Lecture on NCD Prevention and Control as a Health System Strengthening Intervention delivered by Dr Albert Francis Domingo at the UP Manila College of Public Health on 19 January 2018.

1. NCD Prevention
and Control
as a
Health System
Strengthening
Intervention
Albert Francis E. Domingo, MD, MSc
College of Public Health, UP Manila
19 January 2018

2. Outline
• What is Public Health?
• What is Health System Strengthening?
• What is the burden of Noncommunicable Diseases?
• What are the Action Plans for NCDs?
• How will NCD prevention and control help achieve
Universal Health Coverage (UHC)?
• What is done in practice/field implementation?

3. What is
Public Health?

4. Personal Care vs. Public Health
• Public health: Improvement of health through the
organized efforts of society (not individuals),
through social interventions. Examples:
• Disease screening programs
• Immunization programs
• Environmental protection
• Health promotion
Reference: Gray, 2004 (p. 293), with modification

5. Who is/are the patient(s)?
What are the diagnostics and therapeutics?
Figure from: GBD 2013 Risk Factors Collaborators (2015)

6. Public Health Practice
The strategic, organized, and interdisciplinary
application
of knowledge, skills, and competencies necessary
to perform essential public health services and other
activities
to improve the population’s health.
Reference: Association of (US) Schools of Public Health, 1999

7. Healthy population
Population at risk
Population with sickness
Sick that need
hospitalization
but have no
access to hospital
care
Sick
and
Hospitalized
People needing
rehabilitation

8. What is
Health System
Strengthening?

9. What do we want from health
systems?
• Improve health outcomes
• Reduce exposure to modifiable risk factors
• Prevent complications and further deterioration
• Ensure equitable spread of improved outcomes
• (i.e., leave no one behind)
• Avoid financial risk due to costs of care

10. Resource generation
Financing
Provision
Stewardship
HIV/AIDSTBFP/MCHNCDs
Population groups (susceptible and ill)
HIV/AIDSTBFP/MCHNCDs
Disease management programmes
horizontal
vertical
diagonal
Stewardship
Resource generation
Financing Provision
Health policy Population
Healthsystemfunctions

11. What is the burden
of Noncommunicable
Diseases?

12. Noncommunicable Diseases
4 Diseases, 4 Modifiable Shared Risk Factors
Tobacco
Use
Unhealthy
diets
Physical
Inactivity
Harmful
Use of
Alcohol
Cardio-
vascular
Diabetes
Cancer
Chronic
Respiratory
Infection
Infection

13. Smoking
Sedentariness
Unhealthy diet
Obesity
Thick waistline
Raised blood pressure
Raised blood sugar
Raised blood lipids
Harmful use of alcohol

14. Self-harm and
interpersonal violence;
unintentional injuries;
transport injuries
Major NCDs: Diabetes,
urogenital, blood, and
endocrine diseases;
cardiovascular diseases;
chronic respiratory
diseases; neoplasms
Mental and
substance use disorders
Other NCDs
Maternal and
neonatal disorders
HIV/AIDS and TB
Diarrhea, lower respiratory,
and other common
infectious diseases
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-6 7-27 28-364 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+
Causes of Death over the Life-Course in the Western Pacific Region (2013, both sexes)
Forces of nature, war, and legal intervention Nutritional deficiencies
Other communicable, maternal, neonatal, and nutritional diseases Neglected tropical diseases and malaria
days years
Data from the Global Burden of Disease (2013) as published in The Lancet

15. Forces of nature, war, and
legal intervention
Self-harm and interpersonal
violence; unintentional
injuries; transport injuries
Major NCDs: Diabetes,
urogenital, blood, and
endocrine diseases;
cardiovascular diseases;
chronic respiratory
diseases; neoplasms
Mental and substance use
disorders
Other NCDs
Nutritional
deficiencies
Maternal and
neonatal disorders
HIV/AIDS and TB
Diarrhea, lower respiratory,
and other common
infectious diseases
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-6
7-27
28-364
1-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80+
Causes of Death over the Life-Course in the Philippines
(2013, both sexes)
Other communicable, maternal, neonatal, and nutritional diseases Neglected tropical diseases and malaria
Data from the Global Burden of Disease (2013) as published in The Lancet
days years

16. Epidemiological Transition
0
10
20
30
40
50
60
70
80
90
100
110
0
100
200
300
400
500
600
1954 '57 '60 '63 '66 '69 '72 '75 '78 '81 '84 '87 '90 '93 '96 '99 '02 '05 2008
Deathsper100,000population
(non-communicablediseases)
Deathsper100,000population
(communicablediseases)
Year
Communicable Diseases Malignant Neoplasm Diseases of the Heart
Source: Philippine Health Statistics, various years

17. /SDGs

18. What are the action
plans for
Noncommunicable
Diseases?

20. SDG3: Ensure healthy lives and
promote well-being for all at all
ages• Reduce maternal mortality
• End preventable deaths of newborns
and children under 5 years of age
• End epidemics of AIDS, TB, malaria
and NTDs and combat hepatitis,
water-borne diseases and other
communicable diseases
• Reduce by one third premature
mortality from NCDs and promote
mental health
• Strengthen prevention and
treatment of substance abuse
• Halve deaths and injuries from road
traffic accidents; ensure universal
access to sexual and reproductive
health
• Achieve universal health coverage,
access to quality essential health-
care services and access to
medicines and vaccines
• Substantially reduce deaths and
illnesses from hazardous chemicals,
pollutants and contaminants
• Strengthen implementation of the
WHO FCTC, as appropriate
• Support R&D of vaccines and
medicines in accordance with the
Doha Declaration on the TRIPS
Agreement and Public Health
• Substantially increase health
financing and development of the
health workforce in developing
countries
• Strengthen country capacities for
early warning, risk reduction and
management of national and global
health risks

22. NCD prevention and control
as part of national SDG responses
Target 3.8
Universal Health
coverage
Target 3.4
NCDs
& Mental
Health
Target 3.b
Access to NCD
medicines
Target 17.8
Data disaggregation
to identify vulnerable
population
Target 3.a
Implementation
of WHO FCTC
Target 3.5
Reduce
harmful
alcohol
Target 3.b
Research
for NCD
medicines

23. Vision:
A world free of the avoidable
burden of NCDs
Goal:
To reduce the preventable and
avoidable burden of morbidity,
mortality and disability due to
NCDs by means of multisectoral
collaboration and cooperation at
national, regional and global
levels
Guidance provided by the WHO Global NCD Action Plan 2013-2020

24. 2025 milestone: 9 voluntary global NCD targets
By 2030, reduce by one third premature mortality from NCDs
2030 milestone: NCD-related targets in the SDGs
2018 milestone: Four time-bound commitments
WHO Global
NCD Action Plan
2013-2020
2011 UN
Political
Declaration on
NCDs
2014 UN
Outcome
Document on
NCDs
Governance Risk factors Health systems Surveillance
Components of national NCD responses
WHO Regional
NCD Action
Plans
How the targets for 2030 relate to the targets for 2025
Agenda for
Sustainable
Development
2016-2030

25. In the Western Pacific Region
Objectives:
1. Raise the priority accorded to the
prevention and control of NCDs
2. Strengthen national capacity,
leadership, governance, multisectoral
action and partnerships
3. Reduce modifiable risk factors through
creation of health-promoting
environments
4. Strengthen and orient health systems
through people-centred primary health
care and universal health coverage
5. Promote and support national capacity
for high-quality research and
development
6. Monitor trends and determinants

26. Source of icons: World Heart Federation Champion Advocates Programme

27. How will NCD
prevention and
control help achieve
Universal Health
Coverage?

28. What is Universal Health Coverage
(UHC)?
• All people having access to quality health services
without suffering the financial hardship associated
with paying for care
• All people (population coverage)
• having access to quality health services (service
coverage)
• without suffering financial hardship associated with
paying for care (financial risk protection)

29. (Berman, 2012)

30. The NCD Causation Pathway
Underlying
determinants
• Globalization
• Urbanization
• Population ageing
• Social determinants
Common risk factors
•Tobacco use
•Unhealthy diet
•Physical inactivity
•Harmful use of alcohol
•Air pollution
•Age & heredity (non-
modifiable)
Intermediate risk
factors
• Raised blood sugar
• Raised blood pressure
• Abnormal blood lipids
• Overweight/obesity
• Abnormal lung function
Diseases
• Cardiovascular disease
• Cancer
• Diabetes
• Chronic respiratory disease
• Complications
Adapted from WHO (2005) Preventing Chronic Disease: a Vital Investment.
Country
Primary
Health Care
Tertiary
Health Care

31. The Continuum of Care
Health
Risk
exposure
Risk contact
Latent
disease/injury
Early
disease/
injury
Disease
progression
Advanced
disease/injury
Chronic
Disease or
impairment
Death
Primary Prevention:
Reduce risk exposure
Secondary
Prevention:
Detect and intervene
early
Tertiary Prevention:
Reduce progress or
complications of
established disease
ResourceGeneration,
Financing,Stewardship
Interventions

32. To get what we want, how should
we implement health programmes?
Essential attributes
(1-3/5)
Some domains for action
Quality Regulations and regulatory environment
Effective, responsive individual and population-based
services
Individual, family and community engagement
Efficiency Health system architecture to meet population needs
Incentives for appropriate provision and use of services
Managerial efficiency and effectiveness
Equity Financial protection
Service coverage and access
Non-discrimination

33. To get what we want, how should
we implement health programmes?
Essential attributes
(4-5/5)
Some domains for action
Accountability Government leadership and rule of law for health
Partnerships for public policy
Transparent monitoring and evaluation (M&E)
Sustainability and
resilience
Public health preparedness
Community capacity
Health system adaptability and sustainability

34. What are the health system
building blocks?
People-Centred Health Care Services
Health
workforce
Resource
generation and
health
financing
Essential
medicines,
commodities
and
technologies
Health
information
system
Good Governance

35. UHC Action Framework for the Western Pacific Region

36. Designing a Holistic Model of Care
Continuum
of Care
Level of Care
Self-care Family and
household
level
Community
level
General
primary care
District
hospitals
Referral
hospitals
A B C D E F
Health
Promotion
1
Disease
Prevention
2
Screening, Risk
Assessment, and
Diagnosis
3
Treatment and
Rehabilitation
4

37. A Sample Holistic Model of Care for
DiabetesContinuum
of Care
Level of Care
Self-care Family and
household
level
Community
level
General
primary care
District
hospitals
Referral
hospitals
A B C D E F
Health
Promotion
1 Healthy
lifestyle
Healthy
lifestyle
Regulation of the
sale and
marketing of
sugar-sweetened
beverages
Disease
Prevention
2 Risk factor
screening
through medical
history
Outpatient
nutrition
counselling
Screening, Risk
Assessment, and
Diagnosis
3 Careful
assessment of
family history
Early detection
Fasting plasma
glucose
screening
HbA1C
screening
Treatment and
Rehabilitation
4 Adherence to
medication
Foot care
Community-
based
rehabilitation
Patient support
groups
Periodic eye
examination
Diabetic registry
Surgery and/or
hemodialysis as
indicated
Assistive devices
Specialist
management of
co-morbid
diseases (TB)

38. What is done in
practice/field
implementation?
The case of Solomon Islands

39. Raising the
Profile of NCDs

40. Increasing
Public Awareness

41. Avoiding
Alcohol

43. SolPEN

44. Facebook.com/aedomingo@AlbertDomingo