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									Noncommunicable Diseases
Why Address NCDs?
• 60% of global deaths are due to NCDs (and
  still increasing)
• 40% of cancer is preventable
• 80% of cardiovascular disease, stroke and
  diabetes is preventable
• A large part of chronic respiratory diseases
  is preventable
• Cost-effective secondary prevention
  interventions exist and have worked in many
 Projected Forgone National Income due to Heart
 Disease, Stroke and DM in Selected Countries, 2005-
 2015 (in billion dollars)

            Brazil   Canada   China   India   UK    Nigeria   Russia

Estimated    2.7      0.5     18.3    8.7     1.6    0.4       11.1
Loss 2005

Estimated    9.3      1.6     131.8    54     6.4    1.5       66.4
Loss 2015
•The extent of the NCD problem
•in the Western Pacific Region
     Most Life Years Lost in Western Pacific Region
     are due to NCD (DALYs lost, 1999)

               Communicable diseases,                       Noncommunicable
               maternal and perinatal
               conditions and nutritional                   conditions



         AFR    EMR      SEAR     WPR       AMR   EUR

                                                    DALY = Disability-Adjusted Life Year
                                                     Source: World Health Report, 1999
Chronic diseases in Western Pacific, deaths, all
ages, 2005
(total deaths 12,397,000)

 Com m unicable,
  m aternal and                                     CVD

           Other chronic

                               disease          Cancer
Projections for Chronic Disease in WPR
next 10 years

• 106 million people will die
• Deaths from infectious diseases, maternal
  and perinatal conditions, and nutritional
  deficiencies combined will increase by 1%.
• Deaths will increase by 20% - deaths from
  diabetes will increase by 51%.
Top Risk Factors in this Region

           << Inactivity

             Unhealthy Diet >>

           << Tobacco

                    Alcohol >>
  Why Address NCDs?

Major NCDs have
  shared preventable
  risk factors:
• Tobacco use
• Unhealthy diet
• Physical inactivity
• Harmful use of
    Philippines NCD Situation

   The Philippines is one of the 23 selected
    countries contributing to around 80% of the
    total mortality burden attributable to chronic
    diseases in developing countries, and 50%
    of the total disease burden caused by non-
    communicable diseases worldwide.
                         (Source: Lancet, 2007)
                                    MORTALITY: TEN LEADING CAUSES BY SEX
                             Number, Rate/100,000 Population and Percent Distribution
                                               Philippines, 2004
                                                                                           Both Sexes
                       Cause                                 Male     Female
                                                                                 Number      Rate       Percent*

1. Heart Diseases                                            40,361     30,500    70,861       84.8         17.6

2. Vascular System Diseases                                  28,930     22,750    51,680       61.8         12.8

3. Malignant Neoplasm                                        21,395     19,129    40,524       48.5         10.1

4. Accidents**                                               28,041      6,442    34,483       41.3          8.6

5. Pneumonia                                                 15,822     16,276    32,098       38.4          8.0

6. Tuberculosis, all forms                                   17,841      8,029    25,870       31.0          6.4

7. Ill-defined and unknown causes of mortality               10,916     10,362    21,278       25.5          5.3

8. Chronic lower respiratory diseases                        13,084      5,891    18,975       22.7          4.7

9. Diabetes Mellitus                                          7,970      8,582    16,552       19.8          4.1

10. Certain conditions originating in the perinatal           7,809      5,371    13,180       15.8          3.6
Source: The 2004 Philippine Health Statistics
* percent share from total deaths, all causes, Philippines
** External Causes of Mortality
Last Update: February 11, 2008
Top Ten Leading Causes of Morbidity

Overall (both sexes and all ages)

Rank 4. Hypertension

Rank 7. Diseases of the Heart
                Source: FHSIS, 2006
  Risk Factors
90% of Filipinos has one or more of these 6 prevalent
  risk factors:

       Physical inactivity       60.5%
       Smoking                   34..8%
       Hypertension              22.5%
       Hypercholesterolemia      8.5%
       Overweight                20%
       Obesity                   4.9%
       Diabetes                  4.6%

                    Source: (NNHeS, FNRI 2003)
 Low and Fruits Consumption Among

• Dangerously low fruit & vegetable
   – Only 19% of national population eat fruit
     & vegetables more than four times a day
   – Recommended standard: 100% eating
     FIVE servings DAILY
   – Total daily requirement must be
   – Actual consumption is only 111g/capita
Increasing Diabetes Morbidity

• Diabetes prevalence has increased
  significantly over the years to 20.06% among
  Filipino adults (20 y/o and above)
• Adult incidence of diabetes from 1998 to
  2007 is likewise alarming at 8.5%.
  (Source: Philippine Cardiovascular Outcome Study – Diabetes
  Mellitus, 2008)
                Trends in overweight among
                   children 0-10 years old
                                                                           2         6-10

          1.5                                                 1.4

           1                                            0.8
                0.4             0.4
          0.5                         0.4

                            0               0
                1993        1996      1998         2001       2003        2005
          Trends in overweight among

          7                                                      11-12
          6                                                      13-19

          5                              4.2

          4                                    3.4
                    2.5   2.5
          3   2.2


              1993        1998           2003        2005
    Tobacco Use Among Youth

   Current Use of Tobacco
    Product Among Adolescents
     Both Sexes: 22% (20% in
       Boys: 34%         (27% in 2003)
       Girls: 14%        (13% in 2003)
                (Source: GYTS 2007)
    Alcohol Use

   11% of Filipinos 15-74 years
    regularly drink alcoholic beverages
    (>4 days/week)
   24% of Filipinos 15-19 years are
    current drinkers (2001 survey
   42% of Filipinos 15-27 years are
    current drinkers (2002 survey
   Mean value of pure alcohol
    consumed per day: 4.8 grams (2003
    World Health Survey n=4951)
             Summary of Economic Costs in US$)*
              for Four Smoking-related Diseases
          (2003, using SAMMEC methodology figures)

                                     Productivity      Productivity
Smoking-related    Health Care
                                     Losses from       Losses from    Total Costs
  Diseases           Costs
                                        Death            Disease

Lung Cancer           9,188,871        189,709,987         3,407,151 202,306,009

CVD                507,315,052      2,930,533,343        38,910,556   3,476,758,951

CAD                236,888,476      1,312,836,695        88,922,515   1,638,647,686

COPD               104,561,119         569,530,925       54,043,648    728,135,692

All 4 Diseases     857,953,518      5,002,610,950       185,283,871   6,045,848,339

       *$1=PhP 52.
       Source: Tobacco and Poverty Study in the Philippines,2006.
   DOH Early Actions on NCD
   Prevention and Control

• Non-communicable Disease Prevention and
  Control Service established 1986 with EO
  119 reorganizing the Department of Health
• Developed vertical programs in early 1990s
   – Cardiovascular Disease Prevention and
     Control Program
   – National Cancer Control Program
   – Diabetes Prevention and Control Program
 Non-communicable Disease Prevention
 and Control Service
 Launched advocacy and IEC campaigns against
  known risk factors

        YOSI KADIRI –anti smoking

         – regular physical activity

         low salt, low fat, high fiber diet
 DOH Milestones on NCD Prevention and
Year 2000
External evaluation study on existing programs
as basis for integration conducted;
Degenerative Disease Office under NCDPC
mandated to manage NCDs;
The Health Sector Reform Agenda was
introduced advocating changes of service
delivery, governance, financing and regulations,
which facilitated the integration of NCDPC-related
DOH Milestones on NCD Prevention and
Integrated Community-Based NCDPC
Demonstration Project in Pateros and Guimaras
Framework for the Integrated Community-Based
NCD prevention and control program (NCDPCP)
Training Module on the Integrated CB-
NCDPCP developed
National Mental Health Policy
   DOH Milestones on NCD
   Prevention and Control
Healthy Lifestyle (HL) approach (focusing on 3 major risk
factors: physical inactivity, tobacco use and unhealthy diet)
was mainstreamed;
National advocacy program on HL developed with
Philippine Heart Association;
“Mag HL Tayo Campaign” was launched;
Nationwide training of Regional NCDPC Coordinators
and Training staff/HEPOs on the promotion of HL
Anti-Tobacco Law (RA 9211) was passed.
   DOH Milestones on NCD
   Prevention and Control
 Philippine Coalition for the Prevention of Non-
Communicable Diseases established;
 Advocacy with commercial food establishments to
offer healthier menu options to the public started;
Training of national government agencies on HL (DILG,
DepED, DSWD, DOT, etc.)
 Policy Development Study completed identifying policy
agenda in support to the integrated NCDPC Program;
 Demonstration project in Guimaras and Pateros was
assessed and results show very promising results.
Revision of National Mental Health Plan
   DOH Milestones on NCD
   Prevention and Control
 Breast Cancer Intervention Study in Pateros and
Chronic Respiratory Disease Study in Guimaras;
 3rd Public Health Convention on NCD Prevention and
Control on local initiatives to promote HL

 Post NCD impact survey in Guimaras and Pateros
 DOH-NCDPC adaptation of the WHO NCD Framework
for Action for the Philippines
 National Policy on Injury Prevention Program
Operational Framework for Sustainable Establishment of
Mental Health Program
   DOH Milestones on NCD
   Prevention and Control
 4th Public Health Convention on NCD Prevention and
Control accelerating NCD actions
 Finalization of manual of operations for community-
based NCD prevention and control
Framework for NCD Prevention and
Control Action
•   Follows the causation pathway of NCDs and
    supports the following actions:
     – Environmental Interventions
     – Lifestyle Interventions
     – Clinical Interventions
     – Advocacy
     – Research and Surveillance
     – Political and Community Leadership,
        Intersectoral Partnerships and Community
     – Health systems strengthening
Causation Pathway
Causation Pathway

Intervention Pathway
Strategic Approach
                     1                                       2                                         3
                     1                                       2

                                                  4      Advocacy
                                             Research, Surveillance, Evaluation
                                                                            Health Sector Response
                                                                            Health sector governance
                                                                            Health sector leadership
                                                                            Integration of NCD prevention and
         “Whole of government”                                              control into national health strategy
         Political will
         Political leadership
         Healthy public policies and laws

    6                                                                                                                7
                                                                            Health Systems Response
                                                                            (Health Systems Strengthening)
                                                                            Health workforce development
         “Whole of society”                                                 Health services organization/delivery
         response                                                           Financing
         Community leadership                                              People-centred systems of care
                                                                            Focus on prevention
         Intersectoral partnerships

         Community mobilization
  Integrated NCD Prevention and
  Control Program

Vision: Improved quality of life for all Filipinos
Mission: To ensure that quality prevention and
   control NCD services are accessible to all,
   especially to the vulnerable and at-risk
Goal: To reduce mortality, disability and morbidity
   due to NCDs (CVDs, CA,COPD,DM).
  Integrated NCD Prevention and
  Control Program

   – To reduce the exposure of population to
      risks related to NCDs primarily smoking,
      unhealthy diet, physical inactivity and
      alcohol use.
   – To increase the proportion of NCD cases
      given appropriate treatment and care.
Policy Statement No. 1

• The Integrated NCD Prevention and
  Control Action follows the causation
  pathway of NCDs as a framework for
• It supports the WHO Global and
  Regional Strategy for NCD Prevention
  and Control.
    Policy Statement No. 2
• Adoption of an integrated, comprehensive and community
  based response to NCD prevention and control
   – Focuses on common risk factors guided by a life course
   – Encompasses the three levels of disease prevention:
     primary, secondary and tertiary level;
   – Emphasizes strategies which would benefit entire population
     or large packets of population, but also takes care of high-
     risk populations;
   – Integrates across settings; such as health centers, schools,
     workplaces and communities;
   – Makes explicit links to other government programmes;
   – Emphasizes intersectoral action
Policy Statement No. 3

• Intensify health promotion to effect changes
  that lead to significant reduction in mortality
  and morbidity due to NCDs
   – Changing lifestyles
   – Changing the environment
   – Reorienting the health system from the
     curative mode to the preventive or
     wellness mode
 Policy Statement No. 4

• Foster complementary accountabilities in the
  implementation of an Integrated NCD
  Prevention and control program
  –   DOH
  –   LGU
  –   Other GOs/NGAs
  –   Other Sectors, including Private sector and other
Guiding Principles

•   Equity
•   Sustainability
•   Rights based
•   Continuum of care throughout the life cycle
•   Evidence based
       Current Issues and Challenges:
                            • A core national coalition of
                              stakeholders is established
Coalition Building for NCDs   but mostly from the health
                            • There is a need to expand
                              partnerships to other
                              sectors, including the
                              private sector.
                            • Whole of government and
                              whole of society approach
                              is needed to build
                              momentum and sustain
Current Issues and Challenges:
• Integrated and comprehensive approach is
  established but there is a need to further
  advocate among the health workforce and
  stakeholders on effectiveness of this
• Human resource, both in quantity and
   Current Issues and Challenges:
• Surveillance System for NCDs and risk factors is
  available but currently limited.
• Main sources of data are from the Philippine Health
  Statistics, national prevalence surveys, a cancer registry
  and other registries from NGOs and professional
• NCD data from FHSIS and hospitals are very limited
• PHilHealth could have been a very good source of data
• DOH should enhance information systems to generate
  timely and relevant data for continuing policy
  enhancement and program response.
  Current Issues and Challenges:
  Service Delivery
• Health promotion and education is conducted
  nationally mostly by the health sector.
• Health services and products addressing NCD
  needs are available in the field at varying levels,
  depending on local government resources and
• Suggested NCD package of services are
  established but need to be advocated, adopted,
  implemented and monitored at all levels of care.
• Referral systems should be enhanced to effectively
  prevent and manage NCDs.
Current Issues and Challenges:
• Some policies and legislations are already in place to
  facilitate implementation of relevant NCD
• Republic Act 9211 is in place, but needs more strict
• Ensuring affordability and accessibility of essential
  medicines and diagnostic services
• There is a need to come up with additional regulatory
  mechanisms, e.g. nutrition labeling, to support and
  strengthen current initiatives on NCD prevention and
Current Issues and Challenges:
• NCDs often result to catastrophic expenditures,
  plunging many families deeper into poverty.
• Many are often not able to continue with
  treatment and care, contributing to the growing
  burden of diseases due to NCDs.
• About three-fourths of the diabetes patients had
  given up diabetes care because of financial
  difficulties at one time in the past.
• 67% experienced shortage of money because of
  diabetes-related expenditure, and borrowed
  money or pawned assets.
• Philhealth coverage was lowest among the
  informal sector at 15%. (Source: Costs, Availability, and
  Affordability of Diabetes Care in the Philippines, Higuchi, et all,
  WHO, 2008)
 Study on an “Outpatient Prescription Drug Benefit for
 PhilHealth Members with Hypertension”

• Lack of affordable access to outpatient antihypertensive
medicines leads to avoidable disease progression and costly
inpatient admissions.

• Inpatient care for hypertension and its sequelae is expensive
and hypothesize that many hospitalizations could be avoided
with appropriate antihypertensive therapy provided in
ambulatory care.

• Avoiding expenditures for one hospitalization could pay for
one year of anti-hypertensive medicine treatment for three (3)
 Way Forward
• Operationalize and promote integrated
  approach to NCD prevention and control at
  the local level.
• Ensure access and availability of relevant
  services and products, including NCD drugs,
  in the communities and among affected and
  vulnerable populations.
• Enhancing referral systems will provide for
  the continuum of care along the spectrum of
  non-communicable diseases. .
Way Forward
• Strengthen linkages with relevant government
  and nongovernment agencies
• Awaken social accountability of various
  stakeholders and sectors to address the
  NCD related problems
• Utilize the whole of society and whole of
  government approach
Way Forward

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

 Health promotion and advocacy are cross-
  cutting interventions that the broad network of
  stakeholders can collaboratively engage in as
  part of social responsibility.
 Such should be consistently provided as
  support to other interventions to change
Way Forward

• Ensure sustainable financing. Different financing
  mechanisms such as funding, resource allocation,
  contracting and reimbursement can be utilized.
• Local governments should be encouraged to
  increased their resources and investments for NCD
  prevention and control.
• Improve social health protection through the
  enhancement PhilHealth‟s benefit package to cover
  lifestyle diseases, to increase the benefit package‟s
  support value and to improve the coverage of the
  indigents and those in the informal economy.
Way Forward
•   Improve access to, availability of and
    reliance on low cost medicines
     – Strengthen Botika ng Barangay
        Improve physical accessibility
        Improve procurement of medicines and
        availability of medicines
        Promote public reliance on quality assurance
        of low cost medicines
Invest in cost-effective interventions

    Health Benefits and Costs of 3 Interventions Combined
          Deaths Averted                     Cost per head
Intervention    Deaths Averted      Intervention         Cost per head
Salt                  8.3 million
Reduction                           Salt Reduction              0.36
                                                           (0.14-0.38 low-mid
Tobacco               5.5 million   Tobacco Control             income)
                                                          (0.52-1.04 High mid
Control                                                          income
Multi-drug           17.9 million   Multi-drug                 1.08
Treatment                           Treatment              (0.75-1.40)
       TOTAL         31.7 million                TOTAL         1.44
                                                         (0.89-1.78 low-
     31.7 million † 36 million =                           mid income)
    88% of global goal                                   (1.27-2.88 high
                                                           mid income)
Way Forward

• Pursue the policy agenda on the following:
  (1) Lowering of saturated fat and lower salt content in
  food offerings; 2) Mandating fast food chains and
  restaurants to keep public informed of the nutritional
  value of food offerings; 3) Providing subsidies/ tax
  breaks to encourage manufacture and sale of
  healthier food options; 4) amendment of the Food
  Fortification Law; (5) legislation of graphic health
  warnings on tobacco packages, etc
• Fulfill the research and development agenda in
  collaboration with government agencies and private
  organizations to fill in program data needs:
Way Forward
 The integrated approach would provide for
  harmonized NCD prevention and control
  policies and programs, delivery of services
  and health care financing thereby creating a
  “seamless and smooth system” to achieve
  good health outcomes and coverage.
 However, commitment of all public and
  private stakeholders and integrated planning
  must be set in place before objectives can be
  fully realized.
    Key Strategies for Local

• Localize healthy public policies
• Build coalitions and partnerships
• Enhance community participation
• Create a supportive organizational and
  physical environment
• Intensify health education and public
Key Strategies for Local
• Institutionalize local assessment and
• Build or expand local capacities
• Reinstall supervision
• Establish financing schemes
• Install regulatory mechanisms
• Unify monitoring and evaluation efforts
 Lessons on Local Implementation

• National policies are useless if not locally
• Success lies largely in the hands of
  implementing units
• Experience with PIPH-AOPs shows that
  effective strategies for NCDS are not fully
• Operationalizing this policy at the local level
  will ensure effective prevention and control
  efforts for NCDs
• “We cannot afford to say „we must tackle
  other diseases first – HIV/AIDS, malaria,
  tuberculosis – then we will deal with chronic
  disease‟. If we wait even 10 years, we will
  find that the problem is even larger and
  more expensive to treat”

• Olusegun Obasanjo, President , Federal
  Republic of Nigeria.
Recent and Current Evidence
showed that....
• Preventing and controlling major
  risk factors in an integrated manner
  and employing health promotion
  across the life course at the level of
  family and community is thus most

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