NSM-NCD2013 Keynote Address - Multi-Sectoral Approach(MSA) to Prevent Non-Communicable Diseases

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NSM-NCD2013 Keynote Address - Multi-Sectoral Approach(MSA) to Prevent Non-Communicable Diseases

  1. 1. 4/15/20131Keynote Address:Multi-Sectoral Approach (MSA)to PreventNon-Communicable DiseasesLokman Hakim S, MD, PhDDeputy Director General of Health (Public Health)Ministry of Health, MalaysiaNSM NCD Conference 201326 March 2013Kuala Lumpurlokman.hakim@moh.gov.myMinistry of HealthMalaysiaThe Causation Pathway ForNon-Communicable DiseasesUnderlyingDeterminants•Globalization•Urbanization•PopulationAgeingCommon RiskFactors•Unhealthy diet•Physical Inactivity•Tobacco & Alcohol use•Age (non modifiable)•Heredity(non modifiable)IntermediateRisk Factors•Overweight/obesity•Raised blood sugar•Raised bloodpressure•Abnormal bloodlipidsSource: Adapted from Preventing Chronic Disease: A Vital Investment. Geneva, WHO 2005.2
  2. 2. 4/15/20132There are Four Major Groups of Non-Communicable Diseases;Four major lifestyles related risk factorsModifiable causative risk factorsTobacco useUnhealthydietsPhysicalinactivityHarmfuluse ofalcoholNoncommunicablediseasesHeart diseaseand stroke    Diabetes   Cancer   Chronic lungdisease 38.314.920.86.59.510.71.85.410.14.3 4.7 5.30510152025NHMS II (1996) NHMS III(2006)NHMS 2011Prevalence(%)Prevalence of Diabetes,≥30 years (1996, 2006 & 2011)Total diabetesKnownUndiagnosedIFGSource: National Health & Morbidity Surveys (NHMS)32.2 32.712.819.805101520253035NHMS III (2006) NHMS 2011Prevalence(%)Prevalence of Hypertension,≥18 years (2006 & 2011)Total HPTKnownUndiagnosed20.635.18.426.60510152025303540NHMS III (2006) NHMS 2011Prevalence(%)Prevalence of Hyper-cholesterolaemia,≥18 years (2006 & 2011)Total HCholKnownUndiagnosed4TRENDS IN NCD RISK FACTORS
  3. 3. 4/15/2013316.629.1 29.44.414.0 15.105101520253035NHMS II(1996)NHMS III(2006)NHMS 2011Prevalence(%)Prevalence of Overweight & Obesity,≥18 years (1996, 2006 & 2011)OverweightObesityPrevalenceofAbdominalObesity,≥18years(2006&2011)19.628.633.644.748.051.055.762.8 63.261.463.256.250.41020304050607018-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+PREVALENCE(%)AGE GROUPS (years)30.137.147.154.12030405060NHMS 2006 NHMS 2011PREVALENCE(%)MALES FEMALESPrevalence of AbdominalObesity by age groups(NHMS 2011)5BurdenofDiabetesinMalaysia:(Adultsage18 years&above)60500,0001,000,0001,500,0002,000,0002,500,0003,000,0003,500,0004,000,0004,500,0005,000,00005101520252006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020EstimatedpopulationPrevalence(%)YearEst. population, 2006 Est. population, 2011 Prevalence projection, 2006 Prevalence projection, 2011Currentprojection
  4. 4. 4/15/20134AdmissionstoMOHHospitalsduetoCirculatoryDiseases&Cancer7y = 130995e0.0208xR² = 0.7959y = 53166e0.0523xR² = 0.8716020,00040,00060,00080,000100,000120,000140,000160,000180,000200,0002005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020Circulatory diseases Malignant neoplasms Projected, Circulatory diseases Projected, CancerPrimaryRenalDiseases8y = 314.5x + 1735.7R² = 0.96340100020003000400050006000700080009000New dialysis patientsNew dialysis patients Projected new dialysis patientsSince 2003, diabetesaccounted for > 50%of the primary renaldisease of new dialysispatients
  5. 5. 4/15/2013592000200320042008Global Strategy for the Prevention and Control ofNoncommunicable DiseasesGlobal Strategy on Diet,Physical Activity and HealthAction Plan on the Global Strategy for thePrevention and Control of NCDs201020092011Global Strategy toReduce the HarmfulUse of AlcoholWHO Global StatusReport on NCDsPolitical Declaration on NCDsWHOs global road map to prevent andcontrol NCDs2012+ Realizing the commitments made in the Political DeclarationUNSecretary-General:NCDsindevelopingcountriesarehidden,misunderstoodandunder-recordedA rapidly rising epidemic in developed anddeveloping countries…… with serious socio-economic impacts,particularly in developing countries.Workable solutions exist to prevent mostpremature deaths from NCDs and mitigate thenegative impact on development.The way forward: These solutions need to bemainstreamed into socio-economic developmentprogrammes and poverty alleviation strategies.10
  6. 6. 4/15/2013611UN High-levelMeeting on NCDs(New York, 19-20 September 2011)High-levelMeeting113 Member States34 Presidents & PrimeMinisters3 Vice-Presidents andDeputy Prime Ministers51 Ministers of ForeignAffairs & Health11 Heads of UNAgencies100s of NGOsPoliticalDeclarationEstablish multisectoralnational plans by 2013Integrate NCDs intohealth-planningprocesses and thenational developmentagendaPromote multisectoralaction through health-in-all policies andwhole-of-governmentapproachesBuild national capacityWhatWHOisdoingDevelop a GlobalMonitoring Frameworkand targetsDevelop a globalimplementation plan2013-2020Provide technicalsupport to developingcountriesIdentify options forpartnershipsCoordinate work withother UN AgenciesMeasure resultsWorld Health Assembly in May 2012:Decided to adopt a global target of a 25% reduction in premature mortalityfrom NCD by 202512
  7. 7. 4/15/20137Highlights:UN PoliticalDeclarationHeads of States and Governments and representatives committed to:• Establish/strengthen, by 2013, national multisectoral policies andplans for NCDs, taking into account the Global Strategy for NCDs andits Action Plan;• Integrate NCDs policies and programmes into health-planningprocesses and the national development agenda of each MemberState;• Develop national targets and indicators based on guidance provideby WHO and give greater priority on surveillance;• Accelerate implementation of the WHO FCTC, the Global Strategy onDiet, Physical Activity and Health, and the Global Strategy to Reducethe Harmful Use of Alcohol;• Strengthen health systems that support primary care, prioritise earlydetection and treatment, and improve access to affordable essentialmedicines for NCDs.13What is Multi-SectoralApproach?• Working together across sectors to improve health andinfluence its determinant• A number of other terms are used, often inter-changeably,for engaging sectors outside of health. These include:• Inter-sectoral action for health.• Multi-stakeholder action.• Whole-of-government.• Health-in-all policies.• Healthy public policies.14
  8. 8. 4/15/20138Why MSA?• Governments can make substantial achievements in reducingthe burden of NCDs through MSA.• Forging new collaborations and partnerships are critical inmaking progress in addressing the NCD epidemic.• Partnership occurs at different levels:• Individuals, families and communities.• Government, communities and NGOs.• Government, development partners (within countries), civilsociety and, as appropriate, the private sector.15‘Whole-of-Government’ and‘Whole- of-Society’approach• ‘Whole-of-Government’ denotespublic service agencies workingacross portfolio boundaries toachieve a shared goal and anintegrated government responseto particular issues• Responsibility for health and itssocial determinants rests withthe whole society, and health isproduced in new ways betweensociety and government.16
  9. 9. 4/15/20139Social Determinants of Health17Challengesin operationalising Multi-sectoral Approach (MSA)• No or ineffective multisectoral mechanism at national level;• No high-level commitment and support for coordinatedoperation;• No or low level representation from different sectors in MSAmechanisms;• No mandate, agreed roles and responsibility of sectors;• No joint plan with agreed target, indicator approach, andinputs; and• No auditing and valid reporting mechanism.18
  10. 10. 4/15/201310NCD Targets & MSA• 25% relative reduction in NCD mortality (between 30-70years) has been adopted as a global target during the 65thWorld Health Assembly in May 2012.• A set of global targets and indicators has been decided in aFormal Meeting with Member States in November 2012, andwill be presented for adoption in the 66th World HealthAssembly (WHA in May 2013).• The Global Monitoring Framework on NCDs consists of 25indicators, with 9 voluntary global targets.• Having targets and indicators will provide clear direction forMSA and facilitate identifying the role and responsibility andaccountability for the different sectors. 19What is new?"Best buys" interventions to address NCDsPopulation-basedinterventionsaddressingNCDrisk factorsTobacco use - Excise tax increases- Smoke-free indoor workplaces and public places- Health information and warnings about tobacco- Bans on advertising and promotionHarmful useof alcohol- Excise tax increases on alcoholic beverages- Comprehensive restrictions and bans on alcohol marketing- Restrictions on the availability of retailed alcoholUnhealthydiet andphysicalinactivity- Salt reduction through mass media campaigns and reduced saltcontent in processed foods- Replacement of trans-fats with polyunsaturated fats- Public awareness programme about diet and physical activityIndividual-basedinterventionsaddressingNCDs inprimary careCancer - Prevention of liver cancer through hepatitis B immunization- Prevention of cervical cancer through screening (visualinspection with acetic acid [VIA]) and treatment of pre-cancerous lesionsCVD anddiabetes- Multi-drug therapy (including glycaemic control for diabetesmellitus) for individuals who have had a heart attack or stroke,and to persons at high risk (> 30%) of a cardiovascular eventwithin 10 years- Providing aspirin to people having an acute heart attack20
  11. 11. 4/15/201311TobaccouseHarmfuluse ofalcohol• Excise tax increases• Smoke-free indoor workplaces and public places• Health warnings• Bans on advertising and promotion• Excise tax increases on alcoholic beverages• Comprehensive restrictions and bans on alcoholmarketing• Restrictions on the availability of retailed alcohol• Salt reduction through mass media campaigns andreduced salt content in processed foods• Replacement of trans-fats with polyunsaturatedfats• Public awareness programme about diet andphysical activityHEALTHY CITIES AND ISLANDS SETTINGS SUCH AS SCHOOLS, WORKPLACESADVOCACY, HEALTH IMPACT ASSESSMENT  HEALTH IN ALL POLICIESMSA, ‘Best Buys’ and SectorsMSAUnhealthydiet andphysicalinactivityMinistries including• Health• Agriculture• Finance•Transport• Trade and Industry• Education• Labour• Urban planning• JusticeOther stakeholders including• Industry• Civil society• NGOs• AcademiaMINISTRIES Health, Agriculture, Finance, Transport, Trade and Industry Education, Labour, Urban planning, JusticeOTHER STAKEHOLDERS Civil society, NGOs, Academia, Private sector, Donor, developmentpartners21Examplesof bestpractices andeffectiveapproachesfor MSA- Tobacco Control• Tobacco taxation and HealthPromotion Foundations inAustralia, Lao PDR, Korea,Malaysia, Mongolia, Tonga,Viet Nam• Plain packaging- a pathbreaking approach in Australia22
  12. 12. 4/15/201312Examples of best practices and effectiveapproaches for MSA- Promoting Healthy Diet• Healthier foods in Singapore-Hawker Fare• Salt reduction in China and Mongolia• Eat smart restaurants (700+), Hong Kong(China)• Eat smart @ school (400), Hong Kong(China)23Examplesof best practices andeffectiveapproachesfor MSA-Promoting Physical Activity• Exercise equipment in public parksin Lao PDR, China, Korea• Walk paths, and cycling tracks inCambodia, Korea, China, Malaysia• Community physical exercise groupsclubs in Seongbuk, Korea and Shanghai,China• Walking days in Dalin, Seongbuk, Xiamen24
  13. 13. 4/15/201313Examples of best practices and effectiveapproaches for MSA- Tobacco Control & Reducing Harm fromAlcohol• The Mongolia’s President initiative inalcohol control, non- alcohol ingovernment’s function and new alcohollegislation.• Development of legislation: drinking anddriving, use of helmet, blood testing:China, Cambodia, Philippines, Vietnam.• Regulating informal alcoholcontrol in Vietnam. 25Examples of best practices and effectiveapproaches for MSA-Healthy Cities• Smoke-Free Cities:• Harbin, QingDao, China.• Makati and Marikina, Philippines.• Luang Prabang, in Lao PDR.• Siem Reap, Cambodia .• Environmentally sustainable healthy urbantransport (ESHUT) in 5 Asian cities:• Promote walking, cycling.• Public transport system.• Reduce use of private vehicles.• Smoking ban.• Promoting health and hygiene.• Barrier-free transport environments.26
  14. 14. 4/15/201314Examples of best practices and effectiveapproaches for MSA-Healthy Settings: Health PromotingSchools and Work Places• Health Promoting schools for multiplehealth interventions - Singapore, HongKong, Macao (China).• Healthy workplaces - Shanghai, HongKong, China.27MSA-Entry PointsNational multi-ministerial forumNational• Effective only with commitment at the highest level,need a good driver, Health in All PoliciesCity/District/Village levelSubnational• More feasible, leverage local government, collectivevoice of community, government closer to thecommunity, local ordinancesTobacco/Alcohol/Physical ActivityRisk factor• Facilitators-activism, pressure groups, champions,international agreements (FCTC), global reporting,more palpable interventions, common good /commonenemyInterministerialLocalGovernmentCross sectorworking groups 28
  15. 15. 4/15/201315MSA – Accountability and Reporting• Experiences from MDG 4 and 5 in accountability framework.• Agreed national targets and indicators.• Sector-specific roles, responsibility, target, inputs and outputs.• Joint statement and joint plan.• Across sectors audit, evaluation.• Public reporting.29Rio+20:“NCDsconstituteoneofthemajorchallengesforsustainabledevelopment”“We understand the goals ofsustainable development can onlybe achieved in the absence of ahigh prevalence of debilitatingcommunicable and NCDs, andwhere populations can reach astate of physical, mental and socialwell-being.” [paragraph 138]“We acknowledge that the globalburden and threat of NCDsconstitutes one of the majorchallenges for sustainabledevelopment in the 21st century.”[paragraph 141]30
  16. 16. 4/15/201316UNSystemTaskTeamonthepost-2015UNDevelopmentAgenda:NCDsisapriorityforsocialdevelopmentandinvestmentsinpeople“The MDGs did not adequately address… increase in NCDs. ” [paragraph 19]“Priorities for social development andinvestments in people would include:… NCDs. Access to sufficient nutritiousfood and promotion of healthy lifestyles with universal access topreventive health services will beessential to reduce the high incidenceof NCDs diseases in both developedand developing countries.” [paragraph 67]31National Strategic Plan forNon-Communicable Diseases(NSP-NCD)2010-2014• Presented and approved by the Cabinet on 17December 2010• Provides the framework for strengthening NCDprevention & control program in Malaysia• Adopts the “whole-of-government” and “whole-of-society approach”Seven Strategies:1. Prevention and Promotion2. Clinical Management3. Increasing PatientCompliance4. Action with NGOs,Professional Bodies & OtherStakeholders5. Monitoring, Research andSurveillance6. Capacity Building7. Policy and Regulatoryinterventions32
  17. 17. 4/15/201317Strategy 7: Policy & RegulatoryInterventions• Main thrust of NSP-NCD• Health promotion and education will increaseawareness and knowledge• However changes in behaviour is strongly influencedby our living environmentAwareness KnowledgeBehaviouralChangeSupportive livingenvironmentHealth promotion & educationsPolicies & regulations33CabinetCommitteeforAHealthPromotingEnvironment• To support the implementation of NSP-NCD, the Cabinet on 17 December 2010approved the establishment of a Cabinet-level committee, chaired by the RightHonourable Deputy Prime Minister, and comprises of 10 members1. Minister of Health2. Minister of Education3. Minister of Information, Communications, Arts & Culture4. Minister of Rural & Regional Development5. Minister of Agriculture and Agro-based Industry6. Minister of Youth & Sports7. Minister of Human Resource8. Minister of Domestic Trade, Co-operatives and Consumerism9. Minister of Housing and Local Governments10. Minister of Women, Family and Social AffairsMain TOR: To determine policies that creates a livingenvironment which supports positive behavioural changesof the population towards healthy eating and active living34
  18. 18. 4/15/201318Challengesfor Malaysia• The main challenge in policy and regulatory interventionsremain that they are mostly under the responsibilities ofministries and departments other than Ministry of Health• Ministry of Health needs to take leadership role.• Need to find a win-win solution – “mutuality of interest”.• Economic and “political” consideration remains paramountand needs to be acknowledged.• For Malaysia, the establishment of the Cabinet Committee wasan important initial step to achieve the “whole-of-governmentapproach”.• The health sector needs to play a strong advocacy role.35Summary• Preventing and controlling NCD is an urgent priority for allcountries.• Most of the drivers of NCDs and their risk factors lie outsidethe control of the health sector.• MSA is required to create enabling environments, so thathealthy choices are the easy choices.• MSA is also required to break the cycle of poverty and NCDs.• The prevention and control of NCDs and their risk factorshave a positive impact not only on health, but also onproductivity and economic and social development.36
  19. 19. 4/15/201319Thank you37

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