Flagship Deep dive training report Training DetailsTransforming Health Sectors for Population Health: NCD Lens (7-8th November 2019) 1. Governance - Common challenges Organizational

1 Transforming Health Sectors for Population Health: NCD Lens (7-8th November 2019)

Flagship Deep dive training report

Training Details:

Transforming Health Sectors for Population Health:

A Non-communicable disease lens

(7-8th November 2019)

Submitted By:

Y. K. Pant, I.A.S., Project Director, UKHSDP

Dr Amit Shukla, Joint Director, UKHSDP


Contents

S.No. Topic Page No.

A. Admin Details

A.1 Nomination call from DEA 3

A.2 Training letter from World Bank 4-6 A.3 Nominations from State Government 7

A.4 Clearance letter from State Government 8

A.5 Political Clearance 9

B. Academic Details

B.1 Learning Objectives 10

B.2 Agenda 10

B.3 About Resource Persons 10

B.4 Sessions 12-76

B.4.1 Lecture 1 12

B.4.2 Lecture 2 27

B.4.3 Lecture 3 68

B.4.4 Lecture 4 76

B.5 Group Work 86

B.6 Learnings & Way Forward 90









1. Learning Objectives :

A. Understand opportunities and challenges involved in reorienting health

sectors towards population health.

B. Use systems thinking approaches to understand the underlying problems

and drivers of the NCD epidemics.

C. Identify the array of strategies needed to address NCDs and, in so doing,

position the health sector for transformational change.

D. Identify change barriers and enablers by conducting a change readiness

assessment.

E. Design change strategies that can support a major reorientation of the

health system towards population health.

2. Agenda:

DAY 1 AM: Introductions + Understanding the problem

PM: Country-based exercises

DAY 2 AM: Strategies to address NCDs

PM: Managing transformational change + panel discussion

Speakers

1. Olusoji Adeyi, The World Bank

2. Gerard Anderson, Johns Hopkins Bloomberg School of Public Health

3. Sara Bennett, Johns Hopkins Bloomberg School of Public Health.

4. Cyrus Engineer, Towson University and Johns Hopkins Bloomberg School

of Public Health

5. Connie Hoe, Johns Hopkins Bloomberg School of Public Health.

6. George Pariyo, Johns Hopkins Bloomberg School of Public Health.

7. Daniela C. Rodríguez, Johns Hopkins Bloomberg School of Public Health.

8. Miriam Schneidman, The World Bank.


4. Sessions/Lectures


Introductory Presentation

Transforming Health Sectors for Population Health: A Non-

communicable disease lens

Johns Hopkins Bloomberg School of Public Health & The World Bank

7th-8th November 2019

Welcome and IntroductionsDr Daniela Rodriguez

Dr George Pariyo

Dr Sara Bennett

Joining us later:Dr Olusoji Adeyi, World BankMs Miriam Schneidman, World BankDr Connie Hoe, JHSPHDr Gerard Anderson, JHSPH


Learning Objectives

• Understand opportunities and challenges involved in reorienting health sectors towards population health

• Use systems thinking approaches to understand the underlying problems and drivers of the NCD epidemics

• Identify the array of strategies needed to address NCDs and, in so doing, position the health sector for transformational change

• Identify change barriers and enablers by conducting a change readiness assessment

• Design change strategies that can support a major reorientation of the health system towards population health.

Ground rules

• Ask Questions: There are no stupid questions.

• Participation: Everyone in this room has relevant expertise….. The workshop is designed to allow facilitate exchange and mutual learning. It will only be successful if everyone participates fully. Give everyone a chance to contribute and encourage others to do so.

• Cell phones and other disruptions: please keep cell phones turned off during the workshop.

• Give your honest feedback: Constructive criticism is appreciated and is the only way that we can improve


The Need for Change: Transforming Health Sectors for

Population HealthWorld Bank Flagship Course

Deep Dive Session

Lecture 1

Sara Bennett PhD

The NCD crisis

• NCDs – cardiovascular diseases, diabetes, cancer, chronic respiratory infections, and mental health disorders responsible for more than 70% of global deaths

• Burden is greatest in LMICs – where 78% of all NCD deaths occur

• We have a package of known “best buy” interventions

• Implementing that package could:-• Avoid 10 million premature deaths by 2025 (WHO 2018)

• Increase GDP per capita by about 0.7% annually over 5 years (World Bank 2019)

So, why is it so challenging to introduce this package?


What are the needs that the emerging epidemic of non-communicable diseases places on our health systems?

What brought you to this course?What needs for change do you see in your own health sector?

Common themes in transforming health sectors for population health

Governance: Strategic policy frameworks;

leadership; sustainable intersectoral action and

partnerships

Community Care: integrated, multipurpose and

multidisciplinary PHC teams that proactively manage

community health

People-centeredness in all services and systems

Public Health Service: well resourced & effective public health service providing surveillance or risk & disease, & health promotion &

prevention

Effective systems that support public health and align incentives with health promotion & prevention including HRH, Financing, Medicines and Information systems

Adapted from: Jakab et al 2018


Health Council of Canada review of a decade of health reforms 2003-2013

Source: Health Council of Canada 2013

So, why were the Canadian Health Reforms unsuccessful?• Government spending increased

substantially

• Progress was made in specific areas (uptake of electronic medical records, reduction in waiting times) but failed to have transformational impact

• Lacked a clear vision and goals for the system as a whole

Leadership (at all levels)

Policies & legislation

Capacity development

Innovation & spread

Measurement & reporting

Enablers


Outline of Lecture

• Identify the changes needed in health sectors – and the barriers to implementing those changes

• Consider one particular case – Malaysia – and the successes and failures it has encountered in transforming its health sector

Key Messages

• Transformational change in the health sector will be necessary to address NCDs

• To facilitate transformational change – we need to identify and concertedly address the barriers to change

• Leadership, strategic planning, capacity development, and learning-by-doing will be key to strengthening implementation


What changes are needed? And what are the barriers?

Unpacking the puzzle

Governance

Community Care

People-centeredness

Public Health Service

Effective supporting systems: HRH, Financing, Medicines and Information systems

Adapted from: Jakab et al 2018


1. Governance - Common challenges

• Organizational culture that values hierarchy and rules over horizontal collaboration and innovation

• Resistance to change eg. from highly siloed disease control structures

• Clinical orientation of staff – may limit intersectoral efforts, undermine PHC

• Lack of skills to play the coach

• Lack of accountability for results

2. Community Care – Wagner’s Chronic Care Model


2. Community Care

Needs• CHW cadres to engage communities• Reorient health worker

communication with clients to emphasize information provision and empowerment

• Coordination across different health care providers

• Shared medical records to support referrals and discharges and ensure continuity of care

• Clinical guidelines

Common challenges• CHWs may not exist, or lack relevant

skills (with poor literacy to acquire them), and/or is over-burdened

• Health professionals reluctant to concede power in professional relationship with clients

• Referrals across different levels of system weak, between public & private sectors non-existent

• Specialists may be unwilling to pivot from direct patient care to supporting PHC teams

3. Public Health ServiceManagement of environmental, food, toxicological and occupational safety

Interventions, to address social determinants and health inequity

monitoring of health determinants, risks, morbidity & mortality

Responding to outbreaks & natural disasters

Inform, educate & empower people

with health knowledge


Air pollution in Delhi

• 12.5% total deaths in India, attributable to air pollution

• What can be done?• Collect data on sources of air

pollution (so you know where to start)

• Overhaul transport systems reducing reliance on cars

• Close down polluting power plants• Ensure enforcement of existing

legislation eg. closure of landfills (Patel 2019)

3. Public Health Service - Challenges

• Lack of a public health infrastructure – absence of national, regional, local agencies, and legal authority for work

• Lack of support services – public health labs

• Lack of trained public health workforce

• Weak regulatory capacity – especially for enforcement

• Lack of vital registration systems, and fragmented and/or incomplete health information systems


4. People-centeredness

Dignity & Respect

Responsive & Accountable

Services

Focus on the whole person

Demand side changes:• Increase health

literacy• Improve capacity

for self-management & self care

• Develop community leaders for NCDs

Provider side changes:• Increase capacity for

holistic & compassionate care

• Ensure effective and efficient coordination of care

• Make facilities accessible and convenient to community

4. People-Centeredness Challenges

Source: Hower et al 2018


Using patient narratives to strengthen provider training

Source: http://www.dipexinternational.org/2018/01/premature-birth-in-kenya-sharing-mothers-voices/

5. Supportive & Aligned Health Systems

• Health Financing • Ensuring that benefit packages cover key

NCD conditions• Payment mechanisms should:-

• incentivize community care• Incentivize coordination between health and

population based outreach programs

• Health Workforce• Align health workforce production with

emerging needs• Reorient medical and specialist training to

providing support to frontline community health teams

• Develop new cadres of public health workers (epidemiologists, public health specialists)

• Reorient education to emphasize communication and client engagement

• Medical Supplies• Ensuring the availability of needed

medicines at all levels of the health system• Health insurance or pooled payment

systems that minimize the financial burden for those suffering from NCDs

• Health Information• Establish regular surveys of NCD related

behaviors• Establish information systems (eg.

electronic medical records) that facilitate sharing of information across levels, and potentially across sectors

• Enable access for patients to their own medical records


Insights from Malaysia

The Starting Point for Malaysian Reforms • Strong community-level systems employing community health

workers (CHWs) – but with maternal and child health focus

• Nurses form the backbone of the health system (<10% public sector doctors work in primary care centers)

• Significant political will for reform

Major policy documents• National Strategic Plan for NCDs 2010-2014, and 2016-2025• Also specific action plans for: nutrition, tobacco, salt reduction, active living,

obesity, cancer control, alcohol control and chronic disease management at the primary care level


Key Reforms in Malaysia

Governance:

Align incentives for leadership with goals of program (KPIs in performance management)

Community Care:

Integrate new prevention & screening activities

Establish common treatment guidelines

People-centeredness:

Reorient community level systems drawing on CHWs

Public Health Service:

Institute national risk-factor surveillance and national registries

Systems: Improve health informatics to support continuity of careRe-profile health staff at primary care level creating multi-disciplinary teams

Effects on Risk Factors

Source: MOH (2016) National Strategic Plan for NCDs


Continuing Challenges

• Shortages of relevant health workers, especially dieticians and nutritionists

• Private sector widely used (provides >60% ambulatory care) – BUT exclusively oriented to curative care

• Community not used to accessing health facilities when healthy…low uptake of screening services

• Strong NCD care in hospitals (eg. Stroke units) but weak referral mechanisms - so on discharge people sent home with inadequate instructions for PHC team

Questions for participants

• Which of the reforms pursued in Malaysia would be priorities in your own setting? Are there other reforms that would be higher priorities?

• What challenges would you anticipate in pursuing your priority reforms? How similar or different are they to those encountered in Malaysia


Lecture 2

©2017, Johns Hopkins University. All rights reserved.

The Burden and Trends of Non-communicable Diseases in Low and

Middle Income Countries

Understanding causes and drivers

George W. Pariyo, MBChB PhD

Senior Scientist, Health Systems Program

Director, Health Systems Summer Institute

Department of International Health

Johns Hopkins University

© 2014, Johns Hopkins University. All rights reserved.©2017, Johns Hopkins University. All rights reserved.

Session Objectives

Review the evidence on the growing NCD

burden and trends in LMICs

Identify behavioural and other risk factors for

NCDs in LMICs

Discuss equity dimensions of NCDs

Discuss a systems approach to addressing

NCDs



Non-communicable diseases: Definition

Chronic condition that cannot be

passed from one person to another

o Causation may or may not be the result

of an infectious process

Source: CDC NCD Short Course


Characteristics of NCDs

Complex etiology (causes)

Multiple risk factors

Long latency period

Non-contagious origin (noncommunicable)

Prolonged course of illness

Functional impairment or disability




Types of NCDs

Cardiovascular disease (e.g., Coronary heart disease)

Cancer

Chronic respiratory disease

Diabetes

Chronic neurologic disorders (e.g., Alzheimer’s, dementias)

Arthritis/Musculoskeletal diseases

Unintentional injuries (e.g., from traffic crashes)



Top 10 causes of death globally, 2015

Source: WHO 2017

0 2 4 6 8 10

Road injury

Tuberculosis

Diarrheal diseases

Alzheimer's disease

Diabetes mellitus

Trachea, bronchitis

Lower repiratory illness

COPD

Stroke

Ischaemic heart disease

Deaths in Millions



Major causes of deaths in Low and Middle Income Countries : 1990-2015

Source: Pariyo GW, Wosu AC, Gibson DG, Labrique AB, Ali J, Hyder AA. Moving the agenda on non-communicable diseases: policy implications of

mobile phone surveys in low and middle-income countries. J Med Internet Res. doi:10.2196/jmir.7302

59% 60%64%

67%

0%

10%

20%

30%

40%

50%

60%

70%

80%

1990 2000 2010 2015

Percent

Year

Non-communicable diseases

Communicable, maternal, neonatal, and nutritional diseasesInjuries

LMIC Deaths, Age-standardized: 1990-2015



40 Million Global NCD Deaths (2016)

78% are in LMICs

Source: WHO – NCD Country Profiles 2018


40 Million Global NCD Deaths (2016)

Source: WHO Global NCD Report, 2014

78% are in LMICs

31%

16%

7%

3%

15%

0%

5%

10%

15%

20%

25%

30%

35%

Cardiovascular

diseases

Cancer Chronic

respiratory

diseases

Diabetes Other NCDs

Percent

NB: 20%

Communicable, maternal, perinatal and

nutritional conditions

9% Injuries



Quick NCD facts for LMICs

LMICs had 85% of all cause global premature adult

deaths (30-69)

75% of all adult premature deaths were caused by NCDso Of these, 78% were in LMICs

Majority of NCDs (about 75%) due to one of theseo Cardiovascular diseaseo Cancerso Diabeteso Chronic respiratory disease



Slow Decline in NCD Death Rate (1990-2017)

Source:

Charts by Pariyo GW 2019 – based on data from:

Global Burden of Disease Collaborative Network.

Global Burden of Disease Study 2017 (GBD 2017) Results.

Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2018.

Available from http://ghdx.healthdata.org/gbd-results-tool.

Selected countries, Age-standardized: 1990-2017

100

300

500

700

900

1 9 9 0 1 9 9 5 2 0 0 0 2 0 0 5 2 0 1 0 2 0 1 5 2 0 1 6 2 0 1 7

DEA

THS

PER

10

0,0

00

Argentina Bangladesh Chile Colombia DRC Ecuador Ethiopia

Ghana India Indonesia Kenya Libya Nigeria Norway

Peru Switzerland Tanzania Uganda VietNam



Slow Decline in DALYs (1990-2017)

Source:







10000

15000

20000

25000

30000

35000

1 9 9 0 1 9 9 5 2 0 0 0 2 0 0 5 2 0 1 0 2 0 1 5 2 0 1 6 2 0 1 7

DA

LYS

PER

10

0,0

00





People in low and middle income countries are dying from NCDs earlier


48%

28%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Low and middle income countries

High income countries

Percentage

70+ years

< 70 years



People in low and middle income countries are dying from NCDs earlier


48%

28%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Low and middle income countries

High income countries

Percentage

70+ years

< 70 years

Pre-mature mortality –

dying in the age 30 –

69 years


Little to no change in NCD prevalence (1990-2017)

Source:







80000

85000

90000

95000

100000

1 9 9 0 1 9 9 5 2 0 0 0 2 0 0 5 2 0 1 0 2 0 1 5 2 0 1 6 2 0 1 7

ALL

NC

D C

ASE

S P

ER 1

00

,00

0






Little to no change in NCD incidence (1990-2017)

Source:







100000

110000

120000

130000

140000

150000

160000

170000

180000

1 9 9 0 1 9 9 5 2 0 0 0 2 0 0 5 2 0 1 0 2 0 1 5 2 0 1 6 2 0 1 7

NEW

NC

D C

ASE

S P

ER 1

00

,00

0





Risk factor

Behavioral, lifestyle, environmental exposure, or a

genetic characteristic that is associated with

increase in occurrence of a particular

disease, injury or other health condition

Principles of Epidemiology, CDC 2006



Non-Modifiable risk factors

Risk factor that cannot be reduced

or controlled by intervention, for

example:

• Age

• Sex

• Genetics



Modifiable risk factors

Behavioral risk factors that can be

reduced or controlled by

intervention, thereby decreasing the

risk of disease




Four Major Individual Risk Factors

Tobacco Use Unhealthy diet Harmful use of

alcoholPhysical inactivity

NB: Air pollution is also an important risk factor for NCDs – may operate at

individual and population levels


4 major behavioral risk factors for NCDs

Tobacco use

Unhealthy diet

Physical inactivity

Harmful use of alcohol

Source: WHO NCD Report, 2014



Common Behavioral Risk Factors

Source; CDC NCD Short Course

Tobacco Use

Unhealthy diets

Physical Inactivity


Cardiovascular disease

Diabetes

Cancer

Chronic respiratoryconditions

All four risk factors are modifiable

1. Globally, 45% of all deaths were attributed to these 4 risk factors

2. Globally, 2/3’s of NCD deaths were attributed to these 4 risk factors


Preventable infections which are risk factors for NCDs

Hepatitis B virus

o E.g., Chronic liver disease and hepatocellular carcinoma

Human papilloma virus

o Associated with cervical cancer

Tuberculosis

o Associated with Chronic obstructive pulmonary disease (COPD)

o Some medications may aggravate diabetesSource: WHO NCD Report, 2014



Other preventable conditions which cause NCDs

Air pollution (e.g., vehicles, in-door from biomass fuels)

o Lung cancer

o Asthma

o Chronic obstructive pulmonary disease (COPD)

Poor food preservation

o E.g., aflatoxins from fungi on peanuts linked to Hepatocellular Ca

Environmental pollution

o See this NIH site for list https://www.cancer.gov/about-cancer/causes-prevention/risk/substances



Some facts about suicide mortality

Suicides among 15 – 29 year old accounted for nearly one third of all

suicides globally

Suicide second leading cause of death among those aged 15 – 29

years

o and girls aged 15 – 19 years

For each suicide death, at least 20 others attempted suicide

Prior suicide attempt is a risk factor for eventual suicide death

About 50% of suicides occurred in lower and lower-middle income

countries

Only 10% of lower and lower-middle income countries had a national

separate suicide prevention strategy




Behavioral risk factors lead to metabolic risk factors

Metabolic means biochemical

processes involved in the body's

normal functioning

o Raised blood pressure

o Obesity

o Raised blood glucose

o Raised blood lipidsSource: CDC NCD Short Course


Causal Map for NCDs

ENVIRONMENTAL

Air pollution

Environmental pollution

Poor food storage

BEHAVIORAL

Tobacco use

Unhealthy diet

Physical inactivity


METABOLIC

Raised blood pressure

Obesity

Diabetes

Raised blood lipids

NCDs

Source: Diagram adapted from WHO global brief on hypertension (2013)

Multi-point interventions are needed. The most effective way to reduce NCDs on

a population level is to act on reducing risk factors

Toxins



Fitted and projected estimates show downward trend of smoking prevalence (2000 - 2025)

Source: WHO – NCD Country Profiles


Increasing obesity (2000 - 2025)(Percentage of adults with BMI of 30 kg/M2 or higher)




Distribution of risk factors in adults -Bangladesh

Source: Zaman et al 2015 - Clustering of non-communicable diseases

risk factors in Bangladeshi



Increasing risk factors - Bangladesh




Multiple risk factors - Bangladesh





Multiple Chronic Conditions May Co-exist in Same Patient – USA

Source: Schneider et al 2009


Multiple chronic conditions

Higher burden of MCC in LMICs

Central Europe, Eastern Europe and Central Asia show

inverse relationship between SES and prevalence of MCC

o Higher SES have lower prevalence of MCC

South East Asia (e.g., Bangladesh, India) tend to have higher

SES associated with higher prevalence of MCC

o Why?

References - see WHO – NCD Country Profiles 2018; Zaman et al 2015; Hajat &

Stein 2018



Multiple chronic conditions pose special challenges for health systems

Gender differences in prevalence of MCC

o US women had higher prevalence of 2 or more chronic conditions

than men

Socio-economic differences in MCC vary by setting

o Central Europe, Eastern Europe and Central Asia - higher SES have

lower prevalence of MCC

o South East Asia (e.g., Bangladesh, India) tend to have higher SES

associated with higher prevalence of MCC



Health care costs for MCC increase

exponentially

o higher costs in caring for person with MCC than the additive

costs of caring for separate individuals with single condition

o Increasing prevalence of MCC with age

more frequent clinic visits, hospitalizations, medications




Interventions for MCC need to consider possible

clustering of NCDs and other chronic infectious

conditions and potential aggravation due to MCC

o Increased risk of stroke among those with diabetes

o Increase in number of depressive symptoms with number of

chronic conditions

o HIV and its treatment increase risk of cardiovascular disease

o Treatment for TB may aggravate diabetes


Discussion point

What are likely to be characteristics

of countries which will meet their

global targets for NCDs?o Strong health systems

o Income level

o etc




Proportion of deaths due to NCDs –Adults 30 – 69 years by Income Group



Risk of premature death due to NCDs –Ghana, Nigeria, Tanzania, Uganda


Ghana

Tanzania Uganda

Nigeria



Risk of premature death due to NCDs –Afghanistan, Libya


Afghanistan Libya


Risk of premature death due to NCDs –Bangladesh, India, Indonesia


Bangladesh India

Indonesia



Risk of premature death due to NCDs –Poland, Ukraine


Poland Ukraine


Risk of premature death due to NCDs –Argentina, Colombia


Argentina Colombia



Risk of premature death due to NCDs –Norway, Sweden, Switzerland, United States


Norway Sweden

Switzerland United States


Inadequate Health Systems Response to

NCDs



National health systems response needs strengthening

Poor access to basic primary health care including opportunities for

screening and basic lab tests

o e.g., Screening services could pick up high blood pressure

o Even when diagnosed, poor continuity of care and lack of

adherence to medications results in preventable heart attacks and

strokes

Gaps in affordability of basic NCD system requirements

o Essential technologies (6)

e.g., BP equipment, weighing scale, height boards, blood and

urine screening for glucose and proteins, etc

o Essential medicines (10)

e.g., Aspirins, statins, insulin, metformin, bronchodilators, etc

Source: WHO NCD profiles, 2018


National health systems response needs strengthening

Few health care facilities offering CVD risk stratification for

management of patients at high risk of heart attack and stroke

Lack of availability and use of cardiovascular disease

guidelines

o Slightly over half of countries in 2017 reported having

CVD guidelines

when present, reported to have been utilized in only half

of the facilities

in the African region only 28% of countries

Source: WHO NCD profiles, 2018



Not Having Blood Pressure Measured -Uganda

Source: Uganda MOH STEPs Report 2014


Summary Burden of NCDs is high and increasing

LMICs are most affected

There are often geographic, income and gender gaps

NCDs are preventable especially by targeting modifiable

behavioral risk factors

Lots of data already exist in public domain

Need to increase availability and use of data to inform

NCD policy and interventions e.g., from STEPs or similar

surveys



Health Systems are Complex Adaptive

Systems


Health systems are complex adaptive

systems and not linear relationships

An approach that uses linear only

assumptions is inadequate

Measurable results are great but remember …….

58



Gives deeper insights into:

how a system works,

why it has problems,

how it can be improved

Systems thinking

Graphic adapted from Ahn A.C. et al. PLoS Med 3:956-960 (2006).


Systems thinking is about relationships

Source: Don de Savigny



Causal loop diagram illustrating factors influencing dual practice during the 1990’s

Source: Paina, L. et al., 2014. Advancing the application of systems thinking in health: exploring dual practice and its management in Kampala, Uganda. Health Res Policy Syst, 12(August), p.41. Available at: http://www.health-policy-systems.com/content/pdf/1478-4505-12-41.pdf.


Examples of tools for analyzinghealth systems bottlenecks

Fish-bone diagram (Ishikawa diagram)

Flow-chart

Pareto chart

Run-chart

Control chart

Causal loop diagrams



Basic structure of a Fishbone (Ishikawa) Diagram

NB: Air pollution is also an important risk factor for NCDs – may operate at individual and population levels

Effect


Tanahashi Model of Effective Coverage

Source: T. Tanahashi (1978). Health Service Evaluation and its Coverage, Bulletin of the World Health Organization, 56 (2): 295-303 (1978)



The Community Equity Effectiveness Loop

Source: Tugwell et al (2006). Systematic Reviews and Knowledge Translation. Bulletin of the World Health Organization, August 2006, 84 (8)


122 countries have completed STEPS

42 WHO African Region21 WHO Region of the Americas16 WHO Eastern Mediterranean Region6 WHO European Region11 WHO South-East Asia Region,26 WHO Western Pacific Region

Source: Am J Public Health. 2016;106:74–78.



Relatively few studies on NCDs in LMICs


Institute for Health Metrics and Evaluation

healthdata.org



Risk of premature death due to NCDs -Ghana



Risk of premature death due to NCDs -Tanzania




Risk of premature death due to NCDs -Uganda



Risk of premature death due to NCDs –Nigeria




Risk of premature death due to NCDs -Afghanistan



Risk of premature death due to NCDs -Libya




Risk of premature death due to NCDs -Bangladesh



Risk of premature death due to NCDs –India




Risk of premature death due to NCDs –Indonesia



Risk of premature death due to NCDs -Poland




Risk of premature death due to NCDs -Ukraine



Risk of premature death due to NCDs –Argentina




Risk of premature death due to NCDs –Colombia



Risk of premature death due to NCDs –Norway




Risk of premature death due to NCDs –Sweden



Risk of premature death due to NCDs –Switzerland




Risk of premature death due to NCDs –United States of America



Lecture 3

Effective Systems Strategies To Address NCD Epidemics

World Bank Flagship Course

Day 1, Lecture 3

Olusoji Adeyi

Which strategies might work in my context?

Learning Objectives

• Identify and illustrate different system-strengthening strategies to address NCDs in specific contexts

• Assess the relevance of such strategies in each context


Types of interventions to consider: examples

• Informing and shaping policies

• Legislation and regulation

• Translating policy, legislation, and regulation into action

• Information and communication

• Policy-based interventions that do not require conscious and direct behavior change by individuals

• Direct management or delivery of services or programs;

• Changes in financing

• Changes to key inputs along the value chain, such as training, equipment, or supplies

On the evidence: WHO’s “Best Buys” & Other Recommended Interventions

• From a longer list of 88 interventions, including overarching/enabling policy actions, the most cost effective interventions, and other recommended interventions

• Three categories:1) Best Buys [Interventions CE ≤I$100 per DALY averted in LMICs]. Included here.

2) Interventions with CE > I$100 per DALY averted in LMICs. Included here.

3) Other interventions from WHO guidance (cost effectiveness not available). These are not included in this session.

[Source: WHO. Tackling NCDs: "Best buys" and other recommended interventions for the prevention and control of noncommunicable diseases. 2017. WHO/NMH/NVI/17.9. https://www.who.int/ncds/management/best-buys/en/


Reduce Tobacco UseBest Buys [Interventions CE ≤I$100 per DALY averted in LMICs]• Increase excise taxes and prices on tobacco products

• Implement plain/standardized packaging and/or large graphic health warnings on all tobacco packages

• Enact and enforce comprehensive bans on tobacco advertising, promotion and sponsorship

• Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public places, public transport

• Implement effective mass media campaigns that educate the public about the harms of smoking/tobacco use and second hand smoke

Interventions with CE > $100 per DALY averted in LMICs• Provide cost-covered, effective and population-wide support (including brief advice, national toll-

free quit line services) for tobacco cessation to all those who want to quit6

Reduce the harmful use of alcohol

Best Buys [Interventions CE ≤I$100 per DALY averted in LMICs]

• Increase excise taxes on alcoholic beverages

• Enact and enforce bans or comprehensive restrictions on exposure to alcohol advertising (across multiple types of media)

• Enact and enforce restrictions on the physical availability of retailed alcohol (via reduced hours of sale)

Interventions with CE > I$100 per DALY averted in LMICs

• Enact and enforce drink-driving laws and blood alcohol concentration limits via sobriety checkpoints

• Provide brief psychosocial intervention for persons with hazardous and harmful alcohol use


Reduce unhealthy dietBest Buys [Interventions CE ≤I$100 per DALY averted in LMICs]• Reduce salt intake through the reformulation of food products to contain less salt

and the setting of target levels for the amount of salt in foods and meals

• Reduce salt intake through the establishment of a supportive environment in public institutions such as hospitals, schools, workplaces and nursing homes, to enable lower sodium options to be provided

• Reduce salt intake through a behavior change communication and mass media campaign Reduce salt intake through the implementation of front-of-pack labelling


• Eliminate industrial trans-fats through the development of legislation to ban their use in the food chain

• Reduce sugar consumption through effective taxation on sugar-sweetened beverages

Reduce physical inactivity


• Implement community wide public education and awareness campaign for physical activity which includes a mass media campaign combined with other community based education, motivational and environmental programs aimed at supporting behavioral change of physical activity levels


• Provide physical activity counselling and referral as part of routine primary health care services through the use of a brief intervention


Manage cardiovascular disease and diabetes

Best Buys [Interventions CE ≤I$100 per DALY averted in LMICs]• Drug therapy (including glycemic control for diabetes mellitus and control of hypertension using a total risk*

approach) and counselling to individuals who have had a heart attack or stroke and to persons with high risk (≥ 30%) of a fatal and non-fatal cardiovascular event in the next 10 years

Interventions with CE > I$100 per DALY averted in LMICs• Treatment of new cases of acute myocardial infarction** with either: acetylsalicylic acid, or acetylsalicylic acid and

clopidogrel, or thrombolysis, or primary percutaneous coronary interventions (PCI)

• Treatment of acute ischemic stroke with intravenous thrombolytic therapy

• Primary prevention of rheumatic fever and rheumatic heart diseases by increasing appropriate treatment of streptococcal pharyngitis at the primary care level

• Secondary prevention of rheumatic fever and rheumatic heart disease by developing a register of patients who receive regular prophylactic penicillin

• Preventive foot care for people with diabetes (including educational programs, access to appropriate footwear, multidisciplinary clinics)

• Diabetic retinopathy screening for all diabetes patients and laser photocoagulation for prevention of blindness

• Effective glycemic control for people with diabetes, along with standard home glucose monitoring for people treated with insulin to reduce diabetes complications


Manage Cancer


• Vaccination against human papillomavirus (2 doses) of 9–13 year old girls

• Prevention of cervical cancer by screening women aged 30–49, either through: Visual inspection with acetic acid linked with timely treatment of pre-cancerous lesions; Pap smear (cervical cytology) every 3–5 years linked with timely treatment of pre-cancerous lesions; HPV test every 5 years linked with timely treatment of pre-cancerous lesions


• Screening with mammography (once every 2 years for women aged 50-69 years) linked with timely diagnosis and treatment of breast cancer

• Treatment of colorectal cancer stages I and II with surgery +/- chemotherapy and radiotherapy

• Treatment of cervical cancer stages I and II with either surgery or radiotherapy +/- chemotherapy

• Treatment of breast cancer stages I and II with surgery +/- systemic therapy.

• Basic palliative care for cancer: home-based and hospital care with multi-disciplinary team and access to opiates and essential supportive medicine25

Manage chronic respiratory disease


Symptom relief for patients with asthma with inhaled salbutamol Symptom relief for patients with chronic obstructive pulmonary disease with inhaled salbutamol Treatment of asthma using low dose inhaled beclometasone and short acting beta agonist


Pollution Prevention and Mitigation:Highlights for Policies and Programs

• Make pollution prevention a priority; integrated into planning

• Mobilize, increase, and focus funding

• Establish systems to monitor pollution and its effects on health

• Build multisectoral partnerships for pollution control

• Integrate pollution mitigation into planning processes for NCDs

• Research pollution and pollution control

[Source: Lancet Commission on Pollution and Health. 2017. https://www.thelancet.com/commissions/pollution-and-health]

In Practice: Evidence is Essential but Not Sufficient for Policy Traction and Program Success


Environmental Scanning for Policymakers & Change Agents: Example – “PESTLE analysis”

Factors

• Political

• Economic

• Sociocultural

• Technological

• Legal factors

• Environmental

Video at: https://www.youtube.com/watch?v=VrmZLaFY3YE

Analytical tools to inform policy process and options:Example – “PolicyMaker”

PolicyMaker: A Structured political analysis and policy advocacy tool that integrates three methods of applied political analysis.

• Political mapping techniques to analyze the political actors in a policy environment

• Political risk analysis – to provide a quantitative assessment of the feasibility of a policy

• Organizational analysis and rules-based decision systems to suggest strategies that can enhance the feasibility of a policy.

Five Steps of Analysis: Policy; Players; Opportunities and Obstacles; Strategies; and Impacts.

[Sources: http://www.polimap.com/poliuses.html and


Lecture 4

Leading Transformational Change

Cyrus Engineer, DrPHClinical Professor, Towson University,

Adj. Professor International Health Johns Hopkins Bloomberg School of Public Health

Session Overview

2

• Understand change definitions, types including transformational change

• Identify barriers and responses to change• Recognize Kotter’s eight-stage process to effect

meaningful change• Review a country case (South Africa) and their approach

to effecting change • Apply eight stage framework to develop a plan for NCDs

(group work)


Reading and References

Kottler, J. (1995). Leading change: why transformation efforts fail. Harvard Business Review, 73(2), 59-67.

Kotter, J. P., & Rathgeber, H. (2006). Our iceberg is melting: Changing and succeeding under any conditions. Macmillan.

Bridges, W. (2009). Managing Transitions. Nicholas Brealey, Boston, Massachusetts.

https://vimeo.com/ondemand/ouricebergismelting?autoplay=1

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.

Introduction – change, change management, change types, change requirements and change community

Change is difficult

“Any customer can have a car painted any color that he wants so long as it is black.” Henry Ford

p. 72. Chapter IV, : Remark about the Model T in 1909;


There is something to be said about rituals and hardwiring….

“I like to sleep on my side of the bed… at home and wherever I go… even if I am all alone or have a magnificent view of the Mont Blanc at the other end – I MUST to sleep on my side of the bed”

CE

Change Management

“the process of continually renewing an organization’s direction, structure, and capabilities to serve the ever-changing needs of external and internal customers’

Moran, J. W., & Brightman, B. K. (2000). Leading organizational change. Journal of workplace learning, 12(2), 66-74.

“Change management is a collective term for all approaches to prepare, support, and help individuals, teams, and organizations in making organizational change.

“change management as the practice of applying a structured approach to transition an organization from a current state to a future state to achieve expected benefits. (See the ACMP Standard for Change Management©, page 9)

Change types – Ackerman (1997)

Developmental – enhance current systems, processes or skills

Transitional – planned new state, dismantle old state with a structured transition plan

Transformational – radical emerges from “throwing away the sand box”, visioning, trial and error, wake up calls- Requires shift in mind set for critical mass in an organization” culture


Change requirements – Key ingredients

In addition to courage and resilience, requires….

Transformational leadership, evidence informed change process – systems theory, change commitment, and alignment among and between change sponsors, change agents, and change targets ”

11–

Full Range of Leadership Model – Change Leadership

Source: B. M. Bass, “From Transactional to Transformational Leadership: Learning to Share the Vision,” Organizational Dynamics, Winter 1990, p. 22. Reprinted by permission of the publisher. American Management

Association, New York. All rights reserved.

11–

Characteristics of Transactional Leaders

Contingent Reward: Contracts exchange of rewards for effort, promises rewards for good performance, recognizes accomplishments

Management by Exception (active): Watches and searches for deviations from rules and standards, takes corrective action

Management by Exception (passive): Intervenes only if standards are not met

Laissez-Faire: Abdicates responsibilities, avoids making decisions

Source: B. M. Bass, “From Transactional to Transformational Leadership: Learning to Share the Vision,” Organizational Dynamics, Winter 1990, p. 22. Reprinted by permission of the publisher. American Management

Association, New York. All rights reserved.


11–

Characteristics of Transformational Leaders

Idealized Influence: Provides vision and sense of mission, instills pride, gains respect and trust

Inspiration: Communicates high expectations, uses symbols to focus efforts, expresses important purposes in simple ways

Intellectual Stimulation: Promotes intelligence, rationality, and careful problem solving

Individualized Consideration: Gives personal attention, treats each employee individually, coaches, advises

Change Community and change alignment

13

Change community characteristics

Change Sponsor - individuals who have the authority or power, resources and credibility within the organization to require change

Change Agent – individuals or teams that have the responsibility for implementing the change or assisting (consultants)

Change Target – individuals who will be affected by the change and required to make changes in their work, roles, processes, attitudes or behaviors.

Expectations – role clarity

Change Sponsor - must be committed, consistently display support for change through “influential communication and meaningful consequences”

Change Agent must be committed to supporting sponsors’ have capacity or be developed for change intended

Change Target – must be committed to new ways of thinking and operating to fully realize the intended outcome.

Complacency

Addressing Complacency – From everything is fine to true urgency


Where do I start?

Obstacles experienced during major organizational changes, HBR (2006)

Funny why it gets worse before it gets better….

Bridges transition model and the productivity dip

Ambrose, D. (1987). Managing complex change. Pittsburgh: The Enterprise Group.


Kotter’s 8 steps

Kottler, J. (1995). Leading change: why transformation efforts fail. Harvard Business Review, 73(2), 59-67.

In summary – three phases

Conner, D. R., & Kelly, D. (1979). The Emotional Cycle of Change. In W. Pfeiffer & Jones (Eds.).

The 1979 Annual Handbook for Group Facilitators. LaJolla, California: University Associates.

Conner and Patterson (1982)Conner, Harrington and Horney (2000)


Model of the Forces and Factors That Influence HCO Culture

NCDs…. Is our iceberg melting?

FredAliceLouisBuddyThe ProfessorNoNo

NCD – Case – South Africa

South Africa –Background: complex burden of combination of chronic infectious illness and non-communicable diseases.

Aim – develop, test and implement a chronic disease management model for SA and study efficiency, quality and sustainability with the goal to improve life expectancy37 Primary Health Care Centers in 3 districts

Approach (2010-2014)– Integrated three modelsOverarching – Continuous quality improvement PDSA MRC UK (2000) Chronic Care Model (adapted)IHI’s Breakthrough series (change management)

: Phased study (2010-2014 ) – planning, diagnostic, intervention (Jan 2011-Jan 2013), impact, sustainability and improvement .

Mahomed, O. H., & Asmall, S. (2015). Development and implementation of an integrated chronic disease model in South Africa: lessons in the

management of change through improving the quality of clinical practice. International Journal of Integrated Care, 15.


NCD Case – South Africa

Sponsor – Non-communicable disease department

Agents – Faculty – senior technical adviser, public health medicine specialist, district management teams, HIV/AIDS, Tuberculosis, NCD, mental care coordinators, local and provincial staff

Targets – 37 PHCs in 3 districts (urban and rural – convenience sample)

Results – “produced comprehensive and sustainable organisational and community change through a radical shift in the approach to service delivery. Key requirements for implementing and sustaining change are change management; project planning and the use of quality improvement tools [29], and these together with health service ownership were the central themes that resonated throughout the implementation process.”

NCD Lessons – Change Management ( South Africa)

- classic resistance to change especially in the implementation phase –• Denial - designated workers e.g. HIV/AIDS nurses wanted to focus only on their

program• Role ambiguity and confusion especially due to cross messaging• Flavor of the month - Managers overwhelmed with existing work – new position

created – ICDM Champions --- however this created further conflicts• Culture of curative care – not enough preparation on community side (health

promotion or empowering communities)• Community health worker seen as a courier of medication

• Conclusion - “The implementation of the integrated chronic disease management model is feasible at primary care in South Africa provided that systemic challenges and change management are addressed during the implementation process.”

In conclusion

“In times of change the learner will inherit the earth while the learned find themselves wonderfully equipped to live in a world that no longer exists.”

Eric Hoffer (1902-83)


5. Group Work



Identifying and adressing NCD related issues in Health Systems

of Nigeria NCD Training Group Work

The World Bank Training, Washington DC

7-8th November 2019

COUNTRY SNAPSHOT – NIGERIA

1. Population: 206. 1 Million people2. Per capita GDP: $5, 252 3. Life Expectancy: 4. Dual burden of disease:

• communicable/MCH/Nutrition: 63%• NCDs 29%• Injury 8%

5. Thought not the top one cause of disease burden, NCDs prevalence and risk factors prevalence are fast increasing

6. NCDs may be major problem in coming years so a great opportunity of investing time

Diseaes burden of Nigeria

communicable, MCH & Nutrition

injuries

NCDs

Major NCD Conditions

CVD cancer

COPD Diabetes


Health System Challenges1. Health financing:

• High percentage of OOP expenditure: constituting about 70.3% (showing rising trend as in 2016 it was 76%)

• Limited fiscal space2. Service delivery

• roles and responsibilities of the different levels of the health system, with respect to PHC, remain unclear.

• More than 70 percent of all secondary facilities and about 35 percent of PHC facilities are private. Services provided by the private sector are either subsidized (e.g. faith-based health facilities) or full- cost (e.g. privately owned clinics and hospitals).

• Shortage of health workforce: densities of nurses, midwives and doctors that are still too low

3. Gender disparity• Women has higher NCD premature death rate• Men has much higher alcohol use 22% vs. 5%• Women have higher Obesity rate and higher level physical inactivity 12%

vs. 4%, 27%vs. 22%

NCD risk factors1. Top NCDs are

• CVD: Ischemic Heart disease/Stroke • Cancer

2. Top Risk factors

• Physical inactivity 25%• High blood pressure 18%• Harmful use of Alcohol 13%• Obesity : 8%• Tobacco use


Root Cause Analysis: High OOPS in NCDs In Nigeria

OOPS

Poverty Low Accountability of Health System

Low Resource Allocation to Health System Non Inclusive Policies

North South Divide

Multi layered Health System

Extensive Pvt System

Priority to CDs

Low GDP No Risk Pooling

No Job Security

Law & Order

Strategies for addressing Issues emerging from RCA: NCDs in Nigeria

Classification Intervention Change Actors

Political Policy regarding Universal Health Care through Risk Pooling (Health Insurance for primary ie screening, vaccinations, point of care in hypertension, dialysis, and tertiary care ie renal transplants etc )

Sponsor

Economic Financial Provisions (Budgetary through taxation /External Aid/World Bank Project as soft loan) for resource /risk pooling.

Sponsor /Agent

Social Health education through transformational change strategies. Target

Technological Beneficiary identification and payment reimbursement IT platforms

Agents

Legal Making provisions for Quality Health Care Services for private services

Environmental No evident risk to environment.


Kottler Steps

Kotter Steps Already Being Done To do Rationale

Creating a climate for Change

Create a Sense ofUrgency

Nothing Communicating to political bosses regarding political gain of adressing OOPS of NCDs

1. 70 % OOP of all Health exp2. 35% of all primary care in

Private sector

Building The Team Multiplestakeholder

Health Protection Authority No accountability in existing system

Develop the Change and vision Strategy

NoNe Policy regarding Universal Health Care through Risk Pooling (Health Insurance for primary ie screening, vaccinations, point of care in hypertension, dialysis, and tertiary care ie renal transplants etc )

NCDs being low priority due to lower proportion of mortality have opportunity of health investment.

Kottler Steps (contd.)

Kotter Steps Already Being Done To do Rationale

Engaging and enabling the whole organization

Communicate for buy in

None Inter and intra departmental advocay

1. To bring all stakeholder on board

Empower others to act

None Incentives Motivation

Create short term wins

None Short term indicators Motivation

Implementing and Sustaining Change

Don’t Let Up Financial provision for continuation

Make it Stick Peoples programme ownership


6. Learnings & Way Forward:

A. Reorientation of Health System towards the approach of population health

is vital for achieving leverage to address NCDs. This reorientation is fraught

with many challenges like following :

A.1: Orientation of all cadres of Health Care workers in public health.

A.2: Developing institutes and other infra for NCD redressal. For eg

developing stand alone sub centres and PHCs to fully fledged Health and

Wellness Centres.

A.3: Appropriate and continuous funding for NCD intervention can be a

make or break factor and due focus is to be kept on this area.

B. To understand proper extent and pattern of NCDs and its casual elements a

wider cell, apt in screening (through routine CBACK forms, FHS etc ), needs

to be developed in health system. Along with it capacity enhancement of

system needs to be done so that it becomes efficient in identifying suitable

intervention as per need and sensibility of local population at risk in such a

manner that system is oriented more towards preventive aspects of NCD

adressal rather than just curative part of it. For these strategies like health

education and positive information are also to be taken in consideration.

C. Social, physical and financial barriers in accessing interventions for NCDs

are to be identified and put in place specially for vulnerable and

marginalized population.

D. Capacity development for evaluating design anomalies or benefits in

prevailing interventions for NCD intervention should be inculcated

intrinsically in system through trainings and partnerships with knowledge

partners in field.


List of Participants

No. First Name Last Name Organization Email Address

1 Sutayut Osornprasop World Bank [email protected]

2 Jawaharlal.

K

Kulandairaj Health and Family Welfare Training Centre [email protected]

3 Bharathi Balaiah Government of Tamil Nadu [email protected]

4 Nivedita

Priyadarshini

Ilango Tamil Nadu Health System Reform Program [email protected]

5 Venkat

Lakshmi

Mookkan Tamil Nadu Health System Reform Program [email protected]

6 Jerard Maria

selvam

George National Health Mission [email protected]

7 Amit Shukla UTTARAKHAND HEALTH SYSTEMS

DEVELOPMEMT PROJECT [email protected]

8 Yugal

Kishore

Pant UTTARAKHAND HEALTH SYSTEMS

DEVELOPMEMT PROJECT

[email protected]

9 Ilie Volovei Bank [email protected]

10 Viorica Volovei NGO [email protected]

11 Rialda Kovacevic Bank [email protected]

12 Julia Mensah Bank [email protected]

13 Shuo Zhang Bank [email protected]

14 Yi Zhang Bank [email protected]

Instructors:

1 Olusoji Adeyi, The WorldBank

2 Gerard Anderson, Johns Hopkins Bloomberg School of Public Health

3 Sara Bennett, Johns Hopkins Bloomberg School of Public Health

4 Cyrus Engineer, Towson University and Johns Hopkins Bloomberg School of

Public Health

5 Connie Hoe, Johns Hopkins Bloomberg School of Public Health

6 George Pariyo, Johns Hopkins Bloomberg School of Public Health

7 Daniela C. Rodríguez, Johns Hopkins Bloomberg School of Public Health

8 Miriam Schneidman, The World Bank

mailto:[email protected]








Documents

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