Capacity, Key Accomplishments and Situational Analysis for NCDs in South Asian Countries(cont...)

Several gains have been made in surveillance. The Bangladesh Network for Non-Communicable Disease Surveillance and Prevention (BanNet) data network has been created and includes government and private clinical institutions. The recently formed Alliance for Community Based Surveillance (ACSNet) promotes periodic population-based surveys of NCDs and their risk factors.

A national risk factor survey is planned for completion in 2010. The 2006 Bangladesh

Urban Health Survey included NCD-related items in slum and non-slum areas of the country’s six largest city corporations. The 2003 Bangladesh Health and Injury Survey (BHIS) was the largest injury survey conducted in a developing country.

The new Centre for Control of Chronic Diseases in Bangladesh (C3D) aims to bring scientific rigor to the study of the NCD burden; develop community-based prevention and management programs; and evaluate the link between NCDs and poverty in the country, as well as the health system’s response to NCDs. In spite of this progress, there is no current surveillance of NCDrelated morbidity and mortality, nor a cancer registry.

In 2008, total expenditures on health amounted to 3.5 percent of GDP. Household out-of-pocket expenditures at drug outlets account for 46 percent of total health sector expenditures, making such drug purchases by far the single largest expenditure item within the sector.

Standard Efficiency-based Rationales(cont...)

Nonrational Behavior

The assumption that people act rationally (i.e., maximize their expected utility) represents a core pillar of economic thought and most economists would not approve of dismissing the rationality assumption altogether, not least because doing so would open the way to paternalism in a broad range of areas.

However, children and adolescents tend not to take the future consequences of their choices into account, irrespective of whether they are informed of them. They act myopically (in the sense of mpatiently) and, hence, nonrationally.

Standard Efficiency-based Rationales(cont...)

Non-standard Economic Rationales: Behavioral Economics

A new paradigm of behavioral economics is slowly emerging, with a realization that the traditional concept of the sovereign, rational, and always well-informed consumer may not in all instances help in understanding and predicting people’s decisions and behavior. It holds that there are situations in which people act with bounded rationality.

Standard Efficiency-based Rationales(cont...)

Non-standard Economic Rationales: Behavioral Economics(cont...)

Time-inconsistency is easily confused with insufficient information, especially with addictive goods. The outcomes of these market failures may be identical, but the causes—and hence the policy implications— differ significantly. While the solution to time-inconsistency is to provide effective commitment devices, which are mechanisms that reinforce a previously adopted decision, the solution to limited information is to provide more of it, particularly to young people.

Aligning Policy Options with Burden and Capacity

Policy options in some key areas will vary among countries depending on country capacity and burden.For this, understanding the relationship between the country-level noncommunicable disease (NCD) burden and country health system capacity is useful for tailoring the policy options developed from this framework and prioritizing efforts that align with country capacity.

Thus, a general estimate of countrylevel burden and capacity and a map of their relationship was developed (Box A4.1). Using this capacity index score and mapping it with the percentage of the total country burden due to NCDs (in forgone disability-adjusted life

Aligning Policy Options with Burden and Capacity(cont...)

To support these findings, several other standard indicators were used, of

(i) health system infrastructure (physicians/10,000 population, hospital beds/10,000 population, out-of-pocket expenditures for health as a proportion of total health expenditures (THE)

(ii) service delivery (prenatal care services and vaccine coverage)

Aligning Policy Options with Burden and Capacity(CONT...)

Applying the framework to a lower capacity country setting can then highlight the subset of options for population-based and individual-based interventions that are strategic (Table 4.3 in main text). With limited capacity, planning and human resource development constitute the focus and an emphasis within the population-based mode—within the health sector, as compared to clinical mode efforts.

Risk factor and health sector capacity assessment, policy for risk factor reduction, and financing to support these activities also are strategic starting points in this setting. As one moves to a middle burden and middle/higher capacity context, broader efforts become strategic.

Aligning Policy Options with Burden and Capacity(CONT...)

Moving to the higher burden and higher capacity context, the framework is more expanded. Again, for both population- and individual-based interventions, capacity assessment, planning, and human resource development are common issues. Surveillance systems address both prevention and treatment.

Policy development includes those implemented both within and outside the health sector and the development of clinical quality initiatives. The need for a regulatory framework an health financing emerge as major items. Monitoring and impact evaluation become critical to guide decisions for scaling up and for broader implementation.

Capacity, Key Accomplishments and Situational Analysis for NCDs in South Asian Countries

Afghanistan

Capacity, Key Accomplishments, and Situational Analysis

The public health system was completely disrupted during the conflict years and is being rebuilt. Currently, the Ministry of Public Health does not directly provide health services. The private sector is the prominent source of outpatient services, especially in urban areas, and includes both not-for-profit nongovernmental organizations (NGOs) and for-profit providers and

Capacity, Key Accomplishments and Situational Analysis for NCDs in South Asian Countries(cont...)

Afghanistan

Capacity, Key Accomplishments, and Situational Analysis

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) was signed in 2004 but little implementation has occurred. All cigarettes are imported. A cigarette tax has been brought in, although it is the lowest in the region (8 percent). Cigarette smuggling is an issue but it is unclear how substantial. In addition, the country faces a tremendous challenge with narcotics and illicit drug use.

Capacity, Key Accomplishments and Situational Analysis for NCDs in South Asian Countries(cont...)

Many qualified professionals fled the country during the conflict. Currently, approximately 3,000–4,000 physicians are in the country but they are particularly scarce in rural areas. There is a severe shortage of medical specialists in NCDs (especially psychiatry). Training institutions were weakened and some collapsed during the conflict.

However, neighboring countries are providing assistance. International agencies assisted with establishing a national Midwifery Education Accreditation Board in 2005.

Capacity, Key Accomplishments and Situational Analysis for NCDs in South Asian Countries(cont...)

Bangladesh

Capacity, Key Accomplishments, and Situational Analysis

The Health Nutrition and Population Sector Program is Bangladesh's five-year plan for health. It adopted a sectorwide approach to improve coordination and ownership and has identified three NCDs—cancer, CVD, and diabetes—as major public health problems. The current Strategic Investment Plan is notable for including prevention and control of major NCDs.

Capacity, Key Accomplishments and Situational Analysis for NCDs in South Asian Countries(cont...)

The public sector primary care system offers an essential services package. However, NCD prevention and treatment services are not included and health workers are not trained in NCD treatment. Most people, including the poor, use private practitioners for first-line clinical care.

Clinical treatment is also sought from the informal sector and through pharmacies, both licensed and unlicensed. Diabetes, stroke, heart diseases, and their symptoms are routinely considered appropriate for treatment outside the formal health care system.NCD treatment mostly

Strategies to Improve Health Systems(cont...)

Establish a Regional Network of Surveillance and Burden Assessment to Improve National Capacity through Knowledge Sharing and Experience Exchange

Surveillance—a challenge across the region—is critical not only for policy formation but for the development of efficient programs that will reach the target population. This is a country-level activity and countries have made much progress recently with technical support from WHO and financing support from development partners.

Regional Institutional Capacity and Past Collaboration

Efforts have already been targeted toward a number of the above strategies. For example, WHO is leading efforts in tobacco, surveillance, health policy development, creating an evidence base for intervention, and NCD training. Much progress has been made. The goal of this chapter has been to highlight the common issues where justification for a regional strategy is strong and build on what has been done.

A critical element for a regional policy or activity to get off the ground, as noted in Guiding Principles For Regional Collaboration, is having institutions that can lead and manage

Conclusions

Table 7.2 Some regional institutions important for policy development, implementation, and technical assistance

Country Capacity Assessments and Accomplishments

A focus of this book burden assessments and may be conducted less frequently. However, they can be very useful by helping predict strategies as to what can be done and by highlighting ongoing efforts that can be scaled up and built on. Since policy options are the output of this book, understanding country capacity becomes critical.

Box A1.1. Country capacity

Health system capacity is a function of the specifications of the service package required, the mix of resources used to deliver it, the ability to fully use each resource, and the ability to use the resources efficiently.

Country Capacity Assessments and Accomplishments(cont...)

In 2000 and in 2005 WHO Headquarters in Geneva and the WHO Regional Offices conducted national NCD capacity assessment surveillance globally to benchmark and track the status of country-level NCD prevention and control efforts in a systematic manner.

These surveys had four objectives:

* To assess the current situation in relation to existing capacity for NCD prevention and control

* To identify constraints and needs; to set priorities

Country Capacity Assessments and Accomplishments(cont...)

The major findings were a growing commitment to advocacy, more NCD policies and action plans, lack of capacity to develop an HRH workforce for NCDs and lack of public health institutions with leadership and expertise for planning and implementation, inadequate staffing in the government NCD lead unit, little legislation and minimal capacity to develop it, no national surveillance systems, few disease-management efforts, and few efforts in monitoring and evaluation.

Country Capacity Assessments and Accomplishments(cont...)

Examples of key health system indicators are as follows:

Assess

* Risk behaviors

* Mortality

* Morbidity

* Utilization

* Economic burden