Strengthening the health system response to NCDs

in Europe Melitta Jakab (WHO-DSP) Jill Farrington (WHO-DNP)

Enrique Loyola (WHO-DNP) Juan Tello (WHO-DSP)

Copenhagen, Denmark

November 5, 2015

Outline

Overview of the work progamme

Regional trends in NCD outcomes and core interventions

Findings in 12 country assessments

OVERVIEW OF THE WORK PROGRAMME

Overview

• Goal is to support MSs to accelerate gains in NCD outcomes

• Country assessments: analytical work as entry point with medium-term policy follow-up

• Systematic approach to identifying health system challenges and opportunities

• Multidisciplinary national & international teams work toward consensus

• Background paper • Assessment guide • 12 country assessments

• ARM, BLR, CRO, EST, HUN, KAZ, KGZ, MDA, MKD, POR, TAJ, TUR • Good practice briefs • Policy dialogues and policy development • Continuous sharing of experiences across the region

Building a region-wide momentum

Sharing good practices

Purpose Why have countries embarked on this journey?

An entry point to evidence-informed policy development and dialogue

Seek to integrate fragmented risk factor and disease specific programs

Create a closer link between health system strengthening and health gain

Build a political momentum to address NCDs

Policy impact

3

4

4

6

6

7

10

0 2 4 6 8 10

Tobacco legislation

Info technology

Major SD reform

Incentives

Guidelines & training

Further analysis

Gvnance and NCD plans

Number of countries reporting follow-up action (out of 10)

Included NCDs into development plan

New tobacco control law in line w/ FCTC

Complete re-orientation of PHC

Strengthening e-health system for NCDs

Policy impact • One component of intensifying pressure to

respond to NCDs more effectively

• Forging in-country partnerships for greater impact (UNDP, World Bank, OECD)

Mutually reinforcing with Health 2020

11

Experience sharing

• Annual Flagship course on health system strengthening

• Since 2011 with a focus on NCDs

• Each country assessment is integrated

• 50+ participants

• Russian/English

Three pillars of the assessments

Health system

strengthening

through addressing

health system

challenges and

responding to

opportunities for

scaling up coverage

of core services

Core

services

Population

interventions

Expected

health gain

Achieve 25%

mortality

reduction for

NCDs by

2025 Individual

services

THE REGIONAL PERSPECTIVE ON NCD OUTCOMES AND CORE INTERVENTIONS & SERVICES

y = -11.401x + 551.99 or 40,4% between 2010 and 2025

y = -6.9757x + 325.42 or 42.2% between 2010 and 2025

y = -11.242x + 604.17 or 35.3% between 2010 and 2025

y = -19.125x + 943.98 or 39.8% between 2010 and 2025

0

100

200

300

400

500

600

700

800

900

1000

2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024

SDR

, age

s 3

0-6

9 y

rs, m

ajo

r N

CD

, pe

r 1

00

.00

0

Year

Age-standardized NCD death rates 30-69 and projections to 2025

European Region EU members before May 2004 EU members since May 2004 CIS

Source: WHO. European Health for All database, 2015

Regional trends in premature NCD mortality are promising

… but a number countries with high avoidable burden and large gender gap

Source: WHO. European mortality database, 2014

Shaped by patterns in premature CVD mortality

Core services Population interventions

Voluntary Global Targets Core interventions

30% reduction in the

prevalence of current tobacco

use

• Wide-range of anti-smoking interventions (FCTC)

– Raising tobacco taxes

– Smoke-free environments

– Warning about the dangers of tobacco and smoke

– Bans on advertising, promotion and sponsorship

20% reduction in the harmful

use of alcohol

• Interventions to prevent harmful alcohol use

– Raising taxes on alcohol

– Restrictions and bans on advertising and promotion

– Restrictions on the availability of retailed alcohol

Halt the rise in diabetes and

obesity

30% reduction in salt intake

10% reduction in inactivity

• Interventions to improve diet and physical activity

– Reducing salt intake and salt content

– Replacing trans-fats with polyunsaturated fat

– Promoting public awareness about diet and activity

Core services Individual health services

Voluntary Global

Targets

Core services

25% reduction in

prevalence of raised

BP

50% of eligible

receive drug therapy

• CVD & Diabetes

– Risk-stratification in primary health care -detection and management of

hypertension, cholesterol, and diabetes through multi-drug therapy

– Prevention in high risk groups and sec. prevention after AMI incl. aspirin

therapy

– Rapid response and secondary care after AMI and stroke

Halt the rise in

diabetes

• Diabetes

– Effective detection and general follow-up

– Patient education and intensive glucose management

– Hypertension management among diabetes patients

– Preventing complications (e.g. eye and foot exam)

• Cancer

– Prevention of liver cancer through hepatitis B immunization

– Screening for cervical cancer and tmt of precancerous lesions

– Early case finding for breast cancer and tmt of all stages

TOBACCO

Implementation status of FCTC in 53 MSs

Source: European Tobacco Control Report 2013: http://www.euro.who.int/__data/assets/pdf_file/0011/235973/European-Tobacco-

Control-Status-Report-2013-Eng.pdf Slide: Kristina Mauer-Stender

NUTRITION & PHYSICAL INACTIVITY Selected global targets in 53 MSs

0 % 20 % 40 % 60 % 80 % 100 %

Breastfeeding

Physical inactivity

Anaemia

Adult obesity

Childhood obesity

Stunting

Wasting

On track off track

Slide: Joao Breda

ALCOHOL Core interventions in 53 MSs

0 % 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % 100 %

Have legal requirements for product information on alcohol containers

Adjust taxes on alcoholic beverages for inflation

Have legal requirements for warnings on alcohol advertising

Have restrictions on alcohol product placement

Have a written national or subnational alcohol policy

Have a minimum age limit of 18 years for buying alcoholic beverages

Have random road-side breath-testing

Have a limit on blood alcohol concentration of 0.8 g/l or less for drivers

In place Not in place

Source: Global Status Report Adapted from slide: Lars Moller

Target 9 Evidence from recent STEPS surveys

% adults (40-64 yrs) with a 10 yr CVD risk of 30% or more, or with existing

CVD**

Of these.... % receiving drug therapy and

counselling***

Kyrgyzstan (2013) 17.4% 49.0%

Uzbekistan (2014) 20.2% 58.7%

Turkmenistan (2014) 20.5% N/A

Republic of Moldova (2013)* 23.0% 51.2%

Source: WHO STEPS surveys

Proportion of primary health care facilities which offer a cardiovascular risk stratification for the management of

patients at high risk for heart attack and stroke, 2015

0%

10%

20%

30%

40%

50%

60%

In more than 50%of PHC facilities

In 25% to 50% ofPHC facilities

In less than 25% ofPHC facilities

None

% c

ou

ntr

ies

off

eri

ng

CV

ris

k st

rati

fica

tio

n

WHO European Region EU NIS

Source: NCD Country Capacity Survey 2015

% adults with raised blood pressure* who are NOT currently on medication for it

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Uzbekistan(2014)(18-64 yrs)

Turkmenistan(2014)(18-64 yrs)

Georgia(2010)(18-64 yrs)

Moldova(2013)(18-69 yrs)

Kyrgyzstan(2013)(25-64 yrs)

Female

Male

Both sexes

*Systolic BP >= 140 and/or diastolic BP >=90 mm Hg

Source: WHO STEPS surveys

FINDINGS IN ASSESSMENT COUNTRIES

Assessment countries have enjoyed growth

$0

$5 000

$10 000

$15 000

$20 000

$25 000

$30 000

$35 000

$40 000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

GD

P p

er

cap

ita,

PP

P (

curr

en

t in

tern

atio

nal

$)

GDP per capita

Armenia Belarus Croatia Estonia Hungary

Kazakhstan Kyrgyzstan Macedonia, FYR Republic of Moldova Portugal

Tajikistan Turkey European Union

Source:

Variation in level of development and priority to health

0%

2%

4%

6%

8%

10%

12%

14%

16%

$-

$5 000

$10 000

$15 000

$20 000

$25 000

$30 000

GD

P p

er c

apit

a (i

nte

rnat

ion

al $

)

GDP per capita & GGHE%GGE (2014)

GDP/capita, PPP ($Int) GGHE (%GGE)

Source:

Premature NCD mortality & development

ARM

CRO

EST

HUN

KAZ

KGZ

MKD

POR

MDA

0

100

200

300

400

500

600

700

800

$- $10 000 $20 000 $30 000 $40 000 $50 000 $60 000

SDR

, maj

or

NC

Ds,

30

-69

ye

ars,

bo

th s

exe

s, p

er

10

0,0

00

(2

01

0)

GDP/capita, PPP ($int) (2010)

Source:

NCD outcomes in assessment countries

• Regional averages masque trouble spots

• Trends are less smooth and more fragile in individual countries (BLR, KGZ, MDA, TAJ)

• Cancer mortality is high and/or stagnating in a number of countries (ARM, HUN, MKD, POR)

• The male – female gap is substantial and not closing in some cases

Score cards Population interventions

Indicator average (1-3)

Raise tobacco taxes 3 2 Not Assessed 2 2 3 1 1 1 1 1.78

Ensure smoke-free environments 3 3 Not Assessed 2 1 1 2 1 1 1 1.67

Issue warnings on the dangers of tobacco and smoking 3 3 Not Assessed 2 2 2 1 1 2 2 2.00

Ban advertising, promotion and sponsorship 3 2 Not Assessed 2 2 2 2 2 1 1 1.89

Provide quit l ines and nicotine replacement therapy 3 1 Not Assessed 1 1 2 1 1 1 1 1.33

Raise taxes on alcohol 1 3 Not Assessed 1 1 1 1 2 1 1 1.33

Restrictions or bans on advertising and promotion 3 2 Not Assessed 2 1 1 3 2 1 1 1.78

Restrictions on retail availability of alcohol 3 3 Not Assessed 3 1 1 1 2 2 1 1.89

Minimum purchase age regulated and enforced 2.5 3 Not Assessed 2 2 2 1 1 1 2 1.83

Allowed blood alcohol content for driving 1.5 2 Not Assessed 2 2 3 3 2 1 2 2.06

Reduce salt intake and salt content on foods 2.5 1 1.5 1 1 1 1 Not Assessed 1 1 1.22

Virtually eliminate trans -fatty acids from the diet 2 1 2 1 1 1 Not AssessedNot Assessed 1 1 1.25

Reduce free sugar intake 1 1 3 1 2 1 1 Not Assessed 1 1 1.33

Increase intake of fruit and vegetables 2 2 2 1 3 1 2 Not Assessed 1 1 1.67

Reduce marketing pressure on children to consume food and non-alcoholic beverages2 1 1.5 1 1 1 1 Not Assessed 2 1 1.28

Promote awareness about diet and activity 2 2 1.5 2 2 1 2 Not AssessedNot Assessed 1 1.69

Overall average (1-3)

2.34 2.00 1.92 1.63 1.56 1.50 1.53 1.50 1.20 1.19 1.63Country average (1-3)

Score by country

Po

pu

lati

on

inte

rven

tio

ns

Anti-

smoking

intervention

s

Intervention

s to prevent

harmful

alcohol use

Intervention

s to improve

diet and

physical

activity

Score cards Individual services

Indicator average (1-3)

Risk stratification in primary health care 3 2 2 Not Assessed 2 2 1 2 Not AssessedNot Assessed 2.00

Effective detection and management of hypertension 1.5 1 2 Not Assessed 1 1 1 1 Not AssessedNot Assessed 1.21

Effective primary prevention in high-risk groups 2 1 2 Not Assessed 2 1 1 1 Not AssessedNot Assessed 1.43

Effective secondary prevention after AMI including acetylsalicylic acid 3 1.5 2 Not Assessed 2 2 3 1 Not AssessedNot Assessed 2.07

Rapid response and secondary care after AMI and stroke 2 2.5 2 Not Assessed 1 1 1 1 Not AssessedNot Assessed 1.50

Effective detection and general follow-up Not Assessed 2 2 1.5 2 1 Not AssessedNot AssessedNot AssessedNot Assessed 1.70

Patient education on nutrition and physical activity and glucose managementNot Assessed 2 1 1.5 1 2 Not AssessedNot AssessedNot AssessedNot Assessed 1.50

Hypertension management among diabetes patients Not AssessedNot Assessed 1 1 1 Not AssessedNot AssessedNot AssessedNot AssessedNot Assessed 1.00

Preventing complications Not AssessedNot Assessed 1 2 1 Not AssessedNot AssessedNot AssessedNot AssessedNot Assessed 1.33

Overall average (1-3)

2.30 1.71 1.67 1.50 1.44 1.43 1.40 1.20 N/A N/A 1.58

Ind

ivid

ual

ser

vice

s CVD and

diabetes

Diabetes

Country average (1-3)

Score by country

Hypertension awareness, treatment and control can be vastly improved

80

60 60

48,6 45

27

40 39

18,5

31,5 31

17

10

16,4

10

2

0

10

20

30

40

50

60

70

80

90

EST MDA HUN TUR TJK KGZ

% o

f th

ose

w e

leva

ted

BP

Aware Treated Controlled

20,1

7 1,2

42,2

19,7

3,7

0

10

20

30

40

50

Aware Took meds inlast 24 hrs

BP undercontrol

% o

f th

ose

wit

h

ele

vate

d b

loo

d p

ress

ure

Men Women

Political commitment to

NCDs

Explicit priority setting

approaches

Inter-agency action

Empowerment and people

centredness

Effective model of service delivery

Coordination across providers

Regionalization Incentive systems

Integration of evidence into

practice

Distribution and mix of human

resources

Access to quality medicines for

chronic diseases

Effective management

Adequate information solutions

Managing change

Ensuring access and financial

protection

Fifteen health system challenges and opportunities to respond to NCDs

Many countries face health system barriers to scale up NCDs

• Population interventions – Lack of explicit priority setting processes

– Making inter-sectoral action work effectively

• Individual services – Model of care fragmented

– Incentives are insufficient and not aligned

– Pharmaceutical policies need to be more comprehensive

– Information solutions are under-utilized

• Cross-cutting – Empowerment and people-centredness need

greater emphasis

The magic word

A L I G N M E N T

Good practice Estonia scales up CVD prevention and disease

management in PHC

Model of care Integration of evidence

into practice

Incentives Adequate information

solutions

Good practice Turkey scales up cancer screening

16

6

12

63

6

31

76

9

34

83

22

0

10

20

30

40

50

60

70

80

90

Breast Cervical Colorectal

% o

f ta

rge

t p

op

ula

tio

n

Cancer screening coverage rates

2007 2012 2013 2014

Empowerment and people-centredness

Coordination across providers

Adequate information solutions

Political commitment to

NCDs

Explicit priority setting

approaches

Inter-agency action

Empowerment and people

centredness

Effective model of service delivery

Coordination across providers

Regionalization Incentive systems

Integration of evidence into

practice

Distribution and mix of human

resources

Access to quality medicines for

chronic diseases

Effective management

Adequate information solutions

Managing change

Ensuring access and financial

protection

Focus of expert consultation

EXTRA SLIDES JUST IN CASE

The way forward

2012 2013 2014 2015 2016 2017 2018 2019

HUN MDA KGZ TUR TJK

BLR EST CRO

… …

ARM KAZ MKD POR

Guide piloted

and published

Good practice

briefs launched

Synthesis report and launch event

Exploring key policy issues

Enabling cross-country learning

Perfecting the country work

Policy follow-up

… …

Process for country assessments

• Agreement on objectives and scope

• International and local multi-disciplinary teams set up

• Online preparatory meetings to discuss methodology, allocate tasks, and organize

• 5-10 day multi-disciplinary expert mission with feedback loop

• Draft report prepared and circulated for comments in host country and in WHO

• Policy dialogue

• Follow-up steps agreed and work plan

• Report completed and published

Ap

pro

ximate

ly 12

m

on

ths

PR

EPA

RA

TOR

Y

PH

ASE

M

ISSI

ON

P

HA

SE

REP

OR

T W

RIT

ING

&

FO

LLO

W-U

P

Cancer plan Existence of operational

policy/ strategy/ action plan for

cancer

Breast cancer screening General availability of

breast cancer screening (by palpation or

mammogram) at the primary health care

level

Bowel cancer screening

General availability of bowel cancer

screening (by digital exam or

colonoscopy) at the primary health care

level

Cervical cancer screening

General availability of cervical cytology

at the primary health care level

Radiotherapy public system

General availability of radiotherapy in the public system

(number)

Armenia √ √ x √ 2

Azerbaijan x x x x 2

Belarus √ x x x 13

Georgia x √ √ √ 1

Kazakhstan √ √ √ √ 18

Kyrgyzstan √ √ √ √ 1

Republic of Moldova √ √ x √ 1

Russian Federation √ Not recorded x √ 126

Tajikistan √ √ x √ 1

Turkmenistan Not recorded √ x √ 5

Ukraine √ √ x √ 47

Uzbekistan √ √ x √ 16

Country

Programme covering cancer early diagnosis,

treatment & care

Cancer registry Oral morphine

available in public health sector

Availability of community/ home care

for people with advanced/ end stages of

disease

Armenia √ √ × ×

Azerbaijan √ √ × ×

Belarus Not recorded √ √ √

Georgia Not recorded √ × ×

Kazakhstan Not recorded √ × √

Kyrgyzstan √ × √ √

Republic of Moldova √ √ √ √

Russian Federation √ √ √ √

Tajikistan √ √ × ×

Turkmenistan √ √ √ Don’t know

Ukraine √ √ × Don’t know

Uzbekistan √ √ × ×

Source: WHO NCD Country Capacity Survey 2015

ALCOHOL Core interventions in 53 MSs

Source: Global Status Report Adapted from slide: Lars Moller

9 Have legal requirements for product information on alcohol containers

13 Adjust taxes on alcoholic beverages for inflation

15 Have legal requirements for warnings on alcohol advertising

36 Have restrictions on alcohol product placement

38 Have a written national or subnational alcohol policy

43 Have a minimum age limit of 18 years for buying alcoholic beverages

46 Have random road-side breath-testing

51 Have a limit on blood alcohol concentration of 0.8 g/l or less for drivers

0

5

10

15

20

25

30

Fully met Partially met Not met

N0

. WH

O E

uro

pea

nM

emb

er S

tate

s

National NCD guidelinesapproved

Provision of drug therapyat PHC

Progress monitoring on NCD indicators 9 & 10

Source: NCD Country Capacity Survey 2015