Noncommunicable Diseases (2005-2015)

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

Projected Forgone National Income due to Heart Disease, Stroke and DM in Selected Countries, 20052015 (in billion dollars)
Brazil Estimated Income Loss 2005 Canada China India UK Nigeria Russia

2.7

0.5

18.3

8.7

1.6

0.4

11.1

Estimated Income Loss 2015

9.3

1.6

131.8

54

6.4

1.5

66.4

The extent of the NCD problem in the Western Pacific Region

Most Life Years Lost in Western Pacific Region are due to NCD (DALYs lost, 1999)
75 %

Communicable diseases, maternal and perinatal conditions and nutritional deficiencies

Noncommunicable conditions

50

25

Injuries
AFR EMR SEAR WPR AMR EUR
DALY = Disability-Adjusted Life Year Source: World Health Report, 1999

Chronic diseases in Western Pacific, deaths, all ages, 2005

(total deaths 12,397,000)
Injuries 10%

Com m unicable, m aternal and perinatal, nutritional deficiencies 12%

CVD 33%

Other chronic diseases 9% Diabetes 2%

Chronic respiratory disease 14%

Cancer 20%

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%.

Top Risk Factors in this Region

<< Inactivity

Unhealthy Diet >>

<< Tobacco

Alcohol >>

Why Address NCDs?

Major NCDs have shared preventable risk factors: Tobacco use Unhealthy diet Physical inactivity Harmful use of alcohol

Philippines NCD Situation

The Philippines is one of the 23 selected countries contributing to around 80% of the total mortality burden attributable to chronic diseases in developing countries, and 50% of the total disease burden caused by noncommunicable diseases worldwide.
(Source: Lancet, 2007)

MORTALITY: TEN LEADING CAUSES BY SEX Number, Rate/100,000 Population and Percent Distribution Philippines, 2004 Both Sexes Cause Male Female Number 70,861 51,680 40,524 34,483 32,098 25,870 21,278 18,975 16,552 13,180 Rate 84.8 61.8 48.5 41.3 38.4 31.0 25.5 22.7 19.8 15.8 Percent* 17.6 12.8 10.1 8.6 8.0 6.4 5.3 4.7 4.1 3.6

1. Heart Diseases 2. Vascular System Diseases 3. Malignant Neoplasm 4. Accidents** 5. Pneumonia 6. Tuberculosis, all forms 7. Ill-defined and unknown causes of mortality 8. Chronic lower respiratory diseases 9. Diabetes Mellitus 10. Certain conditions originating in the perinatal period Source: The 2004 Philippine Health Statistics * percent share from total deaths, all causes, Philippines ** External Causes of Mortality Last Update: February 11, 2008

40,361 28,930 21,395 28,041 15,822 17,841 10,916 13,084 7,970 7,809

30,500 22,750 19,129 6,442 16,276 8,029 10,362 5,891 8,582 5,371

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

Risk Factors
90% of Filipinos has one or more of these 6 prevalent risk factors:

Physical inactivity Smoking Hypertension Hypercholesterolemia Overweight Obesity Diabetes

60.5% 34..8% 22.5% 8.5% 20% 4.9% 4.6%

Source: (NNHeS, FNRI 2003)

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

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)

Trends in overweight among children 0-10 years old

2.5
0-5 2 6-10

2
1.6
Percent

1.5
1

1.4

1.3

1
0.6 0.4 0

0.8 0.4

0.5

0.4 0

0 1993 1996

1998
Year

2001

2003

2005

Trends in overweight among adolescents

7
5.8
11-12 13-19

6 5
4.2 3.4 3.1 2.2 2.5 2.5 4.4

Percent

4 3 2 1 0 1993

1998 Year

2003

2005

Tobacco Use Among Youth

Current Use of Tobacco Product Among Adolescents Both Sexes: 22% (20% in
2003)

Boys: 34% Girls: 14%

(27% in 2003) (13% in 2003)

(Source: GYTS 2007)

Alcohol Use

11% of Filipinos 15-74 years regularly drink alcoholic beverages (>4 days/week) 24% of Filipinos 15-19 years are current drinkers (2001 survey n=10,240) 42% of Filipinos 15-27 years are current drinkers (2002 survey n=20,000) Mean value of pure alcohol consumed per day: 4.8 grams (2003 World Health Survey n=4951)

Summary of Economic Costs in US$)* for Four Smoking-related Diseases (2003, using SAMMEC methodology figures)

Smoking-related Health Care Diseases Costs Lung Cancer CVD CAD COPD All 4 Diseases 9,188,871

Productivity Losses from Death 189,709,987

Productivity Losses from Disease

Total Costs

3,407,151 202,306,009

507,315,052
236,888,476

2,930,533,343
1,312,836,695

38,910,556
88,922,515

3,476,758,951
1,638,647,686

104,561,119
857,953,518

569,530,925
5,002,610,950

54,043,648
185,283,871

728,135,692
6,045,848,339

*$1=PhP 52. Source: Tobacco and Poverty Study in the Philippines,2006.

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

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

DOH Milestones on NCD Prevention and Control

Year 2000

External evaluation study on existing programs as basis for integration conducted; Degenerative Disease Office under NCDPC mandated to manage NCDs; The Health Sector Reform Agenda was introduced advocating changes of service delivery, governance, financing and regulations, which facilitated the integration of NCDPC-related efforts

DOH Milestones on NCD Prevention and Control

2001 Integrated Community-Based NCDPC Demonstration Project in Pateros and Guimaras started. Framework for the Integrated Community-Based NCD prevention and control program (NCDPCP) formulated; Training Module on the Integrated CBNCDPCP developed National Mental Health Policy

DOH Milestones on NCD Prevention and Control

2002 Healthy Lifestyle (HL) approach (focusing on 3 major risk factors: physical inactivity, tobacco use and unhealthy diet) was mainstreamed; National advocacy program on HL developed with Philippine Heart Association; 2003 Mag HL Tayo Campaign was launched; Nationwide training of Regional NCDPC Coordinators and Training staff/HEPOs on the promotion of HL Anti-Tobacco Law (RA 9211) was passed.

DOH Milestones on NCD Prevention and Control

2004 Philippine Coalition for the Prevention of NonCommunicable Diseases established; Advocacy with commercial food establishments to offer healthier menu options to the public started; 2005 Training of national government agencies on HL (DILG, DepED, DSWD, DOT, etc.) Policy Development Study completed identifying policy agenda in support to the integrated NCDPC Program; Demonstration project in Guimaras and Pateros was assessed and results show very promising results. Revision of National Mental Health Plan

DOH Milestones on NCD Prevention and Control

2006 Breast Cancer Intervention Study in Pateros and Chronic Respiratory Disease Study in Guimaras; 3rd Public Health Convention on NCD Prevention and Control on local initiatives to promote HL 2007 Post NCD impact survey in Guimaras and Pateros DOH-NCDPC adaptation of the WHO NCD Framework for Action for the Philippines National Policy on Injury Prevention Program Operational Framework for Sustainable Establishment of Mental Health Program

DOH Milestones on NCD Prevention and Control

2008 4th Public Health Convention on NCD Prevention and Control accelerating NCD actions Finalization of manual of operations for communitybased NCD prevention and control

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

Causation Pathway

Causation Pathway

Intervention Pathway

Strategic Approach 1 1 2 2 3

Advocacy

Research, Surveillance, Evaluation

Health Sector Response Whole of government

response

Health sector governance Health sector leadership Integration of NCD prevention and control into national health strategy

Political will Political leadership Healthy public policies and laws

6
Health Systems Response
(Health Systems Strengthening)

7
Whole of society response
Community leadership Intersectoral partnerships Community mobilization Health workforce development Health services organization/delivery Financing People-centred systems of care Focus on prevention

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).

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.

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.

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 highrisk populations; Integrates across settings; such as health centers, schools, workplaces and communities; Makes explicit links to other government programmes; Emphasizes intersectoral action

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

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

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

Current Issues and Challenges: Governance

A core national coalition of stakeholders is established but mostly from the health Coalition Building for NCDs 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.

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

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.

Current Issues and Challenges: Service Delivery

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: Regulation

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: Financing

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)

Study on an Outpatient Prescription Drug Benefit for PhilHealth Members with Hypertension
Lack of affordable access to outpatient antihypertensive medicines leads to avoidable disease progression and costly inpatient admissions.
Inpatient care for hypertension and its sequelae is expensive and hypothesize that many hospitalizations could be avoided with appropriate antihypertensive therapy provided in ambulatory care.

Avoiding expenditures for one hospitalization could pay for one year of anti-hypertensive medicine treatment for three (3) patients.

Way Forward
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. .

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

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

Way Forward
Health promotion and advocacy are crosscutting 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.

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 PhilHealths benefit package to cover lifestyle diseases, to increase the benefit packages support value and to improve the coverage of the indigents and those in the informal economy.

Way Forward

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

Invest in cost-effective interventions

Health Benefits and Costs of 3 Interventions Combined
Deaths Averted Intervention Salt Reduction Tobacco Control Multi-drug Treatment TOTAL Deaths Averted 8.3 million Salt Reduction 5.5 million 17.9 million 31.7 million Tobacco Control Multi-drug Treatment TOTAL Cost per head

Intervention

Cost per head (US$)

0.36
(0.14-0.38 low-mid income) (0.52-1.04 High mid income

1.08 (0.75-1.40) 1.44 (0.89-1.78 lowmid income) (1.27-2.88 high mid income)

31.7 million 36 million =

88% of global goal

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:

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.

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

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

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

 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.

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