Kg/M2 ** >90,80 cm in male , female *** <5 servings/D

Source : NHESII ,III , IV

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

Health Status , Thai Population aged 15+


NHES IIIPrevalence 6.9% (2004-5)
Awareness 43.4% Control 12.2%

Prevalence 6.9% Diabe tes


Awareness 68.8% Contr ol 28.5%

NHES IV (2008-9)

Prevalence 22.0%
Awareness 28.6%

Prevalence 21.4%

Cont rol 8.6%

Hyperten sion

Awareness 49.7% Control 20.9%

Prevalence 15.5%
Awareness 12.9%

Prevalence 19.4%
Awareness 27.3%

Control 6.2%

Hypercholesterole mia

Control 14.8%

BNCD-DDC/Seri/Ced 25-10- 50 THAILAND

Resource availability and allocation

The Universal Health Care Coverage Policy for entire population Total expenditure on health (% of GDP) -3.5% GDP in 1994 and reached 4.0% in 2008 The share of public financing sources - 74.0% of THE

How about the role of partnerships ?


The role of partnerships What next ?


/ Primary Health Care

Preven tion Policy

Comm unity

Awareness, environment and resources support, Competency Community for risk & diseases reduction

govern ment

Local

Family
Individual
Health Service Network , / / Public Health

Awareness, Self Management (Risks & Disease & Increase QOL)

Success Factors

Federal govern ment


Awareness, Support self management & prevention & care, sustainable health care system

System

58

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