Country Capacity and Accomplishments and Application of the Policy Options Framework(cont...)

Nepal

Key Policy Options and Strategic Actions

Assess

* Create a national NCD surveillance system. Initial efforts should focus on risk factors including

tobacco (especially among women), alcohol use, and injuries. The core public and private

institutions with experience and capacity should be tapped for capacity development and

technical assistance.

Country Capacity and Accomplishments and Application of the Policy Options Framework(cont...)

Maldives

Key Policy Options and Strategic Actions

Assess

* Create a national NCD surveillance system. A national system is needed to inform strategic

planning and policy development. Limited efforts for subnational behavior risk factor

surveillance for tobacco and youth have been undertaken. However, the system should also

include NCD mortality, morbidity, health services utilization, and economic burden data

Country Capacity and Accomplishments and Application of the Policy Options Framework(cont...)

India

Key Policy Options and Strategic Actions

Assess

* Create a national NCD surveillance system. A national surveillance system is needed for strategic planning and policy development. The IDSP is a good effort to develop a national ongoing risk factor surveillance system but is now stalled. Using a state-based approach is reasonable but national and regional funding and technical support will be needed. In addition, systematic surveillance of morbidity and mortality will be needed. With regional

Country Capacity and Accomplishments and Application of the Policy Options Framework(cont...)

Bhutan

Key Policy Options and Strategic Actions

Assess

* Develop a national NCD surveillance system. While some initial efforts are evident, little has

been done toward a national system. Vital registration for mortality needs to be expanded

beyond hospital, and morbidity and risk factors need institutionalization. In addition, a strategy

for injury surveillance is needed. Public and private institutions must be tapped to support

Country Capacity and Accomplishments and Application of the Policy Options Framework(cont...)

Bangladesh

Key Policy Options and Strategic Actions

Assess

* Develop a national NCD surveillance system. Much has been done toward a national system. The national risk factor survey under way needs to be institutionalized and a strategy for injury

surveillance is needed. Public and private institutions must be tapped and coordinated in

support of NCD surveillance efforts. In addition, enhanced morbidity and mortality surveillance

in subpopulations such as Matlab and BanNet are critical.

Country Capacity and Accomplishments and Application of the Policy Options Framework(cont...)

Afghanistan

Key Policy Options and Strategic Actions

Assess

* Move towards integrated surveillance which includes communicable diseases and then phase inbehavioral NCD surveillance that includes tobacco and mental health. The way forward for

broader surveillance will be to take stock of public and private institutions that may play key

roles, including NGOs that are services providers and that track morbidity and mortality. Basic

data are needed to develop sound policy and prevention efforts. Adult tobacco use is uncharacterized, although small studies suggest that use is high as is found among youth.

Mental health is a major issue yet poorly characterized.

Country Capacity and Accomplishments and Application of the Policy Options Framework(cont...)

Table 6.1 NCD capacity profile of selected indicators by country

Source: Authors.

Country Capacity and Accomplishments and Application of the Policy Options Framework(cont...)

Introduction

This chapter presents, for each country, key policy options and strategic actions for NCDs (Table 6.1 and Appendix 1; more detailed information of key accomplishments and a situational analysis for each country are included in Appendix 5.)21 The options and actions adopt the program management cycle of the policy options framework (Assess, Plan, Develop and Implement, Evaluate) developed in Chapter 5.

Country Capacity and Accomplishments and Application of the Policy Options Framework

Key Messages

* South Asian countries are generally putting a low level of effort in surveillance and NCD burden

assessments, and no country is reviewing the evidence base.

* Some countries have NCD units and national overarching policies, but only Maldives has explicit national targets.

Common Challenges for Tackling NCDs(cont...)

Box 5.1 The private sector and NCDs

The concept of employers playing a larger role in improving employee fitness and health is not new. The U.S. government is encouraging employers to invest in workplace health promotion, and about 95 percent of its large employers and one third of its smaller ones offer wellness programs. A growing awareness of the costs linked to risk factors provides the grounds for government promotion of workplace-based initiatives.

Johnson & Johnson launched a frequently cited model of employer-based health promotion in the 1970s and reports having saved US$38 million in health care costs between 1995 and 1999 by promoting healthy lifestyles (Zeidner 2004).

Common Challenges for Tackling NCDs(cont..)

Economic

* Costs of NCDs put strains on budgets of government and other financiers of care because

treatments use some expensive private goods and services.

* High catastrophic spending and impoverishment among individuals is too common. This

exacerbates equity issues because most health financing is private and out of pocket.

Common Challenges for Tackling NCDs(cont..)

Economic

* Costs of NCDs put strains on budgets of government and other financiers of care because

treatments use some expensive private goods and services.

* High catastrophic spending and impoverishment among individuals is too common. This

exacerbates equity issues because most health financing is private and out of pocket.

Common Challenges for Tackling NCDs

Common Challenges for Tackling NCDs

The policy options framework provides a guide to strategic decisions. However, the country context and past experiences and traditions are major factors that must also be considered. In South Asia, four main areas of common challenges are as follows:

Political

Introducing the Policy Options Framework(cont...)

Other key points include:

* Prevention policies are implemented by both the health sector and key non-health sector

stakeholders such as ministries of finance (tobacco tax) and of transportation (injury prevention). By contrast, most treatment policies are implemented within the health sector.

* Prevention policies apply to the general public with spin-off applications in the private sector.

Treatment policies apply equally to both the public and private sectors.

Opportunities for Prevention and Control(cont...)

Framework Convention on Tobacco Control

The Framework Convention on Tobacco Control (FCTC) marked its fifth anniversary in

2010. It is unique for two reasons: it is the first international health treaty and it has become one of the most widely and rapidly ratified treaties in the history of the United Nations. The FCTC represents a new approach to international health

cooperation and is a model for a global response to the harm that tobacco causes to health.

Opportunities for Prevention and Control(cont...)

Global and National Policy Context for NCDs

In 2000, the World Health Assembly adopted a resolution (WHA/53.17) endorsing a WHO Global Strategy for the prevention and control of NCDs. The Director-General of WHO was requested to continue giving priority to the prevention and control of NCDs and the member states were requested to develop national policy frameworks and to promote initiatives.

Rationale for Action(cont...)

Health Sector Perspective

To fully capitalize on the demographic dividend, healthy aging is necessary, which in turn, requires tackling NCDs. But many opportunities for their prevention and control are available. Experience from developed countries indicates that the increase in CVD during a similar phase of the epidemiologic transition could be blunted and even dramatically reduced by changes in risk levels within the population and through primary care for NCDs.

Opportunities for Prevention and Control

Key messages

* The global NCD policy of WHO, a policy that focuses on strategic NCDs, is well established, and

the role of government efforts depends on the disease burden; on health and non-health sector

capacity, priorities, and resources; and on the policy environment.

* Many opportunities for NCD prevention and control are available and affordable. Feasible

strategies exist.

Rationale for Action(cont...)

Health Sector Perspective

The future increase in the disease burden and risk factors will both put a strain on services delivery and stress budgets. Programs and services need to be reoriented toward efficient NCD prevention and control while also tackling the substantial remaining burden from communicable diseases, and MCH and nutrition issues.

In order to efficiently deliver services for NCD, the health system infrastructure will need retooling and human resources will need training and new skills. In addition, health financing suitable for many people requiring ongoing lifelong treatment will be needed. Fetal and childhood undernutrition is a lagging regional problem that is leaving a legacy of NCDs.

It is recognized as a major long term-risk factor in the development of adult chronic diseases including heart disease, diabetes, hypertension, and stroke (Barker 1992; Barker and Clark 1997). All countries in South Asia, including those with more favorable health indicators, are struggling with undernutrition.

In addition, many among the current adult population were exposed to undernutrition when they were young, creating a large pool of those at elevated risk. The legacy of this risk factor will be generational and closely linked with social-determinant risk factors noted already. This reinforces the need for continuing efforts to address this risk factor, which will fall on the health sector.

Rationale for Action(cont...)

NCD can hold back development and poverty reduction efforts in low-income countries. At the macroeconomic economic level, Figure 3.2 provides an illustration of diminished health from NCDs ultimately leading to lower economic growth and poverty. In South Asia, while empirical evidence is scant, projections suggest that over the next 10 years deaths from heart disease, stroke, and diabetes may lower GDP in India and Pakistan by 1 percent (WHO 2005). In Sri Lanka, where life expectancy has increased the most in the region, chronic illness is an important cause of withdrawal from the labor market (World Bank 2008a).

Figure 3.2 Illustration of the macroeconomic effects of NCDs

Rationale for Action(cont...)

In developed countries the poor and disadvantaged experience a larger NCD burden of risk factor and disease than do the rich. In South Asia, the disease burden may currently be greater in the rich, but it will be shifting and concentrating in the poor. Risk factors, such as tobacco use, are already more common among the poor.

Addressing social determinants requires not only health policies that are s

Rationale for Action(cont...)

Social and Political Perspective

From both a social and political standpoint, a very strong case can be made that action is warranted. As noted in Chapter 1, South Asians are 6 years younger than those in the rest of the world at their first heart attack.

This burden is especially hard on the poor, who after a heart attack, face a lifelong major illness, the need to finance substantial portions of their care out of pocket,

Rationale for Action

Key Messages

* Compelling reasons to address NCDs in South Asia now include social and political factors (South Asians experience a disproportionate burden of noncommunicable disease), economic factors (costs and efficiency), equity factors, and health sector factors (unprevented and unmanaged NCDs are straining services and budgets).

* From a social and political perspective, South Asians suffer from a relatively heavy CVD burden that is especially tough on the poor; unfavorable social determinants add to this burden.

Implications for South Asia(cont...)

The Social and Economic Impact of NCDs in the Russian Federation

The Russian Federation’s unprecedented mortality upsurge due to noncommunicable diseases (with cardiovascular disease the main cause) and injuries in the last two decades, coupled with fertility rates that are well below replacement level, has several implications beyond the

sociodemographic makeup of the country.

Shrinking population:

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Implications for South Asia(cont...)

The impact on individuals in terms of short- and long-term disability, premature death, and forgone wages will be significant. At the macroeconomic level there will be adverse impacts on labor productivity and while empirical data are scant, productivity declines and reduced economic growth may occur.

South Asian countries all face a double-disease burden. Most people in rural populations moving to urban areas will experience changes in lifestyles that may increase their NCD risks. Extreme poverty and fetal and early childhood undernutrition account for a sizable part of the total burden.

Implications for South Asia

Population aging is a major feature in South Asia and will result in a demographic dividend due to favorable dependency ratios. However, as noted in Chapter 1, aging is occurring rapidly and without the social changes that accompanied aging in developed countries decades ago. In addition, the international health community has become increasingly concerned with the shift of the disease burden toward NCDs while a residual burden for MCH remains.

Country Level Aging and Disease Burden(cont...)

Sri Lanka

In combination with substantial declines in fertility since the 1970s, advances in human development have led to rapid demographic aging (Figure 2.8). The proportion of the population 65 years and older will increase from 6.7 percent in 2000 to 13.6 percent in 2025. This demographic transition has been accompanied by an epidemiologic transition, that is, a growing NCD burden.

Figure 2.8 Age structure in Sri Lanka, 2000 and 2025

Country Level Aging and Disease Burden(cont..)

Pakistan

Pakistan is in the early stages of the demographic transition, which is expected to advance in the future (Figure 2.7). The proportion of the population 65 years and older will move from 3.9 percent in 2000 to 5.4 percent in 2025.

Figure 2.7 Age structure in Pakistan, 2000 and 2025

Country Level Aging and Disease Burden(cont...)

Nepal

Nepal is in the early stages of the demographic transition, which is expected to advance in the future (Figure 2.6). The proportion of the population 65 years and older will move from 4.2 percent in 2000 to 5.8 percent in 2025.

Figure 2.6 Age structure in Nepal, 2000 and 2025

Country Level Aging and Disease Burden(cont...)

Maldives

Maldives is in the mid to later stages of the demographic transition, which is expected to advance in the future (Figure 2.5). The proportion of the population 65 years and older will move from 3.5 percent in 2000 to 6.3 percent in 2025.

Figure 2.5 Age structure of Maldives, 2000 and 2025