Addressing NCDs in Asia through a Health System Lens

Addressing NCDs in Asia
through a health system lens
Dr Nima Asgari

My talk in brief
 This is primarily based on a chapter
from our most recent publication.
 I want to acknowledge the authors of
the chapter:
 Melisa Tan, Victoria Haldane, Sue-Anne
Toh & Helena Legido-Quigley from NUS
 Martin McKee from LSHTM
1. Summary of the current 4 main NCDs
situation in Asia including risk factors
2. Examples of health system response
3. Challenges

NCDs in Asia
Situation summary

Overall NCD situation in Asia
 52% of the global NCD
deaths in 2016 was in
WHO South-East Asia and
Western Pacific regions-
21 million deaths
 80% of all cause DALYs in
2016 in the Western
Pacific Region are from
NCDs
 NCD deaths in the South
East Asia region increased
by 44% from 2000 to
2016 (6.3 to 9.1 million)

Picture is not this black and white:
Every Asian country is in a different stage of
demographic transition due to ageing
Add to this internal and external migration
Add to this urbanization and creation of
megacities and peri-urban health issues
 Exclude mental health issues and road traffic
accidents

For CVD summary
 We see a mixed picture. Japan, Korea and Singapore show a
decrease while it is increasing in South Asia
 Hypertension control is a big issue as it is a proximal risk factor

Controlled hypertension in selected countries
PURE study, Palafox et al.
Country
No of
participants
No with hypertension
(>140/90) (%)
Hypertensive participants
% Aware % Treated % Controlled
Malaysia 11 825 5509 46.6 48.1 41.2 12.5
China 46 751 19 471 41.6 41.7 33.7 8.0
Philippines 1671 855 51.2 54.5 46.1 13.5
Iran 6013 1598 26.6 52.6 51.1 18.3
Bangladesh 2747 1080 39.3 24.2 16.1 4.0
India 27 458 8473 30.9 42.1 33.6 13.7
Pakistan 1294 435 33.6 47.4 37.2 17.5

For cancers
 In 2008, 44% of all cancers and 51% of all cancer deaths globally occurred in Asia
 Expect a 75% increase in number of cases from 6.1 million in 2008 to 10.7 million by 2030
 Expect an increase in cancer death rate in Asia from 67% in 2008 to 70% by 2030

For respiratory diseases
 3 major risk factors in Asia: tobacco, infections and air pollution
 At least 250 million in WPR use tobacco and 250 million in SEAR use smokeless tobacco. Strict
regulation in the West and trade liberalization is pushing firms to focus in Asia
 65% of all global years lost to air pollution is in Asia. Most due to industry and vehicle use but in low
income setting, indoor air pollution from biomass use for cooking is also a contributor.

For diabetes mellitus
 Estimated 60% of global 362 million diabetics live in Asia- Expected to double by 2030.
 Urban>rural, sugar and junk food consumption and trade liberalization issues
 Rising DALYs everywhere apart from Japan and Singapore
 South Asians more prone: younger, lower obesity, more complications, die younger

Health system response to NCDs
Examples from Asia

Leadership and governance
Japan
Health Japan 21-
multisectoral response
to NCDs:
 Emphasizes community
involvement
 Development of local
health promotion plans
 Community salons for
>65 to increase social
interaction
Singapore
The war on Diabetes:
 Implementing multiple
other strategies and
plans together
 Whole of government
and involves people
 Healthier choice sign to
nudge people to eat
healthier food
 National steps challenge
 Healthier ingredients
scheme for local food
manufacturers
Sri Lanka
National NCD policy:
 Healthy lifestyle centres
in PHC settings
 Risk factor screening for
NCDs and referral up
the chain
 However poor uptake

Healthcare Financing
Use of specific
insurance schemes
Late stage medical care
insurance for the >75 in
Japan
 Premiums and subsidies
are means tested
 Government subsidy =
50%
 Contributions from other
insurance schemes = 40%
 Premiums paid by the
elderly = 10%
 OOP = 10% of health costs
(capped)
Source Japan HiT-APO
Hypothecated taxes to
raise funds
Sin tax use in Thailand
and Philippines:
 Additional 2% surcharge
added on the duty and
excise tax levied on
alcohol and tobacco to
fund Thai Health
Promotion Fund
 Philippines uses sin tax
to supplement
PhilHealth funds for
promotion, prevention
and curative services
Taxes to change
behavior
Sugar tax in the
Philippines:
 The impact of sugar tax
in Philippines was a 14%
increase in cost of
sweetened drinks
 Global data shows
strong global evidence
to indicate price
elasticity of -1.3%
consumption for every
1% rise in cost

Health workforce
 Not enough trained HCW to manage NCDs well in all levels
 Limited supply of mainstream staff, low training, low retention, maldistribution
and internal migration are causes of concern in Asia
 Midlevel health workforce can be used for routine activities which do not
require much clinical judgement
Using Community
Health Workers
 Control of BP and Risk
Attenuation (COBRA-
BPS) pilot: home health
education by CHWs in
rural communities in S.
Asia achieved successful
BM management
 Similar results shown in
Pakistan and Iran
Enhancing nurses
skills
Nursing Now campaign:
 Flexible training to
update skills by
Narayana health, India
 Care to go beyond
campaign to attract and
retain nurses in
Singapore
Local people, local
training, local bonding
Thailand programme for
training local doctors
 Local universities recruit
local rural students and
train them locally with a
focus on community
health. Students feel
part of community and
remain after graduation.

Service delivery
 Screening: If not done well, is a waste of resources. Makes providers and
policy makes feel good but doesn’t find cases cost effectively.
 Service delivery in the community: HOPE-4 cluster RT in Malaysia was
designed after analysis of barriers in health system for managing
hypertension. Looks at task shifting, simplified guideline use and single
dose combination therapy to improve hypertension management
 Service integration: Providing tobacco cessation services to TB patients in
India as 20% TB cases are due to tobacco use, but needs sustained support
 Palliative care: Great expansion after creation of palliative care society in
Mongolia. They lobbied to include palliative care training for medical and
social work students. All provincial hospitals have palliative care units and
pharmacies can distribute morphine to cancer patients.
 Medicines: Right drugs, at right place, at right price, prescribed and used
correctly: need inventories, procurement, supply chains, correct
prescription practices and health literacy

Final words
Promises and challenges: from global to local

The story so far
 Multiple international commitments and targets for NCDs
 2011 UN declaration: reduce NCD mortality by 25% by 2025
 SEAR NCD action plan 2013-2020: target 80% coverage of essential NCD
medicines
 2016 SDG 3 targets include 3 NCD specific targets; UHC, and several ‘means of
implementation’ targets relevant to NCDs, including health workforce and
medicines
 Progress on UHC cannot be achieved without progress on NCD
prevention and control
 Cost-effective NCD interventions exist, that can be safely delivered
by frontline health services

Addressing NCDs in Asia contd.
Need a whole-of-society approach that should include governments,
civil society, academia, industry and communities across a wide range
of sectors to co-produce health.
Health systems in Asia can deliver high-quality care only if they invest
in the necessary resources and optimize their investment decisions.
The essential components include motivated health workforce,
equitable and effective financing mechanisms, appropriate and
accessible service delivery across the continuum of care, and
responsive to the needs of diverse population including elderly and
migrants.
Countries must ensure to have systems in place for safeguarding health
against powerful vested interests, particularly when engaging in
public–private partnerships.

APO’s website: www.healthobservatory.asia
You can download the book from here:
Thank you

Addressing NCDs in Asia through a Health System Lens

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